Protecting and Enhancing Health: Community Engagement, Collaborations, and Incentives for Prevention
Eduardo J. Simoes; Ciro V. Sumaya
Posted: 05/21/2010; J Prim Prev. 2010;31:21-29. © 2010 Springer
Introduction
The US health care system and its reform has become a focal point of public debate, engaging many who traditionally have not participated in the dialogue around population health needs and resources. In this essay, we discuss aspects of a transformed health care system that addresses major health needs of Americans through health promotion, disease prevention, and personal health care (i.e., diagnosis and treatment). We bring attention to the role of communities and patients on the health issues with a focus on public (population) health practice, emphasizing collaboration among government health agencies at all levels and other health-related public and private organizations.
This discussion is necessary, relevant, and timely because it is occurring concurrently with the emerging national, state, and local discourse on health reform. Significant funding targeting health system changes are already unfolding with the American Recovery and Reinvestment Act (ARRA) of 2009. (Steinbrook 2009; Agency for Healthcare Research and Quality 2009; US Department of Health & Human Services 2009).
Given the context described, this commentary will specifically discuss recent health trends and systemic approaches that:
- Engage communities and individuals through a participatory process in health promotion, disease prevention, and health care delivery;
- Reorganize health insurance to create incentives for prevention; and
- Promote collaboration across government agencies, community-based organizations, and other potential partners at the national, state, and local levels.
We conclude by defining the implications of taking a community-oriented approach to integrating these different aspects of the health system.
Trends: Health and Health Care Gaps
The role and level of effectiveness of health care in the United States is questionable if the health indicators of Americans (e.g., life expectancy at birth, infant mortality, number of years living with a disability, number of years of quality life, percent of people reporting poor health) are compared to those of populations of similarly developed countries and even of a few less developed countries (Avendano et al. 2009; Banks et al. 2006). Although Americans live longer than ever before, their life expectancy has stabilized over the past 10 years and is shorter than that of residents of most developed countries (Day et al. 2008). Contributing to this finding are the higher rates of death in the US, compared to these countries, from diseases and conditions such as ischemic heart disease, stroke, many forms of cancer, chronic obstructive pulmonary disease, diabetes, and infant-obstetric complications (Heron et al. 2009). However, most of these deaths are largely attributable to preventable risk factors such as tobacco smoking, hypertension, high cholesterol, physical inactivity, and overweight/obesity (Danaei et al. 2009). Yet, minimal funding support, an estimated 2–3% of total health care expenditures, is directed toward prevention (Satcher 2006). Although some have suggested that prevention is costly and not economically beneficial (Kahn et al. 2008; Russel 2009), evidence shows that promoting health and reducing disease through prevention can be cost-effective (Cohen et al. 2008).
Although the overall effect or influence of social determinants on the health of Americans may differ from that of other developed countries, problems within the US health care system(s) appear to have contributed considerably to the comparatively low health standing of the US. This conclusion is highlighted when scrutinizing particular inadequacies in disease prevention, health education, and access to health care. Moreover, the number of Americans without health insurance for an entire year has increased in recent years from 32 million (15% of the nonelderly population) in 1988 to 45 million (17% of the nonelderly population) in 2007 (DeNavas-Walt et al. 2008). Lack of health insurance and subsequent lack of access to health care is especially problematic for several minority groups, lower socioeconomic groups, and the less educated population—those who often need insurance the most (Bodenheimer 2004; Institute of Medicine 2002).
Health care costs in the US are becoming unmanageable, totaling 17.6% of the US gross domestic product in 2009, compared to an already high 13.6% in 1994 (Mercer Human Resource Consulting 2009). By 2018, national health care expenditures are expected to reach $4.4 trillion—more than double 2007 spending (Siska et al. 2009). Health care costs are also becoming unaffordable for industries and organizations offering health benefits to their employees, with health plan cost per employee increasing 3.3% in past 15 years (3.0% in 1994 vs. 6.3% in 2009; (Mercer Human Resource Consulting 2009). Dissatisfaction with the quality of health care has increased over time, as measured by a survey of both patients and health care practitioners (Kaiser Family Foundation 2008). A poor perception of what the health care system offers to address health problems has also been reported (Kaiser Family Foundation 2008).
