Elements of a Healthy Community

Health can be defined in many ways by different people. In its simplest form, health has been defined as merely the absence of disease and disability. Although this definition of health has been used historically, the World Health Organisation (WHO) has established a more useful and broader definition of health that highlights the connection of health and community:

Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief or economic and social condition.

Prerequisites for health include: peace, shelter, education, food, income, a stable eco-system, sustainable resources and social justice and equity. As such, a healthy community continually creates and improves the environment and expands resources such that the prerequisites for health are provided and all citizens of the community move toward the broad definition of health.

Social Determinants of Health

To create a healthy community, the focus must shift from an individualistic, medical view of health to a view that considers health within the context of the social environment and policy perspective. This is not to say that individuals should be taken out of their own health equation. Rather, a person’s health and that of the community are products of the social environment and the choices that the individual makes as members of the community. To address health issues in a meaningful way, consideration must be given to the relationship between health/wellness and the key components of the environment in which people live and work:

• quality education;
• adequate and safe housing;
• employment opportunities and job skills training;
• access to public transportation and recreational opportunities;
• healthy, clean and safe physical environments; and
• health education and access to health care (Norris, Lampe, 1994).

By taking the key components into consideration, we recognize that there is a fundamental relationship between a person’s environment, his/her behavior, and his/her health.

Resiliency

Traditional resilience-building initiatives have focused on infrastructure and environmental sectors. Although the ultimate goal of these efforts is to protect human life, health, and economic vitality, too often a commensurate focus on the people served by this infrastructure is lacking in preparedness plans and frameworks. The centrality of health to both societal and individual wellness suggests that a commitment to building human resilience should be at the forefront of any workable model. Accepting the World Health Organization's definition of health as a state of physical, mental, and social well-being informs the understanding that true health resilience must derive from stronger health and health care systems, improved population health, and the capabilities to sustain physically, mentally, and socially healthy individuals and communities amid large-scale changes.

Whether a community is in the path of a natural disaster, the target of an act of terror, or simply striving to meet the demands of increasingly dense urban populations, a community resilience paradigm can help communities and individuals not just to mitigate damage and heal, but to thrive. This article discusses experiences from recent, large-scale disasters to explore how community resilience might serve as a sustainable paradigm for organizing public health and medical preparedness, response, and recovery. By strengthening health systems, meeting the needs of vulnerable populations, and promoting organizational competence, social connectedness, and psychological health, community resilience encourages actions that build preparedness, promote strong day-to-day systems, and address the underlying social determinants of health. Thus, community resilience resonates with a wide array of stakeholders, particularly those whose work routinely addresses health, wellness, or societal well-being.^[2]

Health Equity

The current economic crisis in Africa has posed a serious challenge to policies of comprehensive and equitable health care. A research looked at the extent to which the Zimbabwe government has achieved the policy of "Equity in Health" it adopted at independence in 1980, that is provision of health care according to need. The research identified groups with the highest level of health needs in terms of both health status and economic factors which increased the risk of ill health. It described a series of changes within the health sector in support of resource redistribution towards health needs, including a shift in the budget allocation towards preventive care, expansion of rural infrastructures, increased coverage of primary health care, introduction of free health services for those earning below Z$150 a month in 1980, increased manpower deployment in the public sector and the reorientation of medical training towards the health needs of the majority.

The implementation of equity policies in health have however been challenged by several trends and features of the health care system, these becoming more pronounced in the economic stagnation period after 1983. These include the reduction in allocations to local authorities, increasing the pressure for fees, the static nominal level of the free health care limit despite inflation, the continued concentration of financial, higher cost manpower and other resources within urban, central and private sector health care and the lack of effective functioning of the referral system, with high cost central quaternary facilities being used as primary or secondary level care by nearby urban residents. While primary health care expansion has clearly been one of the success stories of Zimbabwe's health care post 1980, the research noted plateauing coverage, with evidence of lack of coverage in more high risk, socio-economically marginal communities. Measures to address these continuing inequalities were discussed. Their implementation is seen to be dependent on increasing the capacity and organisation of the poor to more strongly influence policy and resource distribution in the health sector.

Social/Cultural Cohesion

In some rural areas, such as in Zimbabwe, traditional leaders play an important role in conflict resolution. While they could benefit from capacity building, in order to more effectively carry out this role, rural populations were generally content with their efforts. A rural programme in Colombia invests in influencing and capacity development of rural women’s organisations to ensure that rural women lead and influence peace building processes. It has changed the way in which rural women are perceived and has led to the successful lobbying of government on public policies benefiting rural women. Informal dispute resolution training workshops in rural Liberia have also led to higher rates of peaceful property resolution in rural areas.

