A review of theories, concepts and interventions relating ...

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Connected Communities

A review of theories, concepts and

interventions relating to community-level

strengths and their impact on health and

well being

Eva Elliott, Ellie Byrne, Fiona Shirani, Yi Gong, Karen

Henwood, Helen Morgan, Michael Shepherd, Stephen

Palmer, Gareth Williams

A REVIEW OF THEORIES, CONCEPTS AND INTERVENTIONS RELATING TO COMMUNITY-LEVEL STRENGTHS AND THEIR IMPACT ON HEALTH AND WELL BEING

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A review of theories, concepts and interventions relating

to community-level strengths and their impact on health

and well being

Eva Elliott, Ellie Byrne, Fiona Shirani, Yi Gong, Karen Henwood, Helen

Morgan, Michael Shepherd, Stephen Palmer, Gareth Williams

Executive Summary

This paper draws on two reviews of the relationship between strong communities and

health and well being. The first is a theoretical and conceptual review of recent ideas

that presuppose the existence of community relationships and indicate their potential

contribution to social improvements. The second is a systematic review of community

strengthening interventions that have been evaluated in terms of their impact on health

and well being.

Whilst there is a wealth of concepts that describe different ways of understanding

communities, and theories that could explain the production of social benefits, including

health and well being, these are often portrayed relatively narrowly and uncritically.

Changing relationships between citizens and the state also shape the ways in which

ideas such as resilience, social capital and community organizing are interpreted in

government policy.

Despite the rise in popularity of community concepts in public health, the quality of

intervention evaluations is poor. In particular the transformational claims for some

interventions were presented uncritically. The impact of interventions such as time-

banks, community gardens and participatory arts projects on health should be

investigated. However non-intervention research on how communities can best mobilise

internal and external resources for health gain is also needed.

Key words

Health and well being, community, social capital, resilience, social action


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A review of theories, concepts and interventions relating

to community-level strengths and their impact on health

and well being

This review has two elements. The first is a scoping and consolidation of the theoretical

and conceptual literature underpinning current approaches to strengthening communities

and the second is a systematic review to synthesise findings from evaluations of

programmes and interventions. The purpose of this dual approach was to clarify the

conceptual and theoretical underpinnings of interventions and policy approaches and to

examine their relationship to plausible and actual health outcomes. Finally a

public/policy dialogue involving academic researchers, policy makers, practitioners and

community representatives was held to discuss preliminary findings as well as

experiences and ideas about the value of strengthening community approaches to health

and well being. Papers relating to all aspects of this study are available as separate

documents.

The focus of the first review was on concepts and theories which relate to the idea of a

„strong‟ community in some way. Underpinning all these ideas is the assumption that

there is something that can be understood as „community‟ (whether this is felt or

practiced through place, common identities or shared experiences) and that its very

definition implies potential resources or strengths that can provide social benefits. In this

review we have explored the salience of these to health and well being, particularly in

the context of related income and health inequalities. In this review we identify theories

and concepts at two main levels. At the first level there are concepts that define

communities and their strengths in particular ways. These include ideas about social

capital, social cohesion, capability, community resilience or adaptation and resistance.

At a higher level are political ideas concerning the nature of society and the production

of social which presupposed the existence and value of strong communities. These

include communitarianism, mutualism, localism and co-production.

Theoretical concepts in modern usage relating to community strengths were analysed by

taking the historical context of the development of concepts and changes in their

popularity. The diagram in figure 1 does not represent a logic model but a map of how

authors have linked concepts in a more narrative way. Exploring the synergies between

concepts illustrates how some have become increasingly popular since the financial crisis

and recent political changes, with greater emphasis on community self-reliance and

responsibility.

However, as the diagram illustrates, the community-level concept that has sustained its

popularity in the field of health and well being is that of „social capital‟, and it seems to

be a concept that is popular in many ways across the political spectrum. Lynch and

colleagues (2000) suggest that those on the political right see social capital as an


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opportunity to argue for a withdrawal of the state from welfare and social provisions,

whilst those more towards the left maintain that state support is crucial to the

accumulation of social capital (Baum 1999). This division is evident also in recent

differentiations between the of Big Society Conservative coalitionists, on the one side,

and Good Society Blue Labourites on the other.

Figure 1: Map of strengthening community concepts and theories

Social capital refers to the values that people hold and the resources that they can

access, which both result in, and are the result of, collective and socially negotiated ties

and relationships (Edwards et al. 2003). The central premise of social capital is that

social networks are a valuable asset (Field 2003). Recent writings have extended the

concept of social capital from an individual asset to a feature of communities. In contrast

to the focus on individuals in the work of Bordieu (1986) and Coleman (1988), Putnam

(2000) is more concerned with social capital as a feature of communities. His approach,

which has also been described as communitarian (Moore et al 2005), calls attention to

the notion of civic virtue, which is most powerful when embedded in a network of

reciprocal social relations. Putnam is pessimistic about contemporary society, arguing

that there has been a decline in civic life, associated with individualisation.

