Originally introduced in the 1920's to provide quality primary care services, community health centers (CHCs) have been employed widely around the world as a means to increase access to health care and enhance both community and population health outcomes.1-3 Community health centers have become recognized as a cost effective means to deliver healthcare services, particularly to populations that are underserved such as persons who are homeless, living in poverty, new immigrants or located in rural and isolated settings.1,4-8 Given the expense of providing health care, the increasing demands for access to health care and client expectations for services, it is essential to evaluate both the effectiveness and efficiency of CHCs.8,9 However, to date there has not been a comprehensive framework developed to evaluate CHCs; this may be due to the complex nature inherent to CHCs in view of the potential range of services that may be offered and the challenges in measuring health outcomes. Thus, the aim of this scoping review is to explore how services and outcomes of CHCs are evaluated through: i) understanding how CHCs are defined and/or described in the literature; ii) delineating the services and/or elements that CHCs may include; and, iii) identifying frameworks used to evaluate services and outcomes of CHCs. By achieving these aims, it is anticipated that it will be possible to develop a comprehensive evaluation framework to better assess services, outcomes and efficacy of CHCs.
Early conceptualizations of CHC-like care services seem to have developed in the early 1900 s.10-13 In Great Britain, a proposal for community-based services was first presented in a “white paper” in 1920, which became the basis for the current models of CHCs operating within the National Health Services.12 In Canada, the first CHC model noted in the literature is the Mount Carmel Clinic in Winnipeg, Manitoba, which was established in 1926.10,11 The Mount Carmel Clinic was originally mandated to serve new immigrants, including a thriving Jewish community; however, over time the health services evolved to provide community-centered care to Winnipeg's North End residents that now includes refugees, homeless persons and street involved individuals (e.g. street youth, sex trade workers).10,11 The concept of CHCs was introduced as a significant change to health policy in the United States in the 1960 s and Australia in the 1970 s to address gaps in access to health care and to recognize that health was inextricably linked to both the economic interests of individuals and the state.14-16 In the United States, CHCs developed with the civil rights movement that sought to improve the health care needs of Americans living in deep poverty and which built upon initiatives through President Lyndon B. Johnson's “War on Poverty”.13,17 Globally, entities described as being CHCs also exist on all other continents besides Australia and North America, including Africa,13,18-20 Asia,3,7,21,22 Europe,23-25 and South America.26-28
An initial systematic literature search and review of 4363 peer-reviewed articles from seven databases (ABI/INFORM, Academic Search Premier, CINAHL, Embase, PsycINFO, PubMed and SocINDEX) for a concept analysis of CHCs revealed there is varied and inconsistent application of this concept. Specifically, there appears to be: i) a lack of standardized terminology and taxonomy for CHCs; ii) various definitions for CHCs; and, iii) variability in the scope and range of healthcare services provided by CHCs or similarly described concepts. However, the findings of this initial search and review of the literature supports the viability of conducting a scoping review to explore frameworks or models that evaluate services and outcomes of CHCs.23,29-31 No systematic or scoping reviews that address the primary and secondary questions for this scoping review were found in this literature search.
The term CHC is used interchangeably with both facilities or agencies that offer primary care services aligned with a more traditional approach to medical care12,22,32,33 and those organizations that offer a more comprehensive range of community-oriented services aligned with principles of primary health care.7,17,24,34,35 Synonymous terms that closely reflect these narrow or broader interpretations of healthcare provision include primary health centers, primary care clinics, and community health service centers.36-38 Additional terms that reflect a more specialized population or geographical variation of CHCs include community mental health centers, migrant health centers, and local community services centers.1,12,13,23,25,39 These variations in terminology and taxonomy will be accounted for in development of the search strategies for each of the databases incorporated into this scoping review (see Appendix I).
