ABSTRACT
Background: The health care delivery model in the United States does not work; it perpetuates unequal access to care, favors treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for primary health care, universal health coverage, population health, addressing the social determinants of health, and community empowerment, creates opportunities for community health scientists to develop innovative solutions for addressing community health needs.
Methods: We developed a model community health science approach combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our community health science team has collaborated community members, leaders, and organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.
Results: From 2000-2020, we established partnerships with community organizations and worked together to reduce the risk of chronic disease in a vulnerable minority community by stimulating lifestyle changes, increasing healthy behaviors and health knowledge, and improving care seeking and patient self-management. Our programs have also provided structured community health science training in high-risk communities for hundreds of physicians and other health care workers in training.
Conclusion: Our community health science approach assumes that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the U.S. begins to seek solutions to chronic health disparities and health inequities, community health science provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest error that U.S. health care systems could make in trying to better address population health and the social determinants of health, would be ignoring the important community initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for reducing health disparities. This has been the greatest lesson we have learned during the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.
Introduction
“The present health care delivery model in the United States does not work; it perpetuates unequal access to care, favors treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are minorities (Native Americans, Hispanics, and African Americans) and those of lower socioeconomic status. Because the nation’s poor are most affected by built-in inequities in the health care system and because they have little political power, policy makers have been able to ignore their responsibility to this group.1
When we wrote these words more than a decade ago, we had several motives. First, we wanted to call attention to a health care system that through its complacency and silence was providing tacit support to a system of care that was inequitable and ineffective in meeting the needs of minorities and the poor. Second, we were advocating for more emphasis in primary care – and especially the specialty of family medicine – on addressing the social determinants of health as the upstream causes of disease. And, third, we proposed community health science as the vehicle for addressing the needs of low-income patients and reducing health disparities by linking together clinical practice, public health, and community organizations.
The motivation for our research, training programs, and community-engaged practice leading up to and since the publication of the article, was to remediate a system of care in the United States where primary care is not available to many and primary health care is not practiced.2 Primary Care (PC) is familiar to most Americans and refers to the care continuity care directed at the health needs of individuals by physicians and other health care workers. It includes diagnosis and treatment of acute and chronic illnesses, health promotion and disease prevention, and patient education and counseling. Primary Health Care (PHC) is a much broader concept and consists of three components: 1) meeting people’s health needs throughout their lives; 2) addressing broader determinants of health through multisectoral policy and action; and, 3) empowering individuals, families and communities to take charge of their own health.3-6 By providing care in  the community as well as care through  the community, PHC addresses not only individual and family health needs, but also the broader issue of public health and the needs of populations.
Stronger integration between primary care and public health with a focus on population health has enjoyed limited and sporadic periods of popularity and success in the United States during the past 50 years.7 The Community-Oriented Primary Care (COPC) model introduced in the 1970’s provided a workable framework for integrating public health into primary care practice, and in the late 1990’s accountable care organizations brought renewed attention to the role of medical systems in improving population health.7-10 However, the need to address the social determinants of population health in the U.S. has only very recently emerged as a topic of importance in discussions about reforming U.S. health care. 11,12And while primary care and public health organizations have long recognized the potential benefits of integration, significant longstanding barriers will need to be overcome first before any meaningful progress can be achieved.13
The historical lack of support in the U.S. for population health, medicine and public health integration, addressing the social determinants of health, and community empowerment, has created a situation where practitioners and researchers work independently in their local communities to address these components. This often leads to creating “non-system” approaches to meeting the health needs of vulnerable populations in local communities.4,14,15The authors have worked together as a team during the past 20 years to create innovative solutions to community health problems by combining community-based participatory research (CBPR), community-based service learning training experiences, and community-based practice. The purpose of the present manuscript is to describe our community health science approach and the ways we have worked in partnership with community members to improve health outcomes. Our efforts have been focused in two areas: 1) building community health capacity for testing program interventions reducing and eliminating risk factors for chronic disease, and, 2) training the next generation of physicians and other health professionals how to address the health needs of vulnerable patients when working in a system that eschews systemic approaches to addressing the social drivers of health and disease.
The Community Health Science Approach
During the past 30 years we have developed and directed more than six different academic units addressing health disparities located both inside and outside the medical center. The community health science approach we developed is based on these experiences and incorporates principles derived from community-based participatory research, asset-based community development, and community-oriented primary care.8,16-19 The common element these approaches share is their reliance on co-creating solutions through partnerships between community members and leaders, local organizations, and health care organizations. Our approach also draws on Dr. Kurt W. Deuschle’s community medicine approach, which combines clinical medicine, population health, and social science.1 Therefore, our community health science approach defines health as a social outcome resulting from systematically combining clinical science, collective responsibility, and informed social action.
