Just a Thought
Informed People Create Change: Community engagement for health promoting networks (Part 2)
How does community engagement enhance health networks?
“Engagement” means people first, issues second. This, in turn, means that relationships matter more than methodologies and “toolkits”. Given that we are all confronting the challenges of health and healthcare improvement together, as fellow citizens, we are all responsible and accountable to each other, for our service systems, and for the institutions of regulation, governance, and democratic participation. The techniques used in community engagement are essential elements in reaching consensus for promoting a cause in which we are all concerned.
Community engagement is the art of networking the networks.Networking is a “tool” to facilitate, sustain, and share innovation and engagement. It provides health promoting networks with innovative challenges that have been stimulated by consumer, carer and public involvement in the health agenda. It involves engagement by confronting new challenges. Most people do not feel engaged unless they are intellectually challenged.
Why do consumers get involved?
Bastian (1998) suggests that consumer activism in health derives from six broad strands:
- Groups that form around local geographical interests, generally in response to a single issue of public concern.
- Groups that form among people sharing the same health condition or experience.
- Groups that are forged among people with a shared experience of being harmed by a product (or by people advocating a particular treatment or practice).
- Groups that protest particular practices or developments on an ideological basis.
- Population groups with a shared identity who come together to represent their concerns and interests.
- Generic groups and coalitions that are formed to advocate on behalf of the whole population.
Involving consumers early in the process is essential. It helps to develop appropriate policies, ensure that the right issues are addressed from the beginning, and that the strategies used are feasible. Planning and negotiating about different purposes, methods, investments and expectations should happen at the beginning of the process, not when project outcomes start to become less visible.
Picture in your mind, for a moment, a spider's web—exquisite, delicate, structured, purposeful, functional, connected, fragile, strong, distinct—a web is all of these and more. A spider's web, as a structured, functional maze of connections and interrelated fibers, is based on a model; however, no two webs are identical. The model does not determine form, it simply preserves function. The success of the spider's web, and ultimately the spider, is contingent on its ability to constantly adapt to changes in the environment. How does the spider, and the spider web, do this? That remains a mystery.
Now picture our community—exquisite, delicate, structured (we think); purposeful, functional (it is); connected, partially fragile (yes); strong and distinct (indeed). The community—our community—is a network of connections and interrelationships among individuals, institutions, and groups of individuals and institutions that are also structured, functional, and distinct. And, like the spider web, the success of our community lies in its ability to constantly adapt to internal and external changes. Some communities fail, some succeed. How, or why, do successful communities survive in our constantly changing world? Specifically, how have and how might the interconnections within communities adapt to changing social, economic and environmental conditions and remake, or redefine, themselves as successful and self-sustaining? This analogy presents some promising ideas and possible solutions to our concern.
Part 2 in this series aims to synthesise some of the models literature cites in which community engagement techniques have been successfully used to build upon existing community structures as well as to create new connections necessary for community renewal. The purpose is not to present one definitive model which could be used in all, or even in some, communities. However, the various tools, when used in the appropriate context, contribute to sustainable community networks. Two distinct techniques relevant for potential success and sustainability for health promoting networks are: (i) integration of the health and community activities, and (ii) use of dialogue as a means to facilitate understanding within a community and create an atmosphere for action.
The synthesis that follows does not try to replicate training and education. Rather, it takes a step forwards to support capacity building. Indeed, there is a strong body of opinion that community engagement often becomes an end in itself: a function (and a career structure) increasingly separated from the key purposes of the community engagement. As a relatively marginalised function, community engagement can be operationalised in ways that both meet “tick box” standard requirements and, at the same time, avoid the need for mutual change. Change, and contingent learning, is the essence of being a consumer, or carer, or professional, or manager …. or citizen. After all, people are involved in health and healthcare throughout their lives. And, as we learn—through the course of our own lives by observation or experience or through work on health inequalities, choice, long-term conditions, and community governance—active and effective community engagement changes the nature of relationships at every level in the system: from day-to-day experience, to services' redesign, to governance and the commissioning of major change.
What do we think of when we speak of community? Is it simply a group of people living in the same geographic area? Is it a group of people who share common values, ideas, and beliefs about the world? The term “community” is often defined as a group of people with a shared locality and a shared set of common values. However, it seems as if something is missing from this definition—especially when we talk about our own communities. What is missing is a sense of the linkages, the interrelationships, between community members that serve to identify individuals as part of a community and allow others to recognise individuals as part of a community. The strength of the linkages in the social network is the defining aspect of a strong community.
Social networks are the means by which individual community members interrelate and create a sense of community. Social networks are the interpersonal connections that people participate in as they carry out day-to-day activities. For example, members of a community meet and develop relationships every day at sporting events, school, church, parks, social events, and a variety of other arenas. The capacity to share values and interests allows a community to develop strong bonds and a high level of trust among individuals.
