〈Research Article〉

Building Community Capacity to Address
the Social Determinants of Health― Experiences of Canadian Public Health Practitioners ―Yoshiko Sugie1)【Abstract】
Purpose: To gain a better understanding of community capacity building practice in a Canadianpublic health unit by exploring 1) How public health practitioners develop their knowledge andskills of community capacity building and 2) How their knowledge and skills are transferred to others.
Methods: Theoretical sampling was used to select a team of staff in a public health unit. Qualitative
data was collected through individual staff interviews consisting of semi-structured questions.
Another data source was the author’s participatory observation of the staff’s activities and theirteam meetings. Thematic analysis was used to make sense of the interviews.
Results: Community Health Officers (CHOs) engaged in partnership and collaboration with
community members and other professionals to address the social determinants of health withincommunities. Their great passion for community capacity building was developed through previous
experiential learning about health inequity and the need for intersectoral collaboration. Theircritical thinking and reflective practice further developed their political agency to initiate socialchange. Listening and relationship-building were identified as fundamental skills necessary forcommunity capacity building. Challenges included bureaucracy in a government and difficulty inprioritization of their projects. Their wealth of knowledge seemed to exist independently. The
importance of dissecting and sharing their experiences among the team was emphasized as aneffective approach to professional development, mutual support and coordinated action for change.
Conclusion: The processes in which CHOs have developed their knowledge and skills are very richin variety and depth. Their knowledge and skills are being effectively utilized in community,
however, have not been synergized among the CHO Team. Creating a learning team of CHOs canbe a solution for the possible synergy of community capacity building knowledge and skills, which
can be transferred to other members of the public health unit. The CHO Team can take an initiativein creating a learning community in the public health unit by using their community capacity1)

城西国際大学看護学部看護学科－1－building knowledge and skills within the organization.

Keywords: community capacity building, the social determinants of health, learning community

Ⅰ．Introduction
Community capacity building has been emphasized as an important approach for health promotion
in public health (World Health Organization, 1986; WHO, 2005). Multiple case studies have shownthat community capacity building is effective (Raeburn et al., 2006), but it has been difficult tomeasure and describe its effectiveness (MacLellan-Wright et al., 2007). Also, it has been difficult for
public health practitioners to articulate what exactly they do in everyday practice to build community
capacity in spite that they use the approach in various programs to address the social determinants ofhealth. A study was conducted to gain a better understanding of community capacity building
practice in a Canadian public health unit. This paper reports on the study to explore: 1) How publichealth practitioners develop their knowledge and skills of community capacity building and 2) How
their knowledge and skills are transferred to others.
Several community-based terms are commonly and interchangeably used in the health sector:
community development, community organization, community mobilization, community building,and community capacity building. For example, community organization has a long history in the
United States whereas community development is frequently used in Canada to mean the same idea
(Labonte, 2005). Although these community-based terms carry subtle but important differences (Ife,2010), for the purpose of this paper, I will use the term “community capacity building” to refer to thecommon features of what the different community-based terms describe.

Ⅱ．Method
1. Sampling
Theoretical sampling was used to select a team of staff in a public health unit, who dedicated to act
as resources to communities to build community capacity. The staff position was called Community
Health Officer (CHO). Their job was to work with communities and internal/external stakeholders toaddress the social determinants of health (SDOH) using a community capacity building approach.
Participants for interview were purposefully selected to ensure a wide range of variation in theircareers.

