समूदाय स्वास्थ्य सेवा र सरोकारवाला

 समुदायलाई "एउटै सामान्य नियमहरू अन्तर्गत केही हदसम्म स्थानीयकृत क्षेत्रमा बसोबास गर्ने र साझा मानदण्डहरू, मूल्यहरू र संगठनहरू भएका बासिन्दाहरूको समूह" भनेर परिभाषित गरिएको थियो (ग्रीन र ओटोसन, 1999) तिनीहरूको 2005 पाठमा, म्याकेन्जी र सहकर्मीहरूले यो परिभाषा प्रस्ताव गरे: "सामुदायिक स्वास्थ्यले मानिसहरूको परिभाषित समूहको स्वास्थ्य स्थिति र उनीहरूको स्वास्थ्यको प्रवर्द्धन, संरक्षण र संरक्षण गर्न निजी र सार्वजनिक (सरकारी) दुवै कार्य र अवस्थाहरूलाई जनाउँछ।"

"सामुदायिक स्वास्थ्य" जसले समुदायहरूको विविधता र मूल्यहरू प्रतिबिम्बित गर्दछ, र समुदायहरूले कसरी निर्णयहरू गर्छन्, प्रमाणको व्यवस्थित उत्पादनलाई समर्थन गर्ने क्रमको केही परिमार्जन प्रदान गर्दा, क्षेत्रको उन्नति र परिपक्वताको लागि महत्त्वपूर्ण छ। हामीले सुझाव दिएझैं, सामुदायिक स्वास्थ्यका लागि विद्यमान परिभाषाहरू - शैक्षिक स्थलहरू र सार्वजनिक एजेन्सीहरूमा माथि प्रस्तुत गरिएका लगायत - धेरै समकालीन कार्यक्रमहरूद्वारा उदाहरणका रूपमा सार्वजनिक स्वास्थ्य अभ्यास सेटिङहरूमा सामुदायिक स्वास्थ्यको विस्तारित क्षेत्र फ्रेम गर्नको लागि स्थितिमा छैनन् र त्यसैले, हुन सक्दैन। समुदायका आवश्यकताहरू पूरा गर्न त्यस्ता कार्यक्रमहरू सेवा गर्ने उद्देश्यले गरिन्छ। जे होस्, यी परिभाषाहरूले नयाँ उदीयमान कार्यक्रमहरू र प्राथमिकताहरूको सन्दर्भमा सामुदायिक स्वास्थ्यको अर्थलाई आकार दिन मद्दत गर्न महत्त्वपूर्ण संकेतहरू प्रदान गर्छन्। यी संकेतहरू चार आधारभूत फोकस क्षेत्रहरूमा क्रमबद्ध हुन्छन् जसले सामूहिक रूपमा सामुदायिक स्वास्थ्यको परिभाषा फ्रेम गर्न मद्दत गर्दछ।

A community was defined as “a group of inhabitants living in a somewhat localized area under the same general regulations and having common norms, values, and organizations” (Green and Ottoson, 1999) In their 2005 text, McKenzie and colleagues offered this definition: “Community Health refers to the health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health” 

“community health” that reflects the diversity and values of communities, and how communities make decisions, while providing some modicum of order that supports the systematic generation of evidence, is critical to the advancement and maturation of the field. As we have suggested, existing definitions for community health –including those presented above in academic venues and public agencies – are not positioned to frame the expanding field of community health in public health practice settings as exemplified by many contemporary programs and, therefore, may not meet the needs of the communities such programs are intended to serve. Nonetheless, these definitions do provide important cues for helping to shape the meaning of community health in the context of newly emerging programs and priorities. These cues sort into four basic focus areas that collectively help to frame a definition of community health.

The first focus area – “community” – encompasses population groups and the locus (e.g., place, venue, or other unit) of programs, interventions, and other actions. These elements can overlap and, therefore, are not mutually exclusive, and include: (i) as suggested by MacQueen and colleagues, “A group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings” (MacQueen et al., 2001); (ii) venues or areas that are identified with key activities, such as residence, work, education, and recreation; and (iii) venues or areas that are physically-, geographically-, culturally-, and administratively- or geopolitically-defined. Examples of the latter include groups of persons who are defined by locality (e.g., block, neighborhood, precinct, village, town, city, county, region, other), or who are defined (sometimes self-defined) by racial-ethnic, age, or other characteristics. Most people are members of multiple types of communities (e.g., physical, work, social, spiritual) that may have different priorities, needs, cultures, and expectations.

The second area – “health” – may be defined differently as a function of a community’s experience and expectations. The definition of health in a given community may further define the enterprise of community health and how community health is put into action (e.g., the methods, measures, process, and outcomes used for implementing a community health effort in a given setting).