There are variations in the definitions for CHC; however, the majority of the literature and policy documents where CHC is explicitly defined reflect the more comprehensive perspective of services from a primary health care model that includes primary care, health promotion and preventative interventions at a community or population level.9,10,16,31,34,39-41 For the purposes of this scoping review, a definition of CHC synthesized from key sources in the literature will be used:
Community health centers are healthcare agencies that provide comprehensive primary health care services to address both immediate health issues and broader causes of poor health outcomes through integrated service delivery models of health care to individuals, families, and communities. Community health centers enhance individual, community, and population health outcomes and wellbeing through delivery of primary care services and community-oriented programs that employ health promotion and illness prevention strategies aligned with the principles of primary health care,42 and that incorporate the social determinants of health.
The scope of healthcare services provided by CHCs spans from the provision of primary care services12,14,32,33,43 to a more comprehensive approach of service delivery informed by the principles of primary health care adopted by the World Health Organization from the “Declaration of Alma-Ata” in 1978.18,24,31,44Primary care is typically regarded as the first point of contact for receipt of individual medical care that includes diagnosis and intervention to address specific health concerns, such as acute and chronic illnesses.12,24,32,33,43 Primary care is often associated with the biomedical model approach to health care that is largely physician-driven and focuses on pathological origins of illness and disease.12,22,33,43 In contrast, a primary health care approach is generally described as a socio-environmental or socio-ecological approach to health care that is population-based, oriented to social determinants of health that impact health and wellness, and considers an upstream approach to addressing societal health and wellness.5,17,20,35,45,46 While a primary health care approach does encompass primary care within the principles of the “Declaration of Alma-Ata”, particularly in relation to access to health service delivery, it also includes elements of community participation, intersectoral collaboration, health promotion and illness prevention.17,24,35,45
The range and/or variety of services offered by comprehensive models of CHCs typically include: i) primary care offered through a collaborative interprofessional health care team; ii) health promotion activities; iii) illness prevention services; and, iv) enhanced accessibility to services. Composition of healthcare teams for CHCs reflected in the literature commonly include physicians, nurse practitioners, nurses, mental health workers and social workers.5,23,25,44,47 More comprehensive or specialized CHCs may employ a wider range of care providers and support personnel for addictions, nutrition, dentistry, interpretative services, rehabilitation and specialist care (e.g. internists, gynecologists).19,22,39,44,46,47 Health promotion activities commonly reported in the literature include formal initiatives (e.g. condition-specific clinics, peer-support groups, educational events)26,38 and informal health promotion (e.g. offered during client visits).26,34,35 A focus on illness prevention through CHCs is frequently demonstrated through the inclusion of services such as screening, vaccination and harm reduction programs.20,21,26,34 Accessibility to CHC services and care may be enhanced through innovative scheduling systems, use of technologies (e.g. telehealth and online support), outreach services and transportation initiatives.5,26,28,37
Additional features of comprehensive models of CHCs may include specialization for specific populations or geographical catchment areas and engagement of community constituents. Specific populations served by CHCs include persons with mental health challenges, immigrants, the lesbian, gay, bisexual, transgender, queer (LGBTQ) community, women, and residents of rural areas.5,35,41,45 These specialized CHCs are often designed to facilitate access to marginalized or vulnerable groups, many of whom generally have poorer health outcomes related to socioeconomic disadvantages, social exclusion, cultural practices and/or ethnic demographics.8,41,45,46 Community health centers may be developed to provide care to underserved geographical locations, such as rural or community settings where there may be high demand and opportunity to cost-effectively provide services; physical location to enhance accessibility may be a consideration in these situations.4,9,19,41 Finally, engagement and participation of community members may be incorporated into the operations of CHCs. It is recognized that to promote the overall health of a community and to realize optimal population health outcomes involvement of community members is requisite in both guiding directions of service delivery and uptake of health promotion actions.6,35,41,48 Engagement of community members may be reflected in governance structures that guide CHC operations and, in the case of federally qualified health centers (FQHCs) in the United States, community membership on boards is a requirement.6,40,48 Community engagement and participation can be instrumental as a strategy to increase community capacity in health promotion, such as for influencing health-promoting behaviors, creating supportive environments and, ultimately, realizing economic benefits for society.6,26,46,48
