Community Health Development Research Articles

Health literacy of community leaders in the prevention and control of COVID-19: A cross-sectional study

Community leaders in Thailand play an important role in preventing and controlling infectious diseases, especially during the COVID-19 pandemic. Hence, risk perception and adequate health literacy among these leaders influence the population. This cross-sectional study aimed to investigate the relationships among health literacy, risk perception factors, and the implementation of COVID-19 prevention and control. A self-administered structured questionnaire was administered to 1,338 community leaders in northeast Thailand to assess the level of implementation of COVID-19 prevention and control measures. Multiple logistic regression was performed to identify the influence of risk perceptions and health literacy on the prevention and control of COVID-19. Approximately 64% of the sample was male, and the participants had an average age of 50.51 ± 8.47 years. The factors associated with moderate and high levels of COVID-19 prevention and control among community leaders were moderate and high levels of perceived susceptibility (adjusted odds ratio [ORadj] = 3.01; 95% CI: 2.13–4.25; p-value < 0.001) and perceived severity (ORadj = 1.73; 95% CI: 1.22–2.45; p-value = 0.023) as well as adequate access (ORadj = 1.56; 95% CI: 1.08–2.25; p-value < 0.001) and adequate understanding (ORadj = 2.29; 95% CI: 1.34–3.93; p-value < 0.001), with a level of statistical significance of 0.05. The incorporation of health literacy and risk perception, especially in dimensions such as access, understanding, perceived susceptibility, and perceived severity, is essential for leaders to possess strong skills in community health development, particularly during crises such as the COVID-19 pandemic.

Tinjauan Sistem Pendaftaran Rawat Jalan di Puskesmas Kelurahan Klender Tahun 2023

Puskesmas is a functional health organization as well as a center for community health development. The Klender urban health center currently uses an online registration system and offline registration. This study aims to determine the online and offline outpatient registration system at the Klender Village Community Health Center in 2023. This research is a qualitative research. In this study, researchers directly observed the process of outpatient registration. Retrieval of research data is done by observation and interviews with registration officers. The results of the study found that online registration uses the Jaksehat application, patients do not need to come to the health center to register, patients come to the health center to validate queue numbers to the polyclinic only. Calling patients who register online is prioritized with a system of calling queue numbers 1-5, 11-15 and so on. Offline registration is done by having patients come directly to the puskesmas and queue to register. For calling patients, register offline after patients register online with queue numbers 6-10, 16-15, etc. The problems found in registration were the separate queues for patients who registered online and offline and there was a mismatch in calling patients according to the serial number of the queue. The conclusion in this study is that online registration of outpatients uses the Jaksehat application and offline registration is carried out using the system used by the puskesmas. It is expected that the puskesmas will separate the queues of patients who have registered online with patients who have registered offline.

Holistic Community Health Development In India: An Overview

Holistic Community Health Development In India: An Overview

Examining the Impact of a Behavior Modification Program on Disease Prevention Behaviors among Individuals at Risk of Diabetes: A Quasi-Experimental Investigation.

This study aimed to develop and test a behavior modification intervention to prevent type 2 diabetes (T2DM) among at-risk individuals. The primary goal was to compare diabetes prevention behaviors and fasting blood sugar levels between the intervention and comparison groups. This study utilizes a quasi-experimental design to develop a behavior modification intervention for preventing diabetes. It involves two groups, each with pre- and post-intervention assessments, comprising 60 at-risk individuals equally divided into intervention and comparison groups. The 8-week intervention includes components like risk assessment, dietary skill enhancement, exercise, stress management, and social media platforms (data recording training, follow-up visits, reminders, and visual aids). Data collection includes self-administered questionnaires and blood sugar level measurements. Statistical analysis involved paired t-tests for within-group comparisons and independent t-tests for between-group differences. The findings showed that the intervention group achieved significantly higher average scores in nutrition, exercise, and stress management, and had significantly lower average blood sugar levels compared to the comparison group. These results suggest that healthcare providers and policymakers should develop community health programs and public health policies that incorporate integrative care, leverage social media platforms, and foster collaboration with other health professionals to improve outcomes for individuals at risk of T2DM.