Strong community affiliation creates a sense of security, a sense of belonging that reaffirms our existence as social beings. A strong community allows for diversity while incorporating that diversity into its whole. A strong, effective community creates a sense of ownership and responsibility for the entire group that goes beyond individual self interest. It provides "…individuals with a web of trust and social support that is needed in this transient, swiftly changing society" (Gardner, 1995). When social networks produce lasting ties, linkages, trust, and a collection of shared values, the survival of the community becomes more important than individual self-interest or gain. Community members realise that their own personal wellbeing is closely linked to the health of the community as a whole.
Communities consist of, in varying degrees, a myriad of connections, interrelationships, webs of affiliation, and collaborative networks involving individuals from different social roles, positions and groups. These relationships form the social infrastructure of the community. These connections already exist at some level within a community. Teachers have relationships with students, parents have relationships with their children, and children have relationships with friends. Many of us have relationships with the people we work with, with friends, members of a social club, or a sports league. However, frequently these connections do not go beyond the traditional roles and community norms. Individuals in different roles, as defined by our community and society, do not really have a chance to come together as a community and share ideas. Therefore, the community, or what we perceive as our community, may not be as strong as it could be. Often the community infrastructure is weak because active relationships are weak. What is an active relationship? It is to this that the issue in this series will now turn.
Active relationships are distinct from passive relationships and both are defined with reference to the roles people play in their communities. Relationships among people of the same roles are passive. Relationships that cross role boundaries are active.
Passive connections offer little opportunity for interaction across individual or institutional roles to come together, share ideas, and create a sense of community. Passive relationships are some of the most important relationships in a person's life; however, they are not the relationships that define a community. Passive relationships do not allow a community to adapt in response to external and internal changes. Passive relationships are not the type of relationships that contribute to a sense of identity, recognition, belonging, and empowerment or to an atmosphere of trust that truly define a dynamic community. Therefore, the issue of sustainable community action and renewal is a question of how to turn passive relationships into active relationships.
An active relationship consists of repeated and significant interaction across two or more persons or institutions. Looking at the example of passive relationships outlined above, an active relationship would involve interaction not simply between the teacher and the parents' workplace, or between the parent and the school, but between the school institution and the business institution. Literature cites many models of successful community-industry interaction. For example, initiatives from school-to-work; higher education to industry; and commercial to non-profit organizations. Communities which exhibit this type of active relationship present the greatest potential for sustainable community action and renewal. This type of relationship is conducive in an atmosphere of democratic participation wherein all interested members of the community are able to participate.
In sum, active relationships are relationships based on trust, understanding, and an equal base. More importantly, active relationships unite individuals, institutions, specialists, lay people, and professionals within that atmosphere of trust, understanding and equality. In an active relationship, individuals and institutions who might never have had an opportunity, or a reason (so they thought), to talk to one another come together, communicate with each other, and realise that they have commonalties in some area of life or in their community.
The recent movement toward civic participation is aimed at reuniting the communities so that they are able to utilise specialisd individuals, tools, skills, and knowledge without losing their sense of solidarity. The individuals who make up a community must regain trust in each other as well as trusting specialists who have knowledge which could be helpful. Therefore, a return to democratic participation, civic engagement, and the creation of active relationships capable of sustaining and fostering trust and collaboration is necessary.
Collaboration between members in a community is the active relationship necessary for democratic participation. Such collaboration not only builds a culture of trust and brings the "we" of community back into the political dialogue but also allows for the creation and implementation of new solutions to the problems facing many communities. This question requires an analysis and discussion of an additional concept: social capital. A detailed discussion of social capital—a concept which has undergone a revitalisation of its own over the past few decades—is beyond the scope of dialogue in this series. Suffice it here to explain briefly that a more contemporary use of the term “social capital” was first used in the work of Pierre Bourdieu and James Coleman in the 1970's, in conjunction with "cultural capital" to refer to the stocks of knowledge an individual acquires based on informal social networks. Bourdieu, as well as Coleman, later used social capital to refer to the resources, assets, and advantages individuals acquire as participants in a social or community setting.
The recent work of Putnam (1993b) and Fukuyama (1995) extended the concept of social capital to apply not only to individuals but also to groups, communities, and even nations. This transition allowed them to claim that a community, rather than an individual, has a certain amount of social capital. Communities “build” social capital through the development of active relationships, democratic participation, and the strengthening of community ownership and trust.
