Our nation has elevating rates of despair, forcing us to take a broader approach to address the foundational issues driving such conditions and challenges as depression, anxiety, opioid misuse, and suicide. Community environments—the social, physical, and economic conditions in communities—have tremendous influence on the stressors that people experience in their daily lives and on the development of mental and emotional disorders. A zip code has the ability to predict whether someone is likely to suffer from a preventable illness and live a shorter life. Community environments drive higher rates of illness, injury, and mental health challenges for populations that face bias and discrimination, including people of color, those living with low incomes, immigrants, and the LGBTQ community. By improving community conditions, and pairing this with high-quality mental health services, our society can reduce the likelihood, frequency, and intensity of mental health challenges—and at the same time improve physical health outcomes.
The World Health Organization (WHO) defines mental health as “a state of wellbeing in which every individual realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community.”1 We use the WHO definition throughout this paper, while also recognizing that in practice the term “mental health” reflects different understandings. Clear definitions of mental health have not been standardized, and varied understandings of mental health carry divergent assumptions and implications for our collective capacity to proactively and reactively respond to the needs of the population. In general, “health” has a positive connotation; however, the term “mental health” is often conflated with mental illness, reinforcing a focus on treatment rather than an emphasis on wellbeing as a community-wide goal.
Perceiving mental health to be the sole province and responsibility of the individual diminishes our recognition of the ways community conditions create and exacerbate many mental health challenges. This perspective treats trauma, stigma, shame, and discrimination as issues an individual must solve—not as factors that are created, shaped, or exacerbated by the environment. Essentially, then, the predominant understanding of “mental health,” and the resulting clinical approach, fails to underscore opportunities for primary prevention and interrupts our ability to achieve population-wide mental health and wellbeing.
Mental health and wellbeing is at the heart of thriving individuals, families, and communities. The WHO definition of mental health is the state that many seek to attain, and the community development sector has an important role to play in achieving this possibility across entire neighborhoods. Community development can tap into resident voices and community assets, extending its reach beyond improving the physical and economic potential of communities and supporting durable impacts that foster hopefulness, dignity, respect, and safety—helping an entire population improve.
Collective community action as part of community development is a strategy that meaningfully engages residents and community organizations to transform environmental conditions into those that promote their health, quality of life, and ability to thrive. Done intentionally, community action is work that nurtures mental wellbeing and the ability to influence the events that shape life’s circumstances; it re-weaves the social connectedness among efforts in community development and embeds social justice in assuring economic vibrancy. In neighborhoods that have suffered from disinvestment and prolonged despair, this type of engagement does not degrade by asking, “What is wrong here?” Rather, community action and development moves beyond the trauma-informed question, “What happened here?” to ask the more important question, “What is the untapped potential here that can be activated?”
If intentionally leveraged, community development approaches, coupled with resident community action, can reach across multiple sectors to measurably influence mental wellbeing at a community level. The field is well positioned to leverage its expertise in community organizing, engagement, and collaboration across sectors to guide partnerships that improve the community determinants of health associated with mental wellbeing. This article describes community-level factors that influence mental health and wellbeing; it also outlines examples of how the community development sector is engaging in strategies that impact mental health and wellbeing. In addition, it highlights specific opportunities for community development to advance upstream solutions that can reduce the incidence and intensity of mental health challenges, create health and equity, and foster resilience (the ability to adapt, recover, and thrive in spite of adverse events or experiences).
