Understanding Community Development
December 2020 Issue
ONE OF THE ELEMENTARY school classroom traditions in the small midwestern town where I grew up involved collecting donations for the United Nations International Children's Emergency Fund (UNICEF). In October, hundreds of children in our community would bring conspicuously marked orange boxes home to be filled with coins collected as they went from house to house for trick or treat. I didn't understand what UNICEF stood for and our family didn't celebrate Halloween. But if other kids were going to fill those orange boxes, I was going to do my best to do the same
UNICEF is one of many United Nations community development programs.1 The UN defines community development as "a process where community members come together to take collective action and generate solutions to common problems."2 The definitions of community development have changed over the years to keep up with changing perspectives on the appropriate way to provide assistance. A perspective criticized for being grounded in 19th century colonialism has been replaced with an emphasis on the need for struggling individuals and communities to play a central role in their own betterment.3 Most contemporary definitions of community development include common themes of improving economic conditions, political self-determination, civil rights, education, and sustainability.4 This article describes approaches to community development and the relationship between this concept and O&P care provision.
Community Development and Public Health
The connection between health as defined by length and quality of life and social and environmental factors is widely recognized, and was briefly described in a previous article addressing health disparities and the social determinants of health.5 According to the County Health Rankings model, health behaviors and clinical care account for 50 percent of health outcomes in the United States, with social, economic, and environmental factors accounting for the other 50 percent. Any credible attempt to improve the health of individuals must involve those other factors, and community development is one way to accomplish this challenging goal.
Public health is the term used to describe the health of a population and efforts to improve it. Rather than addressing the specific health needs of individuals, these national or community efforts focus on prevention and promoting wellness within a group.6 Efforts of this scope require collaboration between government and private organizations, and impact the health and well-being of large groups of people and even the country as a whole. Collaborations between government agencies and the pharmaceutical industry to develop a vaccine is an example of a national public health effort. The way that individual behaviors influence health is often a part of conversations about healthcare, but the way social and environmental factors affect health can be more difficult to recognize. For instance, safe and dependable housing, in addition to improving opportunities for consistent access to schooling and superior job opportunities, is closely tied to improved health conditions.7
Some of the financial burden for providing healthcare to disadvantaged populations within the United States is borne by hospitals. The exorbitant costs related to providing mandatory services for individuals who rely on emergency departments in the absence of primary medical care has caused some hospitals to look for creative solutions that involve community development. One Chicago hospital has addressed the chronic health needs of homeless emergency department super-users by providing these patients with a place to live.8 It can be less costly to pay for housing than cover expenses related to medical services and a hospital room. Among other benefits, this housing option reduces dependence on the emergency department as a shelter during inclement weather. This may be an extreme example, but it demonstrates how a broader focus on conditions within a community can impact the health of individuals and the cost of healthcare.
Various methods have been used to combine community development with healthcare to improve the lives of individuals within disadvantaged communities. While the emphasis and terminology may change over time, it is helpful to understand how the underlying principles of various approaches to public health have been applied in different settings.
Community-oriented Primary Care
During the 1950s, physicians in South Africa developed community-oriented primary care (COPC) centers that served the needs of poor rural populations by focusing on "epidemiological assessment of demographically defined communities, prioritization, planned interventions, and evaluation."9 The clinics operated for about a decade before being shut down by the government. When a public health professor from North Carolina travelled to the area a few years later he observed that the overall economic and health condition of the communities had not changed, but "he was struck by the target population's unusually high levels of educational aspiration and educational achievement."9 An effort that began with a focus on healthcare had an impact that was much broader than the immediate health of those who received services. In a 2002 article in the American Journal of Public Health, H. Jack Geiger, MD, MSciHyg, described how Tufts Medical School implemented the COPC model in Bolivar County, Mississippi, during the 1960s and 1970s.9 In addition to providing health services and education, these centers developed programs related to housing, sanitation, and water supply. Associations and councils were formed, and members of these councils got involved in county government. These councils were even able to influence local banking, resulting in an expansion of financial services, more fair lending practices, and increased employment opportunities for local residents.
Geiger described how the educational efforts of the Mississippi COPC centers produced seven medical doctors, five people with doctoral degrees in health-related disciplines, three environmental engineers, two psychologists, substantial number of registered nurses and social workers, "and the first ten registered Black sanitarians in Mississippi history."9 He also points out that even without special programs designed to improve educational opportunities, "local residents who become center staff members tend to invest their increased earnings in two areas: better housing and college education for their children."9 Geiger attributes the success of these centers to "ending the isolation that had kept members of poor rural minority communities cut off from knowledge of, or help from, such traditional sources of support as government agencies, philanthropic foundations, and universities and professional schools."9 Individuals living in disadvantaged areas are often unaware or unable to take advantage of programs and resources that people from more economically stable areas take for granted. Once resources become accessible, many individuals demonstrate similar personal priorities and aspirations in their personal and family lives.