Ten full-time staff, nine currently and one formerly employed, were individuallyinterviewed. Their experience in the position ranged from 2 to 19 years. In addition, they had 5 to 20
years of experience in community work prior to becoming a CHO.
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2. Data Collection
The author conducted participatory observation of the staff’s activities and their team meetings fortwo days per week for six months. Then, semi-structured interviews with ten participants wereconducted using an interview guide. The interview guide was developed by the author after theparticipatory observation and can be found in Table A. The interviews lasted 1-2 hours and were notaudio-recorded. Notes were taken during the interviews.
3. Ethical Considerations
All staff in the team and their manager were fully informed of what the study entails and the
purpose of the study. All staff and the manager agreed to the author's participatory observation of thestaff’s activities and their team meeting. Interview participants provided their consent voluntarily.
Confidentiality is maintained by ensuring information collected from participants cannot be linked totheir identities in this paper.
4. Data analysis
Open coding was performed on the interview notes and then the codes were merged into common
themes. Nine dominant themes were selected for analysis. A table summarizing the themes andrepresentative codes can be found in Table B.
5. Member Checking
After data were analyzed, the results and discussion were shared with all CHOs and the manager tocheck for accuracy.
Table A: Interview Guide
1. What do you like about your work as a Community Health Officer?
2. What skills do you find most important in building community capacity?
3. Please describe challenges that you have encountered in building effective working
relationships with community agencies and groups. How did you deal with the challenges?
4. How do you decide what projects to work on?
5. How do you prioritize your projects?
6. You have volunteered to mentor a new CHO with no previous experience in community
capacity building. What strategies would you use to mentor him/her?
7. What other supports/resources do you think would help you do your job?
8. How do you maintain and further develop your professional knowledge and skills?

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Table B. Themes and Codes
Theme

Codes

Passion for Community Flexibility

Capacity Building Job satisfaction
 Uncertainty of complex issues
 Long process of work Broader scope of practice Values Work at the grassroots level Focus on the social determinants of health

CHO Roles and Skill Set

 Unique descriptions about CHO roles Core component of CHO work Experiential learning Reflective practice Specific skills

Case Management at

 Community’s readiness for CHO’s involvement

Community Level

 Over-commitment
 Withdrawal“Locating Myself”

 Relationships with community partners
 To locate myself in relation to the communities and issues

Bureaucracy

 Government work
 Government politics
 Dilemma of accountability
 Conduits between communities and the municipality

Prioritization

 Juggling many projects
 No time to reflect
 Factors for community capacity building

Professional Development

 Staying current
 Professional and personal development Reflection-in-action

Supports

 Consultation with manager
 Peer consultation
 Request for tangible supports

CHO Team Consultation with CHOs about communities
 Sharing knowledge and experiences－4－

