Tesi etd-09252025-190315
Link copiato negli appunti
Tipo di tesi
Corso di Dottorato (D.M.226/2021)
Autore
SPEZIA, NICOLA
URN
etd-09252025-190315
Titolo
Sense of Community for Healthcare in Peripheral Areas: An Interdisciplinary Exploration
Settore scientifico disciplinare
ING-IND/35
Corso di studi
Ph.D. in Health Science, Technology and Management - Ph.D. in Health Science, Technology and Management
Relatori
relatore Prof.ssa NUTI, SABINA
Relatore Prof. GIANNONI, ALBERTO
Relatore Prof. GIANNONI, ALBERTO
Parole chiave
- Sense of Community
- Peripheral areas
- Rural areas
- Community capacity
- Community engagement
- Citizen participation
- Local governance
- Prevention
- Health promotion
Data inizio appello
16/12/2025;
Disponibilità
parziale
Riassunto analitico
Over the past decades, peripheral and remote areas worldwide have been facing a set of mutually reinforcing challenges, creating a vicious cycle. Population ageing, youth outmigration, declining population density, a stagnant economic fabric, and limited employment opportunities interact with one another, generating a complex environment for healthcare. In this setting, a growing demand–supply imbalance has emerged. On one side, demographic trends are driving increasing health needs. On the other, supply capacity is becoming progressively thinner, constrained by limited resources that put at risk both the accessibility and the quality of healthcare delivery. This imbalance results in structurally poorer outcomes for those living in peripheral regions, contributing to widening health inequalities with urban areas.
To address these issues, a number of policies have been introduced at both the European and national levels. In Italy, the National Strategy for Inner Areas (SNAI) has played an important role by highlighting the structural challenges of peripheral territories and allocating dedicated funds to implement different interventions. However, the prevailing approach has largely been aid-based (“assistenziale”), centered on financial injections and on a view of these areas mainly as vulnerable contexts requiring external support. What is missing—going beyond limited rhetorical assertions—is the consideration of the potential and resources that peripheral areas themselves can mobilize to confront these challenges, together with concrete strategic and operational guidance on how such assets could be effectively leveraged and enhanced.
This thesis is situated within a broader research effort of the Interdisciplinary Research Center “Health Science” at Sant’Anna School of Advanced Studies, developed within the Proximity Care and Tuscany Health Ecosystem (THE) Spoke-10: Population Health projects. Through extensive fieldwork conducted in three peripheral areas of Tuscany, these projects are advancing a paradigm shift. This paradigm shift is based on two main pillars. First, the recognition and integration of local capacities with the expertise of the research group to co-develop innovative tailored solutions and initiatives for health promotion and disease prevention. Second, a broader rethinking of the role of different stakeholders—local policymakers, health professionals, third-sector organizations, and, crucially, the population itself—to enable the sustainability of these solutions in the long term, thus piloting a novel approach for future healthcare delivery.
Within this broader framework, this thesis focuses on the role of citizens and local communities in peripheral areas, exploring which social resources could sustain the proposed paradigm shift. Specifically, it examines whether and how these resources can protect and promote population health, and how they can support the proactive participation of citizens in prevention and health promotion initiatives. For this purpose, this work leverages the concept of Sense of Community (SoC).
Originally developed within the fields of sociology and community psychology, SoC reflects lived experiences of one’s local community, particularly in terms of membership, emotional connection, mutual influence, and the fulfillment of needs within the place of residence. A growing body of research highlights the importance of SoC as a protective factor for individual health and well-being. Moreover, theoretical frameworks identify SoC as a key element of community capacity—expected to shape the ability of local communities to confront challenges and strengthen their resilience. In this view, SoC emerges as a relevant conceptual lens for pursuing the objectives of this thesis, adopting a interdisciplinary perspective that bridges public health and healthcare management. Accordingly, two research questions are addressed: (1) How does SoC function as a social determinant of health in peripheral areas across multiple dimensions?, and (2) To what extent can SoC foster community engagement in prevention and health promotion efforts in peripheral areas?
