Community Approach Research Articles

Public Health Literacy: a concept to develop – Qualitative study among public health professionals

Abstract Background Health literacy can be defined as individuals’ motivation and skills to access, understand, evaluate, and utilize information to make decisions about their health. Despite Sorensen’s widely used definition encompassing both individual and population levels, also known as Public Health Literacy, it remains poorly detailed and is rarely taken into account by measurement tools. As evidenced by the Covid-19 health crisis, limited public health literacy impacts reluctance to accept government recommendations, vaccine hesitancy, and fosters mistrust of science and conspiracy theories in the health field. The main objective of this study was to derive specific public health knowledge and skills from public health professionals for the general population constituted the first step of the development of a public health literacy measurement tools. Methods A qualitative study, based on ten semi-structured interviews with public health professionals from various settings (academic, hospital, health prevention, and promotion), working across various public health fields (nutrition, sexual health, mental health), has been conducted since March 2024. Results Preliminary analysis identified three main themes: (1) fundamental concepts including identification of health determinants, epidemiology and the purpose of public health interventions, (2) critical skills including the assessment of the level of evidence and reliability of public health information, and (3) civic orientation including environmental impact on health and community approach to interventions. Conclusions These detailed insights will guide the creation of a valid measurement tool for public health literacy. This will facilitate the investigation of specific impacts on people’s adherence to public health interventions or messages and the development of actions targeting literacy in a more holistic manner. Key messages • Specific public health dimensions have been identified to enrich the existed definition of health literacy. • Public health concepts, reliability of public health information and community approach constitute the core of public health literacy.

Improving cooperation between Hospital and the Community Mental Health Services of Nicosia

Abstract In order to accelerate psychiatric reform in Cyprus we took advantage of JA Implemental during the pilot implementation of Belgium best practices on facilitating the transfer of mental patients from mental hospital to the community mental health services. A multidisciplinary network has been organized between Athalassa Mental Hospital, that is the only mental hospital in the Republic of Cyprus performing 700 patients admissions yearly, and the Community Services of sector 1 and sector 2 of Nicosia Community Mental Services. The network meets regularly in order to facilitate therapeutic culture change in the direction of increasing the percentage of hospital patients that are motivated and prepared to be voluntarily moved for care by the community multidisciplinary teams. This is going to facilitate discharges from hospital, decrease duration of hospitalizations, decrease the frequency of hospitalizations and revolving door readmissions. This increased cooperation is being built on the basis of administrational procedures and clinical protocols that are based on multidisciplinary consensus. The evaluation starts multidisciplinarily in the hospital. A liaison community mental nurse takes part I the evaluation and motivation of the patients before the discharge from the hospital. A written informed consent process takes place in the hospital for the voluntary admission in the community mental health care setting. Also an effort is being made for early written referrals and appointments for community psychiatrist, psychologist, social worker and occupational therapist. This pilot action plan is going to increase cooperation of the mental hospital with the community mental health services, to decrease stigmatization and reform therapeutic culture to the direction of treatment in the community and recovery approach, according to Belgium best practices included in the JA Implemental project.

The Icehearts Europe Implementation Guide to promote a mentoring programme for youth mental health

Abstract Issue/problem In Europe, 9 million young people (10-19) suffer from mental disorders and 70% of children and adolescents with mental health problems do not receive appropriate interventions at a sufficiently early age. Moreover, during the Covid-19 pandemic a high prevalence of depressive symptoms, anxiety and sleep disorders was observed in the population aged 4-19 years. The Icehearts Europe project (funding: EU4Health 2022 Programme) aims to disseminate at EU level a long-term programme for supporting health and wellbeing of disadvantaged children and adolescents. It is inspired by the Finnish best practice Icehearts, a 12-year long mentoring programme. Five pilot countries (Italy, Denmark, Spain, Slovenia, Estonia) will test the model to raise European awareness of how it works and to get more countries and organisations involved. Description of the problem Icehearts Europe is a preventive mentoring programme based on team sports, recreation and school support activities, with a child-centred community approach. To facilitate its implementation, a practical guide has been developed for grassroots sport and social promotion organisations to help them implement the model in their own contexts. The guide is the result of both a multisectoral cooperation between grassroots sport, health, universities, NGOs, and qualitative study activities (bibliographic research, study visit, group work, analysis of the situation and needs of local contexts). Results From February 2024 the Icehearts Europe Implementation Guide is available in six languages at https://www.icehearts.eu/resources. It is now being adapted by the Icehearts Europe partners into an online training programme for managers. Lessons The guide has incorporated lessons learnt from the Finnish model, considered as an evidence-based approach. It contains several operational tools to implement Icehearts Europe and can be adopted using different approaches: there is no one-size-fits-all solution. Key messages • Developed as a support to the Icehearts Europe piloting partners and as a basis for a fully-fledged online training programme for future Icehearts Europe managers. • To facilitate the implementation of early interventions to promote health and wellbeing of children and adolescents and enable them to cope with disadvantaged conditions.