As small structures designed to enable local people to take responsibility for their own peace, they can have greater legitimacy due to their informality. Research on a peace committee established in rural Zimbabwe finds that peace committees can be effective, sustainable and replicable. Their strengths often lie in their ability to address the community’s basic needs and challenges. The do not have the capacity, however, to deal directly with political level conflicts.^[3]

Social Justice

Social justice revolves around the development and understanding of retributive and distributive principles, their association with historical situations and the political economy, the impact of their institutionalisation on both the individual and social development, and their assessment through various criteria and/or processes. Social justice focuses on justice in the social context rather than solely on the individual as the concept encompasses understanding how multitudes of people interact both within and between themselves.

Nations advance social justice when they remove barriers that people face because of gender, age, race, ethnicity, religion, culture or disability. Thus the issue becomes important for Zimbabwe as it works towards the attainment of an upper middle income economy which entails equal opportunities for everybody. The 2020 theme for the commemoration of the World Day of Social Justice: "Closing the Inequalities Gap to Achieve Social Justice" should guide the country in its policy formulation going forward. Hence from this World Social Justice Day, Zimbabwe should work towards improving the living standards of people and at the same time address serious challenges like financial crises, insecurity, poverty, exclusion and inequality within and among societies.

The lives of Zimbabwean women need to be improved constantly by continuing to empower them through giving them equal opportunities to participate in decision making, access to, control over, ownership, utilisation and fair distribution of resources, at all levels. For the country to achieve social justice the core area of education should be improved continuously and in line with recent technological advancement as this will prepare the young in the future of work. A good education is crucial to ending cycles of poverty and giving everyone the opportunity to fulfil their dreams. However, in Zimbabwe countless people are unable to get an adequate education simply because of their geographical location or because they are facing other discrimination.^[4]

Transportation Options

Transportation impacts a person’s life, economics and health. Adequate transportation is often a prerequisite for accessing healthcare, employment, grocery stores and recreations facilities as well as being socially connected to the community. However, groups of people experience a transportation-disadvantage or the inability to obtain their own transportation. Unsafe streets and highways also present health issues for people who walk or cycle as their means of transportation.

Zimbabwe has been experiencing a tremendous economic crisis for the last 20 years and as a result, small to medium businesses were already struggling to remain afloat. The transport industry is one of the sectors affected by the crisis. Transport plays a crucial role in connecting people, transporting goods and services and fostering sustainable development. Urban productivity is highly dependent on the efficiency of its transport system to move labor, consumers, and freight between multiple origins and destinations.

Road transport is the most dominant mode of motorized transport in Africa, accounting for 80 percent of the goods traffic and 90 percent of the passenger traffic on the continent (UNESCO, 2009). In Zimbabwe, most people used commuter omnibuses daily before they were taken off the road by the government in 2020 and replaced them with ZUPCO which enjoys a monopoly in the public transport sector now, but, the commuter omnibus operators faced a myriad of challenges which included fuel shortages, poor receipting and accounting practices, poorly maintained roads and infrastructure, introduction of ZUPCO and the Public Transport Subsidy.

Access to care

Access to health care and health education are important pieces of a healthy life. However, there are many barriers to receiving health care and health information. When we talk about access to health care, often people think of access to health insurance. Without health insurance, people lack a usual source of care, are twice as likely to delay health care due to cost, and more likely to go without prescription medication. Without health insurance, children are less likely to complete well-child check-ups or have preventive health care.

People who lack health insurance are more likely to be hospitalized for avoidable conditions. The uninsured are less likely to be able to afford other necessities due to medical bills. While lack of health insurance or financial means to pay for health care services are barriers to receiving health care, so are transportation issues, language barriers and lack of health care providers in certain areas of a community. Communities that do not have a public transportation infrastructure limit access to medical care for people who do not have their own transportation, especially if physician practices are not evenly dispersed throughout the community. If a language other than English is predominantly spoken in areas of a community, then medical care and health information needs to be provided in multiple languages.

In developing countries like Zimbabwe, access to healthcare services is often influenced by long distances and travel times to health facilities, the availability of financial resources to travel or pay for care and the availability of medical drugs as well as competent healthcare workers. For example, in Zimbabwe, people in rural areas often have to walk between 10 km and 50 km to access the nearest health facility. Access can be further impeded by a lack of infrastructure, such as dirty roads that are not maintained, resulting in poor road conditions and potholes that create barriers to transport.