The evaluation of CHCs has largely been associated with demonstrating economic feasibility and individual health outcomes in comparison to other types of healthcare services, such as private physician practices, hospital outpatient departments and emergency room visits.7,34,35,36,41,49 Measurement of cost/benefit is influenced by a need to justify government expenditures for fiscal and political purposes, since CHCs are often partially or wholly financed through public funds.2,3,15,16,24,27,29,30,33,45 In the United States, where the healthcare system is predominantly a private enterprise, CHCs designated as FQHCs may be eligible to receive federal funding through the Health Resources and Services Administration to improve and expand services for underserved populations.2,30,40 However, these CHCs must meet specific criteria to qualify for the federal funding, including provision of specific services, and meeting financial and administrative requirements.40,50 In countries where the healthcare system is publicly funded, evaluation of CHCs is often related to parameters such as access to services (e.g. waiting times, geographical location), health outcomes (e.g. management of chronic disease conditions), and impact on hospital services (e.g. admissions, acute care funding).3,8,16,20,37,39,49
While there are some studies and program evaluation initiatives identified that describe approaches to evaluation of CHCs, there appears to be a gap regarding development of a comprehensive evaluation framework to assess services, outcomes and efficacy of CHCs. In reviewing the literature for this protocol, many articles describe evaluations of discrete components of CHCs such as access to care, clinical outcomes, client satisfaction and provider productivity.23,27,30,31 There is some literature that reflects identification of performance indicators, development of performance score cards and other evaluative processes for assessing CHCs.2,29,30,44,49 Through this scoping review, it is anticipated that a more robust exploration of the literature will provide an in-depth understanding of components and frameworks for evaluating services and outcomes of CHCs.
Participant details will not be used as the basis for study selection in this scoping review. Instead, this review will consider studies and other literature sources that reflect evaluation of services and outcomes of CHCs, with a broad view of service provision aligned with the principles of primary health care that is community-centered (whether defined by population or geography).
The main concept of interest for this scoping review is frameworks that evaluate services and outcomes of CHCs. These frameworks may be reflected in evaluation models, theoretical frameworks, quality improvement criteria and/or other conceptual models. Studies and literature sources that reflect types of services, service delivery models and/or evaluative components of a CHC will be the focus of this scoping review.
The context will be CHCs that provide comprehensive health services to specified populations, communities and/or defined geographical areas. Variations on the concept of CHC will be considered, such as community mental health centers, primary health care centers and migrant health centers since these terms are often used to define such community health center services. Studies that focus solely on the provision of primary care services will be excluded, such as physician or nurse practitioner practices that focus on providing individual care to clients.
Types of studies
This review will consider quantitative, qualitative and mixed methods studies relevant to the evaluation of services and outcomes of CHCs. Quantitative studies will include experimental and quasi-experimental designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Qualitative studies that will be considered include, but are not limited to, designs such as grounded theory, ethnography, phenomenology, qualitative description and action research. Data from relevant mixed methods studies will also be used. Studies published in English or French will be included. No time limitation will be placed on publication of literature sources.
The search for other textual data will include unpublished literature such as technical reports, government guidelines, policy, accreditation agencies, and other appropriate sources.
The search strategy will aim to find both published and unpublished studies. An initial limited search of CINAHL and MEDLINE (PubMed) has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a comprehensive search strategy, which will be tailored to each information source. A full search strategy for both MEDLINE (PubMed) and CINAHL is detailed in Appendix I. An initial scan of these two databases using these search strings yielded 2811 results for CINAHL and 5128 results for MEDLINE (PubMed). After removal of duplicates, a total of 7419 results were obtained through this initial scan. Finally, the reference list of all studies selected for inclusion in the scoping review will be screened for additional literature sources.
The databases to be searched include: ABI/INFORM Complete (ProQuest), Academic Search Premier (EBSCOhost), CINAHL (EBSCOhost), Cochrane Library (Wiley), Embase (Elsevier), PsycINFO (EBSCOhost), MEDLINE (PubMed) and Scopus (Elsevier).