Factors for sustainable cross-sector collaboration for health equity: a Dutch qualitative study

Abstract Background Cross-sectoral collaboration between healthcare and the social domain is necessary to address the complexity of health inequity. However, this collaboration is often unsustainable in the long-term, for example due to temporary budgets and professionals changing jobs. We explored the factors that facilitate or restrain sustainable cross-sectoral collaboration by applying an interdisciplinary theoretical lens combining insights from relevant frameworks from governance, interprofessional learning and health policy. Following, we applied the framework in an ‘Integrated Community Approach’ in two Dutch cities (Utrecht and Amersfoort). Methods A qualitative research was conducted, involving 32 semi-structured interviews with professionals involved in an ‘Integrated Community Approach’ in the two Dutch cities in 2022 and 2023. Participants worked at various levels of the municipality, or as a local professional in the medical or social domain in the community. Thematic analysis and a deductive approach were employed- based on the theoretical framework. Results We identified nine components as important for sustainable cross-sectoral collaboration. Whether these components acted as facilitator or barrier varied between participants, depending on their position and organizational context. The nine components could be summarized into three main mechanisms: 1) the foundation for collaboration, which is dependent on having a shared vision and the competencies to engage residents; 2) a pre-condition, which is having support at management level and having the right resources; 3) support, which is provided by data and flexibility. Conclusions Long-term cross-sectoral collaboration is important, complex and depends on various interconnected factors. To improve cross-sectoral collaboration in the long term, it is necessary to disentangle each theme and conduct in-depth analysis of each one individually to facilitate deeper understanding of the context and problem. Key messages • Collaboration between medical and social sectors is challenging, yet significance is clear. While the start is evident, sustaining the ‘how’ is unclear. • The opportunities and obstacles of cross-domain collaboration vary among stakeholders, influenced by both their organization and position within it.

Knowledge, attitudes, and practice of primary care professionals regarding community activities: a descriptive study.

Promoting health via a community approach is one of the most effective strategies for reducing the current incidence of chronic diseases. Primary care (PC), through the implementation of community activities (CA), has the potential to achieve this goal. Yet the implementation of CA at health centers is not standardized and is often thanks only to the voluntariness of health professionals. To ascertain the knowledge, attitudes, and practices of PC professionals regarding the implementation of CA. We carried out a cross-sectional study by circulating a self-administered online questionnaire on CA, across the period December 2022 through June 2023 in Galicia (Spain). All health professionals working in the Galician Health Service PC setting were invited to participate. A total of 521 health professionals participated in the study. They included all types of PC health professionals (physicians, general and specialist nurses -midwives, pediatrics, family and community, mental health- and social workers), including residents in training. Only 14.8% and 12.5% of professionals correctly identified CAs and social prescription (SPr) interventions, respectively. Furthermore, 93.9% recognized that the development of CA in health centers was deficient. Despite this, 76.5% showed a good attitude toward participation in CA. PC professionals find it difficult to identify CA and SPr interventions. Therefore, it is necessary to improve the training of these professionals in the implementation of CA with a view to enhancing population health, reducing the incidence of chronic diseases, and helping lessen the healthcare burden of the health system.

Religious Approaches to Bioethical Reasoning: Bridging Values and Ethics

Religious traditions exert a profound influence on bioethical reasoning, shaping how different communities approach complex ethical issues like end-of-life care, genetic manipulation, and medical interventions. This study investigates the diverse methodologies employed by various religions, focusing on how scriptural interpretation and ethical principles inform their bioethical frameworks. By conducting a comparative analysis across major world religions, the research highlights both the distinct and shared approaches these traditions take toward navigating bioethical dilemmas. Case studies and contemporary examples are examined to illustrate how religious moral reasoning influences decision-making in areas such as ventilator use, feeding tubes, and genetic interventions. The study shows that although religious traditions offer a strong basis for ethical reasoning, their values frequently clash with secular perspectives, making consensus difficult in multicultural societies. Resolving these conflicts is vital for cultivating ethical harmony and encouraging cross-cultural dialogue.