Effective delivery of health care to patient populations, despite being beneficial, cannot fully address Americans’ risk for developing certain preventable conditions. For example, an estimated 26.6% of Americans were obese in 2008 and at risk for developing obesity-related chronic diseases such as type II diabetes and cardiovascular diseases (Centers for Disease Control and Prevention 2009). However, Green et al. 2001 have noted that of every 1,000 people in the US, on average each month, 80% experience symptoms of some type, 32.7% consider seeking medical care, 21.7% visit physician offices, and out of the latter, only about half (11.3% of the total group) visit primary care providers. Thus, if we aim to conduct prevention only through health care delivery, then we should expect that between 11.3 and 21.7% of those who are obese would receive preventive care—and only if all physicians offer preventive care. Thus, such an approach to prevention cannot address the health needs and risks of the majority of the population.
Further, health care delivery has developed in ways that reduce the role of health practitioners (e.g., physicians and other health professionals) as the main informants and decision makers with their patients regarding care. The changing physician-patient relationship has been affected by the minimal time allotted for patient encounters, particularly in managed care settings (Roland et al. 1986; Tamblyn et al. 1997), thus reducing or eliminating interactions that include health education and preventive communication to patients by their physicians.
Positive Trends: Incentives for Prevention and Individuals/Employers as Decision Makers
Although some trends in health and health care in the US should cause concern, other trends offer opportunities for new ways of thinking about health. Health insurance coverage is increasingly one of the most important components of an employment benefit package. In the current economic downturn, employees have a heightened awareness of the value of benefits packages associated with their jobs and may tend to stay in jobs longer if these packages are attractive (ConsumerReportsHealth.org 2008; Employee Benefit Research Institute 2009). However, offering and funding health insurance require employers to achieve a fine balance because of the dramatic increase in costs of health care, which in turn increases the cost of the total employment benefits package. One opportunity to positively shift the balance is implementation of health promotion and disease prevention strategies, which can lead to decreased absenteeism due to illness and increased employee productivity, recruitment, and retention—outcomes that may compensate for increased health insurance benefits costs (Prince 1999). For these reasons, many large employers, working with insurers, have developed health care benefits packages that include wellness programs that are steps beyond the current traditional promotion of physical activity and diet.
Many organizations now offer employees programs that screen for disease risk factors (e.g., biometric screening of weight and sugar levels to identify pre-type II diabetes) and check screening results against claims data to determine previously undiagnosed persons. The at-risk employee is given an opportunity to enroll in a preventive plan. Both screening and preventive measures are low-cost and cost-effective; compliance is monitored and incentivized (Chicoye et al. 1998; McCulloch et al. 1998). Value-based health care is another approach that increases employers’ awareness of the benefits of maximizing employees’ health and quality of life and, ultimately, productivity (Beauregard and Winston 1997; Chernew et al. 2007; Lopert and Moon 2007; Kelly et al. 2008; Rosenthal et al. 2007). These health insurance approaches involve patients in decision-making about maintaining their health and taking responsibility for prevention of disease and provide coverage for appropriate diagnostic and treatment regimens during times of illness. These strategies have been shown to improve health and to be cost-efficient.
Similarly, effective medical practice relies heavily on patients’ and their families’ knowledge of the natural history of a patient’s illness, family medical history, diagnostic and treatment measures, and other health care issues. Thus, individuals and their families can be important partners with health care providers and assist in decision making and compliance with health care (Kenyon and Gordon 2009). Although increased patient participation in health matters is relatively new, interest in greater involvement in the process of maintaining health and preventing and curing diseases has been growing at the individual and community levels (Buckley and Hutson 2004; Kenyon and Gordon 2009).
