This chapter examines how community action is defined in the literature and in the Basque country. It also presents trends to highlight the health and socio-economic context in which community action is taking place.
Community Action to Strengthen Health Equity in the Spanish Basque Country
Abstract
Health and well-being extend beyond the absence of illness to include psychological and emotional stability, as well as active participation in community life. Initiatives to improve health and well-being initiatives are often more effective and sustainable when developed in partnership with local communities and public authorities (Popay et al., 2023[1]). In recent decades, many OECD countries have increasingly embraced community action as a key approach to promoting health. In line with this trend, the Basque Government, and specifically the Department of Health of the Basque Country (DHBC, Departamento de Salud del Gobierno Vasco), is working to develop a dedicated strategy to promote and better organise community action across the region. This report supports the DHBC in its efforts by providing an assessment of the current state of community action to improve health and well-being in the Basque Country, by identifying the main challenges to be addressed and providing targeted recommendations for the strategy.
Although the definition of community action varies across application fields, target populations and institutions, there is broad agreement across the literature on the concept that community action includes a community-centred approach, direct implication of the community in programmes and activities, and a multidisciplinary nature of the public policies to be implemented. Community may refer to a geographical area or to a community of people with common characteristics such as a shared interest or affinity (religion, sport, art, etc.) or a particular disease or diagnosis. The defined area can be as small as a neighbourhood, or it can be a city or a region, and with the increasing digitalisation of society, it can even refer to virtual communities linked by social networks. Other terms for community action present in the literature include community engagement, community empowerment, and collective control (Popay et al., 2023[1]). This report employs the term “community action” as a generic term and, in particular, focusses on community action for health and well-being.
1.1.1. Despite definitional differences, international frameworks highlight core elements of community action
The concept of community action was first mentioned by the World Health Organization (WHO) at the Alma Ata Conference in 1978 as an important part of primary healthcare. It gained further prominence in 1986 when it was included in the Ottawa Charter (WHO, 1986[2]). In 1998, the term community action was included in the WHO Health Promotion Glossary, where it is defined as collective efforts by communities directed towards increasing community control over the determinants of health and thereby improving health (WHO, 1998[3]). In 2017, through a framework development workshop on community action in combination with additional research on scientific and grey literature, the WHO elaborated a definition of community action (WHO, 2017[4]). In 2020, as part of the Universal Healthcare Coverage Goal of the UN Sustainable Development Goals and building on the 2017 community action framework (WHO, 2017[4]), the WHO published a guide on how to use community action to help achieve the health goals and targets of the SDGs (WHO, 2020[5]). Key principles identified by the WHO to be considered in any community action process include trust, accessibility (both geographic and social exclusion concerns), contextualisation (taking into account local language, culture, and context), as well as equity, transparency, and autonomy.
The National Institute for Health and Care Excellence (NICE) is a public body in the United Kingdom under the supervision of the Department of Health and Social Care that provides guidance and advice to improve health and social care, including on community action. NICE defines community action as approaches to maximise the involvement of local communities to improve health and well-being and reduce health inequalities (NICE, 2016[6]). NICE requires that the minimum level of community involvement is participation in needs assessment; merely informing the community does not qualify as community action. Additionally, the NICE definition includes reducing health inequalities as a desired outcome of community action, alongside improving health and well-being. It emphasises the importance of ensuring the participation of those most at risk of poor health to guarantee a fair allocation of resources to the local community.
In the United States, the Center for Disease Control and Prevention (CDC) has long promoted the importance of community action. It established the Committee for Community Engagement in 1995 and published the booklet Principles of Community Engagement in 1997 – later updated in (Center for Disease Control and Prevention, 2011[7]) – which defines community engagement as the process of working collaboratively with and through groups of people who are affiliated by geographic proximity, special interests, or similar situations to address issues affecting the well-being of those people. The CDC considers a definition of community based on virtual links between people. The definition of the virtual perspective recognises that people increasingly rely on virtual communication to access information, meet people, and make decisions that affect their lives. A community in this perspective is a social group with a common interest that interacts virtually in an organised way. This approach recognises that individuals may identify with different communities than those in which others would place them.
The CDC also considers a definition of community based on virtual links between people. The definition of the virtual perspective recognises that people increasingly rely on virtual communication to access information, meet people, and make decisions that affect their lives. A community in this perspective is a social group with a common interest that interacts virtually in an organised way. This approach recognises that individuals may identify with different communities than those in which others would place them.