The search for unpublished studies and other literature sources will include: Google/Google Scholar, government websites (e.g. Ministry of Health and other healthcare departments), healthcare agencies (e.g. non-profit community health centers, such as Mount Carmel Clinic11), and ProQuest Dissertations and Theses.
Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicates will be removed. The remaining citations will be imported to Covidence (Covidence, Melbourne, Australia) where titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. The full text of selected studies will then be retrieved in Covidence and assessed in detail against the inclusion criteria. Studies that meet the inclusion criteria will be imported into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). Full-text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.51 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data will be extracted from papers included in the scoping review using a data extraction tool (Appendix II) developed by reviewers and based on recommendations from the JBI Review Manual.52 Following JBI scoping review methodologies,53,54 extracted data will be reviewed independently by two members of the project team. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The data extracted will include specific details about evaluation frameworks, evaluation methods, populations, study methods, and outcomes of significance to the primary and secondary questions. Authors of papers and other literature sources will be contacted to request missing or additional data where required.
Extracted data from relevant articles and other gray literature will be presented in tabular form that reflects the primary and secondary questions for this review. Data in the tables will reflect the information captured through the data extraction instrument (Appendix II), and include: i) author name(s); ii) year of publication; iii) country of origin; iv) type of source (i.e. peer-reviewed article, technical report, policy, etc.); and v) aim or purpose of literature. For formal research articles, tabular information will also include: i) research design; ii) methodology and methods of the study; and iii) population and sample size. Where there are additional data to describe CHCs, tabular information will report on: i) definition or description of CHCs; ii) strategies or instruments used to evaluate services and/or outcomes of CHCs; and iii) evaluation framework or model used. The tabular data will be accompanied by a narrative summary and synthesis of findings guided by the methodology outlined for JBI scoping reviews.54
Special thanks to Daniel Doherty (Director, Primary Health Care Program, Saint John Area, Horizon Health Network) and Dr. Christy Goss Bigney (Community Health Consultant for the New Brunswick Department of Health) for their interest and support in this project.
Appendix I: Search strategy
Search A: CINAHL
- ((MH “Conceptual Framework”) OR (TI models OR AB models) OR (TI model OR AB model) OR (TI “evaluation framework” OR AB “evaluation framework”) OR (TI “framework evaluation” OR AB “framework evaluation”) OR ((TI Standards) OR (AB Standards)) OR ((TI Standard) OR (AB Standard)) OR ((TI Guidelines) OR (AB Guidelines)) OR ((TI guideline) OR (AB Guideline)) OR ((TI Plan) OR (AB Plan)) OR ((TI Plans) OR (AB Plans)) OR ((TI Tool) OR (AB Tool)) OR ((TI Tools) OR (AB Tools)) OR ((TI Strategy) OR (AB Strategy)) OR ((TI Strategies) OR (AB Strategies)) OR ((TI “theoretical framework”) OR (AB “theoretical framework”))
- ((MH “Community Health Services”) OR (MH “Community Health Centers+”) OR (MH “Rural Health Centers”) OR (MH “Community Mental Health Services”)) OR ((TI “Township health center*”) OR (AB “Township health center*”)) OR ((TI Polyclinics) OR (AB Polyclinics)) OR ((TI “community health services”) OR (AB “community health services”)) OR ((TI “community health center*”) OR (AB “community health center*”)) OR ((TI “Rural Health center*”) OR (AB “Rural Health center*”)) OR ((TI “community health care center*”) OR (AB “community health care center*”)) OR ((TI “Community Clinics”) OR (AB “Community Clinics”)) OR ((TI “Health center*”) OR (AB “Health center*”)) OR ((TI “Community Mental Health center*”) OR (AB “Community Mental Health center*”)) OR ((TI “Publicly Funded Health center*”) OR (AB “Publicly Funded Health center*”) OR “federally qualified health center” OR FQHC)
