Community-centric health: exploring models and communication strategies for neighborhood development and well-being

Once perhaps a contentious issue, there is growing acceptance across the public health sector that health extends far beyond traditional healthcare. Recent literature has acknowledged that the healthcare system is focused on reversing or modifying disease, but not the enhancement of one’s health (Woolliscroft, Gruppen, Markovac, & Meehan, 2023). Subsequently, attention has broadened to an individual’s-built environment, its existing resources or lack thereof, as determinants of health. The term “Social Determinants of Health” (SDOH) has gained prominence, emphasizing the socioeconomic factors that profoundly shape health outcomes (U.S. Department of Health and Human Services, 2020). This paradigm shift underscores the importance of collaborative community efforts to address these determinants. For instance, as of 2022, the USA was home to 1.48 million nonprofits with a 501(c)(3) tax-exempt status, and approximately two-thirds of nonprofit jobs were concentrated in healthcare and social assistance (USAFacts Team, 2023). In recent decades, various strategies and initiatives have emphasized the critical role of nonprofit organizations collaborating with residents to implement comprehensive and collective approaches aimed explicitly at addressing the route causes and drivers of long-term health outcomes. As a result, variouscommunity development models have arisen, including the “Collective Impact” model, first introduced in 2011 (Kania & Kramer, 2011), leading to subsequent research questions:

It is essential to observe what key components are needed within a model to realize progress in achieving improved health outcomes. This analysis will also highlight the important function of a “backbone” organization within collaborative efforts, as well as the need for continued focus on integrating advanced communication frameworks.

Organizations devoted to providing a service that addresses a SDOH exist because there is a fundamental human need that may be lacking for a person. Based on Maslow’s well-known Hierarchy of Needs pyramid, the foundation of our most basic needs are biological requirements for human survival such as air, food, drink, sleep and shelter (McLeod, 2018). Before even looking further north on Maslow’s pyramid, we can already identify instances of damaging air pollution (Muller & Mendelsohn, 2007), an 11.5% U.S. poverty rate in 2022 (Shrider & Creamer, 2023) and 13 million children facing hunger in 2022 (Rabbitt et al., 2024). Actions are often influenced by an individual’s need. This theme continues as the pyramid scales vertical to safety needs, love and belongingness needs, esteem needs and self-actualization. For improved health outcomes in a neighborhood, we must observe the preexisting resources within a community and if all resources address each layer of Maslow’s Hierarchy of Needs. Should an asset inventory be executed in every community across the globe, each asset list would be unique from one another, from different residents with different stories and different historical context, to different levels of accessibility to resources.

Further, systems-level thought when solving complex community health problems is necessary. In 1966, philosopher of science Karl Popper established a framework that divided problems into two categories – clock problems and cloud problems. Popper described clock problems as predictable whereas cloud problems are unpredictable. For example, should a car malfunction, we can break the car into multiple different pieces, diagnose the exact problem, replace the infected piece and put the car back together. As for a cloud problem, if a cloud does not produce enough rainwater, we do not know how to fix it. When thinking from a systems approach, a cloud problem is much more complex and more difficult to solve. Within a cloud problem, the subject may consistently be dealing with changes in its surrounding environment (Dabholkar, 2020). Thus, when thinking about community health challenges and creating a solutions-based approach, deciphering between responses that serve a clock problem versus responses best served for a cloud problem is an important foundational piece.

Following the adoption of the Affordable Care Act (ACA) in 2010, nonprofit health networks have been mandated to conduct and publish Community Health Needs Assessments (CHNAs) every three years. These assessments must outline the specific community served, evaluate its health needs and incorporate feedback from representatives across the community to ensure a comprehensive perspective (Internal Revenue Service, 2024).

Around the same period as the ACA's adoption, the University of Wisconsin Population Health Institute introduced the County Health Rankings Model, a widely adopted framework that identifies key health outcomes and factors ( Appendix 1; County Health Rankings, 2019). This model emphasizes “Length of Life” (mortality) and “Quality of Life” (morbidity) as equally weighted contributors to overall health outcomes, offering a balances lens for evaluating community health. Perhaps most notable about this model is the breakdown of the four key health areas of “Health Behaviors,” “Clinical Care,” “Social & Economic Factors” and “Physical Environment” and their respective relation to outcomes. Based on the model, clinical care, which is subdivided into access to care and quality of care, only account for 20% of health outcomes, where behaviors, social and economical factors and physical environment account for 80%. In addition, social and economic factors, subdivided into education, employment, income, family and social support and community safety, account for twice the impact as clinical care. As an illustrative example among hundreds conducted nationwide, the most recent CHNA published by Lehigh Valley Health Network focusing on Lehigh County in 2022 similarly includes extensive data on income and economics (employment, income, poverty), education (access, attainment), housing and families (evictions, housing costs, housing quality), physical environment and more (Lehigh Valley Health Network, 2022). Needless to say, the work of the University of Wisconsin Population Health Institute and Community Health Rankings have paved the way for advanced thinking on how public health challenges are addressed within neighborhoods.

