Community-Oriented Health Services: Practices

Transcription

Practices Across Disciplines
E l i a s M p o f u, PhD, DEd, CRC
Editor
G
rounded in a transdisciplinary approach, this groundbreaking text provides extensive, evidence-based information on the value of communities as the primary drivers of their own health and well-being. It describes
foundational community health concepts and procedures and presents proven strategies for engaging communities as resources for their own health improvement—an important determinant of individual well-being. It
is based on recommendations by the World Health Organization’s International Classification of Functioning,
Disability and Health and on the premise that healthy communities are those with populations that participate in
their own health promotion, maintenance, and sustenance. The book is unique in its integration of environmental and social justice issues as they significantly affect the advancement of community health.
The text focuses on community-oriented health interventions informed by prevention, inclusiveness, and timeliness that both promote better health and are more cost effective than individually focused interventions. It
addresses the foundations of community-oriented health services including their history, social determinants,
concepts, and policies as well as the economics of community-oriented health services and health disparities and
equity. It covers procedures for designing, implementing, monitoring, and evaluating sustainable community
health coalitions along with tools for measuring their success. Detailed case studies describe specific settings and
themes in U.S. and international community health practice in which communities are both enactors and beneficiaries. An accompanying instructor’s manual provides learning exercises, field-based experiential assignments,
and multiple-choice questions. A valuable resource for students and practitioners of education, public policy,
and social services, this book bridges the perspectives of environmental justice, public health, and community
well-being and development, which, while being mutually interdependent, have rarely been considered together.
Key Features:
• Offers a new paradigm for improving public health through community-driven health coalitions
• Includes evidence-based strategies for engaging communities in the pursuit of health
• Demonstrates how to design, implement, monitor, and evaluate community health partnerships
• Presents transdisciplinary approaches that consider environmental and social justice variables
• Includes contributions of international authors renowned in community health research and practice
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Elias Mpofu
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Elias Mpofu, PhD, DEd, CRC, is professor and head of the discipline of rehabilitation counseling at the University of Sydney. Formerly professor of rehabilitation services at Pennsylvania State University, Dr. Mpofu is a leading researcher–educator on
counseling people with disadvantage, vulnerability, and survivorship in diverse community settings. His research concentrates on the discipline of community-oriented
health interventions, and focuses on explicating best practices in community-oriented
health promotion and maintenance, applying theories and methods on community
action with participatory action research, and interlinking behavioral health indicators
in populations to inform preventive health interventions. His priority research goals
include the objective and subjective profiling of health statuses among communities, important for health intervention design, implementation, and evaluation. The
evidence for the clustering of health assets and vulnerabilities in the context of the
community environment is of particular interest for comprehensive health promotion
to result from this line of investigation.
Dr. Mpofu’s community-oriented research has earned him three international
awards in rehabilitation research from the U.S. National Institute on Disability
and Rehabilitation Research (2008), National Council on Rehabilitation Education
(NCRE), and the American Rehabilitation Counseling Association Research
Award (2007). For his leadership in teaching, Professor Mpofu was awarded the
Rehabilitation Educator of the Year Award by the NCRE in 2010. Professor Mpofu
is editor of the Australian Journal of Rehabilitation Counselling and the Journal of
Psychology in Africa. He also serves on the editorial boards of several rehabilitation counseling-related journals, including Journal of Rehabilitation Administration,
Rehabilitation Research, Education and Policy, Rehabilitation Counseling Bulletin,
Psychological Assessment, and the International Journal of Disability, Development
and Education. Dr. Mpofu is lead editor of Assessment in Rehabilitation and Health
(Pearson, 2010) and Rehabilitation and Health Assessment (Springer Publishing
Company, 2010). Recently, he published a seminal edited book on Counseling People
of African Ancestry (Cambridge University Press, 2011).
Community-Oriented
Health Services
Elias Mpofu, PhD, DEd, CRC
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Community-oriented health services : practices across disciplines / [edited by] Elias Mpofu.
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ISBN 978-0-8261-9817-4—ISBN 978-0-8261-9818-1 (e-book)
I. Mpofu, Elias, editor.
[DNLM: 1. Community Health Services. WA 546.1]
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To my late mother, Mrs. Eta Sheneterai Mpofu, for acting to change
living conditions important for health and well-being in her community.
