Integrating Public Health Practices:

Integrating Public Health Practices: A Position Statement on Community Capacity Development and the Social Determinants of Health for Public Health Services July 2003

Integrating Public Health Practices: A Position Statement on Community Capacity Development and the Social Determinants of Health for Public Health Services 1. Purpose To set direction for Public Health Services (PHS) regarding what community capacity development and the social determinants of health mean in terms of public health practices. The position statement identifies areas for action for PHS to consider in terms of setting strategic directions as determined by Outcome and Partnership Areas, and implications for practice as identified in business and project plans. 2. Associated policy The position statement has been developed in the context of Smart State: Health 2020 and the implementation of this vision through the Integrated Strategies and Performance Project 1. The statement builds on the role of PHS in addressing the social determinants of health, as identified in the Social Determinant Report 2, and the National Public Health Partnerships discussion paper Integrating Public Health Practices 3. The position statement also broadly identifies Public Health s response to community engagement as informed by the Department of Premier and Cabinet s Community Engagement Directions Statement 4 and the resources developed by Queensland Health s Quality Improvement and Enhancement Program - Consumer and Community Participation Program. 5 6 3. Background Concepts such as community, partnerships, prevention, and social determinants form the substance of community capacity development language in public health 7. The convergence of evidence around the social determinants, community capacity and individual capacities such as resilience is one of a number of drivers that highlight the need to integrate public health practices. This means working both horizontally in terms of communities, systems and settings (eg. Safe Communities, Health Promoting Schools) and vertically in terms of specific issues and services (eg. injury and mental health). A definition of integrated public health practice and other key definitions is provided in Attachment 1. While much of the responsibility for building community capacity and addressing the social determinants of health rests with other agencies, it is also clear that health systems generally, and PHS specifically, have a role to play in leading and supporting intersectoral collaboration and community actions to improve population health and well-being 8. Some experts suggest that a community capacity building program undertaken as a program on its own is at risk of being counterproductive given that capacity exists only in relation to specific groups, activities and issues 9. For a health promoting organisation the task is not to create a program called capacity building, but rather to examine how its programs and daily practices support the development of capacity building as a parallel track. 10 Position Statement July 2003 1

The concept of sustainability is critical to investments in community capacity development work. An indication of program success or sustainability is whether the intervention enables the community or partner organisations to have greater competency to not only address the presenting health problem but to also tackle other health-related issues. 11 The challenge for Public Health Services therefore is how to organise our work around groups, activities and issues so that capacity can be built or increased in a way that allows those involved to generalise it to other activities and issues? 4. Role statement Over the last few years, PHS has invested in a number of new projects, system improvements and research to improve the way we do business. These initiatives have given us further clarity about PHS ongoing roles in building community capacity and addressing the social determinants of health. These include: 4.1 Raising awareness of the social determinants of health! monitor and report on the social determinants of health and their effects on health status! increase awareness about health determining social and environmental conditions and trends! promote awareness of the Social Determinants Support Package 12 and key areas for action to health planners, service managers and policy makers! advocate for the development of and promote existing health promoting policies and programs in non-health sectors. 4.2 Coordinating public health planning! engage communities and partners in planning, implementing, monitoring and evaluating initiatives to address health determinants! use community public health planning as a mechanism to coordinate efforts within Public Health Services and with other agencies and sectors at the local level 13! negotiate partnership arrangements and the coordination of activities across local and regional areas to address health determinants. 4.3 Expanding health impact assessment functions! extend the application of health impact assessment to include a focus on the social determinants of health 14! develop and use guidelines to extend impact assessment functions to include policy and planning functions. 15 Position Statement July 2003 2

4.4 Strengthening communities! work through local organisations to enhance existing services and structures that support communities and individuals to improve their health and wellbeing! work with individual organisations to develop networked or integrated programs and services, as appropriate! develop, implement and evaluate programs with communities and other sectors in ways that build social capital, people s sense of control and resilience. 16 4.5 Developing organisational capacity! provide resources to support integration of public health practices! continue research to further our understanding of the causal pathways and intervention points! build workforce capacity including developing skills and methods in evaluation and reporting! continue to develop PHS as a learning organisation including using research and evaluation findings to continually inform and review policies and practices. 5. Critical success factors for building community capacity in public health Following Public Health s investment in the Community Public Health Planning in Rural and Remote Areas Project, the Centre for Primary Health Care has identified critical success factors for building community capacity to undertake public health planning and subsequent interventions 17. Critical success factors have been identified for working with communities, for government departments wanting to incorporate community capacity development approaches as well as a model for evaluating community capacity development programs. These include: On the ground with communities! Choosing the right lens - viewing communities as a place of strength (as opposed to a place of deficits that need fixing) which can be used to enhance public health planning and interventions.! Working with community readiness using identified criteria to assess the readiness of community to engage in public health initiatives and adopting different strategies depending on the level of readiness.! Setting governance ground rules collaboratively establishing the roles, responsibilities and decision making processes between community and Public Health Services so these are transparent and workable.! Providing room to move aligning processes, action and skills so that these change as capacity building moves through the stages of development, maintenance and sustainability.! Integrating reflection and evidence ensuring a mixture of local action learning and reflection alongside wider evidence of good practice to build capacity for public health planning and implementation. Position Statement July 2003 3

