Abstract
In regional Australia “communities of place,” defined as bounded geographic locations with a local society, undertake community-wide primary prevention programs. In helping to prevent chronic illness, communities provide valuable resources to the health system. To understand the role of community–health sector partnerships for primary prevention and the community contextual factors that affect them, we studied eight partnerships. We used an embedded multiple case study design and collected data through interviews, nonparticipant observation, and document analysis. These data were analyzed using a typology of community–health sector partnerships and community interaction theory to frame the key community contextual factors that affected partnerships. The dominant factor affecting all partnerships was the presence of a collective commitment that communities brought to making the community a better place through developing health. We call this a communitarian approach. Additional research to investigate factors influencing a communitarian approach and the role it plays in partnerships is required.
Keywords
Primary health care reform initiatives in Australia are intended to establish a more comprehensive and systematic approach to primary prevention (Commonwealth of Australia, 2009). Reform is intended, in part, to mitigate the increasing burden of chronic illness and to produce a wide-ranging prevention strategy for Australia that will tackle the “great pandemics of non-communicable disease and address health inequalities” (Russell, Rubin, & Leeder, 2008, p. 718). Strategies are designed to target certain populations with significantly higher rates of disease and risky health behaviors, and who are seen as more vulnerable to developing particular health conditions.
The underlying premise is that delivering more preventive health activities through primary health care services will reduce rates of chronic disease. This in turn might contribute to containing the growing demand on health services. The aim of primary prevention is to address illness or disease before it occurs, through the delivery of health education to improve health literacy. Primary prevention also includes enabling access to health services (i.e., screening, immunization), changing aspects of the built and social environment, and making provisions for policy. This definition embodies the ethos of health promotion, or the process of enabling people to take control over those factors that determine their health.
The Role of Communities in Primary Prevention
The modality for the delivery of primary prevention services in Australia is problematic. Currently there is no clear policy about who should provide these services (Russell et al., 2008), or even whether this is a topic worthy of debate. Currently, primary prevention services are provided by all levels of government, general practitioners, and disease-specific groups such as the Cancer Council (a national organization facilitating cancer prevention, research, support, and care). At the local community level, most primary prevention activities are owned and driven by health care personnel, because state and national health systems have a vested financial interest in optimal management of community health to prevent or delay the onset of chronic illness. Stakeholders at national primary health care strategy consultations cautioned against this approach, noting that there should not be an overemphasis on the extent to which primary prevention can be delivered by the health sector alone (Commonwealth of Australia, 2009).
In the United Kingdom, different models for the governance and conduct of primary prevention are emerging, including that of social enterprise. In its rhetoric about a move to change from the big state to “big society,” the labor coalition government envisaged a bigger role for cooperatives, charities, and social enterprises in the running of local services (Cole, 2007). A similar practice of community health development through partnerships with communities is emerging in the United States (Felix, Burdine, Wendel, & Alaniz, 2010). In Australia, the policy discourse supporting communities’ involvement in primary prevention and health is tentative. Although there are a myriad of excellent examples of community involvement in primary prevention, particularly in rural and remote Australia, feasible strategies to support initiatives and legitimize the role of communities are lacking.
Community involvement in primary prevention is difficult because of the way strategies are framed and funded. Funding is prioritized for disease-specific interventions in designated target groups rather than “whole-of-community” interventions. It is hard to obtain funding to implement multisetting, multilevel interventions aimed at changing the health of the whole community. Additionally, the cost effectiveness of multilevel strategies is difficult to analyze, and there is not good evidence for the success or community benefit of these strategies (Hawe, 1994; Shiell & Hawe, 1996).
Finally, the use of theory, which can guide conceptions of community in primary prevention policy, is uncommon. Definitions tend to be pragmatic rather than based on any theory. Community might be perceived as the setting for the delivery of an intervention to a target population, as an administrative area, or as a group of consumers who come together around a common interest. Australian Aboriginal and Torres Strait Islander notions of community refer almost exclusively to the subjective experience of family relationships and spiritual connections to country and place (Taylor et al., 2012). Their understandings of community are poorly positioned vis-à-vis the view of health care as a transaction between providers and consumers of a product. The notion of community as a collective interacting in a specific geographical location is not the dominant conceptualization in health policy (Hawe, 1994; Jewkes & Murcott, 1996). Following from this, the community contextual factors that affect partnership functioning in communities of place are rarely explored.