In Zimbabwe, because of economic challenges, bridges that have collapsed because of rain are not repaired, hindering travelling of patients during critical times and negatively affecting the timely delivery of medical drugs and medical supplies to rural health centres. Even where healthcare services are available and affordable, access to medical drugs is limited. There is often a shortage in the supply of medical drugs, especially in the rural parts of Zimbabwe. It is evident that the economic crisis in Zimbabwe has also led to a shortage of medical supplies and equipment in public health facilities, leaving professional nurses with limited options to provide treatment.^[5]

Affordable Quality Housing

Unsafe and substandard homes put a person at risk for illness or accident. Studies have found that asthma rates are higher for children living in substandard housing. Contributing factors include: poor ventilation, pest infestation, and mold resulting from water leaks.

Increased risk of diabetes has been associated with inadequate housing conditions. Indoor air pollutants can also cause disease. For example, radon and asbestos has been associated with lung cancer. Rates of headaches and migraines are higher in those living in poor quality housing, possibly due to exposure to neurotoxins such as pesticides.

Community Safety

Community safety is a concept that is concerned with achieving a positive state of well-being among people within social and physical environments. Not only is it about reducing and preventing injury and crime, it is about building strong, cohesive, vibrant, participatory communities. This means the perception of safety is as important as measuring injury and crime rates.

But what is perception and why is it important in terms of community safety?

Perception is the way a person thinks about or understands something. What a person perceives is what they see as `real’. And it is this perception of reality that shapes their behaviours. However, is what people perceive real? Is a neighbourhood unsafe because the media report make a big deal of an attack in it? What is the impact of a parent who doesn’t let their children walk to school because they perceive it as too dangerous? Is this useful in teaching the children road safety?

Perception is complex; it is individual and dependent on numerous factors; life experiences, beliefs, type of community (urban vs rural), age, socioeconomic status, type of job and employment status, race and economic structure of the community are some of the factors which influence perception of safety. Hence, within a community, there will be diverse perceptions of safety which need to be addressed. Community safety initiatives need to ensure that these are included, in addition to the interventions for reducing the factors which cause injuries, to develop and support injury-free families/whanau, homes and communities.^[6]

Economic Opportunity

The connection between employment and health has been well documented. People who are unemployed tend to have higher levels of impaired mental health including depression, anxiety, and stress as well as higher levels of mental health hospital admissions, chronic disease (cardiovascular disease, hypertension, musculoskeletal disorders) and premature mortality. Additionally, unemployment is associated with unhealthy behaviors such as increased alcohol and tobacco consumption and decreased physical activity. Gainful employment provides the opportunity for income, access to health care and a higher socioeconomic status (SES).

Although the decision to engage in unhealthy behaviors (smoking, alcohol consumption, illegal drug use) is a personal choice, there are social, economic and environmental pressures that influence a person’s decision. Lower SES communities are more likely to have a higher concentration of liquor and tobacco stores as well as advertisements and marketing of these products.

Zimbabwe was once one of Southern Africa’s most vibrant, productive, and resilient countries. However, for close to two decades, the nation has faced a series of political and economic shocks, the roots of which come from decades of poor governance and deeply entrenched and growing levels of corruption.

Zimbabwe has an estimated population of 14.2 million people, of whom about 10 million live in rural areas. Life for the average Zimbabwean is increasingly difficult, with 63 percent of all households living in poverty and 16 percent in extreme poverty. At the root of this poverty is a lack of economic opportunities caused by a failure to adhere to rule of law, recognize property rights, and create a secure environment for domestic and foreign investment. Exacerbating Zimbabwe’s economic woes is the growing impact of climate change.^[7]

Educational Opportunity

Quality education, from preschool to higher education, is the foundation upon which future success (and access) is built. However, access to quality educational programs is often lacking in poorer communities due to a weaker tax base and a disparity of resources based on socioeconomic status. School buildings tend to be older and in poor repair and the environment surrounding the school may not be conducive for learning (crime, violence and environmental hazards).

Children who struggle in school or perform below their grade level are at an increased risk of dropping out of high school. They also have a higher probability of becoming unhealthy adults. Research shows that people with a college education have a higher quality of life through access to higher paying jobs, longer life expectancy, and less tobacco, alcohol, and drug use. A quality education must start in early childhood. Enrollment in quality early childhood educational programs, particularly for low-income youth, has been shown to improve performance in school, creating greater chances for success throughout the child’s life.