Social capital is useful because it provides one basis for understanding the qualities of

different communities in a more systematic way. For example, the distinction between

bonding, bridging and linking forms of social capital is helpful not only in understanding

the shape of communities and how they change, but also in working with communities to


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develop effective strategies for community regeneration. It was seen as being

something that could both explain the existence of resilient and adaptive communities

and the successes and failures in community organizing and social action.

There are other reasons why social capital may currently be popular in community policy

discourse. It draws attention to the benefits of a form of capital which is not financial

and, despite an increasing turn to mutual and co-productive relationships between

citizens and the state, can be achieved with little government intervention during a time

of recession, whilst also evoking nostalgic notions of community connectedness (Arneil

2007; Franklin 2007). Even where social capital is used in a way that is linked to

community organizing or social action much of the literature looks at social capital-

building through community organizing as a way of building resilience in the presence of

adversity or austerity, rather than providing the basis for resistance to the state or wider

economic inequalities (Edwards et al. 2003, Bowen,2009).

Most of these concepts are portrayed relatively narrowly, uncritically accepting notions of

community as positive and overlooking potentially negative aspects of community life

(Muntaner et al, 2008). In addition, the concept of social capital focuses attention on the

positive consequences of sociability while putting aside its less attractive features e.g.

exclusion of outsiders, excess claims on group members, and restrictions on individual

freedoms such as demands for conformity (Portes 1998; Bowen 2009). Navarro (2002)

suggests that Putnam‟s communitarian approach to social capital has omitted power and

politics; instead the emphasis is on ability to compete for resources, enhanced by the

networks of which the individual is part. Navarro also critiques Putnam‟s lack of

awareness that the absence of togetherness may be rooted in the existence of capitalism

and competitiveness and their adverse effects in alienating and atomizing citizens,

ignoring the issues of inequality and the exercise of power (Edwards et al. 2003, Bowen,

2009).

A frequently cited article in relation to social capital and public health is by (Kawachi et

al. 1997), who argued that high levels of social capital lessen the impact of income

inequality on the health of populations. The paper draws heavily on Putnam‟s

communitarian approach - focused on civic engagement, norms of reciprocity and trust –

whilst the network definitions of Coleman and Bordieu are marginalised (Moore 2005).

Communitarianism has been critiqued in recent years for its failure to provide a

satisfactory answer to „the disintegration of social bonds in advanced societies‟ and

suggesting „a one-dimensional world in which communities are blessed with a cohesion

that is neither chosen, intended, nor lived by the people who produce them‟ (Bowring

1997:97) yet this approach has had a meteoric rise in public health rhetoric.

To see how ideas about social capital and related concepts and theories have shaped

empirical research on interventions a systematic review was conducted to investigate the

effectiveness of community strengthening interventions on health and wellbeing,

Community interventions were defined as forms of social action and co-operation as well

as programmes and interventions that are informed by theories and concepts of

community. “Community” was conceived of in a broad sense and not confined to

geographical area. We therefore included communities of interest, identity and


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institutional settings such as schools. To be included, an intervention must have

demonstrated some element of strengthening relationships, bonds or ties between

people within a community which impacted on health outcomes. This meant that many

“community-based” health interventions were excluded, as they were essentially clinical

interventions being delivered in specific locality.

Figure 1: Systematic Review Flowchart

7024 papers identified through database searching

6373 papers after duplicates removed

6373 abstracts screened

119 full text papers screened

31 papers included

88 excluded

6254 excluded(incl. 145 contextual papers)

Systematic review flowchart

The search returned more than 7000 references. Titles and abstracts were screened for

relevance, and those obviously outside the scope of the review were excluded. The

researchers used a strategy of „if in doubt, leave it in‟. Full texts of all remaining

inclusions were obtained, screened by two researchers for relevance, and then

distributed to the research team for critical appraisal and data extraction.


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Many papers were excluded because they were descriptions of projects with little data on

how efforts to strengthen or empower communities led to health or well being outcomes.

However, critical appraisals highlighted some problems in the papers that were included,

including lack of clarity in the definition of outcomes, too much information on processes,

disconnection between theory and findings, lack of attention to the contexts in which

interventions were located, and lack of attention to wider aspects of social and economic

forces that shape the take up of interventions.