Mental Wellbeing and Community Determinants of Health
There are many ways to describe communities. A community is a group of people with something in common, be it geography, history, experience, purpose, or passion. Regardless of whether community is defined by geographic boundaries or based on population characteristics, there are factors that directly impact the health and wellbeing of the entire community and influence the formation of norms, which also strongly impact health outcomes.2 The public health approach—and, in particular, Prevention Institute’s approach for exploring challenges and solutions to improving population wellbeing—describes community environments as the social, physical, and economic conditions in communities that influence health, safety, wellbeing, and equity outcomes.3
The Tool for Health and Resilience in Vulnerable Communities, or THRIVE, framework offers a systematic method in accessible language for working alongside community residents and organizations to explore the factors that are impacting their health and wellbeing (Figure 1). Within a planning process, THRIVE can be instrumental in assisting groups in developing strategies to reduce mental health stressors, improve options for coping, and enhance resilience factors in a community.4 For many people living with mental illness or experiencing mental health challenges, the community determinants that surround them can have a tremendous impact on recovery and resilience, or further deterioration of mental wellbeing.5
Figure 1: Tool for Health and Resilience in Vulnerable Communities (THRIVE) Framework
Assessing and addressing community determinants of health can help reduce mental health stressors and enhance resilience factors across a community. Looking at the community environment through a mental health and wellbeing lens can help to identify conditions that impact mental health outcomes. For example, the “look, feel, and safety” of a place is critical. Surroundings that are appealing, well maintained, and perceived to be safe and inviting for all community residents foster mental wellbeing, whereas disinvestment by public and private investors in schools and community infrastructure—whether in rural, urban, or suburban areas—contributes to feelings of hopelessness and impacts feelings of self-worth. Another community determinant is “getting around,” or the availability of safe, reliable, accessible, and affordable means of transportation. Engaging in walking and biking can help improve mood and reduce anxiety and depression; at the same time, the realities and perceptions of geographic isolation or lack of safety do the opposite. Addressing the community determinants of health is key to helping communities navigate adversity, restore assets, and assure they have the opportunity to flourish. Structural drivers, such as bias, discrimination, and concentrated poverty, shape these determinants at the community level, pointing to interventions that address and redress such conditions.6, 7 Mental health and wellbeing is created and reinforced by the same community environments that the community development sector seeks to transform.
Communities of color and communities with concentrated poverty often face the compounding challenges of the physical/built environment (e.g., poor housing stock, deterioration of infrastructure, toxic land use, inadequate availability of affordable healthy food and transportation options) and limited equitable opportunity (e.g., quality education and employment opportunities that provide a living wage). These challenges contribute to geographic concentration of higher levels of chronic illness, exposure to violence, substance misuse, mental health challenges, trauma, and multigenerational poverty.8 Ensuring intentional engagement that advances a community’s own priorities into the neighborhood development process can support mental wellbeing, foster stability, preserve the cultural heritage of communities, and mitigate large-scale displacement of residents.
Pillars of Wellbeing
Prevention Institute’s work with the Making Connections for Mental Health and Wellbeing initiative9 has led to the identification of a set of value-based characteristics that must be taken into consideration, alongside the community determinants, to build resilience to withstand stressors that can emerge through the social, political, and economic contexts of society.10 These essential elements have been clustered into the following:
The Emerging Pillars of Wellbeing
BELONGING/CONNECTEDNESS—Feeling part of a community; a sense of acceptance; a belief that you are accepted as you are; having a place or group that is restorative or acts as a refuge
CONTROL OF DESTINY—A sense of purpose; the ability to influence the events that shape life’s circumstances; the ability to make and take action; agency
DIGNITY—A sense of one’s own value; the quality of being worthy of honor and respect; living in a climate of mutual respect and regard for all
HOPE/ASPIRATION—A reassuring belief that something better is possible and achievable; optimism that allows forward movement
SAFETY—The experience of security: interpersonally, emotionally, and with one’s surroundings; possession of a sense of stability
TRUST—A belief in the reliability, truth, ability, or strength of self and others; the ability to count on the circumstances surrounding you
Understanding and committing to these pillars enables the community development sector to strengthen its efforts to be more specific and precise and to have a long term, multigenerational impact in protecting health and wellbeing. When intentionally embedded in community development strategies, the pillars can strengthen the community determinants to protect health, particularly for those living with mental health challenges.
For example, the community development sector’s investment in affordable housing is important; however, the pillars as core values evoke that housing must also be safe to avert distress, and that the built environment in the development and its surrounding neighborhood must support dignity, belonging/connection, and trust to reinforce thriving. Healing values like the pillars can assist the community development sector with achieving its mandate to improve living conditions in underserved communities by intentionally shaping community-driven strategies to shift community culture and facilitate community transformation. Several examples across the country reflect the embedding of these values to the benefit of residents and project outcomes.