We Don’t Have a Health Problem, We Have a Village Problem

Post-industrial societies often lack the social embeddedness that citizens require to fully participate in the civic, environmental, and economic life of their communities. Such an erosion of the social fabric represents a health hazard. Growing awareness, among clinicians and their health allies, of this social malaise and its correlation with poor health outcomes has led to an increased focus on population health and community approaches. It has also given rise to new health programmes aimed at redirecting the emphasis towards socialisation, such as social prescribing, which centres around the referral of patients to community-based activities. The community-building approach advocated here views health as tied to socio-political, economic, and environmental conditions, and while not discounting the value of individual agency, it asserts the need for a collective approach to health creation and the pursuit of social and economic justice for all. Hence, the main argument here is that we do not have a health problem _per se_, but rather a village problem.

Analysis of the Implementation of the Hypertension Control Program Using Linear Regression Test

Hypertension is a condition that is often encountered. Hypertension is a condition when blood pressure rises. Risk factors that can cause hypertension are age, race, gender, lifestyle, sodium consumption, smoking, alcohol consumption, stress level, and education. The urgency of this research is that the number of hypertension patients at the Purwodiningratan Surakarta Health Center experiences a spike every year. Based on a preliminary study at the Community Health Center, data was obtained that the number of hypertension patients in the last five year period experienced a spike, then fell, then spiked again. The objective problem of this research is the increase in hypertension patients, so it is necessary to research the relationship between knowledge, attitudes and family support and efforts to control hypertension. The importance of this research is a manifestation of efforts to control hypertension which continues to experience a surge using interview methods and distributing leaflets with the aim of a community approach. The aim of the research is to analyze the magnitude of the impact of the hypertension control program using the swallow method (interviews and leaflets). The research approach used cross sectional. The sample was 77 hypertensive patients at the Community Health Center. The sampling technique used the accidental sampling method based on inclusion and exclusion criteria. The statistical test uses a linear regression test at a significance level of 0.05.

Allocation of Microgrid-Forming resources for distribution systems reliability improvement

This paper proposes a novel method to allocate distributed generation and energy storage as Microgrid-Forming Resources (MFR) to improve the reliability of medium voltage (MV) grids. A graph-based approach is used, which simplifies the circuit analysis and reduces computational time when compared to exhaustive search methods. First, a medium voltage substation-level Nodal Fault-Effect Matrix (NFEM) is derived from the feeder’s topology, which is used for predictive reliability calculations, and calibrated with historical data. Second, a reduced set of scenarios of MFR allocation are generated using a graph community approach and evaluated in terms of reliability improvement and power and energy requirements of the distributed resources. Two case studies are presented based on real grids with different reliability characteristics and the results indicate that the proposed approach is an insightful tool for distribution system planners to evaluate the integration of microgrids to improve system reliability.

Spinoza, Liberation From Causation, and Community Health Promotion.

What sense does it make to say that a new program implemented in a community with roots as old as evolution caused an observed health benefit? Evaluation of community approaches has often sought to isolate the causal roles of interventions. Central to this is the assumption that there are causes to be proven and isolated. Benedict Spinoza (1632-1677) dismissed the concept of cause, arguing that all things, "substances," are not caused but simply are. Actions of things in nature can influence each other, e.g., erosion of a mountain, but their substance, the mountains simply are. For Spinoza, satisfaction in life comes from realizing and acting in accord with our substance, but this requires communities that support such realization and action. Thus, communities and the vast influences they contain are central to human welfare. Interventions within them do not cause benefits but join with the history, culture, and numerous other features of the community in becoming part of how the community influences its members. Implications include a) expanding the social ecological model fully to embrace multiple influences - including innovative programs - and interactions among them, and c) varied research methods to identify practical lessons about how communities may adopt and incorporate innovations to engender change, rather than a catalogue of interventions that are supposed to change them.

From food insecurity to health equity: multidimensional approaches for Philippine low-income communities.