Finally, papers rarely reflected negative impacts. This may due to the way in which

evaluations are funded. If interventions and evaluations share the same funding source

then there may be a reluctance to throw doubt over an investment, or of the way in

which an intervention has been commissioned.

In terms of the activities that the selected papers described these included community

gardens, timebanks, digital inclusion projects, sports and arts interventions,

environmental change projects and peer support interventions. There were others that

aimed to develop a diversity of activities aimed at facilitating peer or neighbourhood

relationships in ways that were acceptable to the people involved.

In developing a more conceptual overview of the interventions four „ideal types‟ have

been identified (Weber 1949). The following are useful categories for making sense of

different kinds of interventions but does not mean that all interventions fit neatly into

one category or another. These interventions are presented in the form of a two by two

axis: interventions aimed at a specific group of individuals (communities of practice)

versus those aimed at a „neighbourhood‟ or place (geographic community) and those

which either affirm peoples‟ sense of belonging or identity or those which involve a

transformation of capacities, power or resources for those groups of individuals or

places.

The term ‘transformation’ was used in a number of interventions to indicate some kind of

dramatic change in personal or collective capacities, powers, or resources. However

some of these might be thought better as affirmation where the benefits relate to the

personal rewards of social support or friendship. Whilst these changes may for the

individuals themselves be personally transformative the types of transformation claimed

in some of the interventions refer to the acquisition of social or political power. However

whilst some of these papers make bold claims to more radical changes in the dynamics

of structural power relationships (Williams and Labonte 2003, Morsillo and Prilleltensky

2007, Kegler et al 2008, Hamilton and Flanagan 2007, Itzhaky and York 2002) little

evidence or argument is provided to support that view.

Figure 3 is a summary of the kind of health outcomes that were reported alongside

different types of intervention and the theories that were thought to underpin these

changes. Little reference was made to theories other than those associated with social

capital (Michael et al 2008, Saldivar-Tanaka and Krasney 2004, Seyfang 2003, Smith et


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al 2010, Sememza et al 2007, Griffiths 2009, Hopkins 2007), community organizing

(USA) (Michael et al 2008 London et al 2010, Milligan 2004, Saldivar-Tanaka and

Krasney 2004, Itzhaky and York) or community health assets - often linked to

salutogenesis (Batt-Rawden and Tellnes 2005. Kegler et al 2008, Seyfang 2003, Letcher

and Perlow 2009, Milligan 2004, Saldivar-Tanaka 2004). In terms of higher level political

ideas, which presuppose ideas about the value and use of community strengths in the

production of social goods, co-production was the only term that was used and in

relationship to Timebanking. There was a surprising lack of evaluation of Timebanks

given their theoretical basis and claims to support individual and neighbourhood level

health and well being (Letcher and Perlow 2009, Seyfang 2003)

Figure 3: mechanisms and health outcomes

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Figure 4 highlights the strength of evidence for interventions in these domains. The

strongest evidence (possibly because these interventions are the easiest to evaluate) is


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for interventions that aim bring together a group of people, who share a common

experience or characteristic, for friendship or support. In some of these interventions

health benefits were also associated with feeling more closely and positively attached to

the local neighbourhood (Seyfang 2003, London 2009, Saldivar-Tanaka and Krasney

2004, Lakin and Mahoney 2006, Teig et al 2009). However participation could be

experienced as stressful, and the creation of new groups as excluding for others (London

et al 2010, Milligan 2004, Teig et al 2009).

Figure Four: strength of evidence

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Neighbourhood level interventions provided weaker evidence that the social fabric had

changed in ways that improved the health of residents. Whilst evidence was often drawn

just from people actively engaged in these interventions (and not residents who were

not involved but stood to benefit) there was some evidence that interventions such as

community gardens, and environmental regeneration projects which involved local

people in their design saw overall improvements in mental health.

The weakest evidence was for transformative interventions. Whilst there was some

evidence that, in particular, arts and digital inclusion interventions could facilitate new


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learning and new ways of framing or communicating personal troubles as public issues,

there was little evidence that these transformative moments were sustained in the long

term. Though it could be argued that neighbourhood interventions protect residents

from the worst effects of income deprivation in terms of health, and this is certainly

important, there is no evidence that they pull neighbourhoods out of poverty.

However, this failure to find evidence for transformative interventions could be due to

the nature of „interventions‟ themselves. Indeed, the idea of a „transformative

intervention‟, may be a contradiction in terms. This is perhaps the implication in a paper

by Crossley (2001) about a Health Authority funded HIV intervention for an

„empowerment forum‟ for gay men in the North-West of England. Instead of recreating

the gay pride activism of the late 1980‟s early 1990‟s, this health promotion intervention

was perceived by some stigmatizing and humiliating and „just another attempt to get us

to stick condoms on our willies‟p21.