The CDC defines five levels of community involvement. From the lowest to the highest, they are:
1. Outreach, which consists of providing information to the community.
2. Consult, where feedback and information are sought from the community and entities share information.
3. Involve, which includes the community to a greater extent.
4. Collaborate, where partnerships with the community are formed on each aspect of the project from development to solutions.
5. Shared Leadership, where the final decision making is at community level and all entities have formed strong partnerships.
1.1.2. The Basque definition emphasises the social context of health
Based on the concepts explained above, and taking into account the Spanish and Basque contexts, the health authorities of the Basque Country have adopted its own definition of community health and community action. In the last decade, both the Spanish and Basque legislation have moved towards facilitating and enhancing community action, adopting an approach to public health based on social determinants of health from a community and multi-disciplinary perspective. The definitions of community action in the Basque Country are based on principles of equity, accessibility, transparency, and community autonomy.
Community health is the collective expression of the health of a defined community, determined by the interaction between the characteristics of individuals, families, the social, cultural, and environmental milieu, as well as health services and the influence of social, political, and global factors (Department of Health, 2024). While this concept comprises considerations for physical and emotional wellness, it is far broader and more inclusive. The definition follows from the Constitution of the WHO, which defines health as: a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity (WHO, 1998[3]).
Community action is the promotion and facilitation of co‑operative social relationships among individuals within a specific area or living space. One of the cornerstones of health promotion, it enables individuals to gain control over their health to improve it. This process is not solely individual, however, but is intrinsically linked to community health and has a threefold transformative function: improving the living conditions of those who inhabit the shared space; strengthening social bonds and cohesion, including integrating excluded groups; and enhancing individual and collective capacities for action in processes aimed at improving health and well-being.
Recent trends have transformed the health landscape in most OECD countries, including Spanish regions, and among them also the Basque Country. In the past decades, there has been a strong shift in importance from communicable to non-communicable diseases, which has a major impact on health outcomes and health systems (Gottfredson, 2021[8]). More than one‑third of people aged 16 and over reported living with a longstanding illness or health problem on average across 24 OECD countries (2023[9]). Furthermore, heart attacks, strokes and other circulatory diseases caused more than one in four deaths, while around one in five deaths were related to cancer (see Figure 1.1). Population ageing largely explains the predominance of deaths from circulatory diseases – with deaths rising steadily from the age 50. Respiratory diseases were also a major cause of death, accounting for 9% of deaths across OECD countries and, more recently, diseases like Alzheimer’s, which preliminary affect is more prominent among older individuals, have also become an important cause of death.
Excess weight, unhealthy diet, and insufficient physical activity are major risk factors for diseases such as cancer, cardiovascular conditions, and diabetes. In 2021, an average of 54% of adults across 32 OECD countries were overweight or obese, with 18% classified as obese. The OECD estimates that alcohol consumption above recommended levels – more than one drink per day for women and one and a half drinks per day for men – accounts for medical costs equal to about 2.4% of total health expenditure each year. Although tobacco consumption has declined significantly in recent decades – in the Basque Country, for instance, it dropped from 27% to 17% among men and from 20% to 14% among women between 2007 and 2023 – it remains a leading cause of numerous health issues, including cancer, stroke, circulatory disorders, and chronic respiratory conditions. Combined with the impact on labour force productivity, exceed alcohol consumption is estimated to reduce GDP by 1.6% annually in OECD countries over the next 30 years.
In 2021 or nearest year
Source: OECD Health Statistics (2023[10]), https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.
In the last decades, there has been an increased global awareness of the social determinants of health – the non-medical factors that influence health outcomes. These factors are related to the social (like access to education and decent housing), economic (like income and social protection), and environmental (like living in safe neighbourhoods) conditions in which people are born, live and age. According to the WHO,1 social determinants may influence health more than healthcare quality or lifestyle choices, accounting for 30‑55% of health outcomes. In parallel to the changing health landscape, socio‑economic health inequalities have worsened over time, and this has been accentuated recently as COVID‑19 has disproportionately affected poorer populations (Berchet, Bijlholt and Ando, 2023[11]). In most OECD countries, people with the lowest level of education are twice as likely to report their health as poor compared to those with post-secondary education. Similar patterns are observed in other health indicators, such as limitations in daily activities and the prevalence of multiple chronic conditions. This is partly explained by poorer health behaviours, such as smoking and obesity, which are more prevalent among less educated people, as well as poorer working and living conditions. For similar healthcare needs, people in the lowest income group are less likely to make a medical appointment than those in the highest income group. Preventive services such as cancer screening or dental care are also more frequently used by higher-income groups in most OECD countries.