Positive Trends: Communities as Decision Makers
The community, with its resources, networks, and governance capabilities, is a natural locus to advance the protection and improvement of the public’s health. Community capacity can be refined, focused, and enhanced to engage the community effectively in creating and evolving a health vision and assuming accountability for health improvement efforts across its jurisdiction. Different levels and approaches to broad community involvement in health exist, but their commonality is centered within the community, which serves as a fulcrum of direction, input, and accountability (Kenyon and Gordon 2009; Neuwelt et al. 2009). This actively engaged community involvement represents a shift in emphasis, encompassing individuals, families and neighbors, and ultimately everyone in the community. Communities can craft and use processes that serve as integral mechanisms for planning, developing, implementing, and evaluating health and health-related activities. Robust community capacity and processes, because of their local and intimate character, can promote great interest in, acceptance of, and ability to sustain health improvement actions among community residents as they engage with members of the health professions and health systems. Moreover, a community approach lends itself to incorporating broader social determinants of health (e.g., the environment, education, economics, and transportation) into the mix of strategies and interventions to improve public health. Chen, 1989 in describing the four stages in the development of a health care system, placed community medicine (i.e., organized community effort to meet a population’s health care needs) near the top stage. It was surpassed only by the ultimate stage of health care systems, public health, which concerns all the circumstances and conditions affecting the health of an entire population.
Health care professionals, particularly from academic institutions, may be reluctant to adopt community engagement, being fearful or cautious about sharing decision-making responsibilities and power over health matters with the public. Such reservations can create substantial barriers to the community’s ability to have an appropriate voice in health care matters (Kenyon and Gordon 2009). However, when the public is able to make meaningful decisions, community engagement can lead to substantial health gains. Community engagement in the health arena is an expanding, dynamic process with continually emerging issues and challenges.
Community Capacity and Processes: Engagement through Three Major Public Health Frameworks
Organized community engagement and processes can have a significant impact on the health and well-being of the residents. For purposes of this discussion, the role of community engagement and processes can be viewed through three population-based, public health-related frameworks: (a) disease prevention, (b) health promotion, and (c) health care delivery. These frameworks provide major opportunities and avenues for meaningful community engagement. Although presented as separate frameworks, they have significant interplay and interdependence. Further, these frameworks enable collaboration of communities with federal, state, and other organizations in developing and implementing health activities. Communities can be adept at developing various community-wide, health-related programs through their ingenuity and resources; broad collaborations with or support from external agencies and organizations can further augment the impact and outcomes of community-based, health-related programs.
Services and activities in disease prevention, such as screening tests (e.g. blood pressure, blood cholesterol, Pap smear), vaccine administration, environmental assessments, dental prophylaxis, and well-baby examinations, are effective means of protecting our health. Nonetheless, they are often underutilized and undervalued and are not universally accessible. Community interventions organized to increase participation in and use of these preventive measures are essential to reach the entire community, particularly marginalized, poor, and undereducated groups. The media, working alongside the community, is a resource that can disseminate information and provide public service announcements about the need to receive these preventive measures. The availability of transportation to sites that have these preventive services could be addressed through community action.
Health promotion efforts can be augmented by the involvement of an organized community committed to improving its residents’ health. The leadership of communities can actively pursue community-wide events that address health education on topics of interest (e.g., nutrition, exercise, and at-risk behaviors) and can promote health assessment surveys to facilitate a better understanding of the status of local health issues. The community can play an important role in rallying residents toward appropriate action for addressing environmental problems in their neighborhoods or surrounding areas. The media as well as other community resources (e.g., faith-based institutions, schools, and neighborhood associations) can be driving forces to stimulate health promotion efforts and assure that these activities reach the general community. As with disease prevention efforts, health promotion interventions should be evaluated, and results and best practices should be disseminated.
Community engagement and processes can also have a significant impact on the health care delivery system(s). Although health care delivery may have a strong individual focus, it can and should also incorporate a population focus. Unfortunately, this population or community focus is often lacking or minimal, leaving a fragmented health care delivery system in need of integration, accessibility, affordability, quality, and efficiency. The community should be intimately engaged in discussions about developing model medical homes and integrative systems of health that address and coordinate the spectrum of health care services (e.g., primary, specialty, mental, rehabilitative) needed over the life span (Michener 2007). Health care systems need to better consider health-related issues such as patient transportation, access, outreach, cultural competency of providers, and appropriate use of services because these issues have a direct bearing on the health care triad of quality-access-cost. The community can provide valuable input and influence outcomes by participating in the planning, development, implementation, and evaluation of interventions that address these broad determinants of health. Community-driven boards of hospitals and clinic settings in both the private and public sector should play a model strategic role in making changes toward improvement.