The exception to this is a qualitative study by Kegler, Rigler, and Honeycutt (2010). Using Community Coalition Action Theory (CCAT; Butterfoss & Kegler, 2009), these authors identified the ways community contextual factors influenced coalitions in their formative stage. The community contextual factors studied were the history of collaboration, community politics and history, community norms and values, community demographics and economic conditions, and geography. These factors were considered in relation to key CCAT constructs associated with coalition formation: lead agency selection, staffing and leadership, coalition membership, coalition process, and coalition structure. Kegler et al. found that coalition membership might be the most sensitive to community context. Unlike other constructs associated with coalition formation, coalition membership was influenced by all contextual factors.
Community Partnerships for Primary Prevention
Although there might be a lack of clarity about what constitutes a community in health policy, the notion of partnerships between communities and the health sector for primary prevention is common. The Australian National Preventative Health Taskforce wishes to foster “linkages and partnerships across agencies from both the public and private sectors, and at local, regional, and national levels to better integrate primary health care services and the broader prevention effort, and minimize duplication” (Commonwealth of Australia, 2009, p. 62).
Partnerships or coalitions, terms which are used synonymously, are longstanding public health strategies to achieve common goals which would be difficult for any one agency to achieve alone. Reviews of community–health sector partnerships by Wolff (2001) and Kadushin, Lindholm, Ryan, Brodsky, and Saxe (2005) assessed processes associated with partnership functioning. Wandersman and Florin (2003) and Kreutzer, Lenzin, and Young (2000) assessed the outcomes of community–health sector interventions. A smaller number of authors reviewed the effects of collaborative partnerships on community-wide behavior change and more distant population-level health outcomes (Roussos & Fawcett, 2000; Zakocs & Edwards, 2006).
Reviews of community partnerships have revealed only modest successes in improvements of the health of individuals or changes in health systems that can be aligned with partnerships (Berkowitz, 2001; Butterfoss & Francisco, 2004; Kadushin et al., 2005; Kreutzer et al., 2000; Roussos & Fawcett, 2000; Zakocs & Edwards, 2006). Berkowitz suggested that methodological obstacles might account for missing evidence. Granner and Sharpe (2004) showed that existing methodologies might not adequately capture the complexity of participatory partnerships, and in particular not account for partnership processes. For example, the contrasting values, agendas, and differing perceptions of power between communities and the health sector are difficult to assess (Heenan, 2004; Lester, Birchwood, Tait, Shah, & England, 2008; Poland et al., 2005). The level of motivation for the partnership from the concerned community seems to be a significant, although underreported factor. There is an implicit assumption that community partnership members will have sufficient motivation to develop and maintain the partnership (Lackey, Welnetz, & Balistrieri, 2000).
Theoretical Framework for Understanding Community Contextual Factors
The partnerships examined in the study reported on in this article were all located in communities of place or, in other words, locations that had commonly agreed on geographic boundaries and ongoing interactions between the people and local social structures. We used a sociological perspective, specifically community interaction theory (Wilkinson, 1991), to define a community of place and to frame community contextual factors affecting partnerships. Community interaction theory defines a community of place as three interrelated elements: “a geographic locality, a local society, and a process of locality oriented community actions termed the community field” (Wilkinson, p. 2).
The concept of the community field is fundamental when considering how and when communities mobilize and take action. As a dynamic, emergent, and unbounded field of interaction the community field brings together the common interests of the local population across social fields, patterns of stratification, and special interest groups. The generalizing process that occurs is crucial to reflect the interests and joint priorities of a community rather than concerns of individual sectors or groups. Most communities find it difficult to draw people together across political factions and culture because segmented structures, patterns of exclusion, and political or ethnic divisions have an impact (Bridger & Alter, 2008).
