Community-Based Service Delivery

Theory and Implementation

Jung Min Choi, John W. Murphy, Jung Min Choi, John W. Murphy

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032004822
• eBook ISBN: 9781000389449
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

This book takes up the challenge of the failure of most initiatives in community-based service delivery to address the significant philosophical shift that is necessary to create, implement, and evaluate appropriately these sorts of projects. Challenging the tendency to focus entirely on practicalities, the authors emphasize the centrality of philosophy to any successful community-based undertaking. While fully acknowledging the importance of local knowledge and the guidance of projects by local people, this volume shows that these principles are often at odds with the 'Cartesian' mindset that underpins much project planning, with its emphasis on objectivity in science and knowledge. Since all knowledge is mediated by human activity and embedded in language and other modes of expression, this dualist approach must be reconsidered. A thorough rethinking of traditional service delivery, which takes into account issues of data, methodology, and bias together with questions of generalizability, community, power, and communication, this book will appeal to scholars of sociology, social policy, and social work with interests in community-based service delivery.

1 Basics of community-based work

Karen A. Callaghan

The movement to community-based work

For the past several decades, community-based approaches increasingly have become the standard framework for delivering services intended to ameliorate serious social problems and inequities as well as to enhance overall well-being. The original impetus for taking community-based work seriously was the desire to design more effective and relevant intervention strategies. In the 1960s, practitioners from various disciplines were awakening to the reality that underserved and marginalized communities could not be transformed by interventions and treatments that were developed in a social vacuum. Effective personal and social intervention strategies could no longer be disconnected from the context of persons’ social, cultural, political, and economic experiences (Montero, 2002). Furthermore, in this era when popular movements throughout the world were calling for more equality and democracy, community involvement in social planning and development was recognized as a necessary and productive practice.

In the United States, for example, three major pieces of federal legislation mandated new pathways for individuals and communities to participate significantly in the design, implementation, and assessment of a variety of medical, social, and economic programs: the Community Mental Health Act of 1963, the Economic Opportunity Act of 1964, and the Public Health Services Act of 1965 (Ozarin, 1966; Naples, 1998; Wright, 2015). These new practices required decentralization of service delivery as well as rethinking the nature of individual and social problems. The Community Mental Health Act called for closing state hospitals and opening local clinics as the primary sites for treatment and rehabilitation. These clinics would be governed by boards that included membership from the local community. Clinicians would have to document how treatment was being delivered in the “least restrictive environment” with the involvement of family and other community representatives (Murphy & Rigg, 2014, p. 286). Using the community as the framework for mental health treatment also required greater awareness of and sensitivity to the cultural and linguistic contexts of patients and their families.

In a similar vein, the Community Action Programs created by the Economic Opportunity Act required the “maximum feasible participation” of local residents in developing strategies for fighting poverty and discrimination (Naples, 1998, pp. 1–2; Rubin, 1969). The idea was that only through “citizen empowerment” and the use of “co-production” planning and implementation processes could these anti-poverty programs authentically serve the needs of the community (Bland, 2018, p. 214). Participation in the local Community Action Agencies and their partnership organizations would allow residents to develop the self-governance and advocacy skills necessary to play significant roles in official decision-making processes.

Direct participation of local residents was also a driving tenet of federally qualified community health centers, which were instituted as part of the Public Health Services Act (Wright, 2015). Community health centers continue to provide primary care for millions of persons who live at or near the poverty level in high medical need areas (National Association of Community Health Centers, 2019). H. Jack Geiger (2002), a pioneer in the field, emphasized that community development and empowerment of local residents are two crucial elements for successful community-oriented medical practice. Community health centers provide employment and educational opportunities for local residents and, in order to maintain their federally qualified status, they must create governing boards with 51 percent patient members (National Association of Community Health Centers, 2019, pp. 2–3).

What appears to be a fundamental shift in approaches to research, social planning, and service delivery was not limited to these federal programs. Community-orientated, culturally relevant, empowerment strategies for service delivery proliferated in the fields of social work, human services, health care, social epidemiology, and public health. Relying on socio-ecological theories, the fields of social work and human services, for example, promoted a strengths-based intervention model where families in need of support are “asked to participate in decision making and goal setting from the onset” (Batavick, 1997, p. 642).

The ecological framework constituted a significant movement away from reductionistic approaches to analyzing personal and social problems. Rather than focusing on individual pathologies, ecological theories propose that behavior must be understood in the context of a social environment, which is constituted by multiple layers of influences (Bronfenbrenner, 1994). These layers range from the immediate interpersonal context, usually a family environment, to complex relationships and connections within social institutions. From an intervention perspective, the roots of both behavioral problems and possible remediations (strengths) are located within this social environment (Schölmerich & Kawachi, 2016). Clients must participate directly in the identification of problematic situations and, with the guidance of service providers, recognize how to either re-examine or re-orient their decision-making and behavior (Batavick, 1997).

On a global scale, the delivery of primary health care has been shaped by several World Health Organization (WHO) declarations, which define health as “complete mental, physical, and social well-being, and not merely the absence of disease or infirmity” (World Health Organization, 1978, section I). Accordingly, assessing good health or illness must be multifaceted and community-based. Issues, such as the quality of employment, housing, and opportunities for education, as well as the prevailing laws and policies must be taken into account to assess the health of individuals, local communities, and the population as a whole (Kickbusch, 2003). The Alma-Ata Declaration further emphasizes “maximum community and individual self-reliance and participation in the planning, organization, operation, and control of primary health care” as the basis for effective and efficient service delivery (World Health Organization, 1978, Section VII, 5). In addition, the WHO Ottawa Charter (1986) expands the role of community participation from planning clinical interventions to health promotion and directly addressing social, economic, and environmental barriers to well-being. These practices emphasize that through democratic approaches to service planning and delivery, problems can be remedied more effectively. In addition, communities would have direct responsibility for collaborating with government and non-governmental agencies as well as developing and maintaining an adequate service delivery infrastructure (Huang et al., 2018).