Ⅲ．Results and Discussion
1. Passion for Community Capacity Building
What most CHOs appreciate about their job is flexibility. Although they are assigned projects andcommittees by geographical areas and deal with community health issues without geographicalborders, CHOs do not work with rigid guidelines or protocols, or provide only standard services tocommunities. They work on complex issues and situations within communities. One CHO describedthe essential requirement for the job as the ability “to feel comfortable working in a lot of ambiguity.”
I believe the uncertainty of complex issues and situations leads to the flexibility in their work. Mostof the issues and situations they handle embrace many fluid factors, thus making their practicedynamic and mobile. In other words, they need to be flexible in order to respond to uncertain andambiguous issues/situations.
Another CHO said, “I did not know what I was going to do in the beginning,” as her work withhomelessness issues evolved into several tangible projects/programs over time. Community capacity
building is a flexible but long process. She said, “You plant seeds. You may see them grow years lateror may not.” In her case, what she values – social justice – has been embodied in community/publichealth programs through the long process of community capacity building work. Joy in the flexibility intheir jobs cannot be separated from the long process of uncertainty/ambiguity.
All the people I interviewed were attracted to the CHO position by the broader scope of practice.
All of them appreciated being able to work at the grassroots level with a focus on the SDOH. Theirprevious experiences varied: from social workers in community agencies to public health nurses inparticular programs, from clerical work to sexual health educators, and from youth outreach workers
to management. Through their previous experience, they recognized the intertwined, underlying
causes of social/health issues and faced limitations in their work, while wanting to work on issues
from broader perspectives.
All CHOs emphasized the importance of focusing on the SDOH. I noticed that the implicit or
explicit values underlying their passion for community capacity building and their practice are equity
and social justice. One CHO described the core value underlying community capacity building as
compassion and respect. I believe most came to hold these important values not through descriptionsof community capacity building or health promotion, but through their experiential learning aboutcommunity work at the grassroots level.
One CHO recommended John McKnight’s book “The Careless Society: Community and Its
Counterfeits.” CHOs are very passionate for being community-based. They enjoy working in andwith the community to the fullest, although being professionals employed by the municipality.
Working at community level was so important that one person decided to transfer from a management－5－position to a CHO position. “Disconnection with community” when working at a higher order ofgovernment caused her to “loose heart” in her work.
Carlisle’s conceptual framework for advocacy (2000) gives an idea about the stance of CHOs. The
stance of most CHOs is characterized as social health promotion towards the goal of empowermentwith an egalitarian philosophy of practice (co-worker status). They sometimes work at the case level(individual/groups) for community development and at other times work at the level of causes(policy/structure) for community activism. Some CHOs occasionally take the stance of expert as aconsultant, evaluator, researcher, or grant proposal writer when working with community.
2. CHO Roles and Skill Set
Each CHO described their work uniquely: “I am trying to find missing pieces of a puzzle and put
them together;” “I am a bumblebee” going between several people/communities/resources to connect
them; “I like to break down and contain chaos” in communities/agencies. CHOs do not use muchjargon when articulating the core component of what they do. It is almost as if they would loose heart
in a job described by professionally-acceptable, guarded buzzwords. Some CHOs simply described
themselves as a catalyst, link, broker, liaison, messenger or facilitator.
One CHO downplayed her own involvement and stressed the community’s strengths: “Expertiselies in community;” “They are full of ideas.” She said, “they (people in the community) hold thekey.” Her role is to break down the issues they have, reframe their situations, take away barriers andelicit expertise from community. The best part of CHO work for her is the excitement of containing
chaos and problem solving. The most significant learning through her work was that “diversity makes
the healthy community.” She had learned to appreciate the existence of disruptive, challenging
community members who also contributed to the community capacity building process. Without theirchallenging, the result of community capacity building work might have been less fruitful.
One CHO particularly emphasized the importance of volunteering in communities. This CHO had
developed the fundamental skills and knowledge necessary for community capacity building workthrough volunteering in various organizations. Those skills included understanding how anorganization operates, listening, networking, negotiation, conflict resolution, team building,developing relationship, and building trust.
Another CHO said she learned community capacity building skills and knowledge over timethrough working in the front lines. Initially she “blindly reacted” to issues with “no reflection.”
Then, she began noticing patterns in the issues, gaps in services, institutional barriers, needs foradvocacy, and the need to work from larger, bigger levels. Being involved in a community
development project came as a turning point for her. She worked as a change agent in the project thatembraced all components of health and social fields so that “the project crystallized.”－6－Other CHOs developed their community capacity building skills and knowledge when working as
public health nurses, sexual health educators, or social workers. They learned the existence ofsocial/health inequity from direct experience with marginalized populations. Their critical thinking
and reflective practice further developed their political agency to initiate social change, however they
faced the limitations of standardized program policies and guidelines. These limitations eventually
brought them to the CHO position where they could work on systemic issues.
Among the most important skills in community capacity building, two skills recurred in theinterviews: listening and relationship building. I think when a CHO actively listens to communities
and builds relationships with all the stakeholders, a community capacity building process will
naturally follow because the expertise lying in communities themselves will be recognized throughthe CHO’s active listening and synergized by building relationships. The real appeal of community
capacity building seems to be watching synergistic social movement occurring as a change agent at
community level.
Other skills necessary when facing challenges are the ability to “stay back” and “knowing to bequiet.” I observed the CHOs to be out-going and not necessarily quiet people. However, when it
comes to challenges with communities, they know when to be silent and remove themselves from thesituation because they acknowledge community members as central players in community capacity
building.
3. Case Management at Community Level
The term “case management” came to mind to describe the CHOs’ work while interviewing them.
One CHO agreed to describe it as case management on a community scale. Although “management”
itself has a connotation of paternalistic, top-down power relations, “case management” has aconnotation of managing ourselves rather than clients. “Case management” means managing our
involvement with clients, not managing clients’ lives.
Three topics related to the CHOs’ case management emerged in the interviews: the community’s
readiness for CHO’s involvement, over-commitment, and withdrawal.

