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LETTER |
The authors are with the Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester.
Correspondence: Requests for reprints should be sent to Suzanne Cashman, ScD, Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655 (e-mail: suzanne.cashman{at}umassmed.edu).
As guest editors for the forum on community-oriented primary care (COPC) and as authors of an article that traces the conceptual roots of COPC and its proposed future role as an "important conceptual framework" for practice, Mullan and Epstein note the existence of various movements in health care that provide natural allies for COPC.1 We would like to suggest an additional ally—the Healthy Communities movement.
Formulated almost 2 decades ago, the principles of Healthy Communities (HC)2 emphasize a democratic approach to addressing community problems that focuses on strengths.3,4 In merging the COPC and HC approaches to engaging community members, we have discovered a positive synergy. While both approaches spring from a common framework of health broadly defined, the language of HC is more lay friendly and broadly participatory. It begins with members of the lay and professional communities imagining what their neighborhoods and communities can become. This step of creating a shared vision, explicit in HC but only implicit in COPC, is an important element of the process. It develops a common bond and identifies areas of shared concerns.5
Mullan and Epstein note, "The idea of community is the core element [of COPC] and the point of departure for the COPC process."1 Despite the renewed emphasis on community engagement that has appeared in the COPC literature,6,7 however, few articles do more than encourage clinicians to work with community members. Indeed, the emphasis has been placed on the epidemiological skills needed to describe a community and identify its health problems and risks; the skills needed to play a collaborative leadership role in this process are seldom described adequately. One of the contributions of the HC literature is discussion about building effective partnerships among the many players, not simply the health care facility and community members, and the acknowledgement that relationship building and democratic decisionmaking take time. This literature specifically addresses the importance of attention to community-building processes, another area that the COPC literature often finesses. Initiatives that grow from an explicit HC framework recognize the importance of learning to live with—indeed, to value—the tension inherent in balancing process and outcomes simultaneously.8
One example of the allied COPC–HC approach is occurring in central Massachusetts, where a family medicine practice hosted a monthly 8-part discussion series on the principles and precepts of COPC. At the series’ conclusion, organizers made a purposeful, subtle shift from using the COPC paradigm exclusively to incorporating the principles and practice of HC as a way to engage additional citizens. The result has been a community–professional partnership called the East Quabbin Alliance (EQUAL), which has realized remarkable successes in the areas of adolescent and environmental health. The group regularly engages additional citizens and remains closely identified with the family medicine practice.
The notion that other movements can be natural allies of COPC is an important one that practitioners who seek to amalgamate primary care and public health should recognize. As Mullan and Epstein note, while COPC appeals on the basis of practicality and principle, it has not become the prevalent mode of practice in health systems.1 All of us who work in COPC would be wise to seek allies that can help strengthen our efforts. We have found one in Healthy Communities.9
References
1. Mullan F, Epstein L. Community-oriented primary care: new relevance in a changing world. Am J Public Health.2002;92:1748–1755.
2. Hancock T, Duhl L. Healthy Cities: Promoting Health in the Urban Context. Copenhagen, Denmark: FADL Publishers; 1986. World Health Organization Healthy Cities Paper No. 1.
3. Wolff T. Healthy Communities Massachusetts: one vision of civic democracy. Municipal Advocate. Spring 1995:22–24.
4. Flower J. Bridges, not walls—building healthier communities. Healthc Forum J.1993;36(4):65–73.[Medline]
5. Norris T, Pittman M. The healthy communities movement and the coalition for healthier cities and communities. Public Health Rep.2000;115:118–124.[ISI][Medline]
6. Cashman SB, Fulmer HS, Staples L. Community health: beyond care for individuals. Soc Policy. Summer 1994:52–62.
7. Rhyne R, Cashman SB, Kantrowitz M. Introduction and overview of COPC. In: Rhyne R, Bogue R, Kukulka G, Fulmer H, eds. Community Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association; 1998:chap 1.
8. Wilcox R, Knapp A. Building communities that create health. Public Health Rep.2000;115:139–143.[ISI][Medline]
9. Kinder G, Cashman SB, Seifer S, Inouye A, Hagopian A. Integrating healthy communities concepts into health professions training. Public Health Rep.2000;115:266–270.[ISI][Medline]
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