Kindig and Milstein further support this ideology, and the The Rippel Foundation in conjunction with Robert Wood Johnson Foundation (RWJF) and introduced a balanced investment portfolio for equitable health and well-being. Both argued that the USA health investment portfolio is out of balance with an abundance of dollars spent on health care and too little spent on SDOH (Kindig & Milstein, 2018). The USA spent 17.2% of its Gross Domestic Product (GDP) on health care in 2015, more than eight percentage points above the Organization for Economic Cooperation (OECD). Yet despite the spending, life expectancy in the USA in 2015 was 78.8 years, which was two years lower than the OECD average. In 2018, The Rippel Foundation coordinated with RWJF to outline a balanced Well-Being Portfolio as an evolution of the SDOH framework.  Appendix 2 shows a pie chart with six services labeled as “urgent services” and seven components of “vital conditions.” Milstein defines “urgent services” as services that anyone under adversity may temporarily need to regain or restore health and well-being. Urgent services in the Well-Being Portfolio include essential components like acute medical care, addiction treatment and response to crime and environmental hazards. In addition, unemployment support, food assistance and homeless services offer temporary relief to individuals facing adversity (Milstein, 2021). On the left side of the Well-Being Portfolio, seven “vital conditions” are listed. Vital conditions are defined as properties of places and institutions that all people need all the time to be healthy and well. These conditions begin with basic needs for health and safety, where access to clean air, safe water and fresh and nutritious food is prioritized. Equally important is the role of lifelong learning opportunities, which includes accessible education and resources for personal development to equip individuals to thrive socially and intellectually. A thriving community also depends on meaningful work opportunities and economic stability, providing that jobs are not only financially rewarding but fulfilling and conductive to family and community health. Humane housing is also emphasized as being safe, affordable and inclusive, allowing residents to remain close to essential resources like work, schools and recreational spaces. Thriving natural world is also crucial, as neighborhoods need resilience against climate risks and to foster natural resources and sustain a safe habitat for all. Transportation is another essential factor, where a well-designed, safe and accessible system connects individuals to necessary resources. Finally, belonging and civic muscle serve as the heart of vital conditions, nurturing social cohesion and collective power. This aspect ensures that individuals feel connected to their community, empowering them to influence policies and programs that shape their environment and well-being (ReThink Health, 2018). Between vital conditions and urgent services, Milstein stresses in his writings the need for balanced investment in both and not one or the other. All communities must maintain a network of well-equipped, well-connected urgent services:

With consistent and overlapping methodology that health is more than health care, from federally required and detailed CHNAs, to the Community Health Rankings’ model and finally the Well-Being Portfolio, we can now pivot to reviewing various neighborhood development models.

This analysis relies on secondary data sources and publicly available literature to examine community health models and communication strategies. Since no primary data involving human subjects was collected, formal ethics approval was not required for this study.

The concept of “community as a patient” is essential in understanding how health outcomes can be collectively addressed. Similar to a doctor diagnosing and treating an individual, community health practitioners view the neighborhood as a unified entity with its own needs, conditions and potential solutions. Within this framework, models like Rothman’s three methods of community organizing, Comprehensive Community Development Models (CCDM) and the Collective Impact approach have become foundational in addressing complex health determinants in communities.

Social worker and scholar Jack Rothman theorized three distinct models for community organization: Locality Development, Social Planning and Policy and Social Action (Brescia University, 2018). Locality Development focuses on individuals coming together with a common interest or shared unit of identity. As common issues are identified, community members may find themselves without established relationships or the collective problem-solving capacities necessary to address these issues effectively. As a result, the community organizers in this scenario are tasked with convening community, sharing the common resources available, options and all information to make an informed, democratic decision. Examples of Locality Development in action are neighborhood civic associations or neighborhood councils. A foreseeable challenge within Rothman’s first model is finding the right convener who accurately understands the communities’ context; the different community players involved and is not a polarizing figure who risks active community participation and bridge building needed for a solutions-based approach.