Social capital is a measurement of the levels of social trust and active relationships present in the social networks of a community. Strong social networks and high levels of active relationships between individuals from different roles in the community tend to "…foster sturdy norms of generalised reciprocity and encourage the emergence of social trust" (Putnam, 1995). Community members expect and understand that important community issues are going to be dealt with by all members of the community and that multiple viewpoints will be expressed and valued. It becomes normal for diverse community members and institutions to engage in dialogue and debate about issues that affect the entire community.
Cortes (1993) describes social capital as a "measure of how much collaborative time and energy people have for each other, how much time parents have for their children, how much attention neighbours will give to each other's families, what kind of relationships people in congregations have with each other…and the quality of many other potential webs of relationships in a community". Social capital is a way to look at all relationships in a community. It enables us to measure how strong the passive relationships such as the parent-child relationship are and how strong the active relationships between diverse members of the community are. In essence, social capital is expressive of the strength of the entire social network of a community. It is the strength of these social networks, the stock of social capital that truly defines a community and increases the capacity of the community to deal with internal and external problems or changes. In the words of Cortes, "Social capital implies a richness and robustness of relationships among people, that the members of a community are willing and eager to invest in one another … and the quality of many other potential webs of relationships in a community". To this end, Flora and Flora's discussion of "social infrastructure" as a necessary ingredient for successful community engagement offers some much-needed advice. Running throughout the list of ingredients needed for a strong social infrastructure are themes such as trust, diversity of relationships, acceptance of diverse views, and a push toward the community as an inclusive "we" as distinct from "I". Community members need to trust each other so that debate about important issues can occur without individuals becoming disengaged from the group. Individuals who have resources and motivation need to believe that their money and time will benefit both the community and themselves. All of these ingredients represent elements of a developing and increasing stock of social capital. Specifically, communities are strengthened by:
- Accepting controversy as a way for the community to talk about tough issues.
- Accepting that people are not "evil" if they propose a differing point of view.
- Expanding the definition of community to encompass the entire community.
- Expanding who "we" are, with fewer "they", allows for institutions to have allies, not adversaries.
- Distributing, or risking, resources collectively and equally.
- Diversifying and strengthening the social networks.
- Bastian H 1998. Speaking up for ourselves: The evolution of consumer advocacy in health care, International Journal of Technology Assessment in Health Care 14(1): 3-23.
- Beresford P (undated). Researching citizen-involvement: a collaborative or colonising enterprise? In: Barnes M & Wistow G, Researching User Involvement. The Nuffield Institute for Health Services Studies, University of Leeds : 16-32.
- Bichmann W, Rifkin SB Shrestha M 1989. Towards the measurement of community participation. World Health Forum 10: 467-472.
- Bourdieu P 1968b. Structuralism and theory of sociological knowledge. Social Research 35(4), 681-706.
- Bourdieu P Coleman JS 1991. Social theory for a changing society , (eds), Westview Press.
- Consumers' Health Forum of Australia 1990. Guidelines for consumer representatives: suggestions for consumer or community representatives working on public committees. Consumers' Health Forum of Australia, Canberra .
- Cortés E 1993. Reweaving the fabric: The iron rule and the IAF strategy for power and politics. In: H. Cisneros (Ed.), Interwoven destinies: Cities and the nation (pp. 294–319). New York : Norton.
- Flora C Flora JL 1993. Entrepreneurial social infrastructure: A necessary ingredient, The Annals of the American Academy of Political & Social Science, Vol. 529, pp. 48–58.
- Fukuyama F 1995. Trust: The social virtues and the creation of prosperity . NY: Free Press.
- Gardner J 1995. Community Renewal : National civic league. In: Community Education and Social Capital, George Kliminski & Eric C. Smith , http://www.ncea.com/pubs_products/CEJ-Socialcap-2-ncea1.pdf .
- Improving health services through consumer participation: A resource guide for organisations (NHS), www.natpact.nhs.uk
- Kanter RM 1994. Successful partnerships manage the relationship, not just the "deal". Collaborative Advantage , Harvard Business Review, July–August.
- Kearney J 1993. Healthy Participation: Achieving greater public participation and accountability in the Australian health care system. Background Paper No 12, National Health Strategy, Canberra .
- Putnam RD 1993b. The prosperous community: Social capital and public life. American Prospect 13 : 35–42.
- Putnam RD 1995. Bowling alone: America 's declining social capital, Journal of Democracy, 6 : 65–68.
- Putnam RD (ed) 2002. Democracies in flux: The evolution of social capital in contemporary society. New York : Oxford University Press.
- Sang B Keep J 2005. Primary Care Trusts (PCTs), communities, and accountability: The mutual improvement of health and health care, NHS Modernisation Agency, www.natpact.nhs.uk .
- Lane B Dorfman D 1997. Strengthening community networks: The basis for sustainable community renewal, http://www.nwrel.org/ruraled/strengthening.html#a
Project Manager and Editor
8 July 2005