Jane South and Jude Stansfield
Public health is commonly described as the organised efforts of society to promote health and prevent disease, yet the invaluable contribution of communities has often been hidden within a dominant deficit model of health. Ten years ago, A Glass Half Full came as a blast of fresh air into the public health scene; however renewed interest in a salutogenic approach to health occurred at the same time as the demise of health promotion in England. There was a genuine risk that the wealth of existing knowledge on community development might be lost with the move to a new public health system. This article describes a journey that led to asset-based approaches becoming an important part of the local public health offer and recognised within a ‘family’ of community-centred approaches that aim to build empowered and connected communities. Although there is increasing confidence in using community-centred approaches in practice, we discuss what is now required to make that shift to a public health system that is truly oriented to community assets, needs and capabilities.
Building on evidence and practice
In public health, approaches that aim to build social connections, empower communities and promote greater equity are not new – all build on health promotion knowledge and practice that has been built up in the UK and internationally (Health promotion by communities and in communities: current issues for research and practice, What is the evidence on effectiveness of empowerment to improve health?).
Our work in Public Health England (PHE) has focused on getting evidence into action to support the uptake of community-centred approaches as part of a strategic approach to improve health and reduce inequalities Reviews, such as Marmot and Due North, have provided strong justifications for greater community involvement in decision making, and for building community capacity and addressing exclusionary processes as part of a social determinants approach to reducing health inequalities. Having a strong research-based rationale leads to questions about how to move from wider empowerment goals into practical action.
In the early days, PHE’s Healthy Communities programme focused on scoping the range of approaches and developing an evidence-based framework that could be used in commissioning and practice. In 2015, PHE and NHS England published A guide to community-centred approaches for health and wellbeing, introducing the ‘family’ with its four strands: strengthening communities; volunteer and peer roles; collaborations and partnerships; and access to community resources (see Figure 1). Community-centred approaches are intrinsically asset-based as they seek to build on the range of informal and formal assets within communities and strengthen the factors that create health. Established asset-based methods that give specific emphasis to mobilising assets are highlighted in the guide, examples include Asset-Based Community Development (ABCD), C2 – Connecting Communities, and Timebanking. The intention was for the family to represent a suite of options, not as a technical fix but as a way of translating goals of improved social connections, greater equity and empowerment into practical action.
The work on community-centred approaches moves public health away from thinking about the ‘community’ as merely a setting for services, or worse still, a target for professionally determined change. It is built on an understanding that communities matter for health – aspects such as the quality of social connections, the levels of trust in neighbourhoods, and the confidence to participate are all important determinants of health. Conversely, threats to these community-level determinants adversely affect health and widen the health gap through the experience of stress, discrimination, social isolation or loneliness. Developing a community-centred approach in public health means working to maximise the protective factors at a community-level and to mitigate the risks associated with disadvantage. It also means mobilising and strengthening community action and working with people as equal partners (see Box 1). Our focus has been on the community-level as arguably this has been overlooked in traditional approaches to public health. Of course, a salutogenic approach to health and wellbeing involves much more than interventions with communities. It also shapes the way health is defined and measured which in turn links to an assets model for public health evidence. While the ‘family’ image serves as a concise reminder of the suite of practical options and the interconnections between those options, the family aligns with a broader range of asset-based interventions in health and social care. Some of these operate at an individual level or through services and systems. For example, strength-based approaches to managing Long Term Conditions, or recovery methods in social care.
The Family of Community-Centred Approaches for Health and Wellbeing can be found in Public Health England's Health matters: community-centred approaches for health and wellbeing.
What do we mean by community-centred?
- Promotes health and wellbeing or reduces health inequalities in a community setting, using non-clinical methods.
- Uses participatory methods where community members are actively involved in design, delivery and evaluation.
- Measures are in place to address barriers to engagement and enable people to play an active part
- Utilises and builds on the local community assets in developing and delivering the project.
- Develops collaborations and partnerships with individuals and groups at most risk of poor health.
- There is a focus on changing the conditions that drive poor health alongside individual factors.
- Aims to increase people’s control over their health and lives.
Scaling and embedding
Looking back since the publication of A Glass Half Full, the use of community-centred approaches to improve the health and wellbeing of individuals and communities has grown considerably. Mobilising health assets, including working in partnership with local voluntary and community organisations and volunteers, is very much part of the public health offer for many local authorities. The key messages of the PHE and NHS England Guide have been incorporated into national strategies and reflected in national public health programmes. NICE Guidance on Community Engagement sets out the principles of engagement for local health systems, endorsing the development of long term ‘collaborations and partnerships’ with communities alongside actions to build volunteer and peer roles. Identifying local health assets is a NICE quality standard for community engagement and NHS England’s recent Universal Personalised Care model recommends that local areas ‘should have in place a range of community-based approaches and a clear understanding of existing community assets and gaps’.