Socioeconomic Impact of Sports Tourism on Community Health Development in Kwara State, Nigeria

Sports, as a major global contributor to socioeconomic development of the society, has not been explored extensively. Therefore, the current study investigated the impact of sports tourism on the social, economic, and ecological development among the people of Kwara state, Nigeria. The study examined whether sports tourism would have a significant impact on the economic, social, and ecological development of people in Kwara state. Data was collected from a sample of 117 sportsmen and women employing a descriptive survey approach. The study probed into the multifaceted effects of sports tourism utilizing a meticulously designed questionnaire. Findings revealed that economic (c2=130.23), social (c2=159.50), and ecological development (c2=150.90) with p-values < 0.05 alpha value. The study concluded that sports tourism has a significant impact on the economic, social, and ecological development of people in Kwara state. Moreover, the study also suggested that sports tourism should be encouraged since it serves as a seasonal economic advancement for small- and large-scale business. Sports tourism is also helpful to address the social challenges that afflict rural communities thus supporting community health development.

Place, displacement, and health-seeking behaviour among the Ugandan Batwa: A qualitative study.

For many Indigenous Peoples, relationships to the land are inherent in identity and culture, and to all facets of health and wellbeing, physically, emotionally, psychologically, and spiritually. The Batwa are Indigenous Peoples of rural, southwest Uganda who have experienced tremendous social and economic upheaval, due to relatively recent forced displacement and land dispossession. This loss of physical connection to their ancestral lands has significantly impacted Batwa health, and also affected available healthcare options for Batwa. This exploratory study (1) identified and characterized factors that influence Batwa health-seeking behaviour, using acute gastrointestinal illness, a critical public health issue, as a focal point for analysis; and (2) explored possible intersections between the Batwa's connection to place-and displacement-and their health-seeking behaviour for acute gastrointestinal illness. Twenty focus group discussions, stratified by gender, were conducted in ten Batwa settlements in Kanungu District, Uganda and eleven semi-structured interviews were conducted with primary healthcare workers, community health coordinators, clinical officers, and development program coordinators. Qualitative data were thematically analyzed using a constant comparative method. Batwa identified several significant motivators to engage with Indigenous and/or biomedical forms of healthcare, including transition to life outside the forest and their reflections on health in the forest; 'intellectual access' to care and generational knowledge-sharing on the use of Indigenous medicines; and Batwa identity and way of life. These nuanced explanations for health-seeking behaviour underscore the significance of place-and displacement-to Batwa health and wellbeing, and its relationship to their health-seeking behaviour for acute gastrointestinal illness. As such, the results of this study can be used to inform healthcare practice and policy and support the development of a culturally- and contextually-appropriate healthcare system, as well as to reduce the burden of acute gastrointestinal illness among Batwa.

Evaluation of the achievements of community health center work program indicators for community health and development