Contents
Contributors
ix
Preface
xiii
Acknowledgments
xvii
PART I: FOUNDATIONS OF COMMUNITY-ORIENTED HEALTH SERVICES
1. Community-Oriented Health Services: History, Framework, Nature, and
Significance
1
Elias Mpofu, Abdolvahab Baghbanian, Jerome E. Bickenbach, and Jessica Brooks
2. Health Policy Analysis
17
Ruopeng An, Christina Huang, and Abdolvahab Baghbanian
3. Economics of Community-Oriented Health Services
Tracy Comans, Erika Turkstra, and Paul A. Scuffham
4. Ethics and Equity in Community Health
Jerome E. Bickenbach
41
63
PART II: PROCEDURES IN COMMUNITY-ORIENTED HEALTH SERVICES
5. The Role of Community Health Workers in Implementing Community-Oriented
Primary and Preventive Services Across the Lifespan
87
Bruce Rapkin
6. Monitoring and Evaluation of Community-Oriented Health Services
117
Elias Mpofu, Mary K. Lam, Ngonidzashe Mpofu, Ebonee T. Johnson, and
W. Douglas Evans
7. Environmental Metrics for Community Health
Howard Frumkin
135
vii
viii
CONTENTS
8. Quality-of-Community-Life Indicators
165
Robert A. Cummins, Elias Mpofu, and Maidei Machina
9. Community-Oriented Health Services in Low-Resource Settings
Susan Williams and Kevin R. Ronan
183
PART III: EVIDENCE-BASED PRACTICE AND POLICIES IN COMMUNITYORIENTED HEALTH CARE
10. Disability Social Inclusion and Community Health
207
Debra A. Harley, Elias Mpofu, Justin Scanlan, Veronica I. Umeasiegbu, and
Ngonidzashe Mpofu
11. Home-Based Voluntary HIV Counseling and Testing Rooted in a CommunityOriented Strategy in Low-Resource Settings
223
Knut Fylkesnes and Charles Michelo
12. Community Health and Disaster Recovery
243
Kevin R. Ronan, Barbara Kelly, Jeanne LeBlanc, and Susie Burke
13. International Immigrant and Refugee Health Issues
271
Lisa Lopez Levers, Beverley-Ann Biggs, and Amy Strickler
14. Community Health Interventions for People With Developmental
Disabilities
293
Gloria K. Lee, Connie Sung, Laura Skotarczak, and Marcus L. Thomeer
15. International Trends in Community-Oriented Mental Health Services
Alan Rosen, Paul O’Halloran, Roberto Mezzina, and Kenneth S. Thompson
16. Epilogue: What Matters in Community-Oriented Health Services?
Abdolvahab Baghbanian, Elias Mpofu, and Syeda Zakia Hossain
Abbreviations
Index
355
351
315
345
Contributors
Ruopeng An, PhD Assistant Professor, Department of Kinesiology and Community
Health, College of Applied Health Sciences, University of Illinois at UrbanaChampaign, Illinois
Abdolvahab Baghbanian, PhD Postdoctoral Research Associate, Health Systems
and Global Populations, Faculty of Health Sciences, The University of Sydney,
Sydney, Australia
Jerome E. Bickenbach, PhD Professor and Director, Disability Policy Unit, Swiss
Paraplegic Research, Nottwil, Switzerland, and the University of Lucerne
Beverley-Ann Biggs, PhD, MBBS, FRACP, FRCP Head, International and
Immigrant Health Group, Department of Medicine, University of Melbourne, and
Consultant, Infectious Diseases Physician, Royal Melbourne Hospital, Victoria,
Australia
Jessica Brooks, PhD Assistant Professor, University of North Texas, Denton, Texas
Susie Burke, PhD Senior Psychologist, Public Interest, Environment and Disaster
Response, Australian Psychological Society, Melbourne, Victoria, Australia
Tracy Comans, PhD Senior Research Fellow and Postdoctoral Fellow, Health
Technology Assessment, Centre for Applied Health Economics, School of Medicine,
Griffith University, Queensland, Australia
Robert A. Cummins, PhD Emeritus Professor of Psychology, Deakin University,
Australia
ix
x CONTRIBUTORS
W. Douglas Evans, PhD Professor of Prevention and Community Health and
Global Health, The George Washington University, Washington, DC
Howard Frumkin, MD, DrPH Dean and Professor of Environmental and
Occupational Health Sciences, University of Washington School of Public Health,
Seattle, Washington
Knut Fylkesnes, PhD, DMD, MPH Professor, Centre for International Health,
University of Bergen, Norway; Visiting Professor, Department of Public Health,
University of Zambia
Debra A. Harley, PhD, CRC, LPC Professor, Department of Early Childhood,
Special Education, and Rehabilitation Counseling, University of Kentucky, Lexington,
Kentucky
Syeda Zakia Hossain, PhD Senior Lecturer, Discipline of Behavioural and Social
Sciences in Health, Faculty of Health Sciences, The University of Sydney, Sydney,
Australia
Christina Huang, MPH, MPhil Assistant Policy Analyst, The RAND Corporation,
Doctoral Student, Pardee RAND Graduate School, Santa Monica, California
Ebonee T. Johnson, PhD Assistant Professor of Rehabilitation Counseling,
Southern University, Louisiana
Barbara Kelly, BSc, GradDipPsych M. ClinPsych Student, School of Psychology,
Counselling and Community, University of Southern Queensland, Toowoomba,
Australia
Mary K. Lam, MHIM, PhD, FACHI, CHIA Lecturer in eHealth, Faculty of
Health Sciences, The University of Sydney, Sydney, Australia
Gloria K. Lee, PhD, CRC Associate Professor of Rehabilitation Counseling, Office
of Rehabilitation and Disability Studies, Department of Counseling, Educational
Psychology and Special Education, Michigan State University, East Lansing, Michigan
Jeanne LeBlanc, PhD Registered Psychologist, Vancouver, British Columbia, Canada
Lisa Lopez Levers, PhD, PCCS, LPC, CRC, NCC Rev. Francis Philben, C. S. Sp.