There are two important concepts in considering the emergence of the community field: community leadership and the nature of community values and traditions. From an interactional perspective, community leaders can form “an influence relationship with collaborators to bring about real changes that reflect their mutual purposes” (Rost, 1993, p. 99). Holding a formal position in a health organization does not necessarily mean the holder has community leadership potential. Sorenson and Epps (1996) found that relatively few key community leaders in country towns in Australia occupied positions of formal authority; rather, they were people who were active across the community, had links externally, and had a community-wide vision.
The emergence of the community field is assisted or hindered by community traditions, values, and attitudes (heritage narrative structures). Heritage narrative structures are the stories communities tell each other and external bodies about themselves; they help define the community for members and distinguish it from other communities. Bridger and Alter (2008) referred to heritage narrative structures as “selective representations of the past that feed into and are partially driven by the sentiments and interests of contemporary residents” (p. 103). Narrative structures reflect the patterns of stratification and power structures in the community, and most communities have competing heritage narratives, including subversive ones. Dominant heritage narratives are sometimes written into local histories, and residents call on them when describing the history of community action; for example, “We all work together to overcome adversity.”
The Community–Health Sector Partnership Study
We trialed a typology of community–health sector partnerships and analyzed community contextual factors affecting these partnerships in communities of place in Australia. Contextual factors affecting partnerships are difficult to unpack, and the information presented here adds to the existing literature.
Research Design and Setting
We used a prospective multiple case study design to collect qualitative data (Yin, 1984). We chose this design to understand the dynamics present in single settings and then to compare across settings. We also wanted to conduct multiple levels of analysis within a single setting: the partnership processes and interactions between individual partners and the community context in which partners lived and worked. The case study design allows for the in-depth analysis of the interrelationships between these phenomena.
The partnerships we studied were in Australian regional areas that had populations between 5,000 and 20,000 people. Case study sites are described in Table 1. We used regional locations because of the ease of defining case boundaries and the transparency of patterns of interaction. Communities were relatively socially disadvantaged, according to the Australian Socio-Economic Indexes for Areas measure, with a narrow industrial base and with primary industry or mining and resource processing being dominant.
Characterization of Case Study Sites.
Nongovernmental organization
Sampling
We defined a case as a partnership between a community-based nongovernmental organization (NGO), volunteers and/or citizens, and paid public or private health sector employees based in a community of place. Three health professionals with extensive knowledge of primary prevention in two Australian states identified six potential cases. All of the partnerships were actively undertaking chronic illness prevention and they were all based in a community of place in a regional location in one of two Australian states. They all had both health sector and community membership.
We contacted representatives from these partnerships and found that two did not meet all of the criteria. To supplement the potential cases we reviewed abstracts about community partnerships for primary prevention from Australian health-promotion conferences and conducted a Web-based search of primary-prevention or health-promotion initiatives. Purposive sampling resulted in eight cases and representatives from each of the selected partnerships agreed to participate. Two university human research ethics committees and a state Department of Health research ethics committee granted ethics approval in 2008.
Methods
The first author collected the three data sets (interviews, nonparticipant observation, and document analysis) similarly, one case at time, between 2008 and 2010. She conducted semistructured interviews with 86 partnership members or people familiar with the partnerships. Topics covered in interviews included partnership objectives and outcomes, motivations for involvement, and partnership processes. Eight nonparticipant observations of partnership or NGO board meetings and 15 observations of partnership activities were conducted. The first and fifth authors reviewed documentation about each of the partnerships, such as annual reports, information flyers, evaluations, press releases, and academic papers. Interviews were digitally recorded and transcribed by a professional transcriptionist. Notes were taken of the observations and documents were analyzed for information about the partnerships. All data were imported into the software program NVivo (QSR International, 2012), with a separate project for each case.
Analysis
We used a mixed coding approach guided by the deductive codes of the partnership typology. The partnership typology we used is presented as Table 2. Inductive codes and themes were generated through iterative analysis of the data about community motivations and partnership processes. Within-case analysis was conducted first. Using the deductive codes of the partnership typology, each author independently read transcripts about partnership objectives and community and health sector motivations and identified a predominant type. To “type” the partnership for each case, we compared our analyses and found we concurred except in one instance. In this case we read transcripts again and discussed the partnership until we reached consensus. Then the first author coded and themed data to find the most frequently reported-on aspects of partnership functioning and the contextual factors influencing partnerships. We used a matrix to display the partnership types in each case. We used another matrix to show key themes about partnership functioning. From these displays we saw which themes occurred in which cases and whether or not they were related to particular partnership types (Miles & Huberman, 1994). For example, the nature of the community field for each partnership was examined and compared with the partnership types.