Background: This evaluation research is essential as community health plays a crucial role in ensuring the well-being and productivity of a community. Assessing the performance of community health centers in community health development efforts is vital to understand the extent to which various programs and initiatives have achieved their goals and to identify areas that require improvement. Evaluation data provide a clear picture of the effectiveness and efficiency of various activity components, aiding stakeholders, including the government, healthcare institutions, and the community, in making informed decisions when designing, implementing, and enhancing community health programs. Purpose: To assess and analyze the performance of community health development efforts in various activity components, such as community dental health, traditional health practices, sports health, occupational health, and pilgrimage health. Method: This research adopts a qualitative approach with a focus on evaluating the performance of community health efforts at public health centers Keruak, East Lombok Regency. Data collection involves analyzing the performance assessment results, coverage data and performance levels of activity components like community dental health, traditional health practices, sports health, occupational health, and pilgrimage health. Research methods include observing the implementation process of programs, conducting interviews with healthcare personnel, public health centers managers, and the local community. Data analysis is conducted qualitatively by detailing the achievements and challenges faced in each activity component. Results: The results of community health development efforts reflect diverse achievements in several activity components. Community dental health efforts exhibit good performance with a coverage rate of 95.0%, while traditional health practices show less satisfactory performance, reaching only 40.0%. Sports health demonstrates good performance (98.3%), while occupational health exhibits less satisfactory performance (73.1%). Pilgrimage health efforts achieve 100% coverage, indicating good performance. However, the overall average performance of these activity components falls into the 'sufficient' category (81.28%). Evaluation and improvement are crucial, especially for components with less satisfactory performance, to enhance the overall effectiveness and efficiency of community health development efforts. Conclusion: Development efforts indicates significant variation among activity components. While community dental health and pilgrimage health efforts achieve good performance, challenges exist in traditional health practices and occupational health, displaying less satisfactory performance. Sports health efforts demonstrate good performance, and the overall average performance falls within the 'sufficient' level. Therefore, in-depth evaluation of components with less satisfactory performance is necessary, focusing on increasing community participation and improving infrastructure. Recommendations include enhancing information and education regarding traditional health practices and creating a supportive working environment for health. These efforts are expected to enhance the overall effectiveness and efficiency of community health development initiatives. Suggestion: Based on the performance results of community health development efforts, several recommendations can be proposed to enhance the effectiveness and efficiency of health programs. Concrete steps, such as improving information and education regarding traditional health practices, can increase community acceptance of these efforts. In addition to improving recommendations for community health programs, further research should aim to focus on aspects that support sustainable development.

The CSR program of PT Kalbe Farma Tbk in Providing Clean Water in Wonogiri, Central Java

The CSR program of PT Kalbe Farma Tbk, which provides clean water to Wonogiri in Central Java, has been running since 2013. Clean water is a basic human need and crucial for health and community welfare, daily activities, and productivity. Therefore, efforts are needed to meet the clean water needs of the community in Wonogiri, Central Java. This CSR program focuses on the sustainability of the health sector by considering economic, environmental, and health aspects, as well as social and administrative aspects (ESG). This research aims to understand how the CSR program of PT Kalbe Farma Tbk is implemented to provide clean water in Wonogiri, Central Java. In this study, the researcher used a qualitative approach and a case study as a research method to explain the implementation of the program. The provision of clean water by PT Kalbe Farma Tbk has proven to improve the surrounding community's welfare, health, and economic development. PT Kalbe Farma Tbk implements CSR programs as a sustainability initiative in the health sector, considering economic, environmental, social, and governance aspects (ESG).

Climate Change and Water Security Scenario of an Agrarian Locale in Upper Punjab

Climate change is exacerbating both water scarcity and water-related hazards as rising temperatures disrupt precipitation patterns and the entire water cycle. Water is crucial for all types of living creatures; therefore, its availability and quality are important for humans, too. However, water-related issues have increased all over the world, and people are facing more difficulties than in the past. Water scarcity is the most obvious issue, which results from the imbalance between water demand and supply. It has numerous negative effects on community health and societal development. This study was undertaken in the agriculturally oriented rural locale of district Rawalpindi in Pothwar, region of Punjab, Pakistan. The study primarily assessed the magnitude of water scarcity and, further investigated the impact of water scarcity on the health of the local community and looked into the problems faced by women and children. A sample size of one hundred respondents was selected using the probability technique of Simple Random Sampling. Both qualitative and quantitative techniques were used in collecting and analyzing data for this field research. The major sources of water in the locale are distant natural wells. The research indicated that local inhabitants faced many difficulties in tapping distant natural water resources to meet their daily needs. Water is generally stored in plastic drums and plastic tanks, but some local people have also constructed underground concrete tanks. The water used for drinking and meeting various others' needs is contaminated, impure, unclean and hard. As a consequence, several diseases such as diarrhea, vomiting, kidney disorders and jaundice are common in the locale inhabitants because of water scarcity, which forces the people to use water from contaminated resources. Further, they have to bear expenses on the disease treatment, and spend extra money for fetching water.