Endowed Chair in African Studies, Professor of Counselor Education and Supervision,
Duquesne University, Pittsburgh, Pennsylvania
CONTRIBUTORS
xi
Maidei Machina, BS Graduate Student, Faculty of Health Sciences, The University
of Sydney, Sydney, Australia
Roberto Mezzina, MD Psychiatrist and Director of the Department of Mental
Health, Trieste, Italy; Director, WHO Collaborating Centre for Research and Training,
Department of Mental Health, Trieste, Italy
Charles Michelo, PhD, MBChB, MPH, MBA Associate Professor of Epidemiology, University of Zambia, School of Medicine, Department of Public Health
Elias Mpofu, PhD, DEd, CRC Professor and Head, Rehabilitation Counseling,
The University of Sydney, Sydney, Australia
Ngonidzashe Mpofu, BSc Pennsylvania State University, Eberly College of
Science, University Park, Pennsylvania; Founder of STARS Foundation
Paul O’Halloran, BA (Hons), MClin Psych, MAPS Senior Clinical Psychologist,
Director, Mental Health International Networks for Developing Services, and
Consultant, Western Sydney Local Health District, Sydney, Australia
Bruce Rapkin, PhD Professor, Department of Epidemiology and Population
Health, Division of Community Collaboration and Implementation Science, Albert
Einstein School of Medicine, Bronx, New York
Kevin R. Ronan, PhD, MA, BA Foundation Professor in Psychology and Chair
in Clinical Psychology, School of Health, Human and Social Sciences at Central
Queensland University, Rockhampton, Australia
Alan Rosen, AO, MBBS, FRANZCP, MRCPsych, DPM, Grad Dip
PAS Professorial Fellow, School of Public Health, University of Wollongong,
Clinical Associate Professor, Brain and Mind Research Institute, The University
of Sydney, Deputy Commissioner, Mental Health Commission of NSW, Sydney,
Australia
Justin Scanlan, PhD Occupational Therapist and Lecturer at the Faculty of Health
Sciences, The University of Sydney, Australia
Paul A. Scuffham, PhD Professor in Health Economics and Founder, Centre for
Applied Health Economics, School of Medicine, Griffith University, Queensland,
Australia
xii
CONTRIBUTORS
Laura Skotarczak, MHR Doctoral Student and Adjunct Professor, Counselor
Education, University at Buffalo, SUNY, Buffalo, New York
Amy Strickler, MSEd, NCC Doctoral Candidate, Counselor Education and
Supervision Program, Duquesne University, Pittsburgh, Pennsylvania; Evaluation
Coordinator in the Organizational Performance Department at Pressley Ridge,
Pittsburgh, Pennsylvania
Connie Sung, PhD, CRC Assistant Professor of Rehabilitation Counseling, Office
of Rehabilitation and Disability Studies at the Department of Counseling, Educational
Psychology, and Special Education, Michigan State University, East Lansing,
Michigan
Marcus L. Thomeer, PhD Co-Director, Institute for Autism Research; Assistant
Professor at Canisius College, Buffalo, New York
Kenneth S. Thompson, MD Clinical Associate Professor of Psychiatry, University
of Pittsburgh; Medical Director, Pennsylvania Psychiatric Leadership Council,
Pittsburgh, Pennsylvania
Erika Turkstra, PhD Senior Research Fellow, Health Technology Assessment,
Centre for Applied Health Economics, School of Medicine, Griffith University,
Queensland, Australia
Veronica I. Umeasiegbu, PhD, CRC Assistant Professor, Department of
Rehabilitation and Disability Studies, Southern University and A&M College, Baton
Rouge, Louisiana
Susan Williams, PhD Lecturer in Nutrition, School of Medical and Applied
Sciences, Central Queensland University, Rockhampton, Australia
Preface
This book addresses strategies for community-oriented health services, including
those that arise from systemic influences such as environmental and social injustices. It seeks to present an imperative transdisciplinary shift in thinking about
health services toward understanding communities as resources for their own health
improvement. Applying a transdisciplinary approach, this book seeks to bridge the
discourses between environmental justice, public health, community well-being, and
service development, which are rarely considered together in spite of their mutual
interdependence. Little usable information is currently available to educators, policy
makers, development agencies, and social service providers on evidence-informed
procedures for community-oriented health programs addressing environmental and
social justice issues. Thus, this book is intended to provide a rich corpus of information on community-oriented health concepts, procedures, and practices to support
participatory health and well-being by partner communities.
APPROACH AND RATIONALE
This book interfaces community and population health services foregrounding
concepts from the scholarship on community engagement and the World Health
Organization’s (WHO, 2001) International Classification of Functioning, Disability
and Health (ICF). Health participation has been considered mainly from an individual’s perspective regarding involvement in his or her health management or promotion.
However, applying community action theory allows the concept of participation to be
extended to communities as active health agents. Community action theory proposes
that communities are themselves health systems and their health qualities impact individuals who are member dwellers. Healthy communities have populations that participate in their own health promotion, maintenance, or sustenance. Participation, to
an extent, is contextually defined, and a community-oriented health approach allows
for a variety of health enablers to be realized.
xiii
xiv PREFACE
Communities are also open health learning systems in that they enact and change
their health-related practices under their own stimuli and/or from partnerships with
external agencies (e.g., researchers, policy makers, or other communities). The activities that communities enact or adopt have consequences for the health of its members.
Community-oriented health interventions address an individual’s needs at various
levels of participation: personal, socially networked others, and community. Services
for community well-being prioritize the modification of conditions to promote health,
including the creation of sustenance of physical and social environments or living
spaces, normalizing healthy lifestyles, and supporting communities to achieve a quality of life they aspire to or find satisfying.
The WHO’s ICF considers participation an important health quality process and
outcome. Strictly speaking, the WHO’s ICF is an example of a classification and model
of disability and health that reflects the first purely descriptive approach to health. It
conceptualizes health at its core to be a matter of human biology and an objective phenomenon, independent of cultural, linguistic, or social differences. At the same time,
the ICF acknowledges that health is both intrinsically and instrumentally valuable
because of what it enables people to do in their lives—that is, health is also a matter
of how biological states play out in one’s life: what might be called “lived health.”
Because of this, the ICF offers a framework to account for the ethical significance of
health, and therefore the ethical justification for public and community health.
People with chronic illness and disability have historically been marginalized in
their community participation, including the quality and range of health services they
can access. This book gives consideration to (re)habilitative interventions in community settings that add to the great potential to address systemic determinants of health
disadvantage from any cause.
TIMELINESS
This transdisciplinary book is timely in view of the greater appreciation by the health
provider and policy community of the multi-determination of the health and wellbeing of communities, and that communities are the cradles of the health of individuals. The current understanding of community health as multidimensional allows for
comprehensive health improvement efforts with communities as partners. Further,
community-oriented health interventions with their preventive focus, inclusiveness,
and timeliness are more cost effective than individually focused interventions alone.
There is presently a great need in the international community to develop sustainable
partnerships for health in which communities are both enactors and beneficiaries.
Health education, research, and practice, well into the 21st century, will necessarily
focus attention on community-oriented health interventions. The contributing authors
are renowned in community health research and practices. The book’s development
was also assisted by a peer-reviewed editorial board process to provide oversight to
the authors of each chapter.
PREFACE
xv
INTENDED AUDIENCE
This book is intended for use by senior undergraduate and graduate students in public
or population health sciences, including rehabilitation counseling, community psychology, counseling psychology, public health, medical anthropology, social policy,
and related disciplines. Health policy and service providers in the private and public
sectors and international aid agencies will find the book an invaluable resource for
their health promotion and development programs in global communities.