A CHO cannot initiate

community capacity building when a community is not ready because there are few people interested
or not enough resources in the community. A CHO who recognizes issues in the community can be
frustrated when people in the community do not see them as problematic. A CHO may work muchharder than community members, leading to possible CHO burnout without any effective results ofcommunity capacity building. It is often necessary to wait and see for the community to ripen for the
CHO’s involvement.
Public health practitioners may become over-committed to a project or community without
noticing. Over-commitment may occur gradually over a long period of time as the community－7－

becomes dependent on the worker, subsequently making it more difficult for him/her to discharge.
Over-commitment does not build capacity in the community. It just creates community dependency,
which goes in the opposite direction of community capacity building goals. Case management is
critical in this case. Public health practitioners need to critically analyze and plan how to involve
themselves with communities in progress.
When to withdraw from community capacity building involvement may be ambiguous because
capacity building can theoretically be endless. No community can be perfect; therefore there arealways areas of community capacity that can be further developed. Withdrawal may also involve
emotional aspects because of the trusting relationships developed over the time, making timing
difficult to decide. Missing the timing of withdrawal can lead to over-commitment.
4. “Locating Myself”
One CHO who described the ambiguity of community capacity building work said that you need tobe “clear with yourself and your role” and that “if you are lost, you need to take time to reflect.”Since they often handle complex and systemic issues, they are at risk of encountering dilemmas,
frustration, powerlessness, or being lost. To prevent the risk or recover from being lost, CHOs need
to be able to locate themselves in relation to the communities and issues. This CHO has beenreflecting on her relationship with a community partner who is a member of the marginalized, visible
minority population. Despite the CHO’s tireless efforts in understanding the complexity of thecommunity’s issues, the community partner has been keeping a distance from her and mentioning theprivileges the CHO has – being a white person, having a car, and having a good government job. Her
experience is very similar to that described in Langhout’s work (2006) that examined the process ofher situating and locating herself and the reflexivity about her role in a collaborative action research.
At the time of the interview, the CHO said that it might be a good idea to transfer the project toanother CHO who has the same ethnic background as the community partner.
5. Bureaucracy
Some CHOs do not really appreciate being assigned to internal committees/projects even though
they understand their significance. Compared to the flexibility of their community work, the internal
committees/projects are often accompanied by rigidness, bureaucracy and technocracy, being part andparcel of governments. Although the municipal government employs them, CHOs consider bureaucracy
and technocracy as obstacles in the way of community capacity building and empowerment because
they often wear the hat of community representatives. They are allowed to work on community
capacity building and empowerment at the grassroots level by the government but, at the same time,
are restricted to working within the politics of the government. Therefore they may find themselves－8－

in a dilemma of accountability. Boultier and Mason (2008) discussed the similar dilemmas and issues
that health promoters experience.
However, one CHO appreciated her privilege of being a civil servant so that she can be a conduit
between communities and the municipality. This is the positive flip-side of being in the government
structure. Actually, all CHOs work as conduits between communities and the municipality without
explicit appreciation for being a civil servant. It might be the stance they take from Conflict Theory
that contributes to their dilemma of working between the community and the government to someextent. The radical-change-oriented stance from Conflict Theory was clear in one interview with a
CHO in which she said CHOs should fight with governments but not with communities. There arepros and cons of working as a community capacity building worker in a large government body,
however CHOs attempt to effectively use the benefits of being civil servants while advocating for thegrassroots.
6. Prioritization
Prioritization of projects/committees is a difficult task for some CHOs. They cannot put any
projects/committees aside because all of them are important in different aspects. Unless a situation
develops into an emergency, they often take them all simultaneously without having enough time toreflect. They somehow manage to juggle many projects/committees, however, a CHO pointed outthat it could lead to burnout.
Another CHO leaves prioritization to the community. She says there are three factors necessary for
a community capacity building process to occur: opportunity, availability of resources, andcommunity interests. She places her eggs (opportunity) in the community basket and stands back toreflect on how to cast or organize realistic community interests and potential resources. She allows
the community to make the best use of her, letting the community lead. She works hard but notharder than community does, preventing burnout.
7. Professional Development
The approaches to professional development that CHOs use include attending workshops, staying
current, reading reports/articles related to their work, research activities, going back to school, andreflective practice. To my surprise, only one CHO with a nursing background listed reflective
practice as a professional development approach. Reflection recurred frequently in the interview withanother CHO who, however, did not mention it for professional development.

Based on myinterviews and observations, all CHOs were reflective practitioners. They “reflect in action” focusing
on problem-solving.