From food insecurity to health equity: multidimensional approaches for Philippine low-income communities.

Digital Eye Strain: Updated Perspectives.

Digital eye strain (DES) is a growing worldwide concern because digital devices are prevalent in both our work and home lives. The purpose of this review was to summarize clinically relevant and evolving key topics related to DES. A PubMed.gov search was conducted on or before June 8, 2024. No date restrictions were used during the primary search. The search was aimed at detecting all articles related to DES; thus, the search terms only included "digital eye strain" or "computer vision syndrome". The two most used, validated DES questionnaires are the Computer Vision Syndrome Questionnaire (CVS-Q) and Computer Vision Symptom Scale (CVSS17). The world-wide prevalence of DES ranges from 8.2% to 100% depending upon the subjects evaluated and the method used to evaluate them. The most common DES symptoms include headache, eye strain, eye redness, eye itching, tearing, photophobia, burning sensation, blurred vision, eye pain, neck and shoulder pain, and eye dryness. Ocular surface symptoms in DES are integrally tied to decreased blink frequency, which causes ocular surface desiccation, increased osmolarity, and dry eye-like symptoms. The most studied DES-specific treatments are improving subjects' environment, artificial tears, blinking exercises, and near work breaks. DES is a highly prevalent condition that should be regularly screened for in clinic with a validated diagnosis instrument. While there are several treatment options, the community's treatment approach is evolving and primarily focused on treating the visual and dry eye-like symptoms associated with the condition.

Development and application of a rapid research prioritisation process for identifying health research priorities in low- and middle-income countries: the RAPID-RP stakeholder analysis

Background Health research should be locally prioritised by key stakeholders to ensure the best use of available resources, maximum likelihood of research leading to uptake into policy and practice and relevance to the needs of the potential beneficiaries. Established approaches are complex and time-consuming, therefore not feasible in settings where prioritisation is uncommon and time is limited. Objectives We developed and applied a simple, rapid research prioritisation approach to elicit the views of stakeholders. Setting and participants This was a collaboration between a multidisciplinary group of United Kingdom academics, the International Primary Care Respiratory Group and primary care respiratory researchers from four low- and middle-income countries: Brazil, China, Georgia and North Macedonia. We identified 10 topics for research prioritisation through workshops involving 26 topic, methods and local context experts, and considering the programme remit, to develop, adapt and evaluate culturally appropriate community and behavioural approaches for the prevention, early identification and management of chronic obstructive pulmonary disease in primary care. Design and methods In each setting, local research teams convened stakeholder groups of patients, clinicians, managers/policymakers and researchers. Each group briefly discussed the 10 potential research study topics. Discussions were facilitated using short vignettes for each topic, and participants were encouraged to consider importance, feasibility and equity. Individual participants rated each study on a three-point traffic light scale, then ranked them following a facilitated discussion on what drove the ratings. The research team rated then ranked each study considering three further criteria (international novelty, potential for future funding and capacity building on a five-point scale). Within each group, ranks were summed to create a final rank order which guided our research programme and provided insight for future projects. Results In each country, four to eight members attended each stakeholder group. The engagement process was completed in less than 4 hours and feedback was very positive, especially from patients who valued the opportunity to contribute to research decision-making about their own condition. Ranking varied to some extent between groups and settings, but there was consistency around topics that were prioritised among the top five in all groups (identifying efficient chronic obstructive pulmonary disease screening test strategies, evaluations of lung age to aid smoking cessation, feasibility of locally adapted pulmonary rehabilitation, clinical education for primary care staff) and study topics that consistently ranked low (use of e-cigarettes for smoking cessation, weight management to improve chronic obstructive pulmonary disease symptoms and handwashing to reduce infections). Limitations Despite attempts to maximise inclusivity and diversity, stakeholders were mainly limited geographically to the centres where researchers were based, potentially limiting generalisability of views across the countries. Facilitator styles varied and may have influenced some of the discussions and potentially the ranking. Conclusions Despite some limitations, we demonstrated the feasibility and acceptability of the rapid research prioritisation approach stakeholder analysis for identifying locally relevant research priorities in low- and middle-income country settings. Future work Further validation is needed for aspects of the process. We have identified some useful lessons from our evaluation of the process, to facilitate future use of this approach. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 16/137/95.