Partnership Typology.
Study Limitations
Our original intention was to sample cases that demonstrated each partnership type to examine relationships between partnership types and partnership processes. We found that it was impossible to identify partnership types prior to data collection. We also found that in one case, Reid, 1 there was limited community involvement and we did not observe a partnership activity or meeting. The first author collected the data; however, all authors were involved in monitoring initial findings, reading transcripts, and deciding on the overall partnership types.
Results
The results are presented in two areas: first, the application of the partnership typology (see Table 2), and second, the community contextual factors that affected partnership functioning. There were four developmental type partnerships, two empowerment type, and two instrumental type; there were no contribution type partnerships. The community contextual factors that affected partnerships were collective intentions to develop community, the ability to bring community sections together, the nature of community leadership, and the type of heritage narrative structures present in the community. We found that the developmental partnerships always included collective intentions to develop the community.
Partnership Types
What typified the developmental partnerships in Abbey, Cross, Brown, and Green was the explicit intention on the part of the community members, and to some extent the health sector representatives, to develop the community broadly. This motivation was in addition to meeting primary prevention objectives. Given that all partnerships were in communities of place, this motivation is not surprising. All developmental partnerships resulted in significant contributions to improve the communities’ health: the establishment of a health-promotion NGO, a community gym, healthy lifestyle programs aimed at the prevention of chronic illness, and a special program for young Aboriginal mothers and their children. The focus was also on improving the community in addition to the provision of specific programs. The following is an example of how this occurred in developing a community gym using volunteers: Well, the gym was a discussion. We noticed that there were other towns of similar size setting up gyms, and they provided an attraction for the town. We started to chat about, “Wouldn’t it be great?—and I wonder what would be involved.” Then we got serious about it. “Well, we can apply for some grants to get us underway and do a bit of fund raising.” We realized there was going to be a lot more involved than just health-promotion business, so we decided we had to become an incorporated body. (Green, community member [CM])
Community-based NGOs were responsible for all the developmental type partnerships. The partnerships had differing funding arrangements but they all used a mix of paid coordinators and volunteers. The communities were actively involved in all aspects of the partnerships: the management of the partnership, volunteering at events, fundraising, promoting primary prevention to local policy makers, and advocacy. Public and private health professionals contributed in varying degrees through providing technical advice, membership on the management group, and jointly running initiatives. Other sectors such as local governments, local businesses, education representatives, and police were often involved.
Instrumental type partnerships were located in Reid and Mist. The health sector initiated the Reid partnership to provide a structured peer-education program to promote well-being in young people. Community involvement in the partnership was limited at the time of data collection. The needs of the community for a primary prevention approach to mental health prompted the partnership in Mist. The initiator, a government employee, thought a community development model would be appropriate and helped establish a community-based NGO. In partnership with the health sector, the community members developed and managed a community center that was funded through the health sector. At the time of data collection, a reform of mental health service provision was underway. This meant that a more instrumental approach to achieve service goals and objectives was required, and the role of the NGO was less influential.
There were two empowerment partnerships, one in Port and one in West. A university established the partnership in West to engage volunteers in a peer-education program to prevent and manage chronic illness. The community volunteers, in partnership with the university, underwent significant training in peer education and developed an NGO. The university remained one step removed, in an advisory capacity. The local hospital provided accommodation for the organization. The health sector set up a healthy-eating peer-education program in Port. Community volunteers were trained about nutrition and healthy eating and then delivered healthy-eating messages to community groups, such as child care centers. There were no contribution type partnerships. Perhaps this was because in almost all partnerships the community members were active decision makers about the partnership processes. In three cases community members, rather than the health sector, had initiated the chronic illness prevention activities.
Community Contextual Factors Affecting Partnerships
The community contextual factors that affected all partnerships, regardless of type, are discussed below. Some partnership types exhibited some community contextual factors more strongly than other types; for example, the developmental partnerships demonstrated the clearest motivations to develop the community broadly.