Social Planning and Policy attempts to gather analyzed data around a key community issue such as humane housing. However, according to Rothman, community does not play a prominent role in this process:

Like Locality Development, this model possesses foreseeable challenges. Although one may be an expert data analyst, if he or she does not belong to the communities’ unit of identity but exhibits authority to make decisions without consulting the community, an end result could be a lack of trust between groups, or perhaps, community pushing back against the well-intended process.

Social Action as a community organization model focuses on influencing fundamental changes within a community and its redistribution of power. Rothman notes this style is highly confrontational in nature and emphasizes the values of social justice. Examples of social action include the utilization of labor unions as well as boycotts and political marches (Brescia University, 2018).

Each of these models provides a mechanism to involve the community directly or indirectly in health-related decision-making, emphasizing the critical role that social structures and power dynamics play in health outcomes.

In April 2021, Washington D.C.’s Office of Planning, the Deputy Mayor for Planning and Economic Development and the Coalition for Non-Profit Housing and Economic Development released a Comprehensive Community Development Model (CCDM). The model is a community-led strategy meant to support neighborhood development in Ward 7 of D.C. The model’s report included a letter from Stephen Glaude, President and Chief Executive Officer of the Coalition for Non-Profit Housing and Economic Development (CNHED). Glaude writes:

Through collaboration with community members, stakeholders and government officials, the CCDM emphasizes principles such as empowering residents in decision-making, preventing displacement, creating economic opportunities and fostering safe, culturally rich neighborhoods. These priorities reflect a commitment to inclusive growth and well-being (District of Columbia Office of Planning, 2021). Notably, the public report also includes an asset map in education (public, private schools, day-care centers), cultural assets (churches and other religious institutions, community centers, museums and libraries), transportation assets, health assets (including grocery stores, parks, community gardens, hospitals and primary care centers), public safety assets and financial assets. At this current juncture, it is unknown whether or not the CCDM meets some of its neighborhood goals such as enhance public safety, bridging the digital divide and investing in resident-driven art is an unknown. However, the CCDM was intentional about relaying these basic living components and goals back to health and well-being and emphasized collective collaboration.

The concepts mentioned above within Washington D.C. have striking similarities to “Collective Impact,” first explicitly described by John Kania and Mark Kramer in a winter 2011 edition of Stanford Social Innovation Review. Kania and Kramer turned their attention to the work of a nonprofit subsidiary in Cincinnati known as Strive and its emerging work to tackle the local student achievement crisis. Strive actively convened more than 300 leaders of local organizations across Cincinnati and northern Kentucky, including the heads of influential foundations, government officials, school district representatives, the presidents of nearby universities and community colleges and the executive directors of hundreds of education-related nonprofit and advocacy groups. Kania and Kramer write: “These leaders realized that fixing one point on the educational continuum—such as better after-school programs–wouldn’t make much difference unless all parts of the continuum improved at the same time. No single organization, however innovative or powerful, could accomplish this alone. Instead, their ambitious mission became to coordinate improvements at every stage of a young person’s life, from “cradle to career” (Kania & Kramer, 2011). As a result, the education community agreed on a single set of goals all measured consistently by all participating organizations. Positively, 34 of the initiative’s 53 success indicators showed upward trends across preschool children prepared for kindergarten, 4th grade reading and math scores and high school graduation rates (Krosin, 2022).

Collaboration is not an unusual concept. But Collective Impact initiatives have five key components:

1. Common Agenda;

2. Shared Measurement Systems;

3. Mutually Reinforcing Activities;

4. Continuous Communication; and

5. Backbone Support Organizations (Kania & Kramer, 2011).

Common agenda requires all participants have a shared vision for change and a common understanding of the problem. Fundamental disagreements often exist within dimensions of a problem, but it is imperative all participants agree on the primary goals of the initiative. Shared measurement systems stress there must be agreeance on how success is measured and reported within an initiative. As for mutually reinforcing activities, collective impact deeply depends on a group of diverse stakeholders working together. This does not mean all participants do the same thing, but contrary each participant’s activities work in coordination with the actions of others. Continuous communications is a component that highlights trust building among the various stakeholders involved in the initiative. Years of consistent, regular meetings and a commitment by personnel to these meetings build trust, relationships and further enforce the common motivation behind their efforts. Finally, Kania and Kramer’s Collective Impact (2011) write, “Creating and managing collective impact requires a separate organization and staff with a very specific set of skills to serve as the backbone for the entire initiative.” The authors note that absence of a backbone organization is one of the most frequent reasons why initiatives fail. The dedicated backbone staff, separate from participating organizations focus on managing and supporting the initiative through frequent facilitation, communications support, data collection and reporting and the handling of administrative details. Backbones are a necessity because often participating organizations within a collective impact effort do not have the bandwidth to dedicate full-time staff members to one main initiative.