- ((MH “Quality of Health Care”) OR (MH “Guideline Adherence”) OR (MH “Process Assessment (Health Care)”) OR (MH “Program Evaluation”) OR (MH “Clinical Indicators”) OR (MH “Quality Improvement”) OR (MH “Quality Assurance”) OR (MH “Evaluation Research”)) OR ((TI “Quality of Health Care”) OR (AB “Quality of Health Care”)) OR ((TI “Guideline Adherence”) OR (AB “Guideline Adherence”)) OR ((TI “Process Assessment”) OR (AB “Process Assessment”)) OR ((TI “Program Evaluation”) OR (AB “Program Evaluation”)) OR ((TI “Quality Indicators”) OR (AB “Quality Indicators”)) OR ((TI “Quality Improvement”) OR (AB “Quality Improvement”)) OR ((TI “Quality Assurance”) OR (AB “Quality Assurance”)) OR ((TI “Clinical Indicators”) OR (AB “Clinical Indicators”)) OR ((TI “Evaluation Research”) OR (AB “Evaluation Research”)) OR ((TI “Evaluation Studies”) OR (AB “Evaluation Studies”)) OR ((TI “Total Quality Management”) OR (AB “Total Quality Management”)) OR ((TI evaluate) OR (AB evaluate)) OR ((TI evaluation) OR (AB evaluation))
- #1 AND #2 AND #3
Search B: MEDLINE (PubMed)
- ((((((((“models, theoretical”[MeSH Terms] OR Models[tiab]) OR Model[tiab]) OR (“evaluation framework”[tiab] OR “framework evaluation”[tiab])) OR ((“standards”[Subheading] OR standards[tiab]) OR standard[tiab])) OR (((Guidelines[tiab] OR Guideline[tiab]) OR “guidelines as topic”[MeSH Terms]) OR “health planning guidelines”[MeSH Terms])) OR (Plan[tiab] OR Plans[tiab])) OR (Tool[tiab] OR Tools[tiab])) OR (Strategy[tiab] OR Strategies[tiab])) OR “theoretical framework”[tiab]
- (((((“township health center”[tiab] OR “township health centers”[tiab] OR “township health centre”[tiab] OR “township health centres”[tiab]) OR Polyclinics[tiab]) OR “federally qualified health center” OR FQHC OR “Community health planning”[tiab]) OR ((((“community health services”[tiab]) OR (“community health center”[tiab] OR “community health centers”[tiab] OR “community health centre”[tiab] OR “community health centres”[tiab])) OR “community health centers”[MeSH Terms]) OR (“rural health center”[tiab] OR “rural health centers”[tiab] OR “rural health centre”[tiab] OR “rural health centres”[tiab]) OR (“community health care center”[tiab] OR “community health care centers”[tiab] OR “community health care centre”[tiab] OR “community health care centres”[tiab]) OR “Community Clinics”[tiab] OR (“health center”[tiab] OR “health centered”[tiab] OR “health centers”[tiab] OR “health centre”[tiab] OR “health centred”[tiab] OR “health centres”[tiab) OR (“community mental health center”[tiab] OR “community mental health center's”[tiab] OR “community mental health centers”[tiab] OR “community mental health centre”[tiab] OR “community mental health centres”[tiab])) OR “publicly funded health centers”[tiab]))
- (((“Quality of Health Care”[Mesh:noexp] OR ((“Quality of Health Care”[tiab] OR “Guideline Adherence”[Mesh] OR “Guideline Adherence”[tiab] OR “Process Assessment (Health Care)”[Mesh] OR “Process Assessment”[tiab] OR “Program Evaluation”[Mesh] OR “Program Evaluation”[tiab]) OR “Quality Indicators, Health Care”[Mesh] OR “Quality Indicators”[tiab] OR “Quality Improvement”[Mesh] OR “Quality Improvement”[tiab] OR (“Quality Assurance, Health Care”[mh] OR “Quality Assurance”[tiab])) OR “Evaluation Studies as Topic”[Mesh:noexp] OR “Evaluation Studies”[tiab]) OR “Program Evaluation”[Mesh:noexp]) OR “Total Quality Management”[Mesh] OR “Total Quality Management”[tiab] OR evaluate[tiab] OR evaluation[tiab])
- #1 AND #2 AND #3
Appendix II: Data extraction instrument
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