Community Engagement in Other Vital Public Health (Population Health) Functions
Workforce Development
Members of the health professions workforce in the community predominantly take care of sick patients; a smaller number cover population-focused public health services. However, all health professionals should have a strong sense of and commitment to the community and its health needs as a whole. The Institute of Medicine states that “schools [of public health] should [integrate] this ecological view of public health, as well as a population focus, into all health professional education and practice” (Gebbie et al. 2003). To achieve this goal, all health professionals, but particularly the public health workforce, should be substantially exposed to education and training in diverse community-based settings. This training enables health professionals to have a more comprehensive understanding of the realities of health disparities, underserved people and their environments, and community-identified health priorities, as well as the array of technological advancements that may or may not be available to community residents.
Community-based education of the health professions workforce can provide a better basis for relevant policy development and advocacy for health improvement at all levels of society. In addition, in academic health centers and other health professions training programs, diverse community representation is important in the admissions process and in advisory and other committees established for the institutional training programs. Most importantly, the health professions educational and training programs should have accountability to the communities they serve.
Community health workers (e.g., lay advisors, promotoras, peer navigators) are emerging as vital links in health care systems, particularly in the engagement of hard-to-reach populations (Ahmed and Maurana 2000; Centers for Disease Control and Prevention 2005). Community health workers have credibility and trust from the community because they traditionally work with people who are their neighbors; they also often have an intimate understanding of and empathy with underserved neighborhoods.
Research
Research brings advancements in knowledge and development of evidence that documents the efficacy and impact of health promotion and disease prevention services and interventions as well as new diagnostic tools and treatment regimens. However, important health advancements through research may not reach the public effectively; that is, knowledge of advancements disseminate slowly from the laboratory to the patient and the community. Also, even if available, the research products or interventions are often too expensive for use, a problem experienced more often by noninsured or underinsured, minority, and rural populations. Moreover, considerable time may elapse before these new research findings or their products are put into practice (Corrigan et al. 2002).
Community leaders and residents can be significant resources for researchers by their ability to link community residents or organizations with research projects and to affirm the relevance and applicability of research efforts. Leaders and members of the community can also become involved with identifying priority health problems and the research focus needed to resolve these problems (i.e., determining the research question). Additionally, they can assist in crafting the research project—particularly as it relates to community participation as participants or volunteers—and can engage in the dissemination of findings after results and evaluation of the project have been completed. This process, more formally called community-based participatory research, is an emerging research arena that breaks with the traditional research process that is researcher driven (Boutilier et al. 2001; Green and Mercer 2001; Minkler 2005; University of Michigan School of Public Health 2009). Expansion of community-based participatory research efforts in all types of health research is needed, particularly research focused on health promotion, disease prevention, and health services efficacy and efficiency.
Policy
Although health policy development may seem to be dominated by high levels of government, powerful policy organizations in the nation’s capital, and special interest groups, the community and its citizens should be actively involved and consulted on policy goals and direction. Community capacity and processes provide mechanisms for strategically engaging the community with the leadership of organizations that can influence health policy. The community and its extensive collaborations and relationships with federal, state, and other public/private agencies and organizations in health-related activities should provide a platform for influencing health policy. Further, individuals and organizations of the community have the right to contact elected or appointed officials and make their health views known at all levels (i.e., local, regional, state, or federal). With the explosion of electronic and digital communication technology, community members may reach a multitude of people easily through such mechanisms as e-mails, blogs, or twitters.