BASIC CONTENT AND STRUCTURE
A common format is used for most chapters, thus providing a sense of unity throughout the book. Although some chapters feature topics of broad relevance (e.g., ethics and equity in community health), applied sections feature community-oriented
health approaches that are germane to specific contexts (e.g., community mental
health). Insofar as possible, the authors discuss the evidence supporting the specific
community-oriented health approaches they identify. The chapters are written to
address the following broad themes and tailored to their specific topics:
• Professional and/or legal definitions and theories of the community-oriented
•
•
•
health interventions specific to the chapter topic. History of research and practice pertinent to the topic (with a bias toward research on community participatory health and well-being). To the extent possible, the individual chapters
discuss historical and current prospects in establishing community-oriented
health services in the topic area, which contrasts with traditional or narrowly
focused clinical models that could clearly use more community engagement.
Community-oriented approaches that are useful to health improvement,
including asset mapping and resource development for health. Individual
chapters also discuss potential applications of community-oriented health
approaches to health and well-being in the global community. The chapters
seek to address clinic-focused health services to the extent that these are intertwined or feed into community-oriented actions.
Cultural, legislative, and professional issues that impact the specific communityoriented health approaches, including how these address health equity, and, to
the extent possible, related environmental and social justice issues.
Related disciplines influencing community-oriented health services of interest
as would address perspectives across disciplines or specialty areas (e.g., public
health, civic and community engagement studies, social work, health governance
and policy studies, development studies, disability studies, community psychology, counseling psychology, rehabilitation, medical anthropology, and social
psychiatry). To the extent possible, the chapters acknowledge those for which
community-oriented health practices information discussed may be relevant.
xvi PREFACE
• Comparisons with community-oriented health aspects or practices in other
•
similar jurisdictions. The chapters relate the discussion to practices somewhat
common in other settings they are aware or for which there is evidence.
Research critical to issues discussed in the chapter. Each chapter considers
the particular challenges for theory, policy, and action to be resolved through
research or other forms of scholarship.
An Instructor’s Manual, learning exercises, field-based experiential assignments,
and multiple-choice questions are also available to supplement the text. To obtain
an electronic copy of these materials, faculty should contact Springer Publishing
Company at [email protected].
INCLUSIVENESS
The individual chapters of this book aim to present as comprehensive a coverage of
the specific themes as possible. This in many cases is facilitated by a reliance on coauthorships from several regional communities or countries. As far as possible, each
chapter addresses community-oriented health from a variety of health conditions and
traditions. Each chapter also addresses pertinent health policy aspects in the context
of national, federal, or international conventions to highlight the importance of the
community-oriented health concepts being discussed.
Acknowledgments
This work is the result of the collegial contributions of several people who committed
themselves to assisting, in various ways, with the development of the manuscript that
gave rise to this book. Maidei Machina and Elias Machina deserve special mention for
assisting with the book manuscript formatting—including APA styling. Ngonidzashe
Mpofu and Maidei Machina helped with the design and construction of several graphics included in this volume. Drs. Ingvild Fossgard Sandøy and Luis Salvador-Carulla
deserve special mention for networking some of the international contributors to this
volume, adding to the book’s richness of topics and perspectives.
I also wish to acknowledge the following individuals who assisted with content
review and proof editing of one or more chapters in this book: Abdolvahab Baghbanian,
PhD, the University of Sydney, Australia; Jessica Brooks, PhD, University of
Wisconsin-Madison, USA; Paul B. English, PhD, MPH, California Department of
Public Health, USA; David Hunter, PhD, Flinders University Adelaide, Australia; Joel
Negin, PhD, the University of Sydney, Australia; Thomas Oakland, PhD, University
of Florida, Australia; Pradytia Putri Pertiwi, MS, Arbeiter-Samariter-Bund (ASB),
Indonesia; Alex Robinson, PhD, Arbeiter-Samariter-Bund (ASB), Germany.
I would also like to extend my thanks to the editorial staff at Springer Publishing
Company for their support in progressing this book through to its completion.
xvii
CHAPTER
1
Community-Oriented Health Services:
History, Framework, Nature,
and Significance
Elias Mpofu, Abdolvahab Baghbanian,
Jerome E. Bickenbach, and Jessica Brooks
Health drives all human endeavors in that without basic health functioning, nothing much
matters. It drives physical, mental, and social well-being in lived environments (World
Health Organization [WHO], 1946) on the basis of which most human activities are premised. The notion of human health has long been the source of both philosophical and
scientific debate, but in recent years it has been clarified for application in public health,
and in particular epidemiology, by means of the WHO’s International Classification
of Functioning, Disability and Health or ICF (WHO, 2001). Briefly, the ICF serves to
operationalize health in terms of a broad continuum of human functioning, from purely
physiological body functions, through to basic human actions and increasing complex
forms of participation in human life. This has led to a helpful distinction between purely
biological health—the functioning of the human body and mind—and the “lived experience of health,” or how a person’s biological health plays out in his or her complex
human existence, both personal and social and in the context of his or her environment.
Health as the interplay between environmental and individual factors is both a
product of and an object of consumption by enactors of health and well-being, who
are typically community members (Golden & Earp, 2012). Well-being is the subjective sense of relative health from lived health experiences, most often in the context of
community (see Cumming, Mpofu, & Machina, this volume; Dluhy & Swartz, 2006).
The provision and protection of population health is of such overriding importance
that most developed nations commit 8% to 12% of their gross domestic product to
1
2
I: FOUNDATIONS OF COMMUNITY-ORIENTED HEALTH SERVICES
health-related services (Taylor & George, 2014). Nonetheless, access to health care
services varies across communities and individuals, largely influenced by socioeconomic conditions as well as enacted health policies and the manner in which these
policies are translated into community-oriented health services (COHS).