Reflection-in-action involves a continuous conversation with a complex

situation using a whole repertoire of experiences to reframe the problem and thoughtfully experiment－9－with a new strategy (Schön, 1983). Reflective practice develops the professional’s tacit knowledge ofproblem-solving and also contributes to professional and personal development (Moon, 1999, as citedin Boultilier & Mason, 2007).
8. Supports
All the CHOs agreed that they have an excellent, supportive manager. They consult with their
manager without hesitation when facing challenges. One CHO found herself calling her manager at
midnight after agonizing about a challenge she faced and received welcoming consultation from the
manager on the spot. The manager had extensive experience in community capacity building prior tothe current position. Her management style is empowering, respectful, facilitating, and coaching,possessing all the qualities of community capacity building. She is building capacity in the CHO
community. I believe that her management style is one of the main contributing factors to the highretention of CHOs.
CHOs seek support and consultations among themselves as well. Two CHOs are located in a
public health office. CHOs in the same office tend to debrief and consult with each other on an ad
hoc basis. One CHO said that she seeks out different people to consult with based on her challenges
and those who know her best. Many also seek support and consultations from personal relationships.
Additional supports that CHOs request are more training, IT support, clerical support, recognition
among other staff, and more cash allowance for community work.
9. CHO TeamThrough participating in monthly CHO Team meetings, I noticed that two-thirds of the two-hour
meetings are usually spent in consultation with a special guest from another department or division.
Therefore, they do not have enough time to discuss their own business, consult with peers about
projects, or do case study. I asked CHOs what they thought about having a special guest/speaker inevery team meeting and whether they needed more time to share their experiences. I realized after a
few interviews that special guests visit the CHO Team meetings not necessarily to make apresentation but rather to consult with CHOs about communities. Community participation became
the norm for program planning, development, management and evaluation, and takes significant
efforts and time. Bureaucrats and technocrats may not know how to initiate community participation,
most likely do not know who the stakeholders are, and may not have enough budget or time. The
CHO Team seems to be treated as easily-accessible community representatives, thus becoming theportal (or possibly one-time stop) of community participation. Some CHOs said that the consultation
with the CHO Team might be a “check box” or “rubber stamp” in bureaucratic program development.
Regarding sharing their experiences in team meetings, a CHO suggested having monthly peer
－ 10 －

groups by four regions between team meetings for checking with each other and sharing knowledge
and experiences. Some said that sharing their experiences in team meetings was a good idea, whileothers said they were too busy to spare the time.

Others requested the opportunity to shareexperiences as an important approach to professional development.

One CHO emphasized theimportance of dissecting their own experiences and sharing with others.

Ⅳ．Recommendation
Through my interviews, I reconfirmed that each CHO has a wealth of knowledge and skills ofcommunity capacity building. Their extensive experiences are unique, while sharing some common
features.

Their narratives can be developed into an excellent guidebook for public healthpractitioners. However, their knowledge and skills seem to exist independently, because they work
independently. They share more with their respective community partners than they do among
themselves. It seems a shame to fail to respect the possibility of synergy among their knowledge.
Lick (2006) elaborated a conceptual framework for organizational learning and introduced adetailed design process for creating “learning teams.” He defined a learning team as “a team (an‘authentic team’) that aligns and develops its capacity (i.e. willingness and ability) as a team to create
the results its members desire to achieve” (p. 92). I believe that the concept of learning teams can beapplied to the CHO Team to initiate synergistic change towards a leaning community. CHOs havecommon goals of equity and social justice, work on common complex issues of the SDOH, and takecommon action of community capacity building. If the CHO Team become a learning team, theywould have potential capacities to effectively “set and focus on challenging new goals;” “dialogue
and think insightfully together about complex issues;” and “take innovative, coordinated action” (p. 93).

Ⅴ．Conclusion
The processes in which CHOs have developed their knowledge and skills are very rich in variety
and depth. Their knowledge and skills are being effectively utilized in community, however, have notbeen synergized among the CHO Team. Creating a learning team of CHOs can be a solution for the
possible synergy of community capacity building knowledge and skills, which can be transferred toother members of the public health unit. The CHO Team can take an initiative in creating a learning
community in the public health unit by using their community capacity building knowledge and skills
within the organization.

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Acknowledgement
Thanks to Toronto Public Health for providing me with an excellent opportunity to explore
community capacity building. Special thanks to Maria Herrera and Cathy Tersigni for their great
support and insightful comments during my participation in the CHO work. Also, thanks to all CHOs
for sharing their invaluable work experiences with me.

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