Federal and National-level Programs
A number of federal and national-level programs are active in supporting community capacity-building and community processes targeting health. While representative examples are provided in this section, it is noted that many others exist, including state-level programs that are important partners in community engagement. The Kellogg and the Robert Wood Johnson Foundations, Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA) have been strong proponents of community (or of state and community together) engagement approaches. The extensive network of community and migrant health centers overseen by HRSA requires a majority of community representatives on the governing boards of these centers, which are required by law to provide health services to all, regardless of insurance status. The CDC-sponsored Prevention Research Centers are leaders in integrating the concept of community-based participatory research as part of the entire research process from the research question to its development, conclusion, and translation into practice and policy. The Prevention Research Center program along with the CDC-sponsored Centers for Public Health Preparedness has a strong interest in connecting community resources with resources from academic health institutions. The National Institutes of Health incorporate significant community involvement in the Clinical and Translational Science Awards program, which is charged with the application and dissemination of new research findings (i.e., taking the research impact from the laboratory to patients and communities). The Agency for Healthcare Research and Quality gives major attention to health care quality, utilization, efficiency, and effectiveness through its health services research programs. An extensive network of health promotion and disease prevention programs are supported by CDC-sponsored state and local health agency public health programs (e.g., Obesity Prevention, Diabetes Prevention, and Smoking Prevention), by HRSA, and by state health department alliances. The Association of Schools of Public Health and public health training programs not only provide education and training for future public health professionals, but, through their large faculty base, address the development of population-focused research projects and community interventions to improve the health of the public
Implications for the Future
A number of major concerns with the nation’s health and health care systems are provoking calls for a major transformation of current approaches, performance, and direction. Not only is the country beset with health disparities and many health indicators inferior to those of other developed countries, but these issues are present despite per capita health care expenditures that are already inordinately high and continue to increase to unsustainable levels. Additional future health challenges posed by an expanding elderly population, a high rate of unhealthy lifestyles, and increasing problems with obesity with its attendant co-morbidities as well as problems with other chronic diseases will further aggravate this situation.
We propose that engagement of the community with its unique capacity and processes can be a pivotal strategy for initiating, developing, and sustaining the changes needed, particularly public health services, to transform the nation’s health and health care system. For example, although significant knowledge about disease prevention and health promotion exists, the infrastructure and support provided are insufficient to ensure that these strategic public health measures reach the American people, particularly those that need them most. Similarly, the many valuable new technologies in diagnostics, treatment, and rehabilitation that are being developed take prolonged periods of time (even years) before they reach the population. Even if available, they may benefit some segments of the US population more than others, such as the uninsured or underinsured. An improved, transformed health care system should have effective integration and coordination of the continuum of health promotion, disease prevention, and health care delivery throughout the life cycle. Effective integration and coordination will require crucial comingling of population (public) health with health care (personal) services to an unprecedented extent. This expansion of health services will require a major enhancement of essential public health functions that will bring a public health perspective on a par with health care services (Public Health in America 2009). A more robust community engagement will facilitate and put these new approaches to health care on a successful track.
Creating and sustaining an improved, transformed health and health care system will require more effective dialogue, partnerships, and coordination of resources at the federal level along with state- and local-level organizations, foundations, health workforces, hospital and health systems, and insurance companies, among many others. Community engagement can help coordinate resources and monitor the progress being made toward achieving the necessary transformational changes.
Rigorous evaluation and research activities are essential to advance the development of a new transformed health system. First, designs must be developed and tested for comparative effectiveness in terms of health outcomes, acceptability by the community, costs, and access. Mechanisms need to be put in place to assure that innovative approaches for improving individual and community health outcomes are put into routine practice, while also containing health care costs. Researchers must work with and listen to the community, incorporating community norms and capacity and harnessing community powers to effect change and improve and sustain the health of communities, not only individuals. This community-based participatory research is key to translating and disseminating research findings into practice and appropriate utilization by the community. It is also vital that the research questions being pursued effectively cover population (public) health as well as health care delivery (personal); that is, prevention, health promotion, and behavioral research must be supported in addition to biomedical and laboratory-based research.
The newly transformed system should yield outcome measures of both traditional health indicators (i.e., disease-specific status and trends) and non-health-related quality of life indicators (i.e., general well-being elements such as health adjusted life expectancy; Kindig 1998). Improving the social determinants of health, such as population employment and health care coverage, community literacy, and the capacity to organize populations around health issues can be as relevant to health as levels of tobacco smoking, physical inactivity, and obesity.
“The health of one is admirable; the health of all, supreme” (Sumaya 2002). The time has come to enable community-based and public health interventions to improve the public’s health.