The importance of new health challenges and the social determinants of health is also increasing in the Basque Country. The Basque Health Survey (2023[12]) reveals that, while the self-perception of good health has improved between 2007 and 2023, symptoms of anxiety and depression have increased, particularly among women (see Figure 1.2). Differences across socio-economic groups are also significant. For example, Panel A of Figure 1.3 shows that anxiety and depression symptoms affect 25% of men belonging to the lowest socio-economic group, compared to 11% in the highest socio-economic group. Also, more than 46% of women in the lowest socio-economic group suffer from chronic diseases, compared to 39% of men in the same group and to 40% of women in the highest socio-economic group (Panel B).
As percentage of population by sex, 2007-2023
Source: Encuesta de salud del País Vasco (2023[12]), https://www.euskadi.eus/introducion-escav23/web01-a3osa23/es/.
As percentage of population by sex, 2023
Source: Encuesta de salud del País Vasco (2023[12]), https://www.euskadi.eus/introducion-escav23/web01-a3osa23/es/.
Health-in-all-policies is one of the ways to address new pressing health challenges. By integrating health perspective into decision making across various sectors – such as education, housing, and employment – this approach promotes a more holistic response to public health issues. It recognises that the social determinants of health, such as living conditions and income inequality, play a critical role in shaping health outcomes. Evidence in OECD countries shows that policies targeting social determinants reduce health disparities and improve overall population health (OECD, 2019[13]). For example, access to high-quality education and housing not only improves well-being but also reduces the long-term burden on health systems.
Community action is a key element of the broader health-in-all-policies strategy. It plays an important role in empowering individuals and communities to take control of their health. The Ottawa Charter for Health Promotion in 1986, which advocates for Health for All by the year 2000, recognises empowering people to take greater control over their health as a key element for building healthier societies. The conclusions of the 4th International Conference on Health Promotion in Jakarta (1997) reaffirms this approach, listing the strengthening of community action as one of strategies to achieve this goal. The WHO Commission on the Social Determinants of Health report (2008[14]) reinforces the importance of community action in empowering communities and building local capacity. The WHO Framework on Integrated People‑Centred Health Services (2016[15]) further emphasised community action as one of its core strategies.
Evaluations of community action demonstrates its effectiveness in improving health behaviours and outcomes, particularly among disadvantaged populations. A meta‑analysis by O’Mara-Eves et al. (2015[16]) finds that community action positively impacts a wide range of health outcomes. Furthermore, Cyril et al. (2015[17]) show that community action projects are especially beneficial for disadvantaged groups, contributing to a reduction in health inequalities. However, Milton et al. (2011[18]) find no direct evidence of community projects affecting health outcomes. Nonetheless, they show that these initiatives may have an indirect long-term effect on health outcomes, as they lead to improvements in housing, crime reduction, social capital, and community empowerment.
The body of evidence suggesting a positive impact on health has been rapidly growing. Using bibliometric analysis and big data techniques, Yuan et al. (2021[19]) conduct a comprehensive literature review on community action in public health. Results show that since 1980, the number of publications of community action in public health has been steadily increasing year-on-year. Between 1980 and 2003, the number of publications grew smoothly accounting for 9% of the total publications while the period between 2004 and 2020 is characterised by exponential growth, accounting for 91% of publications. Community action in public health has been one of the most influential and dynamic fields of health policy research. The study provides an interesting analysis of the keywords appearing with the strongest intensity in the publications. Among the top ten keywords are empowerment, community participation, aid, association, health promotion and community-based participatory-research. Based on the analysis results, the study provides recommendations to policymakers, practitioners, and researchers:
Policy frameworks should be built for engagement to happen in a co‑ordinated way.
Novel formal or informal measures should be implemented to address critical issues around ownership, empowerment, education, mobilisation, and sustainability of health improvements.
Evaluation schemes should not only emphasise the final effect, but also facilitate the process of dynamic control and adjustment by combining qualitative and quantitative methods.
References
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[7] Center for Disease Control and Prevention (2011), Principles of community engagement - Second edition, https://stacks.cdc.gov/view/cdc/11699.
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[16] O’Mara-Eves, A. et al. (2015), “The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis”, BMC Public Health, Vol. 15/1, https://doi.org/10.1186/s12889-015-1352-y.
[9] OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/7a7afb35-en.
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[13] OECD (2019), Health for Everyone?: Social Inequalities in Health and Health Systems, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/3c8385d0-en.
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