Collective intentions to develop the community
The strongest theme emerging from the analysis of community members’ motivations was that, in almost all partnerships, involvement in the partnerships was driven by a commitment to making the community a better place overall. The motivation was not just better health; it was increased community sustainability and well-being. People involved in the examples below (two developmental and an instrumental partnership) shared a common bond of community that was expressed through helping the community improve its health: I think it [the partnership] connects you up with more people that are also interested [in health], and it is a way of life. [Brown] is a beautiful place and you just want to see everyone enjoying it, and we have got facilities to promote the health activities here. It’s just wonderful to see more and more people getting out walking. (Brown, CM) What is important to our community is seeing this town thrive and not decline any further. It is a cracked record, really, of towns declining in numbers and people drifting into the cities and nothing for young people. So we try and be proactive and nip that in the bud. I think our little community needed something. The gym has provided opportunities for people to keep healthy and active as well as meet people. (Green, CM) The people that drive the partnership have a belief. They want to see a difference in our community and our young people. There are so many people in our community committed to making things work if there is a genuine need. (Reid, CM)
In the Green, Abbey, and Cross partnerships, health professional representatives lived in the community and shared the motivation to develop the community. They were boundary crossers in that they had the interests of their community in mind in addition to their professional roles (Kilpatrick, Cheers, Gilles, & Taylor, 2009): The other thing from a personal point of view is I live here and I work here. This is my area and my community, so I have got a vested interest as a community member to be involved. I know others would share that same sentiment. (Green, health professional [HP])
The contributions that community members made to primary prevention were given with insight about how the health sector might draw on their goodwill. The comment below shows how the Abbey partnership members managed this expectation: At the end of the day I think there is a perception that we can do things more cheaply than they [health sector] can, and we should continue to do them on an ever-decreasing piece of cloth, so to speak. I think there is a perception that because we are a not-for-profit organization we are motivated by willingness to assist the community, and that we will go above and beyond to do it. And at the end of the day that just doesn’t always work. (Abbey, CM)
Bringing the community together for health action
The collective expression of working for the community was inseparably linked with the emergence of a community field. Three of the four developmental partnerships were based in multisector community organizations, and therefore already had the relationships in place enabling the emergence of a community field. For example, a community member from the Cross partnership expressed the importance of community networks: Organizationally we have prided ourselves on our marvelous networks. We’re very strong on developing networks with organizations and people of like minds to further our community. It is the old thing: one voice alone doesn’t change very much, but if you get a collective voice then things can change. (Cross, CM)
In Green, the inclusive community field enabled the entire community to come together. It was a small community, with less than 5,000 people in the region, and it was homogenous with regard to residents’ cultural background: To have a successful committee looking at health promotion you would need a broad group of people from across the area to really be successful. You would need older and younger and middle-aged people, a mix of all of those, as well as people that represent various interests. That’s what we have done. (Green, CM)
In the communities other than Green, there were challenges in uniting different sectors, cultures, and political factions in a whole-of-community approach to health development. For example, in Brown, the community had to act together to develop a health-promotion committee. In contrast, the local council, which had been the sponsor of funding, acted alone: There was a lot of to-ing and fro-ing at that stage in the partnership because there were three or four of us as independent people versus the council. The council seemed to see the health-promotion partnership money as their money, but we were told it was a community fund. The whole community had to see where it needed to spend it. (Brown, CM)
The Abbey developmental partnership, based in an ethnically diverse community, had a strong sense of community and a history of community development. The community field was historically organized across ethnic, political, and class lines, and when it emerged it reflected these divisions. In the West and Port empowerment partnerships, the community field did not emerge. Involvement was restricted to community volunteers and the health sector and the partnerships were not community-wide. In the Mist instrumental partnership it appeared that the community field was active because the partnership was community-wide, including local government, education, and community members. The actions of partnership members (running a community well-being center) were directed to meeting their own work objectives rather than working together on joint community problems. Similar dynamics were found in Reid, another instrumental partnership. Service providers contributed to an education program for young people in line with their own agency objectives rather than solving community-wide issues. In this case it is difficult to say that a community field was activated.