Chapter 2 of this work presents a scoping review of the literature on SoC in the context of disease prevention and health promotion interventions. The review shows that, while several studies have linked SoC to different health and well-being outcomes, research focusing specifically on its role within prevention and health promotion interventions remains limited. In particular, a gap emerges in the empirical study of the relationship between SoC and community engagement in such interventions— despite strong theoretical arguments suggesting that SoC should serve as a catalyst for broad population participation.
Chapter 3 introduces the Population Experience Observatory, implemented in three peripheral areas of Tuscany—Serchio Valley, Casentino, and Elba Island—within the Proximity Care and THE projects. The Observatory serves as a participatory platform to evaluate quality of life as directly reported by residents, as well as a public management tool that supports local governance by actively involving both citizens and key stakeholders. The Observatory is currently active: as of September 2025, around 6,000 citizens have interacted with it, more than 2,600 questionnaires have been collected, and over 850 individuals have joined a panel of “active citizens”, leaving their contacts to be further involved in dedicated local activities. Additionally, over 850 adolescents participated in the Observatory’s youth survey. This tool thus provides the empirical foundation for analyzing SoC in peripheral areas, alongside other key dimensions of population health.
Chapter 4 presents a study based on data collected in the first area where the Observatory was implemented, focusing on the relationship between SoC and the perceived quality of local health and social services. Findings show that, after controlling for socio-demographic and health-related variables, SoC plays a protective role in shaping how people perceive and interact with local services.
Chapter 5 shifts the focus to the adolescent population, leveraging Observatory data from the three peripheral areas to explore the relationship between SoC and exposure to online risks—an emerging issue for youth health. The analysis demonstrates that, once again, after accounting for individual, family, and online behavior variables, SoC acts as a protective factor, reducing the likelihood of exposure to digital risk situation.
Regarding the first research question, the empirical studies presented in this thesis build on earlier evidence from the literature review, reinforcing the role of SoC as a determinant of health and showing its protective effects in the specific context of peripheral areas. With respect to the second research question, while the literature has so far revealed a clear gap in examining the empirical relationship between SoC and community engagement in the general population, findings from the Population Experience Observatory and its related studies suggest a positive link between the two. At the same time, further research in this area is clearly needed, and this represents the future focus of the Observatory’s research agenda.
Taken together, the evidence of this thesis suggests that when communities in peripheral areas possess strong SoC, they are not only better protected in terms of health and well-being but also better positioned to mobilize their own agency to address local challenges. This, in line with the broader context of the Proximity Care and THE projects and the paradigm shift they propose, carries important implications for healthcare in this setting. Policies and practices should evolve to acknowledge and strengthen the primary role of citizens, communities, and community-based resources such as SoC. Within this vision, the role of local stakeholders should be reshaped to become supporters and facilitators of this process of local empowerment. If pursued consistently, this approach could prove crucial in addressing the pressing challenges of peripheral areas, bringing broad systemic benefits and ultimately leading to improved health outcomes and greater resilience in the communities of these territories.
To address these issues, a number of policies have been introduced at both the European and national levels. In Italy, the National Strategy for Inner Areas (SNAI) has played an important role by highlighting the structural challenges of peripheral territories and allocating dedicated funds to implement different interventions. However, the prevailing approach has largely been aid-based (“assistenziale”), centered on financial injections and on a view of these areas mainly as vulnerable contexts requiring external support. What is missing—going beyond limited rhetorical assertions—is the consideration of the potential and resources that peripheral areas themselves can mobilize to confront these challenges, together with concrete strategic and operational guidance on how such assets could be effectively leveraged and enhanced.
This thesis is situated within a broader research effort of the Interdisciplinary Research Center “Health Science” at Sant’Anna School of Advanced Studies, developed within the Proximity Care and Tuscany Health Ecosystem (THE) Spoke-10: Population Health projects. Through extensive fieldwork conducted in three peripheral areas of Tuscany, these projects are advancing a paradigm shift. This paradigm shift is based on two main pillars. First, the recognition and integration of local capacities with the expertise of the research group to co-develop innovative tailored solutions and initiatives for health promotion and disease prevention. Second, a broader rethinking of the role of different stakeholders—local policymakers, health professionals, third-sector organizations, and, crucially, the population itself—to enable the sustainability of these solutions in the long term, thus piloting a novel approach for future healthcare delivery.