While the development of this supportive national infrastructure is important and signals a wider acceptance of community-level action, it is public health practice that has really been at the forefront of change. We have seen a new and growing confidence to use community-centred and asset-based approaches within place-based public health. This means taking action on the wider determinants to improve the areas where people live and work alongside deep and ongoing partnership work with communities. Diverse local approaches to improving neighbourhoods and working with communities of interest show how public health commissioners and providers are adapting evidence-based models in local contexts. The learning that results from doing is important for developing good practice. PHE now has a suite of practice examples that map to the family of community-centred approaches. Each example, written by local staff, provides a summary of the what, why and how of local programmes and, most critically, the learning that has emerged. There are some fantastic examples of putting asset-based approaches into practice. These include:
- an asset mapping project involving communities in Wakefield
- implementation of a community wide intensive approach to smoking and tobacco control in Hull using an asset-based approach
- an asset-based Community Development project in housing estates in Weston-super-Mare
- Community Wellbeing Practices that provide an integrated model of community navigation and social prescribing in Halton.
As uptake of community-centred approaches increases, the drivers of change are not all positive. Financial constraints have undoubtedly led to local authorities exploring different approaches to using scare resources. Community infrastructure has often faced a reduction in funds. More critically, the impact of austerity has been felt in the poorest communities most, and the health inequalities gap is now widening. This does not create easy conditions for implementation of a community-centred approach, and investment in workforce development and community capacity building is needed to do this work well. Despite these challenges, a place-based approach to reducing health inequalities remains a core strategy in public health. Our recent research shows that local authorities can lead transformative change in working alongside local communities to develop better solutions. For example, Dudley’s work on community resilience which builds action bottom-up starting with local conversations or Wirral’s focus on regeneration of place alongside regeneration of communities. These exemplars of whole system community-centred approaches offer a template for how aspirations to build healthier, more connected and empowered communities can be translated to meaningful action by local leaders. Recent guidance on community-centred public health summarises the elements, principles and values that underpin this shift towards whole system working.
A fundamental reorientation
There is much to celebrate as community-centred approaches are no longer on the fringes of public health. But we are not there yet in terms of a community-led public health system that values, mobilises and strengthens health assets as part of mainstream policy and action. This vision needs a fundamental shift in the knowledge base, activities and outcomes of public health. Looking forward, what is needed to make that shift? Bold leadership that takes a whole system approach to health and wellbeing and fosters collaborations across sectors and with the public and communities; Scaling up community-centred approaches and integrating community participation into mainstream public health; Workforce development to equip commissioners and practitioners with the skills to mobilise assets and co-produce impactful programmes and services with communities; Ensuring the wider workforce and volunteers have the right training and support to develop their capabilities as health promotors in the communities where they live and work; Finally, changing what we measure to balance the deficit model of risks and needs with assessment of protective factors and health assets. This must include citizen voice and gathering evidence from those with experience of marginalisation and understanding their stories and solutions to creating health.
This is an aspirational list, nonetheless a fundamental shift can be achieved even in difficult times. Fostering community-level change should be an integral part of a whole-of-government and whole-of society approach to health. This means using an asset lens and embedding community-centred approaches as the normal way of doing public health.
COVID-19 postcript on asset-based public health
The Covid-19 pandemic has brought public health into everyone’s daily lives in a way none of us could have anticipated a year ago. The impacts of this new disease have exposed and exacerbated underlying social and economic inequalities. Yet in this global health emergency, the contribution of communities to public health has never been more evident. The World Health Organization emphasise the importance of solidarity and the collective responsibilities that we all have for each other, particularly those made more vulnerable through the pandemic. In the UK, the first wave of the pandemic stimulated a significant community response. This included community-based organisations coordinating support to those in need or shielding, hundreds of thousands of new and existing volunteers, new mutual aid groups and community networks formed (COVID-19 Voluntary Response: A Blog From Our Chief Executive 2020, Local Heroes. How to sustain community spirit beyond COVID-19). This again underlines the importance of community assets in public health, including those intangible assets – the social networks, the trusted local groups and the commitment of individuals.
Communities and community action remain central to the ongoing public health response. It is hard to think how management of local outbreaks and prevention of long-term health and social impacts will be achieved without effective community engagement and strong local partnerships with community-based organisations and volunteers. The reorientation of the public health system that we called for in the original article is needed more than ever. But we cannot assume that community action will emerge spontaneously and be sustained. The socioeconomic factors that drive health inequalities, including in relation to Covid-19, also affect people’s experience of community life, whether they have sources of support, live in neighbourhoods with high levels of trust and can easily afford to volunteer. A PHE report on the inequal impacts of COVID-19 on Black Asian and Minority Ethnic communities makes the case for participatory approaches alongside taking action on discrimination.
What we are arguing for is a community-centred public health response that gathers community insights, assesses assets as well as needs and aims to strengthen community resilience and empower communities in ways that tackle inequalities head on. As our research on whole system community-centred public health shows, this should not be about piecemeal action, but taking a systematic and scaled approach. It will involve effective co-production with communities at a ‘hyper-local’ or neighbourhood level linked to action on the wider determinants of health, such as housing and poverty, in order to reduce inequalities. There also needs to be greater recognition of the critical public health role that the voluntary and community sector play, including those grassroots groups that connect with the most marginalised. Above all, using a health asset lens in the pandemic, and in recovery, is about building on what’s there, building up where there are gaps or vulnerabilities and ensuring that the experiences and insights of communities drive public health planning and action.
Professor Jane South and Jude Stansfield developed this commentary through Leeds Beckett University. They drew on their work as honorary academic advisers to PHE’s Healthy Communities programme; however, the views expressed in this publication are those of the authors and not necessarily those of Public Health England.
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