Most commonly, community is conceptualized as a group of people who are
linked by social ties to a habitat or geographic setting location, even though they
may be of diverse backgrounds (MacQueen et al., 2001). According to Wilkinson
(1991), three fundamental properties of a community include (a) a local ecology
or an organization of social life that meets daily needs and allows for adaptation to
change; (b) a comprehensive interactional structure, or social whole, that expresses a
full round of human interests and needs; and (c) a bond of local solidarity represented
in people acting together to solve common problems. Community is thus founded
on social interactions, where individuals and groups work together toward a shared
vision in a particular locality. This implies that community is not just a geographic
area or place, but rather could comprise membership that is partially interconnected by
demographics or other social variables that define that specific community. Notably,
those interested in the development of community pay more attention to the quality of
relationships among these elements, with more emphasis on the integrated economic,
social, and environmental structures (Wilkinson, 1991).
Within geographic communities, a sense of community may vary widely with the
lived experience of the community, and this often is mediated by differences in access to
the resources for community participation, including for health. For example, Tennent
and colleagues (2009) reported that sense of community influences self-reported wellbeing. However, people of the same geographic location may experience sense of community in different ways from lack on equity in accessing social determinants of health.
Subgroups within the larger community in themselves comprise communities of interest that may be defined by sharing a common health-related condition (as with support groups) or differential access to health care compared to other typical community
members (as with people with substance use needs or racial/cultural minorities). For
instance, community residents from marginalized groups experience health-damaging
stressors from lack of equitable access to resources for well-being with which to cope
with health-related stressors. Health improvement initiatives across diverse communities need to take into account the existence of communities within communities not
defined by geography (Jones & Wells, 2007) or as defined by health status. Geographic
information systems and other techniques are available for use in defining the subcommunities when simple neighborhood location data alone do not suffice.
The WHO (1986) defined community health as referring to environmental,
social, and economic resources to sustain emotional and physical well-being among
people in ways that advance their aspirations and satisfy their needs (WHO, 1986) in
their unique environment (Lasker & Weiss, 2003). COHS are those that provided for
addressing social health and welfare needs of diverse groups within a community as
perceived or demanded by the collective community membership.
1: COMMUNITY-ORIENTED HEALTH SERVICES
3
Public health policies should be need driven (see An, Huang, & Baghbanian, this
volume). Two implications follow from this premise if true. First, the health services
available and accessible may reflect provider perceptions of the demand for such services as much as health services by their availability can also explain the demand for
them (Taylor & George, 2014). Second, many health needs recognized by the constituent communities may not be provided for or recognized by existing health services,
thereby constraining their capacity and responsiveness to health needs and demands
by community consumers. Thus, despite the apparent social good to provide for the
community health needs, the practices and instruments to provide for such needs may
misalign with what the community wants to access for their health needs (Taylor &
George, 2014; see also Bickenbach, this volume) in the absence of direct participation
by the community in determining the health outcomes they aspire.
This chapter briefly discusses the history of frameworks for understanding COHS
and its significance as a health care approach. To achieve this purpose, the chapter briefly
considers community action theory to underpin participatory COHS. It then considers
participation as a health construct supported by the WHO’s (2001) ICF, which links
to the processes and goals of community health-oriented action. Consideration is also
given to the multifocal and multilayered nature of COHS in their realization in primary
care, public health, community health, and community public health programming.
HISTORY OF COHS
The logic and processes of COHS were laid in the 1940s by Sidney Kark and Emily
Kark in rural Zululand, South Africa (Kark, 1974, 1981). These family physicians
designed a community-focused approach to health care in which health workers from
the community were partners framing the social determinants of health important
for disease prevention, treatment, and care. Their approach considered cultural factors important for COHS, including the identification of health needs. The initiative
resulted in a network of over 40 community health centers across South Africa, heralding the very first comprehensive community-driven health services long before the
Alma-Ata declaration of 1978 (WHO, 1978), which formally recognized the significance of community health centers in prevention and treatment care. The Alma-Ata
declaration of 1978 considered health an indivisible part of development, suggesting
that changes in social determinants of health issues (e.g., on health education, adequate housing, safe water, and basic sanitation) to improve living conditions resulted
in well-being for all.
Other significant COHS initiatives are owed to the work of Dr. Tom Lambo
in Nigeria, who in the 1950s founded a network of community-based care for people with acute or severe psychiatric illness. Under this care program, patients were
housed in ordinary homes by host families, in which homes the patients received
care from visiting multidisciplinary teams of nurses, doctors, and traditional healers
(Adewunmi, 2002; Asuni, 1967). Many other COHS complementing western and
4
indigenous traditions in community settings in mental health care have been documented (see Mpofu, 2006, 2011).
The Alma-Ata declaration also highlighted that people, as members of their
communities, have the right and duty to engage individually and collectively in the
planning and implementation of their health care, and urged governments to develop
and reinforce the abilities of communities to participate in their health care planning.
The 32nd assembly of the United Nations Organization (UNO), which met in 1979,
endorsed the Alma-Ata declaration, committing nations to the provision of COHS.
Around the same time, the WHO (1979) created an international program called
the Network of Community-Oriented Educational Institutions for the Health Sciences
(Richards, 2001). This was the first organization to consider the interface between
community-oriented services and public health within higher education. In the early
1980s, the Institute of Medicine (IOM) called for improvement of primary care services in the United States, particularly for underserved individuals (Connor & Mullan,
1983). The IOM advocated for extensive training of health professionals, using the
community-oriented primary care (COPC) framework as a model, which integrates
public health and primary care to deliver targeted services. To date, the COPC model
is promoted as the ideal method for providing high-quality health care to all people,
yet health educators and practitioners struggle with its theoretical concepts and lack
practical experience (Longlett, Kruse, & Wesley, 2001).