Forging Bonds: Restorative Justice Approaches for African American Communities

Forging Bonds: Restorative Justice Approaches for African American Communities

Interventions to Mitigate the Impact of COVID-19 Among People Experiencing Sheltered Homelessness: Chicago, Illinois, March 1, 2020-May 11, 2023.

Objectives. To compare the incidence, case-hospitalization rates, and vaccination rates of COVID-19 between people experiencing sheltered homelessness (PESH) and the broader community in Chicago, Illinois, and describe the impact of a whole community approach to disease mitigation during the public health emergency. Methods. Incidence of COVID-19 among PESH was compared with community-wide incidence using case-based surveillance data from March 1, 2020, to May 11, 2023. Seven-day rolling means of COVID-19 incidence were assessed for the overall study period and for each of 6 distinct waves of COVID-19 transmission. Results. A total of 774 009 cases of COVID-19 were detected: 2579 among PESH and 771 430 in the broader community. Incidence and hospitalization rates per 100 000 in PESH were more than 5 times higher (99.84 vs 13.94 and 16.88 vs 2.14) than the community at large in wave 1 (March 1, 2020-October 3, 2020). This difference decreased through wave 3 (March 7, 2021-June 26, 2021), with PESH having a lower incidence rate per 100 000 than the wider community (8.02 vs 13.03). Incidence and hospitalization of PESH rose again to rates higher than the broader community in waves 4 through 6 but never returned to wave 1 levels. Throughout the study period, COVID-19 incidence among PESH was 2.88 times higher than that of the community (70.90 vs 24.65), and hospitalization was 4.56 times higher among PESH (7.51 vs 1.65). Conclusions. Our findings suggest that whole-community approaches can minimize disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission between vulnerable populations and the broader community, and reinforce the benefits of a shared approach that include multiple partners when addressing public health emergencies in special populations. (Am J Public Health. 2024;114(S7):S590-S598. https://doi.org/10.2105/AJPH.2024.307801).

Development of a Maturity Model for Medical Patient Registries - A Community Approach.

Development of a generic model to visualize the potential for use and further development of registries to assess the suitability of the registry for a specific purpose. Multi-stage community approach. The maturity model has 9 categories with 105 items. The purpose of the registry is mapped via potential usage dimensions. Important for acceptance is the appropriateness of the requirements in relation to the purposes.

The whole community? Assessing FEMA’s inclusion of Tribal governments in hazard mitigation efforts

The Federal Emergency Management Agency (FEMA) has long advocated for what it calls a “Whole Community approach” to disaster resilience and recovery. This philosophy holds that the priorities of all governmental, commercial, and interest groups should be considered, and their capabilities leveraged, in preparing for and responding to disasters. According to FEMA, federally recognized Tribal governments are part of the “Whole Community.” In this paper we use systematic content analysis techniques to examine policy documents derived from the Hazard Mitigation Assistance grant program to assess whether and how FEMA has taken the concrete policy steps necessary to include Tribal governments in the “Whole Community.” We find that while FEMA has expressed interest in a more equitable and accessible program that serves the needs of Tribal governments, it has taken few practical steps toward this goal.

A systematic literature review on environmental, agronomic, and socioeconomic factors for the integration of small-scale coffee producers into specialized markets in Oaxaca, Mexico

The coffee sector’s challenges, such as low and volatile prices, prompt adopting strategies focused on product differentiation, including high-quality specialty coffee. Nevertheless, documented evidence shows that small producers in Oaxaca, Mexico, are not equally benefiting from this market opportunity compared to other states in Mexico, such as Veracruz or Chiapas. This review article identifies and analyzes the factors in integrating small Oaxacan producers into the specialty market. A total of 138 scientific contributions were analyzed, emphasizing three thematic axes: (1) Trends and behavior of the coffee market. (2) Factors to enable the production of high-quality coffee, and (3) Current situation and challenges of small coffee producers in the specialized market. We found that coffee quality depends on the environment (mainly altitude, temperature, and geographical conditions) and agronomic, genetic, and socio-economic factors. Moreover, agronomic and genetic factors should focus on choosing coffee varieties suited to the environmental conditions of the farm and adopting innovations in production, harvest, and post-harvest processes. The most significant socio-economic factors that hinder small coffee producers’ participation in the specialized market include but are not limited to, lack of information, social connection, and financial resources. However, in the literature analyzed here, it was also possible to identify specific farmworker experiences that operate with a community approach and have inserted their small producers into high-quality market transactions. For this reason, this article suggests that the standardization model of quality from the collective approach within the community-based enterprise is a sustainable and inclusive alternative to achieve the goal: the insertion of small Oaxacan coffee producers into the more significant specialty market.

