Many factors determine the health both of individuals and of the communities in which they live. These factors include income, social relationships, access to and use of basic services such as water supply and sanitation, the quality of available health services, individual responsibility and the quality of the environment. Consequently, public health interventions designed to reduce the risk of ill-health and promote feelings of well-being in a community must consider many social and environmental factors. These factors will vary in importance between communities, because of differences in the current services, facilities, priorities and needs of the communities, and because communities change over time. If health interventions are needed in several areas, they may need to be prioritized before they are implemented. Several programmes, such as primary health care or the Basic Development Needs programme,¹ address the factors that influence the health and well-being of communities. Advice on these programmes is available from a number of sources (see Annexes 1 and 2).

¹ Abdullatif AA. Basic development needs approach in the Eastern Mediterranean Region. Mediterranean Health Journal, 1999, 5:168-176.

This guide focuses on the different health interventions that support the development of healthy communities. Many of the interventions require outside support to the communities, such as from local and national governments and nongovernmental organizations (NGOs). However, the communities themselves also play an important role in identifying problems, defining solutions and setting priorities. Often, communities will also need to participate directly in implementing solutions and in sustaining the improvements made. Indeed, many interventions require commitments from individual community members and households, in addition to commitments from the broader community. Frequently, the most important element in promoting health is to ensure that everyone has access to services.

Characteristics of a healthy community · The physical environment is clean and safe. · The environment meets everyone's basic needs. · The environment promotes social harmony and actively involves everyone. · There is an understanding of the local health and environment issues. · The community participates in identifying local solutions to local problems. · Community members have access to varied experiences, interaction and communication. · The health services are accessible and appropriate. · The historical and cultural heritage is promoted and celebrated. · There is a diverse and innovative economy. · There is a sustainable use of available resources for all.

The purposes of this guide are:

· To help community leaders and people who work with rural communities identify problems that affect health.

· To outline possible solutions to these problems.

· To help in the setting of priorities that will lead to a healthier community.

During the development of the draft version of this guide many workshops and discussions were held with public health practitioners. Based on these discussions, it is expected that health department officials will find the guide a valuable tool for their community health work, and may translate it into local languages or make adaptations to suit local circumstances and conditions. The guide is not exhaustive, however; it does not cover interventions for every situation, nor are the descriptions of interventions detailed. Instead, it is designed to provide information to communities that will enable them to start the process of problem solving. More information about implementing programmes can be obtained from the organizations and documents listed in the annexes at the end of the guide.

1.1 What is a healthy village?

It is impossible to define precisely what is "healthy" for all communities, because this will depend on the perceptions of community members as to whether their village is a "good" place to live. However, a village or rural community can be considered healthy when rates of infectious diseases are low, when community members have access to basic services and health care that meet their needs, and when the community lives in a state of reasonable harmony. Examples of unhealthy and healthy villages are illustrated in Figures 1.1 and 1.2; however, these pictures show extremes and most communities will fall somewhere between the two.

1.2 Structure of the guide

The guide follows a simple format and deals with various interventions. Checklists are provided to help community leaders to assess their problems and evaluate the importance of different interventions.

An initial section looks at how good health is defined and how to identify gaps in the social and physical environment that would hinder the promotion of good health in villages. The importance of technology in improving health is then discussed, including means for providing a safe water supply and good sanitation, for safely disposing of waste and chemicals, and for providing good drainage. The importance of sustaining technologies is also emphasized, because simply installing infrastructure, such as a well or a bore-hole, will not improve community health if it is allowed to become nonfunctional. The importance of personal and community hygiene in promoting health is also outlined, since good hygiene practices are as important as technology for improving health.

The provision of health care and the ways in which communities can access or demand improved health care services are then discussed. This section also examines the health needs of special groups, such as pregnant women, the elderly and people with mental health problems. A final section describes the role of local governments in supporting improvements in rural health.

1.3 Using the guide and setting priorities

The guide is designed to help rural community members and health workers make informed decisions about interventions for their community health problems, by providing information about how to improve different aspects of health. Further information may be also required, such as on the detailed workings of different pit latrines, before final decisions can be made as to the best intervention. However, raising the awareness of community members about the different options for intervention should increase their participation in the decision-making process and help them to select solutions that are appropriate for their community. Although this guide provides a framework for decision-making and should help rural communities to improve the health and well-being of community members, it does not replace local professionals, who will have a more detailed understanding and knowledge of the communities they work in. To improve community health, it may also be necessary to coordinate intervention activities with service bodies such as local governments.

Figure 1.1 Unhealthy village practices

Figure 1.2 Healthy village practices

When considering interventions, it is important to bear in mind the current conditions in a community, as well as the community priorities. For example, a community may be prone to flooding, and have poor sanitation and an inadequate water supply. The community will need to determine which problems are most urgent and which can be dealt with later, and then decide on the interventions for dealing with the most pressing issues. The whole community, and not just a powerful few, should be involved in this decision-making process. Women, in particular, should be given a proper say in improving their village, as they may be most affected by the health problems caused by an unhealthy environment. Whenever possible, a number of interventions should be undertaken at the same time, since this may resolve health problems more quickly and cost-effectively. However, realizing these goals may require a substantial commitment of time and resources from the community, so a balance must be struck between working to improve the village environment and the needs of families to grow food and earn incomes.