BRIDGE Housing is a nonprofit committed to ensuring that public housing residents live in high-quality buildings that meet the same standards for design and safety that residents in market-rate housing enjoy. BRIDGE’s Trauma-Informed Community Building (TICB) model emerged from the need to acknowledge and address the trauma that public housing residents had experienced due to concentrated poverty, violence, low levels of education, displacement, and structural racism and isolation. More broadly, the TICB model uses pillars like belonging/connectedness, dignity, trust, and safety to improve upon traditional resident engagement by considering emotional needs and recognizing the impact of pervasive trauma. In working with residents of the Potrero Terrace and Annex public housing complex, BRIDGE began to engage them in a way that felt comfortable to them. By holding activities in neutral spaces, and ensuring that staff was consistent, BRIDGE created localized “Zones of Safety,” which helped to promote cohesion and connectedness among residents. As a result of participating in TICB activities, BRIDGE residents have improved health and safety outcomes, including reduced depression, improved self-esteem, greater feelings of happiness and relaxation, increased physical activity, a healthier diet, and maintenance of a healthy weight. Residents also reported that they felt a sense of safety while participating in the activities, even if the immediate surroundings were unsafe.11
People United for Sustainable Housing (PUSH Buffalo) in Buffalo, NY, is a local, membership-based community organization fighting to make healthy affordable housing a reality on Buffalo’s West Side. PUSH was founded to create strong neighborhoods with quality affordable housing; decrease the rate of housing abandonment by reclaiming empty houses from neglectful public and private owners and redeveloping them for occupancy by low-income residents; and develop neighborhood leaders capable of gaining community control over the development process and planning for the future of the neighborhood.12 PUSH explores and experiments with different models of governance and participation to fulfill the organization’s vision for “community control of resources,” especially as they engage tenants and develop tenant leaders who “know what they need where they live.” This level of engagement and shared leadership reinforces social cohesion, trust, local wealth, and willingness to advance work for the common good.
Common Wealth Development in Dane County, WI, was founded to protect the Williamson Street neighborhood from disinvestment, concentrated poverty, and violence.13 Common Wealth developed a three-pronged approach to create jobs in the neighborhood: business development, community development, and housing improvements. Common Wealth has renovated and rehabbed 146 properties for rent and supported families with one-on-one counseling for first-time home buyers. Common Wealth recognizes the investment in equitable opportunity through economic self-sufficiency and its capacity to simultaneously build self-esteem and self-confidence.14 Sparked by local parents seeking support in finding employment for their children, Common Wealth established the Youth-Business Mentoring program as its core community development initiative. The program serves over 300 young people annually, training them in job searching skills and financial management. Young people are placed with area employers, who serve as mentors and participate in employment and financial management workshops, realizing multigenerational benefit. Although the development of financial knowledge (often referred to as financial literacy) is necessary, there is growing recognition that the desired outcome is more accurately described as financial wellbeing. This speaks to both the capability to navigate the financial system at an individual level, as well as ensuring that systems and policies are designed to promote widespread opportunity at the community level, such as affordable housing in thriving neighborhoods and access to transit and employment.
These efforts serve as examples of a critical shift for community development groups and coalitions to ask, “What happened here?” and “What are the strengths that can create sustainable improvements to our community?” They create an opportunity to describe common experiences and impacts and begin to work on factors that have produced trauma within entire communities.
Moving Upstream with Community Development
Exploring how the community determinants are expressed in work that focuses on mental health and wellbeing provides insight into how community development can work with other sectors to achieve mutual goals and outcomes. One of the challenges in promoting mental health and wellbeing is moving the collective mindset from solely individual treatment to upstream prevention anchored in community health—especially in communities that have experienced prolonged, multifaceted disinvestment and pervasive exposure to trauma. With expertise in leveraging funds to improve neighborhood conditions and a social justice‒oriented commitment to improving outcomes for low-income communities, the community development sector is well-primed to anchor initiatives that address upstream underlying issues related to mental health and wellbeing, as demonstrated by the following examples.
The Male Engagement Network (MEN) in Boston, MA, is about making connections. Led by Local Initiatives Support Corporation Boston, MEN creates safe spaces where men of color can gather to receive and give support, learn and teach, heal and be healed. MEN’s mission is to build pathways to success for men of color by focusing attention and resources on stressors that obstruct their potential. It offers activities in the Roxbury, Dorchester, and Mattapan communities of Boston that build financial health, housing stability, and mental health. With traction at the neighborhood level, shared priorities for community development, and support through the Making Connections for Mental Health and Wellbeing among Men and Boys initiative, MEN is working with its property managers to identify practices and policies that inhibit access to affordable housing and implementing changes to increase access. For example, MEN is examining how the Criminal Offender Record Information (CORI) may impact housing eligibility for individuals and families; it is working with housing management companies to examine policies on CORI and the housing application practice. MEN has also initiated workplace programs to assure that those working on its properties (maintenance and building services staff) have the opportunity to build financial health and mental wellbeing through worksite programs. Vital Village of the Boston Medical Center provides the local evaluation, a critical component to making the case for further investment in these community-driven approaches.