With Public Health Services and government departments! Conceptual understanding linking community capacity building to effective achievement of public health goals, particularly risk reduction.! Strategic policy ensuring senior managers implement risk management strategies to manage the tensions between local aspirations and the policy goals of elected governments, strategic directions and finite resources.! Operational support appointment of staff to work on the cusp of community networks and government departments. For evaluation! Taking into account Context, Mechanisms, and Outcomes in evaluation.! Using evidence-based tools to measure community capacity (eg. The Community Capacity Index).! Using evaluation for learning and outcome determination. 6. Where to from here? This position statement has been developed under the auspices of the Communities and Local Government Partnership Area within PHS and informs the Partnership Area Plan for 2003-2006. The position statement will be reviewed by the Partnership Area Team as required. In order to operationalise the intent of this position statement, Public Health Units and Networks will need to incorporate the relevant key strategies into their business and project plans. Over the next three years, members of the Communities and Local Government Partnership Area will meet and discuss key areas for action with representatives from other Outcome and Partnership Areas. The Partnership Area will review progress annually in order to reflect on key achievements and to identify areas requiring further development and support including priorities for funding. For additional information or assistance please contact the Senior Project Officer (Community Capacity Development) in the Statewide Health Promotion Unit on (07) 3225 2727 or e-mail paul_harris@health.qld.gov.au. Position Statement July 2003 4

Attachment 1: Key definitions Community capacity development Community capacity development is defined as: "Development work that strengthens the ability of community organisations and groups to build their structures, systems, people and skills so that they are better able to define and achieve their objectives and engage in consultation and planning, manage community projects and take part in partnerships and community enterprises." 18 The Community Capacity Index 19 assesses capacity across four domains. Network partnerships - the formation of partnerships between formal and informal health development structures. Knowledge transfer - the transfer of knowledge between partners. Problem solving - problem solving abilities between and within health development structures. Investment - the development of infrastructure to ensure a network can deliver and sustain a program. Community capacity The concept of "community capacity" refers to the collection of characteristics and resources which, when combined, improve the ability of a community to recognise, assess and take action to address key issues 20. There are five types of capital which communities possess. 21 Financial capital (eg. money, salaries, credit). Human capital (eg. the skills and abilities of community members). Social capital (eg. the levels of trust and reciprocity and the extent of social networks). Physical capital (eg. infrastructure such as roads, public facilities and equipment). Environmental capital (eg. air and water quality). Note that social capital increases the efficiency and effectiveness of other forms of capital in communities 22. The National Health Performance Framework defines community capacity as the characteristics of communities and families such as population density, age distribution, health literacy, housing, community support services and transport. 23 Integrated public health practice In order to maximise the sustainability, effectiveness and efficiencies of public health programs, the National Public Health Partnership has put forward the concept of Integrated Public Health Practice 24 : Integrated Public Health Practice: recognises and responds to the interrelatedness of health determinants and their multiple health outcomes combines capacity building with health gain programs recognises and is relevant to the individual and community's lived experience involves coordinated action across programs and across sectors based on an agreed strategy. Examples of integrated public health practices include Health Promoting Schools, Municipal Public Health Planning and Supportive Environments for Active Living (SEAL). Position Statement July 2003 5

References and further reading 1 Queensland Health (2003) Draft Queensland Health Strategy Map, Integrating Strategies and Performance Project. 2 Services, West Moreton Public Health Unit. 3 Commonwealth of Australia (2001) Discussion Paper on Integrated Public Health Practice: Supporting and Strengthening Local Action, National Public Health Partnership. 4 Department of the Premier and Cabinet, Queensland (2001) Community Engagement Directions Statement. 5 Queensland Health (2003) Queensland Health Position Statement: Consumer and Community Participation to Promote Community Engagement in Health. 6 Queensland Health (2002) Consumer and Community Participation Toolkit: For Queensland Health Staff, Quality Improvement and Enhancement Program. 7 Bush and Mutch (1999) The Community Capacity Health Development Index, Centre for Primary Health Care, University of Queensland. 8 Labonte (1999) The Case for Public Health Work on the Social, Economic and Environmental Determinants of Health, A discussion paper developed for the Aotearoa/New Zealand Health Funding Authority. 9 Labonte and Laverack (2001) Capacity Building in Health Promotion, Part 2: Whose use? And with what measurement? Critical Public Health, 11 (2). 10 Labonte and Laverack (2001) Capacity Building in Health Promotion, Part 1: For Whom? And for what purpose? Critical Public Health, 11 (2). 11 Hawe, Noort, King & Jordens (1997) Multiplying Health Gains: The Critical Role of Capacity-Building in Health Promotion Programs. Health Policy 39(1). 12 Queensland Health (2003) Social Determinants of Health: Support Package for Public Health Services. 13 Davey, Stewart & Spork (2003) Community Public Health Planning and Implementation Review Summary, Griffith University, Queensland University of Technology and Queensland Centre for Public Health. 14 Commonwealth of Australia (2001) Health Impact Assessment Guidelines, enhealth Council, National Public Health Partnership. 15 Natural Resources and Mines, Queensland (2002) Social, Economic and Environmental Assessments: Guidelines for policy and planning, CEO s Committee on Land and Resources. 16 Queensland Health (2003) Summary Report: Findings from the 2002 Queensland Health Survey, Public Health Services and Health Information Centre. 17 Dower and Bush (2003) Critical Success Factors for Community Capacity Building: Key findings from a three year public health project in rural and remote Queensland. Centre for Primary Health Care, University of Queensland. 18 Skinner (1997) Building Community Strengths. Community Development Foundation, Louden. 19 Bush, Dower & Mutch (2002) Community Capacity Index Manual: Version 2, Centre for Primary Health Care, University of Queensland. 20 Ib id 21 Flora (1997) Enhancing Community Capitals: The Optimisation Equation, Rural Development News, 21 (1) 22 Putnam (1993) Making Democracy Work: Civic Transitions in Modern Italy, Princeton University Press. 23 Commonwealth of Australia (2001) National Health Performance Framework Report, National Health Performance Committee. 24 Commonwealth of Australia (2001) Discussion Paper on Integrated Public Health Practice: Supporting and Strengthening Local Action, National Public Health Partnership. Position Statement July 2003 6