Study of defecation places and feces distribution in North Buton Regency

Background: Poor sanitation can likely contaminate drinking water, leading to the development of cholera and other deadly diseases. The number of people who defecate in the open worldwide has fallen by more than two-thirds over the past two decades. Data from the Community Health Development Division of the Southeast Sulawesi Health Office reports that the ODF level in Southeast Sulawesi as of today shows that it is already 59 percent of the total target of 60 percent. So efforts are needed in North Buton Regency to achieve the target of stopping open defecation that has been launched by the Indonesian government. Objective: The aim of this research is to examine defecation habits and places where feces are distributed in North Buton Regency. Methods: This type of research is quantitative descriptive, with a survey approach. The sample in this study was 3,640 houses. Each village/kelurahan is represented by 40 households taken using a simple random sampling technique. Results: The majority of respondents disposed of feces in private latrines, namely 2,769 (76.1%), while the least was defecation in ditches and ditches around people's houses, namely 2 (0.1%), and the majority of houses collected/distributed feces in dug holes. namely 2,369 (65.08%), while the least is accommodated/distributed directly in the river/lake/beach/sea, are15 (0.41%). Conclusion: Most people in North Buton Regency defecate in private latrines, and the resulting feces are channeled/discarded into dug holes in the ground.

High-Density Communities and Infectious Disease Vulnerability: A Built Environment Perspective for Sustainable Health Development

High-density communities have proliferated globally during rapid urbanization. They are characterized by a high population density and limited per capita public spaces, making them susceptible to infectious disease risks. The impact of infectious diseases in these communities, as evident during the COVID-19 pandemic, underscores their vulnerabilities. Yet, research on disease prevention in high-density areas remains limited. This study aims to investigate the relationship between the built environment and the transmission of infectious diseases in high-density urban communities, with a particular focus on the lessons learned during the COVID-19 pandemic. Utilizing Shenzhen city as a case study, this study collected data on the built environment and epidemic trends and involved a generalized linear regression analysis, aiming to understand the key built environment factors that affect epidemic spread in high-density areas. The results from the study revealed that high-density communities experience higher rates of infectious disease transmission compared to their medium- to low-density counterparts. The significant factors identified include land use mixture and walkability, with land use mixture showing the most substantial impact on infection rates. Through a combination of qualitative analysis and empirical research, we constructed a conceptual framework linking containment measures, non-pharmaceutical interventions, and the built environment. The findings emphasize the significance to focus on the health development of high-density communities and offer valuable insights for tailored urban planning and built environment design. These insights are crucial for promoting the healthy and sustainable transformation of existing high-density communities.

Web-Based Sukaraja Puskesmas Services Governance Information System

The Community Health Center is a functional health organization which is a center for community health development which also fosters community participation in addition to providing comprehensive services to the community in its working area in the form of main activities. Currently, at the Sukaraja Community Health Center, all data recording is still done manually using paper media. Because increasingly modern technology requires Puskesmas as one of the health service providers to always improve the quality of its services. The use of computers to process data is very necessary because it can provide benefits and convenience in patient care. In this case, community health centers are required to always improve the professionalism of their employees and improve their health facilities or facilities to provide satisfaction to the community using health services. The objectives to be achieved are: Designing a website-based health center management information system, Improving the conventional health center service system with a computerized system. And makes it easier to process patient data for outpatient, inpatient, pharmacy, counter registration, administration (printing certificates/referrals & health center reports) and general clinics using the waterfall method. The stages of the waterfall method are Requirements, design, implementation, integration, Maintenance. The website-based governance information system that has been produced in this design can process patient data from outpatient, inpatient, emergency health centers and pharmacy services. With this website-based community health center management information system application, data at the Sukaraja Community Health Center is now integrated through a database so that it can process data effectively and efficiently and help provide good services.

Gender-based roles, psychosocial variation, and power relations during delivery and postnatal care: a qualitative case study in rural Ethiopia.