A prompt for the emergence of a community field can be a perceived community threat, and this was the case in the Green partnership. In regional Australia there is a long tradition of involvement in health service development. This is often because of the lack of adequate health services or the threat of withdrawal of services (Collins, 2001): I suppose the purpose of the health-promotion committee is just driving to improve the lot of people. The overall goal is to keep what we’ve got here. For instance, back twelve months or so ago, there was a big scare that we might lose our hospital, as was the case in many other communities. That sort of thing really pushes all of us on to do better things. So there’s plenty of motivation there to strive to at least keep what we’ve got, but also of course motivation among a lot of us to actually improve what we’ve got. (Green, CM)
Community leadership
The presence of local community leadership was very important in each of the partnerships, regardless of the type. A university consortium tried to form a partnership to establish a health-promotion committee in Brown without local leadership. Over time, this changed. With local leadership, and a local organization, the community embraced the idea of primary prevention of chronic illness. The notion that the leader was a person known in the community was the reason behind participation: We see health-promotion activities advertised in the paper, and as soon as they [health-promotion committee] organize something everyone goes, “Oh, well, okay, it’s [name of leader], it’s going to be fine.” The community will then embrace things. (Brown, CM)
Leadership in bringing a community field together was not always vested in an individual in a formal position. Sometimes community members or champions in groups and organizations helped, as one health professional noted: The volunteer members don’t necessarily have capacity to implement but they encourage the rest of the community to become involved. In these rural communities things happen through the grapevine, so having those champions to encourage the rest of the community to get on board is really useful. (Green, HP)
Community leadership was fundamental to recruiting volunteers in the West empowerment partnership. The volunteer leaders did not have connections across the community and the community field was not activated. Consequently, the leaders were reliant on their friendship networks to recruit volunteers.
Community traditions, values, and attitudes
Explicit heritage narrative structures of civic responsibility were apparent in almost all of the communities. These narratives clearly supported the community working together. For some communities, being responsible members of the community was of importance and was regarded as a “good” that should be promoted. In the region in which Green is located there were explicit and recorded community-held narratives about how the community functioned. Community participation and active citizenship were the ways through which community was expressed. The health-promotion committee, composed of health representatives, local government, other government sectors, and citizens, used this narrative to stress the importance of working together to assist the community: My main motivation is to give back to my community. It’s been personally good for me. I’m full of enthusiasm [for the gym]. I love every minute of it, and I hope I can just give a little bit back. That’s all I want to do. (Green, CM)
Another closely related heritage narrative was that of “getting together to support the community.” This was a strong motivator in almost all partnerships, regardless of type: “I think a lot of communities need services because you never are going to have them all. It’s just really important to know as a community that we have given it our best shot” (Reid, CM).
Narratives of civic responsibility were stronger in some communities than in others. For example, in West, a single-industry community, the narrative was that the mining company should provide services. There was not really a strong narrative of civic responsibility in health or other activities. This made it difficult for the volunteer coordinators of the chronic-illness-prevention peer-support program to engender enthusiasm for volunteering in the partnership: I don’t know where the apathy comes from in [town]. I’ve noticed it since I’ve been up here. Whether it’s endemic to [town] or whether it’s all over the place I don’t know. It’s not just confined to our health-promotion activities; it is in our church, as well. (West, CM)
Discussion
The phenomenon of working together to benefit the community, drawing on a bond that exists in everyday life, might be termed a “communitarian approach” to community health development. The term communitarianism has been used to acknowledge, recognize, and value the processes of social relations to create a good society that encourages and balances the social virtues of community with individual rights (Etzioni, 1993). It has been written about from a philosophical stance and as an ideology, and it is a normative concept (Black & Mooney, 2002). It is beginning to make its way into the public health literature, representing a collective rather than individual base for public health (Ataguba & Mooney, 2011). Communitarianism represents an acknowledgment of the bonds that unite and identify communities and the importance of fostering these bonds (Holland, 2007).