There has been increasing international debate on what role the state plays in facilitating or promoting the right to education, and, more recently, in states in crisis. This latter development is due to growing evidence that attacks have been directed on education – schools, teachers, and pupils - by governments themselves or insurgents aspiring to take over government. In Zimbabwe, attacks on education have been recorded from the struggle against colonial rule, where schools provided recruiting grounds for freedom fighters. However, in post independent Zimbabwe, the attacks have been directed at teachers, either directly or indirectly. Education has been both politicized and militarised by the setting up of militia bases in schools, attacking teachers, and exposing pupils to violence.

The impact of the attacks can have serious long-term consequences. Politically motivated violence against teachers does not only affect the teachers in person, but affects the prospects of better communities in general and the nation at large. The Research and Advocacy Unit, in collaboration with the Progressive Teachers Union of Zimbabwe (PTUZ), conducted a national survey in 2010 to document teachers’ experiences with elections. This culminated in two reports, "Every school has a story to tell: Preliminary Report of a study on teachers’ experiences with Elections in Zimbabwe" and "Political Violence and Intimidation of Zimbabwean Teachers". The reports identified the profile of perpetrators of violence, and the types of attacks teachers had to contend with, including attacks in front of school children. In some embarrassing cases, the children were given whips to beat the teachers. Important to note from the findings is the politicization of education as well as militarization by setting up militia bases in schools.^[8]

Environmental Quality

Many environments in which people live, work, and play expose them to pollution and hazards. Fortunately, homes, communities, workplaces, and schools can be designed to promote healthy choices and improve safety. Healthy community design can improve people's health and safety by:

• Improving air and water quality
• Decreasing mental health stresses
• Strengthening the social fabric of a community
• Providing fair access to employment opportunities, education, and resources
• Increasing options for physical activity and healthful diets
• Decreasing injuries and accidents

The ability to live in an area with high environmental quality is associated with gender, age, education level, income, race and ethnicity, and geographic location. Many health-related hazards (like mold, allergens, poor indoor air quality, structural deficiencies, and lead) are disproportionately found in low-income housing. Addressing these determinants is key in reducing health disparities and improving the health of all Zimbabweans. Efforts are needed to overcome barriers to improving environmental quality.^[9]

Quality Affordable food

Eating nutritious food and maintaining a healthy diet are important parts of a person's overall health and well-being. Evidence shows that poor nutrition and an unhealthy diet are leading risk factors for various chronic health conditions, including heart disease, hypertension, diabetes, and other diet-related diseases. The lack of access to affordable and nutritious food is a major public health problem, particularly for the poor and other underserved populations who often live in food deserts where the availability of fresh and healthy food is lacking or limited. Further, the lack of access underscores how the social determinants of health impact underserved populations, which then results in health disparities. Food is a fundamental human need and influences health and quality of life. Access to affordable and nutritious food is a public health priority and requires broader, community-based interventions focused on addressing the social determinants of health and eliminating health disparities.^[10]

Zimbabwe’s economy and food security situation remains fragile. Poor weather conditions, including erratic rainfall and long dry spells, contributed to increased humanitarian needs across the country, while the deteriorating economic situation exacerbated the already rising vulnerability in both rural and urban communities.

Zimbabwe experienced a drought in the 2018/2019 agricultural season, resulting in large-scale crop failure. The 2019 Zimbabwe Vulnerability Assessment Committee projected an estimated 5.5 million rural Zimbabweans to be food insecure during the peak of the 2019/20 lean season, with 3.8 million people in need of food assistance. Urban vulnerability was also on the rise, with the Ministry of Public Service, Labour and Social Welfare estimating that up to 2.2 million people in urban areas were food insecure. Findings and recommendations from the ongoing urban livelihoods and vulnerability assessment further informed the urban situation and humanitarian actions.^[11]

Community Design

Investing in healthy communities has shown a positive return on investment (ROI). The health promotion programs focused on increased physical activity, improved nutrition and a reduction in tobacco usage. Implementation of these programs could reduce chronic diseases including type 2 diabetes, high blood pressure, heart disease, and stroke.

Parks and Recreation

Community conditions that support physical activity include well lit streets, sidewalks that are in good repair, low crime rates and traffic, a lack of graffiti, walking and biking trails, parks and recreational facilities. Children who live in poverty are more likely to be obese when compared to children who live in higher socioeconomic status families (SES). Food choices for a family (or individual) are determined by supply, culture, affordability and availability. Lower SES communities often lack full service grocery stores that supply fresh fruits and vegetables and have an abundance of fast food outlets and convenience stores. As such, people living in these communities have a higher risk of obesity and diabetes (Design for Disease).

References