标题：Long-Term Development of a “Whole Community” Best Practice Model to Address Health Disparities in the Cambodian Refugee and Immigrant Community of Lowell, Massachusetts
摘要：Cambodians in Lowell, Massachusetts, experience significant health disparities. Understanding the trauma they have experienced in Cambodia and as refugees has been the starting point for Lowell Community Health Center's whole community approach to developing community-based interventions. This approach places physical-psychosocial-spiritual needs at the center of focus and is attentive to individual and institutional barriers to care. Interventions are multilevel. The effect of the overall program comes from the results of each smaller program, the collaborations and coordination with the Cambodian community and community-based organizations, and the range and levels of services available through the health center. KEY FINDINGS ▪ This whole community model is applicable to other refugee and immigrant populations because of its culturally centered approach that recognizes that trust and relationship building and change are processes occurring over time through repeated doses of information. ▪ The effect and strength of the approach come from the results of each program and from the collaborations, coordination, and range of services available through the health center. The practice model's effect on the community is greater than simply the sum of its parts. ▪ Multiple gateways to care and cross-referrals among the programs and to medical and behavioral health care have successfully linked Cambodian patients to the whole community of services. Community health centers are particularly well suited for such an approach. ▪ Securing funding to maintain the full scope of the whole community model is continuous. Some of the services have been adapted to be reimbursable, and the web of care is such that parts of the system can temporarily take over for other parts that may have diminished funding. The challenge of securing ongoing funding can be a weakness of the approach. ▪ Evaluation challenges were numerous: limited literacy in the community presented difficulties in design and implementation of data collection tools and evaluation plans, community health workers generally had little experience with scientific methods of evaluation and required significant training, and the evaluation plan evolved over time because of changes from the funders and developing understanding of the community. LOWELL, MASSACHUSETTS, is home to the second largest Cambodian population in the United States; 16.5% of Lowell's population of 105 167 is Asian. 1 However, based on Massachusetts Departments of Education and Public Health data, city officials and Lowell Community Health Center staff estimate that Cambodians represent 25% of Lowell's population. Lowell Community Health Center (LCHC) is a federally qualified health center, recognized for its cultural competence and use of Culturally and Linguistically Appropriate Service standards for cultural, linguistic access to care. 2 In 2008, 22% of its 32 000 patients were Cambodian. LCHC's approach to health disparities begins with understanding the trauma experienced by Cambodians under the Khmer Rouge regime. Many Cambodians starved, witnessed killings, and experienced torture and sexual assault. Those who escaped to refugee camps often found further starvation, disease, and violence. 3 , 4 Sequelae to refugee torture and trauma, including posttraumatic stress disorder and depression, are associated with health risk behaviors 5 and play a role in chronic disease management and ability to seek care. 6