Communitarianism rests in the reality of the existence of a community’s and people’s expression of some degree of commitment to shared values, beliefs, and goals. This is not to say that all communities articulate a single and shared communitarian vision. Clearly, individuals within a community will have different values and commitments regarding health. However, over and above these individual values there is a shared belief that a healthy population is a collective good and that there should be an interest in maintaining the health of the whole community. There is an explicit acknowledgment that the health of the whole community is related to economic and social sustainability. It is this shared value set in most of these communities that affects the community’s capacity for action.
There are two areas where there have been critiques of a communitarian approach. The first relates to the limitations of volunteers in health service provision. If communitarianism can be aligned with volunteerism then there is a considerable literature detailing difficulties with recruiting and resourcing an effective volunteer body in health-related activities (Catalano, Kendall, Vandenberg, & Hunter, 2009). Fuller, Harvey, and Misan (2004) contended that the use of volunteers in peer-led self-management groups might add to the burden in the nongovernment sector. There is also the issue of whether professionals, because of their training, are required to run health interventions. It might be that communitarianism is not quite the same as volunteerism. Communitarianism is a collective expression of community values and goals and based in a common bond of community. Volunteerism is usually a concept referring to individuals rather than collectives.
A second critique has been about government inappropriately shifting responsibility for service provision in health to communities, particularly rural communities (Collins, 2001). Communitarianism might lead to communities being burdened with activities that are the responsibility of governments (Halseth & Ryser, 2007). This is undoubtedly the case in some rural and remote Australian communities but is countered by communities in that they do not see that they have too many options. There is a narrative in some Australian rural and remote communities that if they do not pitch in and try to get service delivery happening then they might go without.
Engaging with whole communities of place in health development is an ongoing challenge. Often it is the most marginalized groups, most in need of interventions, that are the most difficult to engage. The community contextual factor that is possibly most influential in enabling whole-of-community action is the presence of a diverse community field. Kegler et al. (2010) also found that the ability to get broad coalition membership was strongly influenced by community contextual factors, including a history of collaboration. A strong communitarian approach does not necessarily mean engagement across the community. Longstanding community divisions, ethnic differences, and political factions affected almost all partnerships. Aboriginal and Torres Strait Islander organizations and representatives were rarely included in partnerships. This might be because of a history of mainstream community organizations not being representative of Indigenous interests (Campbell & McLean, 2002). It might also be that Indigenous groups do not share a common bond of community with non-Indigenous groups. Clearly, community leadership in connecting across marginalized groups in the community will assist in developing an integrated community field.
Conclusion
Community actions, such as engaging in primary prevention and joining and managing community organizations, draw from and express a bond of community that exists in the everyday life of a community of place. When directed to health improvement, this might be termed a communitarian approach. At the local level these bonds are not difficult to detect, and they facilitate effective community involvement in the primary prevention of chronic illness.
The health system can benefit from acknowledging a communitarian approach, when it exists, in communities of place. A communitarian approach might provide clues to how and why communities join with the health sector in partnerships. One stumbling block is the different paradigms that operate. The community has an interest in economic and social sustainability of the local area, whereas health sectors are worried about national agendas, budgets, and funding demarcations. A communitarian approach, expressed in communities of place, is not really on the radar. While this continues, services such as those reported here remain one-off pilot projects with excellent performance but without a great deal of legitimacy at either the Australian state or federal levels.
Communities of place might be powerful allies in primary prevention and community health development. Much of the potential resource is lost to the health system because of the inability of the health sector to form strategic partnerships to capitalize on the resources for mutual benefit. Local social action is most promising in terms of successful local outcomes. However, through its nature it creates issues in terms of scaling up and transferability to other settings. The final issue then is undertaking research to investigate factors influencing transferability of successful partnerships. The contextual factors that influence the emergence of the community field, such as a communitarian approach, have only just begun to be investigated. Further research is necessary to identify what prompts the emergence of a community field and how this is related to community involvement in health improvement. There might be other factors about the functioning of communities that affect community involvement. Overall, further research in this area will clarify the roles for communities in the primary prevention of chronic illness.
Footnotes
Acknowledgements
We sincerely thank the individuals and organizations involved in the study.
Authors’ Note
Judy Taylor held a Primary Health Care Research Fellowship from the Australian Government Department of Health and Ageing. Margaret Cargo holds an Australian Research Council Future Fellowship.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.