Within this broader framework, this thesis focuses on the role of citizens and local communities in peripheral areas, exploring which social resources could sustain the proposed paradigm shift. Specifically, it examines whether and how these resources can protect and promote population health, and how they can support the proactive participation of citizens in prevention and health promotion initiatives. For this purpose, this work leverages the concept of Sense of Community (SoC).
Originally developed within the fields of sociology and community psychology, SoC reflects lived experiences of one’s local community, particularly in terms of membership, emotional connection, mutual influence, and the fulfillment of needs within the place of residence. A growing body of research highlights the importance of SoC as a protective factor for individual health and well-being. Moreover, theoretical frameworks identify SoC as a key element of community capacity—expected to shape the ability of local communities to confront challenges and strengthen their resilience. In this view, SoC emerges as a relevant conceptual lens for pursuing the objectives of this thesis, adopting a interdisciplinary perspective that bridges public health and healthcare management. Accordingly, two research questions are addressed: (1) How does SoC function as a social determinant of health in peripheral areas across multiple dimensions?, and (2) To what extent can SoC foster community engagement in prevention and health promotion efforts in peripheral areas?
Chapter 2 of this work presents a scoping review of the literature on SoC in the context of disease prevention and health promotion interventions. The review shows that, while several studies have linked SoC to different health and well-being outcomes, research focusing specifically on its role within prevention and health promotion interventions remains limited. In particular, a gap emerges in the empirical study of the relationship between SoC and community engagement in such interventions— despite strong theoretical arguments suggesting that SoC should serve as a catalyst for broad population participation.
Chapter 3 introduces the Population Experience Observatory, implemented in three peripheral areas of Tuscany—Serchio Valley, Casentino, and Elba Island—within the Proximity Care and THE projects. The Observatory serves as a participatory platform to evaluate quality of life as directly reported by residents, as well as a public management tool that supports local governance by actively involving both citizens and key stakeholders. The Observatory is currently active: as of September 2025, around 6,000 citizens have interacted with it, more than 2,600 questionnaires have been collected, and over 850 individuals have joined a panel of “active citizens”, leaving their contacts to be further involved in dedicated local activities. Additionally, over 850 adolescents participated in the Observatory’s youth survey. This tool thus provides the empirical foundation for analyzing SoC in peripheral areas, alongside other key dimensions of population health.
Chapter 4 presents a study based on data collected in the first area where the Observatory was implemented, focusing on the relationship between SoC and the perceived quality of local health and social services. Findings show that, after controlling for socio-demographic and health-related variables, SoC plays a protective role in shaping how people perceive and interact with local services.
Chapter 5 shifts the focus to the adolescent population, leveraging Observatory data from the three peripheral areas to explore the relationship between SoC and exposure to online risks—an emerging issue for youth health. The analysis demonstrates that, once again, after accounting for individual, family, and online behavior variables, SoC acts as a protective factor, reducing the likelihood of exposure to digital risk situation.
Regarding the first research question, the empirical studies presented in this thesis build on earlier evidence from the literature review, reinforcing the role of SoC as a determinant of health and showing its protective effects in the specific context of peripheral areas. With respect to the second research question, while the literature has so far revealed a clear gap in examining the empirical relationship between SoC and community engagement in the general population, findings from the Population Experience Observatory and its related studies suggest a positive link between the two. At the same time, further research in this area is clearly needed, and this represents the future focus of the Observatory’s research agenda.
Taken together, the evidence of this thesis suggests that when communities in peripheral areas possess strong SoC, they are not only better protected in terms of health and well-being but also better positioned to mobilize their own agency to address local challenges. This, in line with the broader context of the Proximity Care and THE projects and the paradigm shift they propose, carries important implications for healthcare in this setting. Policies and practices should evolve to acknowledge and strengthen the primary role of citizens, communities, and community-based resources such as SoC. Within this vision, the role of local stakeholders should be reshaped to become supporters and facilitators of this process of local empowerment. If pursued consistently, this approach could prove crucial in addressing the pressing challenges of peripheral areas, bringing broad systemic benefits and ultimately leading to improved health outcomes and greater resilience in the communities of these territories.
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