The World Health Organization (WHO) strongly encouraged men to support women in receiving maternal healthcare. However, especially in developing countries, maternal healthcare has traditionally been viewed as an issue in women, with men making little or no contribution, even though sexuality and children are shared products. The study aims to understand how gender-based roles, psychosocial variation, and power relations are related to child delivery and postnatal care (PNC) services. The study was conducted in three rural districts of Oromia regional state, Jimma Zone, Ethiopia. An in-depth interview and focus group discussion were held with carefully chosen health professionals, health extension workers, community health development armies, and religious leaders. The data was collected, translated, and transcribed by experienced men and women qualitative researchers. For data analysis, ATLAS.ti version 9 was used. The data were coded and categorized concerning delivery and PNC service utilization. Independent and shared gender-based roles were identified as a means to improve maternal healthcare service delivery. The result obtained three categories, namely, gender-based roles, psychosocial variation, and power relations. Men can persuade pregnant women to use delivery services and PNC. The place of delivery is determined by the levels of gender-based power relations at the household level, but women are usually the last decision-makers. The belief of the community that giving birth in a health facility makes women look clean and neat, as opposed to home delivery, increases their intention to use maternal healthcare services. The study contributes that the role of a man as a husband is crucial in mobilizing others to carry pregnant women to health facilities, contributing to early intervention during labor. The decision-making capacity of women has improved over time, with men accepting their right to make decisions about their health and fetuses. Home delivery and men not being present during delivery are perceived as signs of backwardness, whereas giving birth in health institutes is seen as a sign of modernization and the rights of women.

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial

BackgroundThere are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention.MethodsWe will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms.DiscussionWe expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States.Trial registrationRegistered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

Relationship Between Work Motivation and Health Worker Performance at Kronjo Health Center

Shows that Indonesia is included in the 5 countries with the lowest motivation of health workers, besides Vietnam, Argentina, Nigeria and India. This is due to aspects of fulfilling welfare and information obtained that 175,000 employees 98,512 people or 56% complain about the low incentives received from the institutions where they work. The problem that occurs in health services today is the large number of health workers who do not have high motivation to work due to various factors such as heavy workload, high work risk, domestic and inadequate training programs, but not balanced by good job protection and unsatisfactory wages, not to mention welfare factors and competence factors according to the World Health Organization (WHO). Work motivation and performance of health workers have a very close relationship to performance. Health workers have an important role as executors of health worker services and community health development. This study aims to determine the relationship between work motivation and the performance of health workers at the Kronjo Health Center in 2022. This research is a quantitative study using an analytic survey with a cross-sectional research design. Work motivation in the sufficient category is 16 (38.1%) and the performance of health workers in the good category is 21 (50.2%). this study shows that the p-value = 0.029. this shows that the value of p = 0.029 is still smaller than the critical limit ? = 0.05. There is a significant relationship between work motivation and health worker performance (0.029<0.05).

Peranan Program Jaminan Kesehatan Nasional (JKN) Dalam Mendorong Sustainable Development Goals (SDGs) di Indonesia

The National Health Insurance has received great attention in the Sustainable Development Goals, where one of the main targets is to guarantee a healthy life and promote welfare for all people at all ages or later called Universal Health Coverage (UHC). The National Health Insurance is a social security program based on Law Number 40 of 2004 which aims to provide comprehensive health insurance coverage for every Indonesian so that Indonesians can live healthy, productive and prosperous lives. Whereas Universal Health Coverage is a health system that ensures that every citizen in the population has equitable access to quality promotive, preventive, curative and rehabilitative health services at affordable costs. In this study, in its implementation, there was an increase in the Community Health Development Index which was marked by an increase in health service efforts with cross-sector, central and regional synergy towards achieving Universal Health Coverage. The problem found in this study is that there are still many problems found regarding mothers, babies and toddlers. The nutritional status of the people who have a double burden, as well as problems regarding the quality and access to basic and referral health services which include fulfilling the conditions and facilities for basic and referral health services, fulfilling the availability of facilities and infrastructure for health service facilities both medical and non-medical, and not yet covering guarantee services national health as a whole. The purpose of this study was to find out the planning for the implementation of the National Health Insurance (JKN) program in Encouraging Sustainable Development Goals (SDGs) in Indonesia, especially in Medan City. This research is a descriptive qualitative research. The process of monitoring and evaluating the implementation of activities is carried out according to their duties and functions and in accordance with the procedures and provisions of the 1945 Constitution, Law Number 40 of 2004 concerning the National Social Security System
 Keywords: Role, National Health Insurance, SDGs

