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.