We have described the community health science framework in detail elsewhere.20 Essentially, the model posits that for any community health issue – whether chronic, acute, or infectious diseases; or social determinants such violence, food scarcity, or housing instability – health promotion and disease prevention can only be effective when clinical treatment, population health, and community organization priorities and actions are aligned.21Consistent with asset-based community development, the approach acknowledges that in most communities, resources exist and activities are already underway for promoting health on important community issues.22 Thus, the role of community health science practitioners is to collaborate with those in the community who are already working on any health issue at the clinical, population, or community organization level, facilitate communication and coordination across the different levels, and contribute to partnership-building for creating sustainable solutions for population health improvement.20
(Figure 1 about here)
The Importance of Relationships and Collaboration
Strong and trusting relationships with community partners are the foundation for effectively improving community health outcomes.23,24 These relationships can only be developed by inviting people to your table (the health center) and going to their table (the community), working also with community leaders inside and outside of health services organizations while demonstrating genuine concern for their health and wellbeing.16,25The hundreds of organizations we have worked with during the past 20 years include libraries, faith organizations, neighborhood associations, local government, cultural organizations, schools, colleges and universities, community clinics, recreation centers, community centers, non-profit organizations, hospitals, businesses, and civic organizations, among others.26-28 The organizations all address one or more aspects of the social determinants of health, including education, access to health care, employment and job stability, housing, social capital, and/or food security.29-31
The activities reported here were focused in the South Dallas community of Dallas, Texas. In 2005, South Dallas had a population of 35,000 residents, 68% were African-American and 27% Latino, 60% of households made less than $25 000 annually, 80% of births were to single female-headed households, 52% had less than a high school education, and 57% lacked health insurance. In South Dallas, death rates from stroke and heart disease were more than double the county rates, and premature mortality was extremely high - 45% of deaths occurring among residents aged 65 years or less.32 The vast majority of individuals were renters working in low-wage low-skill service occupations, and crime rates in the area were as much as two to three times higher than in most other parts of the city.
Our location in South Dallas was by invitation resulting from a chance encounter at a community meeting. In 2000, one of the authors (MJD) expressed the opinion during a public forum that the priorities of community residents deserved equal or more weight than governmental priorities when addressing community development needs in low-income areas. Although this opinion ran contrary to the preference of the local government, the opinion was embraced by community leaders and based on the science of asset based community development.22Based on these comments, the Executive Director of the SouthFair Community Development Corporation (CDC), invited the author to participate in the South Dallas Pastor’s Weed and Seed Coalition (Pastor’s Coalition). This group was leading the U.S. Justice Department’s inner-city reclamation program, and the relationships developed with the eighteen African-American faith leaders in this group became the foundation of our 20 year collaboration.33
We also developed relationships with medical teams in other parts of the world – most notably Mexico in the early 2000’s - in order to share information and resources for better managing the health needs of impoverished patients when resources are scarce. At that time, Mexico was spending 5.6% of its GDP on health care compared to about 15% in the U.S., but both systems were facing similar challenges in terms of health care access inequities between rich and poor, concerns over quality, rising costs, and limited resources.34-36 To address these challenges, Mexico (unlike the U.S) developed a National Health Program designed to diminish inequalities, ensure fair financing, and improve responsiveness and health status. Mexico’s close proximity to Texas allowed us to develop a relationship with the government of Chihuahua, Mexico, and the leaders of the The Programa de Desarrollo Humano Oportunidades (Oportunidades) and we adapted the Oportunidades approach for our use in South Dallas.37,38 We have provided a more extensive description elsewhere of the Oportunidades approach and how we adapted it to the South Dallas community.20
Health Promotion Interventions and Training Program Platforms
In 2000, we developed two projects that were subsequently funded in 2001 and became the foundation of our activities for two decades. The first was a project with the Dallas Academy of Medicine - a component of the Dallas County Medical Society – which was beginning the initial stages of developing a system of care for the uninsured “working poor” in the City of Dallas, Texas. The project eventually became Project Access Dallas (PAD), and provided our team the opportunity to develop an expansive health promotion platform in South Dallas. The second was funded by the U.S. Health Resources and Services Administration, for creating the Community Health Fellowship Program (CHFP) for medical students. The CHFP was designed to place medical students in community organizations to complete community-mentored service-learning research projects for improving health in ways identified by the community organizations. These two programs illustrate the primary strategy of the community health science approach – developing and sustaining activities beyond the academic health center designed to advocate for and actively support community organizations addressing the social determinants of health, rather than merely extending health center programming out into the community. This approach engages the AHC as one partner among many in sustainable community change efforts, rather than just building more AHC capacity with little or no regard for existing community initiatives.