Peran Kader Posyandu dalam Pengembangan Kesehatan Masyarakat di Desa Cemengbakalan Kecamatan Sidoarjo

This study aims to find out and describe the existing facts so that a clear picture is found of the role of posyandu cadres in the development of public health in Cemengbakalan Village. The research method uses descriptive qualitative type. This study uses primary and secondary data types. Explaining more clearly the role of posyandu cadres in Cemengbakalan Village to support community health development is the focus of this research. Sources of data obtained through interviews with cadres who play an active role in posyandu activities, records, and archival documentation. The results of the study prove that the role of posyandu cadres in the development of public health in Cemengbakalan Village is achieved by considering the role theory by Soekanto in which the roles are divided into three parts, namely active roles, participatory roles and passive roles. First, the active role, the finding of the active role of posyandu cadres in Cemengbakalan Village which is considered to have been achieved. Second, the participatory role of posyandu cadres in participating in posyandu activities has been declared to have been achieved. Third, the passive role of cemengbakalan posyandu cadres is declared not optimal because there is still a decline in the number of posyandu visits.

The Primary Care Transformation Executive Fellowship to Develop Community Health Center Leaders.

Although many primary care providers from community health centers recognize health disparities and work to transform healthcare, skill gaps and limited support may hinder their ability to be change agents. The Primary Care Transformation Executive (PCTE) Fellowship at A.T. Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA) seeks to address these barriers by providing professional development and support to primary care providers interested in leading change in the nation's health centers. The PCTE Fellowship is a structured, one-year interprofessional learning experience that emphasizes topics such as healthcare transformation, interprofessional practice, leadership development, and systems thinking. Quantitative and qualitative evaluation of the program was accomplished through surveys and semi-structured interviews throughout the fellowship. Feedback from 18 fellows showed perceived improvements in knowledge and skills related to the various curricular topics, increased engagement in leadership activities, and career advancement. Fellows developed practice and quality improvement projects and successfully implemented the projects within their health systems, addressing observed disparities. Professional development and directed support for primary care providers can enhance their engagement in healthcare transformation and advance health equity.

Getting Further Faster: Illuminating Opportunities for Health Departments to Support Community-Driven Social Determinants of Health Interventions.

Getting Further Faster: Illuminating Opportunities for Health Departments to Support Community-Driven Social Determinants of Health Interventions.

지역사회 공동체의식이 건강 및 삶에 미치는 긍정적 효과

Objectives: The aim of the study is to examine the relationship between citizens’ ‘sense of community’ and ‘health and quality of life’ in a Korean city that has both, rural and urban communities. Methods: We analyzed the survey data from “Citizen Opinions for Healthy City Nonsan” conducted in 2020. The survey used a self-reported questionnaire and the data of 1,181 participants were collected through quota sampling among aged over 19 from 15 administrative communities based in Nonsan-si Chungcheongnam-do. We measured the “sense of community” by using the Sense of Community Index, and “health and quality of life” with the WHOQOL-BREF questionnaire. We conducted the correlation and multiple regression analyses to examine the relationship between citizens’ ‘sense of community’ and ‘health and quality of life’. Results: We found that citizens’ sense of community had direct positive effects on all domains of health and quality of life. Conclusion: This study affirms the importance of sense of community in promoting community health and quality of life and suggests that more efforts to actively heighten the sense of community should be made in developing community health programs and policies at the local level.