The third area – interventions – encompasses the scope of the intervention(s) being delivered within the community, and reflects the input, needs, perspectives, and goals of communities as they work to improve their health. This may include interventions such as creating safe and healthful environments; ensuring health equity for all members of the community (Centers for Disease Control, Prevention —Division of Community Health, 2013); implementing programs to promote health and to prevent disease and injury; and fostering linkages between community and clinical programs and other resources to support health (Bauer UE et al., 2014).

The final area – the “science of community health” – encompasses the methods that are used by the field to develop and evaluate the evidence base that underlies the conception, design, implementation, evaluation, and dissemination of interventions. Community health draws upon a multitude of applied and theoretical public health, medical, and other scientific disciplines in terms of methods (e.g., surveillance and surveillance systems [such as the Behavioral Risk Factor Surveillance System and Youth Risk Behavioral System], epidemiology, evaluation), and expertise (e.g., prevention effectiveness, health economics, anthropology, demography, policy, health education, behavioral sciences, and law). However, the evidence base for community health may be inherently limited because of the absence of consensus, or even general agreement, on the definition and scope of a target “community”. Because of the complexity of working in communities, the “clean” scientific methods used in experimental design often are not relevant and cannot be directly applied. Thus, one of the greatest challenges also represents an opportunity for the field of “community health” to develop innovative methods that account for the complexity of communities, variability in how health in communities is defined, and how evidence can be generated that reflects the reality of the communities in which people live, work, and play.

In their assessment of what had been learned about contributions of community-based interventions to public health, Merzel and D’Afflitti suggested several other factors that help to explain the lack, or limited strong effect, of such programs, including methodological challenges to study design and evaluation, concurrent secular trends, smaller-than-expected effect sizes, limitations of the interventions, and limitations of theories used (Merzel and D’Afflitti, 2003). To this list can be added the need for better integration of “practice-based” evidence which is critical to enable public health scientists to understand the community and generate evidence that will be relevant to practice. For many public health outcomes, particularly decreases in chronic diseases, the full benefits of community level efforts to reduce chronic disease risk factors, such as obesity and tobacco use, may not be evident for many years, further challenging program evaluation. The outcomes often are influenced by many factors that might be addressed differently in different communities. The evidence base also may be influenced by circumstances associated with the creation of some community health programs — circumstances that have the potential for constraining the optimal application of scientific methods. However, even in the face of such constraints, the evidence from these practical studies might in reality be more relevant in addressing problems in the communities being served.

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Core principles for advancing community health

We have suggested that there is a need for a broader construct for “community health” that affirms this area as a distinct field within public health practice, and that fostering understanding of a contemporary definition of this maturing field will assist in advancing its goals. To that end, based on the focus areas outlined in this commentary, we offer the following as an example of a definition of community health that accords with needs of U.S. public health practice: “Community health is a multi-sector and multi-disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities, in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities.”

The core principles of community health are built on an understanding of core functions of community health programs and science. In many ways these resemble core public health functions; however, at their core they are explicitly focused on the intersection of the community’s needs, the community’s understanding of and priorities for health, and the best methods for documenting the evidence garnered from practice in the community, as well as the evidence from the science of community health.

We also have suggested that this field relies upon its own “methods of community health” that reflect a blend of approaches from multiple disciplines that have been tailored to this field, but that these approaches are subject to many challenges, some of which are unique to this emerging field. In the face of these challenges, the following core principles are suggested in furtherance of the science of community health:

• Engage communities, governmental, academic, and other stakeholders in developing a shared agenda for applied research on community health in the United States;
• Implement and use results of community health assessments (e.g., measuring and characterizing risk factors within, and the health status of, the community) as a core element in improving a community’s health;
• Identify short- and long-term measures for defining the “healthy community” as an endpoint for the effects of interventions or actions that reflect the community’s interest;
• Improve methods of surveillance for community health, including development of a case definition for a “healthy community”;
• Enhance scientific design principles for generating and documenting both practice- and research-based evidence from programs and interventions that improve community health (using, as indicated, community trials, retrospective cohort studies, cross-sectional surveys and studies, time-series analyses, and ecological studies), and enhancing methods for using “control” communities for evaluation, as well as meeting challenges associated with control communities (e.g., neighborhoods) (Stern et al., 1976; Farquhar et al., 1977; Salonen et al., 1981; McAlister et al., 1982; Wagner, 1982; Fortmann et al., 1995); and
• Maintain engagement with communities from the start through post-completion of a program or intervention (i.e., community health’s commitment transcends implementation and assessment of an intervention by building evidence through sustained engagement with the community).

Ultimately, improved and shared understanding of the meaning of community health should help in furthering broader attainment of healthier communities that are characterized by better health and quality of life for members of the community, however defined. The field of “community health” reflects the needs of the community and exemplifies the best of public health research and methods to achieve the shared goal of improving health.