In recent years, there has been remarkable attention and resources devoted to
community-oriented approaches to public health (see Williams & Ronan, this volume), most notably from both government and nongovernment-affiliated organizations in the United States (e.g., U.S. Department of Health and Human Services, 2000,
2010). Furthermore, scholars from numerous health-related disciplines are investigating health practices using community-oriented approaches to research methods,
including participatory action research, collaborative inquiry, empowerment evaluation, and community-based participatory research (CBPR; Minkler, 2004; Richards,
2001; see also Mpofu, Lam, Mpofu, Johnson, & Evans, this volume). CBPR is the
prevailing framework, which promotes a collaborative partnership approach to
research that equitably involves community members, organizational representatives,
and academic associates (Israel, Shultz, Parker, & Becker, 1998; Kamanda et al.,
2013; Pazoki, Nabipour, Seyednezami, & Imami, 2007). This mutual partnership contributes to a greater understanding of a given health problem, for which knowledge
can be transformed into action to improve the health and well-being of community
members (White, Suchowierska, & Campbell, 2004; see also Williams & Ronan, this
volume). Other disciplines have also applied similar community-oriented approaches
to disaster recovery (see Ronan, Kelly, LeBlanc, & Burke, this volume), mental health
(see Rosen & Thompson, this volume), and economics (see Comans, Turkstra, &
Scuffham, this volume) to shed further light on their usefulness.
A recent systematic literature review by Las Nueces and colleagues (2012) identified relatively few published CBPR studies in the health sciences, suggesting CBPR
5
has been used more as an exemplar to public health than for clinical research (Jones
& Wells, 2007; Wallerstein, 1992). In addition, the majority of the research has been
done in the United States and Canada, where the CBPR concepts have been most
noticeably developed (Viswanathan et al., 2004). For health professionals throughout
the world, there may be inherent obstacles to participation in CBPR as a function of
time-constrained medical appointments and the traditional structure of biomedical
interventions (Jones & Wells, 2007). In addition, there is a focus in medical research
on randomized controlled trials as the “gold standard” for evidence (Israel, Schulz,
Parker, & Becker, 1998). This clinical research accentuates individual characteristics,
neglecting the social and other environmental factors pertinent to health. Moreover,
this type of rigid methodology tends to separate researchers and health practitioners
from the public—further contributing to the historical distrust in research and health
care among socially disadvantaged groups (Jones & Wells, 2007). Researchers and
practitioners alike have called for greater community involvement as well as engagement of diverse communities in research as a strategy to improve its relevance and to
effectively address health disparities (see Bickenbach and Harley, Mpofu, Scanlan, &
Umeasiegbu, this volume).
These calls for more integrated approaches to research and practice in public
health continue to be expressed in major national reports, health policy statements,
and public health project initiatives (Israel et al., 1998). The growing interest in
community-oriented approaches to public health has highlighted ecological approaches
to research, like CBPR, as viable pathways to simultaneously generating new health
knowledge, solving local problems, and designing effective health-promotion interventions (Jones & Wells, 2007; Mendenhall, Harper, Henn, Rudser, & Schoeller,
2014; Perez & Treadwell, 2009; Shattell, Hamilton, Starr, Jenkins, & Hinderliter,
2008). Given that societal factors seem to play a key role in mediating the gap between
social disadvantage and overall health, future research should address health disparities through the implementation of community-oriented services that attempt to
identify, evaluate, and modify both community-level and macrolevel social determinants of health (Campbell & Jovchelovitch, 2000). Through the eradication of health
disparities, all people would afford the basic right to optimal health and well-being
(Puertas & Schlesser, 2001; see also Bickenbach, this volume).
FRAMEWORKS FOR PARTICIPATORY COHS
Structurally, communities are complex entities in their composition and health-related
needs and demands. They also vary in their civic competencies or their ability to engage
in collective action for community improvement (Cottrell, 1976). Civic competencies
presume civic infrastructure or the community improvement forums to identity, prioritize, coordinate, and implement pro-community initiatives, inclusive of those for
community health. Community competence copes with the challenges of collective
6
living, consensus-driven civic action through both formal and informal networks, and
coalitions for the common good, civic health, or the direct and meaningful participation of the community in decisions that affect their health. Community action theory
(see Butterfoss, Goodman, & Wandersman, 1993; Lasker & Weiss, 2003) speaks
to the civic infrastructure for communities engaged in civic health. The WHO ICF
addresses the multilayered notions of health and health participation that are often
the issues communities grapple with in their health promotion. Understanding human
health in this complex way, moreover, has highlighted the fact that health is the outcome of interactions between purely biological features of the human body—which,
when problematic are characterized as health conditions such as diseases, disorders,
and injuries—and a full range of environmental factors, from climate and physical
conditions, to the human-built environment, to the attitudinal and social, economic,
and political environment.
Community Coalition Action Theory
Every community engaged in some form of collective action which defines it as
community (Butterfoss & Kegler, 2009; Minkler, 2000; Nordenfelt, 2000; Schultz,
Krieger & Galea, 2002). Community action is collective action undertaken by residents and community organizations to promote and protect the health and wellbeing of residents. It transforms an amorphous mass of people living in the same
geographic space into a vibrant community, optimizing community resources
(people, technology, natural resources, and supplies) in the service of its members’
health and well-being. Far too often, however, community actions are sporadic and
disorganized, allowing for the involuntary fostering upon the community of health
needs and priorities by outside agencies (both public and private). Neither sporadic,
community-driven action nor well organized ones that are foisted from outside are
likely to yield positive, sustainable results. Close collaboration between the participating organizations and the communities in all project activities, including the
identification of health needs and the supports for them using a community participatory approach (U.S. Department of Health and Human Services & Agency for
Healthcare Research and Quality, 2003), likely translates public health policies into
actual health-positive outcome communities.
