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 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 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 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.

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 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.

FIGURE 1.1

Context of community-oriented health services.

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 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.

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.

References