To conclude community strengthening interventions do not have strong evidence base,

although there is a long tradition of community health development initiatives. The

reasons may include: the complexity and timing of evaluations to understand how

complex changes in community relationships affect health and well being outcomes over

time, lack of commitment or resource to evaluate interventions of this kind and the point

that some forms of community organizing are a response to particular situations and

research opportunities have been missed.

Recommendations:

� Mixed methods research and evaluation is needed on place making interventions

such as community gardens, timebanks and participatory arts interventions and

how different models may facilitate health and well being benefits for people who

are engaged and not engaged.

� Research on community strengthening interventions should be attentive to the

distribution of effects. Research needs to illuminate the processes of exclusion as

well as inclusion through community level interventions.

� Research needs to better integrate theory and empirical research and situate an

understanding of inventions within wider policy, political and economic contexts.

There are a wealth of community related concepts and theories that are not fully

utilized and developed in empirical research.

� In terms of non-intervention research innovative research designs are needed to

identify how policy makers can better understand, and respond to, the needs and

aspirations of communities.

� Researchers need to work with communities to assess how they can best mobilise

internal and external resources (and connections) for health gain.


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References and external links

References:

Arneil, B. (2007). Diverse Communities: The Problem with Social Capital. Cambridge,

Cambridge University Press.

Batt-Rawden, K. And Tellnes, G. (2005) Nature-culture-health activities as a method of

rehabilitation: an evaluation of participants' health, quality of life and function.

International Journal Of Rehabilitation Research, 28 (2) pp. 175-180.

Baum, F. (1999). "Social capital: is it good for your health? Issues for a public health

agenda." Journal of Epidemiology and Community Health 53: 195-196.

Bowring, F (1997) "Communitarianism and Morality: In Search of the Subject." New Left

Review, No. 222: 93-113

Bowen, G. A. (2009). "Social Capital, Social Funds and Poor Communities: An

Exploratory Analysis." Social Policy and Administration 43(3): 245-269.

Coleman, J.S. (1990). Foundations of Social Theory. London, Harvard University Press.

Coleman, J.S. (1988). "Social Capital in the Creation of Human Capital", American

Journal of Sociology. 94 Supplement: (pp. S95-S-120)

Crossley, M.L. (2001) The 'Armistead' project: An exploration of gay men, sexual

practices, community health promotion and issues of empowerment. Journal of

Community & Applied Social Psychology, 11(2), pp. 111-123.

Durston, J. (1999). "Building community social capital." Cepal Review 69: 103-118.

Dynes, R. R. (2005). Community Social Capital as the Primary Basis for Resilience.

Preliminary Paper #344. Newark, University of Delaware.

Edwards, C. (2009). "Next generation resilience relies on citizens and communities, not

the institutions of state ..." Resilient Nation. London, Demos.

Edwards, R., J. Franklin, et al. (2003) Families and Social Capital: Exploring the Issues.

Families and Social Capital ESRC Research Group

Field, J. (2003). Social Capital. London, Routledge.

Franklin, J. (2007). "Social capital: between harmony and dissonance." London South

Bank Families and Social Capital ESRC Research Group Working Paper No. 22.

Griffiths, R., Horsfall, J., Moore, M., Lane, D., Kroon, V. And Langdon, R. (2009) Building

social capital with women in a socially disadvantaged community. International journal of nursing practice, 15(3), pp. 172-184.


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Hamilton, C. And Flanagan, C., (2007).Reframing social responsibility within a

technology-based youth activist program. American Behavioral Scientist, 51 (3), pp. 444-464}.

Hopkins, L (2007). Social capital, health and electronic community in public high-rise estates: An Australian case-study. Health Sociology Review, 16 (2), pp. 169-178.

Itzhaky, H. And York, A. (2002). Showing results in community organization. Social Work, 47(2), pp. 125-131.

Kegler, M.C., Norton, B.L. And Aronson, R.E. (2008) Strengthening community

leadership: evaluation findings from the california healthy cities and communities program. Health Promotion Practice, 9(2), pp. 170-179.

Lakin, R. And Mahoney, A., 2006}. Empowering youth to change their world: Identifying

key components of a community service program to promote positive development. Journal Of School Psychology, 44(6), pp. 513-531.

Letcher, A.S. and Perlow, K.M. (2009) Community-based participatory research shows

how a community initiative creates networks to improve well-being. American Journal of Preventive Medicine, 37(6 Suppl 1), pp. S292-9.