Three qualities make for sustainable community-focused health services:
locality orientation, organization of action, and planning of action. Locality orientation refers to the degree to which action is oriented to the local health needs and
demand of the services to address those needs. Locally oriented action addresses a
range of interests that the action fulfills (physical, psychological, and social wellbeing), as well as who are the participants (sponsors, actors, and beneficiaries) of
the action in the context of the lived environment. Organization of action refers
7
to the effectiveness and sustainability of a community health action inclusive of
health awareness by members of the community and their capacity or willingness
to address perceived health needs or demand services for them. Planning the health
action involves consultative goal setting with participant organizations (or civic
infrastructure for health) as well as planning the implementation and evaluation of
the health actions. With COHS these actions include resource mobilization (environmental/material and human resources), resource allocation and assignment (how
well the procured resources are allocated and/or assigned), and implementation: how
well are health-promotion tasks sequenced, coordinated, and accounted for in the
person’s environment.
WHO ICF PERSON’S ENVIRONMENT AS COMMUNITY
The ICF uses the notion of “functioning” to describe both the biological and environmental influences on health and well-being. The interaction of these two dimensions
constitutes the full, lived experience of health. So described, biological health is obviously what health enables us to do—that is, human life and living. At the same time,
however, by embedding environmental factors into the conceptualization of health,
the ICF is fully compatible with—and provides the scientific tools for describing—
the social determinants of health, and so the focus of community health interventions
or those premised on community action.
The ICF operationalizes health both in an epidemiological and ethically significant manner. Its ethical significance flows from its insistence that health improvements can be brought about as much by means of changes to a person’s environment
as to alterations in his or her body. This has liberated public health—and by extension,
community health—because this insight points the way to the ethically significant
observation that communities are themselves resources for health improvement and
maintenance and that, as active agents in health promotion, communities can themselves become efficient and effective health systems in their own right. By highlighting the importance of the environment in the creation of health and human functioning,
the ICF is the ideal vehicle for understanding that aspect of a person’s environment
we call “community.”
THE NATURE AND SIGNIFICANCE OF COHS
Health needs and services at the community level are characterized by complexity in
access to care, use patterns and policies (see An, Huang, & Baghbanian, this volume).
To address this complexity, current approaches to COHS apply multidisciplinary
solutions spanning the evidence-informed practices from primary health care: public
8
health, community health, and community public health (see Figure 1.1). To ensure
communities achieve sustainable health and well-being, there is need for a concerted
effort from all sectors of health management and care to achieve the common goal to
of health for all.
While clinical medicine has in recent years become more inclusive in seeking to provide coordinated or integrated multidisciplinary care services (including behavioral medicine) to be more responsive to patient communities (Fisher &
Dickinson, 2014; Institute of Medicine [IOM], 2000; 2003), nonetheless, it has
remained provider rather than community driven. Clinical medicine seeks to apply
high-technology interventions to treat, if not cure, health conditions. It is provided
by hospital systems and specialist physical care, with considerable fragmentation of
services among specializations and subspecializations. It is the most visible health
care provider both in institutional presence and social media presence. While clinical medicine services are critical for acute care needs, it is far from addressing community health issues in the sense of health promotion.
Clinical medicine services are comparatively well-funded than typical community health care services (Taylor & George, 2014; WHO, 2008). Nonetheless, the general public may (mis)perceive clinical medicine to epitomize the very best of health
care services while in actual fact they are often very selective in access and usage or
Community public health
Environmental justice
Social determinants of health
Equity of access
Health promotion
Disease prevention
Health environment metrices
Social protection policy
Public health
Population level
Epidemiology of disease
Health inequalities
Public health policy
Normative health
metrices
Primary health care
Disease treatment
Universal coverage
Integrated care
Health education
Intersectoral partnerships
Continuous care
Community health
Neighborhood level
Healthy living
Community resources
for health
Civic health policy
Quality of community
health metrices
FIGURE 1.1 Context of community-oriented health services.
9
with lack of equity. The relative emphasis on primary health care services also has
increased access to health care for community members with significant health vulnerability: children, women, older adults, and those with chronic health conditions.
Primary Health Care Services
COPC services have a focus of prevention and early intervention. In doing so COPC
brings health care closer to where people are than possible with clinical medicine
(Cueto, 2004; Kark, 1974, 1981; WHO, 1986). They typically provide comprehensive
care services spanning acute care and first-level pandemic response, social services,
community liaison, and civic health support partnerships with nongovernmental organizations. They are staffed by generalist physicians and allied health personnel to provide responsive care to the community as demanded by the community members. As
first health care responders, primary health care facilities also maintain an essential
medicines or drugs stock to be able to provide timely and safe health care to community members. They also distinguish themselves in the provision of continuous or
ongoing care to community residents with previous care service, making it possible
to track and tailor care services to individuals.
COPC health care services provide for large numbers of community user constituents (WHO, 1986). Primary health care services are a reliable barometer of community health in their comparatively broader scope and function. For instance, infant
mortality data are robust, predicting morbidity and longevity in populations (Taylor &
George, 2014). This quality comes with their universal access often supported by
public health policies and with that their relative affordability. Comparatively fewer
health access disparities are associated with primary health care facilities and the
access features allow for prevention education information or nonmedical services.
Primary health care services are a centerpiece of any COHS in their typical location
in the user communities, their relatively high accessibility, acceptability, and the comprehensive services they provide. The IOM (2012) proposed six criteria for disease
management and preventive care: patient-centered, effective, safe, timely, efficient,
and equitable. These criteria are all met by adequately functioning and resourced
primary health care services.
Public Health
Historically, public health emerged from the realization that disease prevention
and health promotion were as important to universal health care as interventions
to mitigate diseases after they have occurred in populations. They have a focus on
population-level data on the epidemiology of diseases and also on studying the effectiveness of large-scale interventions to prevent or treat diseases or to propose and
10
implement strategies to reduce health disparities from social determinants of health.
As previously noted, health disparities disproportionally affect minority status groups
based on low income or race/ethnicity with a history of marginalization, females,
gay–lesbian identity disability status, geographic location, or some combination of
these (see Lopez Levers & Biggs; Williams & Ronan, this volume). Public health
interventions seek to create health equity by mitigating the effects of health disparities, if not to reduce or eliminate the health disparities, by implementing policies to
address modifiable social determinants of health. Health equity occurs when individuals and communities have similar opportunities to live a satisfying life free from
preventable or avoidable negative social influences (see Bickenbach, this volume).