Asset-based Community Development
Researchers in the United Kingdom recently published a paper reviewing and synthesizing concepts related to asset-based community development (ABCD), which focuses on "empowering communities to identify and address their own problems through the local assets available to them."11 This approach involves "identifying and building on strengths, or ‘assets' of individuals and communities" rather than just identifying deficits and needs.11 Rather than looking for problems within a community, ABCD uses "appreciative enquiry" and "strengths-based" approaches to find the potential of a community and opportunities for collaboration on specific actions. This helps to address the concern that development efforts driven by organizations and individuals from outside the community tend to be less effective than those initiated by insiders. The people directly affected by substandard conditions have a voice in identifying problems and establishing priorities for addressing them using available resources. These researchers distinguish between individual, collective, and potential assets. Individuals have "positive personal attributes…such as self-efficacy, personal motivation," and other characteristics that are important for managing health.11 Communities also have "tangible community assets" such as parks, libraries, and other public resources. Potential assets are those, like social welfare, "originating outside the neighborhood and controlled by outsiders."11
The authors of this paper were unable to find a published study that implemented the ABCD model and evaluated outcomes related to long-term health conditions or general health and well-being. One explanation for this is that research in this area is hindered by inconsistent definitions and diverse protocols for implementation. These results may also demonstrate the limitations of adopting a particular label, and the value of focusing on proven principles for providing community services. There is evidence that health improves in response to coordinated efforts that make use of social networks, physical resources, and governmental systems, in addition to supporting the positive personal characteristics necessary to make good decisions.
O&P and the Community
It's likely that most of us have never heard about the COPC or ABCD approaches to providing care, or the success that is possible through similar approaches. In 2018, Le and Goffin reported that "semi-structured interviews with COPC subject matter experts to gain professional assessments and opinions on the current relevance and application of COPC in the United States" found that "the underlying principles of COPC are being implemented across the nation, but under different terms, such as ‘healthy communities' or ‘population health.'"10 Much of the political debate around healthcare emphasizes individual responsibility, the large financial burden of providing medical services, and the limitations of socialized medicine. It is worth considering that it is costly for a society to provide both high-quality and substandard healthcare services for a large segment of the population. As individuals and a society we pay the costs either way. Understanding the detrimental effect of the poor health of a large percentage of the population on various aspects of society and the way that it can be improved through community development efforts that focus on social and environmental factors can raise our awareness of our role as members of a broader community.
The context in which we provide O&P care includes a high degree of interconnection between industry, government, and community resources. Almost half of the revenue in many O&P practices comes directly from governmental payers. Many of our patients rely on local, county, and state resources for health, transportation, and other vital services. The care we provide is not separate from these other services and systems. Recognizing the challenges our patients face in navigating the complex systems of which we are a part, and how the individual choices our patients make are influenced positively and negatively by them, can help us understand and support our patients more effectively.
An important goal of community development is to support the ability of individuals to improve their own communities. This involves a commitment to developing positive personal characteristics that support good physical and community health and the ability to access institutional resources. Our interactions with individual patients involve a similar two-pronged approach. We recognize that they must take an active role in their own care, including making healthy decisions, and have access to resources that address social and environmental factors that affect short- and long-term health. Involvement in both of these aspects of their care may require us to develop additional skills and improve our knowledge of available community resources. Skills such as motivational interviewing can help us encourage our patient's commitment to making healthy decisions. Spending time reviewing local and national resources with a patient may be more effective than simply providing services at no charge. Recognizing the broader contexts in which our patients live and function helps expand our understanding of our role in supporting them.
I didn't realize in 1976 that the orange boxes I brought home from Mrs. Baehr's second grade classroom were part of an international community development effort, and I relied on the generosity of my parents and siblings to fill them. We may view our profession as relatively insignificant compared to the larger world of healthcare and complicated community development efforts. Our efforts as health professionals are an important part of a larger system of interrelated civic, healthcare, and political systems. Understanding how our efforts fit within these complicated networks can help us identify how we can contribute more meaningfully to the well-being of individual patients and our local communities. Fulfilling our professional responsibilities as individual practitioners as we provide O&P care to our patients is the most basic level of contribution. Recognizing that as we perform those functions, we are interacting with individuals whose lives are affected by larger networks and systems can help us gain a deeper understanding of how their lives are improved by using those resources to improve their local communities.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.
3. Lotz J. 1971. Community Development—A World View. Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique 62:314-9.
9. Geiger H. J. 2002. Community-oriented primary care: a path to community development. American Journal of Public Health 92(11):1713-6.
10. Le, A., J. Gofin. 2018. The Current Relevance and Application of Community-Oriented Primary Care in the United States. Academic Medicine 93(5): 673-4.
11. Blickem C., S. Dawson, S. Kirk, et. al. 2018. What is asset-based community development and how might it improve the health of people with long-term conditions? A realist synthesis. Sage Open 8(3):2158244018787223.