Kokua Kalihi Valley (KKV), a Federally Qualified Health Center that serves the diverse residents of Kalihi Valley in Honolulu, HI, is addressing the mental health and wellbeing of men and boys through the creation of a youth leadership development program nested within the Kalihi Valley Instructional Bike Exchange, better known as KVIBE. KVIBE is a natural gathering place where multiple generations of boys and young men come together to socialize and repair bikes. KVIBE was established as part of KKV’s commitment to providing community-based health initiatives that honor the development of personal relationships and respect for cultural values to support physical and emotional wellbeing.15 Through its commitment to leadership and connection to land, the young people at KVIBE have catalyzed improvements to the neighborhood’s physical environment, having successfully advocated for the installation of a bike lane on a major road that was formerly unsafe to ride. By nurturing young leadership, entrepreneurial spirit, civic engagement, and healing connections within the community, KKV improves mental wellbeing in Kalihi, while also inspiring and empowering the next generation of leaders and advocates embedded in the community.
Hilltop Urban Gardens (HUG) in Tacoma, WA, is using food sovereignty—the production of healthy and culturally appropriate food through ecologically sound and sustainable methods—to strengthen authentic social connections; improve access and utilization of quality resources, such as food; and improve civic engagement among men, boys, and LGBTQ people of color.16 By understanding the root causes of concentrations of poverty and structural oppression, HUG focuses on interrupting those root causes by concentrating on food independence, anti-displacement strategies, community building, leadership development, and interdependence through social connectivity.17
Engagement to assess local needs and to develop environments that support wellbeing—through direct action and advocacy on matters such as social justice, community safety, housing restoration, fair wages and workplaces, food sovereignty, improved schools, and access to healthy foods—can contribute to strengthening a sense of belonging and shared community agency. The community development sector can find ways to invest in grassroots leadership, avoid distrust and competition, and recognize that the most impacted communities are most capable of leading real solutions to restore mental health and wellbeing. In addition, the sector can facilitate the design of supportive community environments, including recognizing the impact of and mitigating resident displacement, reducing isolation, reconnecting to land, and valuing culture and traditional ecological knowledge.
These examples not only highlight existing efforts to improve mental health and wellbeing in partnership with community development, but they also reveal opportunities to adapt these strategies for other communities that are experiencing similar conditions. Many health-oriented collaboratives want to work on these same strategies to improve the community determinants of health but are uncertain how or where to get started on engaging in strategies. Community development organizations are natural partners to move this work forward and can help the health sector as it seeks to foster vibrant communities.
Time of Opportunity with Natural Partners
The goal of improving mental health and wellbeing at a community level is aligned with the community development sector’s origins and mission, and it builds the social capital necessary to sustain its investments. Generally speaking, the environments that community development creates and reinforces are the same neighborhood environments that support mental health and wellbeing. A supportive, thriving community—one that facilitates equitable opportunities for achieving health, wellbeing, and social mobility—is a vision that no sector or neighborhood can achieve alone. Intentionally engaging residents in processes that reflect values (pillars of wellbeing) and approaches that share leadership and extending multisector partnerships with others could further improve outcomes in community endeavors.
Finding partners with synergies in values is essential to this work. Early theorists and practitioners in the community mental health movement fed the momentum that guided both public health and community development as distinct fields of practice. Thought leaders, such as Drs. George Albee, Stephen Goldston, and Marshall Swift, emphasized that the interactions within a community environment could have a positive or negative effect on health and wellbeing, recognizing the impact of political and economic stressors in society on mental health and wellbeing.18 Over the years, the fields of community development, public health, and community mental health have moved in parallel patterns, sometimes overlapping but most often without intentional shared outcomes. It is time to create new alignments across these sectors. As we reflect on current conditions within communities across the country, as well as the emergence of exemplary efforts, we see opportunities for community development to intentionally partner and engage with public health and community mental health. This mutually beneficial partnership will foster economic development, provide safe and affordable housing, and transform community environments to promote social connectivity and resilience through a set of equity-driven principles—purpose, people, practice, and platform.