The “new public health” approach also reflects the influence of this call to develop a more community-based, participatory orientation. For example, analyses of problems emphasize ways in which social and political issues are often directly responsible for community health outcomes (Awofeso, 2004). Consequently, interventions should involve empowering communities to hold local governments accountable for addressing social determinants of health and creating healthier environments (de Leeuw et al., 2015). Social epidemiologists have also adopted an eco-social framework to identify the conditions that foster the social reproduction of inequalities and barriers to services as key risks to public health (Krieger, 2012). In this regard, Krieger (2009) notes that public health projects must be based on “understanding how societal context and social injustice are embodied” and, therefore, deploy “place-based” methodologies that reveal unique lived experiences of actual communities (pp. 93–94).

Furthermore, community-based research methodologies have been touted by both the WHO and the US Centers for Disease Control (CDC) as necessary to develop the level of engagement that can “foster connectedness and trust” between agency staff and local residents (Centers for Disease Control and Prevention – Division of Community Health, 2013, p. 10). The CDC guidelines advise those conducting research on health inequities that “the perspectives of community members can bring static data to life by revealing the lived experiences behind the data” (Centers for Disease Control and Prevention – Division of Community Health, 2013, p. 19). Likewise, the WHO mandates the use of participatory health research methods, especially when working with indigenous populations. In this context, the term “participatory” means “that the entire [research] process, from planning to reporting, will be transparent and accessible to all parties involved” (World Health Organization, n.d.).

Clearly, the argument has been made for some time now that community participation in the design and implementation of research, planning, and interventions is crucial for both the legitimacy and effectiveness of any project. Participatory strategies can produce changes on multiple levels and lead to a dramatic social transformation of poor and marginalized communities (Shahrokh & Wheeler, 2014, pp. 46–52). Addressing the need for health-related interventions, for example, by developing a network of community health workers and better collaboration with local government planning boards, fosters the alleviation of individuals’ problems and improves a community’s capacity for organizing and political negotiation. Furthermore, attempting to understand the historical place and cultural context of a community prior to identifying salient problems and developing interventions is likely to make service delivery appear more relevant and accessible (Krieger, 2009). However, the question remains whether these participatory approaches truly reflect the fundamental conceptual and philosophical shifts that are necessary for any project to become authentically community-based.

There is no doubt that many practitioners genuinely are committed to community engagement and even empowerment. Holistic models of social intervention and research that focus, in part, on addressing institutionalized forms for exploitation, oppression, and marginalization are clearly preferable to one-dimensional clinical approaches that tend to treat these problems as individual pathologies. However, commitment to these more inclusive practices and strategies alone cannot make a project community-based. Too often, the involvement or engagement of communities is superficial and considered ancillary to the work of practitioners, which is sanctioned by established theoretical knowledge bases and disciplinary standards and protocols. Therefore, to avoid marginalizing the very participation they seek to facilitate, practitioners should realize that becoming community-based requires more than new strategies or tactics. Surely, numerous logistical concerns must be addressed to create the social and physical spaces that will foster communication and participation. However, a more fundamental change in thinking, in terms of the actual philosophical perspectives in play, is warranted. Specifically, embracing an important epistemological shift is necessary to implement and sustain community-based work.

Epistemology and community-based work

As Fals Borda (2013, p. 161) suggests, if authentic community participation is the goal, then the knowledge that drives interventions or research projects can no longer be the monopoly of professional practitioners. In other words, community-based work cannot be sustained when only the perspectives and information supplied by “experts” are viewed as real knowledge, that is, a valid basis for understanding and decision-making. From this epistemological standpoint, known as dualism or Cartesianism, knowledge is associated with objectivity. To maintain this status, valid and reliable knowledge must be as uncontaminated as possible by “subjective” information and analysis. Within dualism, facts exist independently, and only under the right conditions can human beings adequately grasp and make use of this type of information. Therefore, data collection methods that minimize interpretation must be used (Hughes & Sharrock, 1998). The introduction of subjective elements, such as opinions, interests, values, beliefs, or personal experiences, will produce biased and unreliable results and compromise the integrity of the knowledge generated. In order to pursue objective knowledge, researchers and practitioners typically employ quantitative, scientific research methodologies, which through standardization produce solid, precise facts devoid of any interpretive errors. In other words, facts that are value-free.

Claims that data are value-free are thought to provide reassurance that the interests and beliefs of persons have been removed or at least controlled. In this context, objectivity is associated with transcending the biases imposed by perspectives or standpoints (Rorty, 1985). Associating subjectivity with this tainted status, however, creates serious problems for practitioners and researchers interested in community-based work. Within Cartesian epistemology, a community does not have and cannot generate valid knowledge. Indeed, the information garnered from communities is considered too idiosyncratic and unsophisticated to be used as a justification for in...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• List of contributors
• Introduction: Theory and community-based work
• 1. Basics of community-based work
• 2. Unpacking culture: A community-based approach
• 3. Developing and evaluating community-based health interventions: The role of data
• 4. Methodological reflections on research in a community service organization
• 5. Community-based work in the absence of identity
• 6. A community does not exist
• 7. There is no generalizability in community-based work
• 8. Philosophy and the embrace of bias in community-based medical education
• 9. Community-based work and the natural language problem
• 10. Power and positionality in community-engaged work and community-based participatory research
• Conclusion
• Index