Scale up of the learning circles: a participatory action approach to support local food systems in four diverse First Nations school communities within Canada

BackgroundAddressing Indigenous food security and food sovereignty calls for community-driven strategies to improve access to and availability of traditional and local food. Participatory approaches that integrate Indigenous leadership have supported successful program implementation. Learning Circles: Local Healthy Food to School is a participatory program that convenes a range of stakeholders including food producers, educators and Knowledge Keepers to plan, implement and monitor local food system action. Pilot work (2014–2015) in Haida Gwaii, British Columbia (BC), showed promising results of the Learning Circles (LC) approach in enhancing local and traditional food access, knowledge and skills among youth and adolescents. The objective of the current evaluation was therefore to examine the process of scaling-up the LC vertically within the Haida Nation; and horizontally across three diverse First Nations contexts: Gitxsan Nation, Hazelton /Upper Skeena, BC; Ministikwan Lake Cree Nation, Saskatchewan; and Black River First Nation, Manitoba between 2016 and 2019.MethodsAn implementation science framework, Foster-Fishman and Watson’s (2012) ABLe Change Framework, was used to understand the LC as a participatory approach to facilitate community capacity building to strengthen local food systems. Interviews (n = 52), meeting summaries (n = 44) and tracking sheets (n = 39) were thematically analyzed.ResultsThe LC facilitated a collaborative process to: (1) build on strengths and explore ways to increase readiness and capacity to reclaim traditional and local food systems; (2) strengthen connections to land, traditional knowledge and ways of life; (3) foster community-level action and multi-sector partnerships; (4) drive actions towards decolonization through revitalization of traditional foods; (5) improve availability of and appreciation for local healthy and traditional foods in school communities; and (6) promote holistic wellness through steps towards food sovereignty and food security. Scale-up within Haida Gwaii supported a growing, robust local and traditional food system and enhanced Haida leadership. The approach worked well in other First Nations contexts, though baseline capacity and the presence of champions were enabling factors.ConclusionsFindings highlight LC as a participatory approach to build capacity and support iterative planning-to-action in community food systems. Identified strengths and challenges support opportunities to expand, adopt and modify the LC approach in other Indigenous communities with diverse food systems.

Effects of Community Assets on Major Health Conditions in England: A Data Analytic Approach.

The broader determinants of health including a wide range of community assets are extremely important in relation to public health outcomes. Multiple health conditions, multimorbidity, is a growing problem in many populations worldwide. This paper quantified the effect of community assets on major health conditions for the population of England over six years, at a fine spatial scale using a data analytic approach. Community assets, which included indices of the health system, green space, pollution, poverty, urban environment, safety, and sport and leisure facilities, were quantified in relation to major health conditions. The health conditions examined included high blood pressure, obesity, dementia, diabetes, mental health, cardiovascular conditions, musculoskeletal conditions, respiratory conditions, kidney and liver disease, and cancer. Cluster analysis and dendrograms were calculated for the community assets and major health conditions. For each health condition, a statistical model with all community assets was fitted, and model selection was performed. The number of significant community assets for each health condition was recorded. The unique variance, explained by each significant community asset per health condition, was quantified using hierarchical variance partitioning within an analysis of variance model. The resulting data indicate major health conditions are often clustered, as are community assets. The results suggest that diversity and richness of community assets are key to major health condition outcomes. Primary care service waiting times and distance to public parks were significant predictors of all health conditions examined. Primary care waiting times explained the vast majority of the variances across health conditions, with the exception of obesity, which was better explained by absolute poverty. The implications of the combined findings of the health condition clusters and explanatory power of community assets are discussed. The vast majority of determinants of health could be accounted for by healthcare system performance and distance to public green space, with important covariate socioeconomic factors. Emphases on community approaches, significant relationships, and asset strengths and deficits are needed alongside targeted interventions. Whilst the performance of the public health system remains of key importance, community assets and local infrastructure remain paramount to the broader determinants of health.