London, R.A., Pastor, M.,Jr, Servon, L.J., Rosner, R. And Wallace, A.,(2010) The Role of

Community Technology Centers in Promoting Youth Development. Youth & Society, 42(2), pp. 199-228.

Lynch, J., P. Due, et al. (2000). "Social capital - Is it a good investment strategy for

public health?" Journal of Epidemiology and Community Health 54: 404-408.

Michael, Y.L., Farquhar, S.A., Wiggins, N. And Green, M.K. (2008) Findings from a

Community-based Participatory Prevention Research Intervention Designed to Increase

Social Capital in Latino and African American Communities. Journal Of Immigrant And

Minority Health, pp. 281-289.

Milligan, C., Gatrell, A. And Bingley, A. (2004) 'Cultivating Health': Therapeutic

Landscapes and Older People in Northern England. Social science & medicine, 58(9), pp. 1781-1793.

Moore, S., A. Sheill, et al. (2005). "The Privileging of Communitarian Ideas: Citation

Practices and the Translation of Social Capital Into Public Health Research." Public Health

Matters 95(8): 1330-1337.

Morsillo, J. And Prilleltensky, I. (2007) Social action with youth: Interventions,

evaluation, and psychopolitical validity. Journal of community psychology, 35(6), pp. 725-740.

Muntaner, C., J. Lynch, et al. (2008). Social capital and the third way in public health. In

J. Green and R. Labonte (eds) Critical Perspectives in Public Health.London, Routledge.


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Navarro, V. (2002). "Politics, Power, and Quality of Life: A Critique of Social Capital."

International Journal of Health Services 32(3): 423-432.

Portes, A. (1998). "Social Capital: Its Origins and Applications in Modern Sociology."

Annual Review of Sociology 24: 1-24.

Putnam, R. D. (2000). Bowling Alone: The Collapse and Revival of American Community.

New York, Simon and Schuster.

Saldivar-Tanaka, L. And Krasny, M. (2004) Culturing community development,

neighborhood open space, and civic agriculture: The case of Latino community gardens in New York City. Agriculture and Human Values, 21 (4), pp. 399-412.

Semenza, J.C., March, T.L. And Bontempo, B.D. (2007) Community-initiated urban

development: An ecological intervention. Journal Of Urban Health-Bulletin Of The New

York Academy Of Medicine, 84(1), pp. 8-20.

Seyfang, G. (2003) Growing Cohesive Communities One Favour at a Time: Social

Exclusion, Active Citizenship and Time Banks*. International Journal of Urban and Regional Research, 27(3), pp. 699-706.

Smith, S., Bellaby, P. And Lindsay, S. (2010) Social Inclusion at Different Scales in the

Urban Environment: Locating the Community to Empower. Urban Studies, 47(7), pp.

1439-1457.

Teig, E., Amulya, J., Bardwell, L., Buchenau, M., Marshall, J.A. And Litt, J.S. (2009)

Collective efficacy in Denver, Colorado: Strengthening neighborhoods and health through community gardens. Health & Place, 15, pp. 1115-1122.

Weber M (1949) Objectivity in Social Science and Social Policy” in The Methodology of

the Social Sciences. ed./trans. E. A. Shils and H. A. Finch. New York: Free Press.

Williams, L. And Labonte, R. (2003) Changing health determinants through community

action: power, participation and policy. Promotion et Education, 10(2), pp. 65-71, 88, 104.

Links to project reports and documents:

Shirani F et al (2011) Paper 146: The Centrality of Social Capital - Concepts of

Community in the Era of the Big Society. Cardiff University School of Social Sciences

Working Series http://www.cardiff.ac.uk/socsi/resources/wp146.pdf

Full review references, technical reports and references will be available at:

http://www.cishe.cardiff.ac.uk/en/content/cms/cishe-projects/completed-research

http://www.cardiff.ac.uk/socsi/resources/wp146.pdf

http://www.cishe.cardiff.ac.uk/en/content/cms/cishe-projects/completed-research

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The Connected Communities

Connected Communities is a cross-Council Programme being led by the AHRC in partnership

with the EPSRC, ESRC, MRC and NERC and a range of external partners. The current vision for

the Programme is:

“to mobilise the potential for increasingly inter-connected, culturally diverse,

communities to enhance participation, prosperity, sustainability, health & well-being by

better connecting research, stakeholders and communities.”

Further details about the Programme can be found on the AHRC‟s Connected Communities web

pages at:

www.ahrc.ac.uk/FundingOpportunities/Pages/connectedcommunities.aspx

http://www.ahrc.ac.uk/research/fundedthemesandprogrammes/crosscouncilprogrammes/connectedcommunities/

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