Community health workers (CHWs) are primary implementers of public health
policy (see also Martin Fylkesnes & Michelo, this volume; WHO, 2008). Public health
services mostly focus on normative metrics for health important for benchmarking
the differences in health statuses among populations for the purposes of policy intervention for correcting for known health vulnerabilities in segments of populations
(e.g., children, women; see Frumkin, this volume). Public health services tend to be
top-down in orientation in the sense that implementers are typically not community
dwellers and carry a mandate originating external to the community. It is not unusual
for public health workers to consult with local communities to better target the public
health policy-driven interventions for which there is evidence. In this way, public
health services have a layer of community responsiveness albeit rarely at the formative stages of health policy and/or with extensive community consultation.
Community Health Services
Community health services have the pursuit of health as the overarching goal rather
than disease prevention per se. These typically seek to build community assets for
health at the neighborhood level to support meaningful community engagement or
involvement. They are designed to have multiplier effects on health-related outcomes
from empowering community citizens to make healthy lifestyle choices. The most
effective of community health interventions are raising the standard of living of community members through various community-friendly initiatives that address basic
life sustenance issues such as the provision of sanitation and water supply services,
affordable housing, transportation, employment, safe open spaces for exercise, recreation parks, and healthy food markets (Dluhy & Swartz, 2006; Taylor & George,
2014). Raising the standard of living as a tool for health promotion appears to achieve
its effects by reducing risk for infectious diseases, preventing diseases associated with
poverty, affording community citizens a sense of control over their lives, or reducing stress from the vagaries of meeting basic subsistence or personal safety. As an
example of the effects of the lived environment on health and well-being of community members, affordable housing plays a critical role in the health and well-being of a
11
community, yet is out of reach for more people on low income in both developing and
developed countries. Many community residents on low income live with “housing
stress,” which is when they pay much of their earnings for their housing, which leaves
little to spend on decent food, health care, and education (Burke & Pinnegar, 2007).
For instance, in 2007, about 80,000 low-income Australians paid more than 50% of
their income on rent (Donald, 2007; see also Williams & Ronan, this volume). Public
welfare housing supports in the form of tax benefit, public housing, and rental assistance are community-oriented interventions likely to positively impact the effects of
housing stress and make way for healthier communities. Communities with physical
infrastructure barriers such a major highway that cut through the neighborhood had
lowered sense of wellbeing from risks for motor-vehicle accidents and reduced access
from social services across the divide (Mindell & Karlson, 2012; see also Harley
et al., this volume). The health benefits from interventions to modify environmental
factors that impact health and well-being are likely with the participation of local
community coalitions with a stake to promote intersectoral collaboration with other
sectors, such as employment, education, and rural or urban planning (AHURI, 2009;
Burke & Pinnegar, 2007; Mindell & Karlson, 2012; see also Frumkin, this volume).
Quality-of-community-life indicators (see Cumming et al., this volume) typically
consider both objective well-being from perceptions of the lived community environment and also objective indicators such as opportunities for participation in health
community initiatives and also the resources for healthy living.
Local communities have lived experience of needs, priorities, and aspirations
that nonresident professionals have not. Supporting civic infrastructure for community competence (Cottrell, 1976) such as community coalitions for health (Butterfoss
et al., 1993) contributes to sense of control by community members and indirectly
to health and well-being. For instance, quality of family life, which is important for
disease prevention and mitigation, is enhanced with resources health and wellbeing.
Local communities with strong coalitions for health have pro-civic health policies
or those that consider health and well-being integral to all community initiatives or
activities.
Community Public Health
Community public health is emergent from the interface of public and community
health services in the context of environmental and social justice. It focuses on interventions to promote health and well-being and prevent disease from environmental hazards, as well as noninfectious and nonoccupational environmental and social
factors. Environmental hazards could be physical, chemical, and biological agents
from industrial processes, and particularly the waste or emissions resulting. It also
addresses health care access inequities that may result from social determinants of
health. Social determinants of health include food supply, housing, economic and
12
social relationships, transportation, education, and access to health care. They are
life-enhancing resources, and their distribution between and within communities
may vary with demographics of gender, education, race/culture, geographic location,
and so on. They influence health-related quality of life and are often the targets for
modification by community public health interventions.
Community coalitions typically work with public health policy makers and health
care providers to translate public health policy into real community health benefits
(U.S. Environmental Protection Agency, n.d.). Community public health uses environmental health metrics (see Frumkin, this volume) and equity of health measures
to index the quality of community health. Consequently, community public health
prioritizes social protection policies across community sectors in the utilization of
community resources for health (see also An et al., this volume; Comans, Turkstra, &
Scuffham, this volume; Wagner, Austin, & Von Orff, 1996), targeting the most common preventable diseases from environmental and social inequalities, equity in
health within communities, and intervening to change conditions that lead to disease
(Brennan, Baker, & Metzler, 2008).
SUMMARY AND CONCLUSION
COHS are multidisciplinary in nature, given the complexity of influences that make for
community well-being. Contributions to the research and practice in COHS are therefore from diverse disciplines such as public health, civic and community engagement
studies, social work, health economics, health governance and policy studies, development studies, disability studies, community psychology, counseling psychology, rehabilitation, medical anthropology, and social psychiatry. Public health interventions focus
more on population-level interventions while community health interventions focus
more on neighborhood levels. The interfacing of public and community health services
as in community public health allows for the strengths of both to advantage the health of
communities. COHS are comprehensive in providing universal access to citizen members. The focus of COHS on modifiable environmental conditions for health, their robust
effects on disease prevention and health promotion, timeliness, context responsiveness,
and cost-effectiveness make them the choice health delivery model of the 21st century.
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Community-Oriented Health Services: Practices

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