Purpose
- Apply a health, equity, and wellbeing lens to support the fulfillment of mission
- Address bias, discrimination, and institutional and structural racism and classism
- Acknowledge the systematic production of inequities by accounting for impact of community trauma and mental health and wellbeing
- Foster connections and facilitate collaboration between people, systems, issues, and opportunities
People
- Create a shared vision that galvanizes partners and holds others accountable to mental health and wellbeing
- Lift and activate community voice, participation, and leadership
- Engage in inclusive multisector partnerships
Practice
- Develop tools and approaches that build and sustain health, equity, and wellbeing
- Train and build capacity across systems and sectors to engage in community prevention strategies
Platform
- Make the case for community strategies through communications and media
- Leverage financing and funding across sectors to support equity
- Identify existing and establish new metrics and measurement to support impact of strategies
Community development’s efforts and alignment with other sectors working to impact community environments reinforce the need for community prevention strategies. Engaging in comprehensive, multisector community prevention strategies elevates the community development sector’s capacity to fulfill its mission by promoting thriving community environments through improved individual, family, and community mental health and wellbeing, supporting its mission to improve the living conditions of the most vulnerable communities. Now is the time for the community development sector to actively seek these synergies to advance upstream prevention and community-driven solutions to fulfill the WHO definition of mental health—fostering resilience and supporting those who are tremendously impacted by inequities, those living with mental illness and mental health challenges, and the broader community.
Sheila B. Savannah,
Larissa J. Estes
Acknowledgements
The authors received funding support by the Blue Shield of California Foundation, Well Being Trust, and the Movember Foundation. Larissa Estes co-authored this article during her tenure at the Prevention Institute; she has since become the Manager of Community Partnerships at UCSF Benioff Children’s Hospital Oakland. Special thanks to Rob Baird, Alexis Captanian, Ruben Cantu, Justice Castañeda, Rachel Davis, Sonja Lockhart, and Lisa Fujie Parks for their support and guidance in the development of this contribution.
1. World Health Organization (WHO), “Mental health: a state of well-being” (Geneva: WHO, 2014). Accessed May 30, 2018.
2. Prevention Institute, “Countering the Production of Health Inequities: A Framework of Emerging Systems to Achieve an Equitable Culture of Health.” (Oakland, CA: Prevention Institute, 2016).
3. L. Cohen et al., “A Time of Opportunity: Local Solutions to Reduce Inequities in Health and Safety” (Oakland, CA: Prevention Institute, 2009).
4. Prevention Institute, “Back to Our Roots: Catalyzing Community Action for Mental Health and Wellbeing” (Oakland, CA: Prevention Institute, 2017).
5. Prevention Institute, “Back to Our Roots.”
6. Prevention Institute, “Countering the Production of Health Inequities.”
7. WHO and Calouste Gulbenkian Foundation, “Social Determinants of Mental Health” (Geneva: WHO, 2014).
8. Centers for Disease Control and Prevention (CDC), “Adverse Childhood Experiences (ACEs)” (Atlanta, GA: CDC, 2016). Accessed April 26, 2018.
9. The Making Connections for Mental Health and Wellbeing among Men and Boys initiative, funded by the Movember Foundation, uses a gendered approach to mental health, allowing for a focus on the unique norms and experiences of men and boys in coping, help-seeking behaviors, social pressures, and social connections. We recognize that women’s experiences are distinct from men’s and that mental illness can affect men and women differently. Although this initiative focuses on men and boys, the pillars of wellbeing have been resonant with practitioners who focus on mental wellbeing among women and populations across the gender continuum.
10. Prevention Institute, “Back to Our Roots.”
11. E. Weinstein, J. Wolin, and S. Rose. “Trauma Informed Community Building: A Model for Strengthening Community in Trauma Affected Neighborhoods” (San Francisco, CA: BRIDGE Housing, 2014).
12. PUSH Buffalo, (Buffalo, NY: PUSH Buffalo, 2018). Accessed May 30, 2018.
13. Common Wealth Development, (Madison, WI: Common Wealth Development, 2018). Accessed May 30, 2018.
14. Clubhouse International, “What Clubhouses Do” (NY: Clubhouse International, 2016). Accessed April 26, 2018.
15. Kalihi Valley Instructional Bike Exchange (KVIBE), (Honolulu, HI: KVIBE, 2017). Accessed May 30, 2018.
16. R. Cantu et al., “Cultivating Our Roots: Leveraging a Gendered and Cultured Lens to Advance Community Strategies to Improve Population Wide Mental Health and Wellbeing” (Oakland, CA: Public Health Institute, 2018). Accessed May 30, 2018.
17. Hilltop Urban Gardens (HUG), “About HUG” (Tacoma, WA: HUG, 2018). Accessed May 30, 2018.
18. S. Goldston, Concepts of Primary Prevention: A Framework for Program Development (Sacramento, CA: Office of Prevention, California Department of Mental Health, 1987).