The specific role of a backbone organization is still under further investigation. In 2012, The Greater Cincinnati Foundation (GCF) and nonprofit consulting firm FSG started a partnership with a focus on evaluating various backbone organizations that are beyond the beginning phases of launching its collective impact initiatives (Turner, Merchant, Kania, & Martin, 2012).  Appendix 3 lists GCF’s initial cohort of six backbone organizations. In evaluating the impact of the six backbone organizations, all were measured against the following four questions proposed by GCF and FSG:

Evaluations of backbone organizations consider how well they guide strategy, support coordinated activities and establish shared measurement standards. In addition, these organizations play a key role in fostering public support, shaping policy and mobilizing financial resources to sustain their initiatives (Turner et al., 2012).

While Kania and Kramer’s writings of Collective Impact gained traction, the concept was also met with opposition and criticism. In the Global Journal of Community Psychology Practice, Tom Wolff, PhD emphasized 10 places where the collective impact model goes wrong. Wolff mentioned Collective Impact emerges as a top-down approach and is not a community development model. He notes for the model to be successful, future emphasis on community having a seat at the table is paramount. Wolff also raises concerns over Collective Impact assuming coalitions are capable on securing needed funding and its ability to find a committed, well-funded backbone organization (Wolff, 2016). The full table outlining all 10 of Wolff’s arguments on where Collective Impact gets it wrong is listed under  Appendix 4.

The on-going dialogue and intrigue around Collective Impact emerged in the Tamarack Institute’s 2016 Community Change Series article entitled “Collective Impact 3.0: An Evolving Framework for Community Change.” In the new framework proposed by Tamarack, the five original conditions of Collective Impact are updated:

1. from Common Agenda to Movement Building;

2. Shared Measurement to Strategic Learning;

3. Mutually Reinforcing Activities to High Leverage Activities;

4. Continuous Communication to Inclusive Community Engagement; and

5. Backbone to Containers for Change.

Authors Mark Cabaj and Liz Weaver write, “Although we reaffirm that these conditions are ‘roughly right,’ we believe they are too narrowly framed to capture how successful CI (Collective Impact) actually operates, particularly efforts that are explicitly embedded in a movement-building approach to community change” (Cabaj & Weaver, 2016). The authors encourage readers to continually work to upgrade the Collective Impact approach based on constant, ongoing learning on what it takes to transform communities and notes the Collective Impact approach, whereas a strong foundation will always be unfinished business.

Health communications is the study and use of communication strategies to inform and influence individual and community decisions that affect health (Malikhao, 2020). The concept of health communications is comparably well beyond the scope of health care communications. Within neighborhood development and supporting system change efforts, a strong emphasis must be placed on tailoring the message, how to properly target the message to audience segments and message framing. While previous community models have mentioned collaboration across sectors and the convening of grass tops and grass roots, a room full of diverse perspectives can easily lead to a damaging, negative result. To overcome such challenges and influence a safe space for meaningful, productive conversations across diverse viewpoints, the role of a neutral facilitator skilled in communications is a necessity.

A group of more than a dozen thought partners and communication practitioners led by Jolie Bain Pillsbury, PhD created the conceptual model of Results Based Facilitation (RBF). RBF is a competency-based approach that moves groups from talk to action by focusing on meeting results and an accountability framework (Pillsbury, 2015, p. 3). Effective RBF concepts include the Person-Role-System framework and the concept of boundaries of authority, role and task (B/ART) that enables one to consider their own role and the roles of others within a meeting (Pillsbury, 2015, p. 69). Defining and differentiating the roles of not only yourself, but other meeting participants and how they contribute to a meeting’s end result is a key competency within RBF. Another RBF competency is the 3R framework (Relationships, Resources and Results) to design and facilitate meetings that move talk into action. Effective usage of the 3R framework also enables meetings to be designed that build relationships within meeting participants (Pillsbury, 2015, p. 129).  Appendix 5 and  Appendix 6, respectively, provide more insight into both B/ART and the 3R framework.

But effective communication methods are even essential when leading a company’s change in direction or strategy. John P. Kotter’s book Leading Change turned eight reasons why organizations fail into eight key components for successfully transforming organizations. Because community and neighborhood development work exist on the foundation of transformational change, Kotter’s notes are often relevant, even though the book’s content is intended to the for-profit industry. Nestled within the book’s eight-stage process is Developing a Vision and Strategy and Communicating the Change Vision. Both elements are more than relevant to the work of neighborhood development where there is a clear vision for change among participants. The author writes, “vision refers to a picture of the future with some implicit or explicit commentary on why people should strive to create that future” (Kotter, 1996, p. 68). Clarifying general direction for change, motivating people to take action and coordinating the actions of individuals are three key components to creating a strong vision:

Characteristics of an effective vision are listed as imaginable, desirable, feasible, focused, flexible and communicable. The latter stresses that any vision is easy to communicate and can be successfully explained within five minutes (Kotter, 1996, p. 72). Dealing with opposition and resistance can be avoided by using the power of and rather than or. Take for example, within neighborhood development the task of balancing the best interests for all stakeholders involved while committing to an overarching goal. In the for-profit industry, the relevant question is not “do we cut costs or improve the product?” but “how do we both reduce our expenses and increase product quality?” While business teachings emphasize the power of and, community development models and communication practitioners should practice such techniques to avoid opposition from stakeholders.

The usage of metaphors, analogies and examples should also be strongly considered as an effective tool. Consider the following two examples for communicating a vision for a for-profit organization:

1. We want to begin designing and manufacturing more products that are perceived by the customer base as different, highly recognizable and prestigious. Such products will have significantly higher prices and margins. Compared to:

2. We are going to be making fewer Fiats and more Mercedes (Kotter, 1996, p. 92).

The two examples show a stark contrast in length, and assuming the reader does not value Fiats more than Mercedes, the point comes across. How could we apply such technique to communicating a neighborhood development initiative? Here’s one example: We believe this park should serve as the living room for its small neighborhood. Safe, clean and inviting to all. Although learning this art can be a daunting task, thankfully organizations such as FrameWorks Institute are active in providing training on how to effectively communicate social problems that impact health. FrameWorks’ mission is to help shape effective communications by applying social science methods to study how people understand social issues and how best to frame them (Frameworks Institute, 2023).

Recognizing the value of health communications, the World Health Organization (WHO) released a Strategic Communications Framework for effective communications in 2017 (World Health Organization, 2017). WHO listed their principles for effective communications as accessible, actionable, credible and trusted, relevant, timely and understandable. However, staffing challenges are present when considering how many marketing/communications employees are on-staff for nonprofit organizations. Based on the 2022 Nonprofit Communications Trends Report, 41% of organizations with budgets between $500,000 to $1 million and 35% of organizations with budgets of $1 million to $5 million have single-person communications teams (Cindy May Marketing, 2022). While the guidance and frameworks provided by WHO are beneficial, challenges remain for small-staffed nonprofits in creating vehicles for effective storytelling.

The nature in how we interpret and address health continues to be rapidly evolving from the concept of SDOH and vital conditions, as well as rebalanced measures of investments. As it becomes widely accepted that health happens where individuals live and its existing environmental factors, neighborhood and community organizing is a key component to our long-term health outcomes. Different community models and concepts have been practiced throughout the USA in the 21st century including the evolving Collective Impact Model. Future research across upcoming decades will be essential in measuring health outcomes tied to specific community development models. Nonetheless, as we begin to look at health from a broader lens, it is also imperative to replicate such for health communications. Results Based Facilitation and FrameWorks offer thought-provoking models into how we frame our message, and guidance is also provided by the WHO. However, as nonprofits continue to play a key role in place-based neighborhood development efforts, small staff sizes challenge its storytelling capabilities with the generation of paid, owned and earned media.

The author expresses sincere gratitude to the Leonard Parker Pool Institute for Health (LPPIH), a 501(c)(3) nonprofit subsidiary of Lehigh Valley Health Network, for fostering an environment supportive of cross-sector collaboration, holistic neighborhood development and capacity building initiatives in the Allentown, PA community. The author also thanks Samantha Shaak, PhD, and Lisa Lindley, DrPH, MPH, CHES, for their careful review and thoughtful suggestions during the proofreading stage of this manuscript.

Funding: The author declares no specific funding for this work.

Competing interests: The author declares no competing interests.

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