A genuine leader is not a searcher for consensus but a molder of consensus.
Martin Luther King Jr
Driven by passion1 and necessity,2 family physicians are no strangers to a leading role in health care. However, when it comes to community engagement (CE)—defined as “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people”3—it is necessary but often difficult4 for physicians to put aside this proclivity and assume a supportive rather than a leadership role. While family physicians—who are in intimate contact with patients’ fears, hopes, and aspirations—are often viewed by citizens as community leaders,5,6 they face challenges to avoid a pure leadership role while fulfilling CanMEDS health advocate requirement to “contribute their expertise and influence as they work with communities”2 and the reality that they themselves are members of the communities they seek to influence through CE. Striking a balance in this dilemma requires the family physician to be a powerful catalyst, not a biased cause for community change; however, no practical guides exist to help family physicians determine their role when a community they serve chooses to mobilize for an issue.
Community engagement can be a challenging but ultimately rewarding process for a family physician to navigate. Our family physician lead author (D.H.) faced such a challenge when the purity of water in Newfoundland communities was questioned7–10; this experience, more fully described on page 628, led to a novel, pragmatic 8-step strategy called Figure 8, also known as F8 (pronounced as Fate), to help family physicians find a consensual niche in CE initiatives that positions them as catalysts and powerful collaborators in community initiatives (Figure 1). Figure 8 is a framework for rapid, consensual CE with minimal resources (but a lot of effort and commitment) that empowers the family physician to become a catalyst for change while politely avoiding the leadership role that can inadvertently blunt the collective will of the citizens they serve. The framework’s principles (ie, continuity, fluidity, and fate) also reflect a role that molds into CE and does not lead the actions (Box 1).
The Figure 8 strategy: An 8-step strategy to guide family physicians engaging in community initiatives.
Figure 8 principles
The 8-step strategy is based on the following principles
Continuity: expect to revisit the steps until the community is satisfied with your engagement
Fluidity: there is no specific step that you start with or end with; it is possible to enter at any point in the process
Fate: the decision about your role in a community initiative is outside of your control. The community defines your role in its movement; you do not force a role onto the community
In this article we will describe the 8-step strategy and use our experience in Newfoundland (page 628) to highlight its benefits and rurally proven, broad applicability.7
Until 2014, residents in 2 rural Newfoundland communities reliant on artesian wells were unaware that arsenic, a harmful metal,11–14 had entered their water supplies and that some residents had been drinking water that was contaminated with 100 times the safe limit (0.010 mg/L)15,16 for decades.8–10 Consuming drinking water with very high levels of arsenic over a lifetime can increase the risk of bladder, liver, and lung cancer.15,16
Applying the 8 steps
Listen.
Family doctors have front-row seats to the collective concerns of our patients.17 Signs that a community needs or wants changes might be subtle and not immediately obvious, so we need to pay close attention.
We had many patients expressing similar worries about sickness in their communities and possible links to their drinking water. Others were distressed by gold prospectors’ (who measure arsenic in the process of looking for gold18) warning them against drinking their well water.
Identify the question.
Think about the comments and concerns that you have been hearing as echoes emanating from a common source. This source is a question your community is grappling with and your task is to pinpoint this question. This involves viewing the evidence holistically as interconnected pieces of the same puzzle. Fit the evidence together to identify the final overarching question and continue listening to your community if you require more information. If necessary, consult with a subject matter expert in order to help define or refine the question.
In our case, the common themes were arsenic and water safety. The community’s question was, Are there unsafe arsenic levels in our well water?
Educate yourself.
After identifying the question, learn about the underlying topic. It is very important to be knowledgeable about the issue that you and your community will be dealing with so that you can provide meaningful, informed support. To proceed without educating yourself on the subject would be reckless, and there are many free resources available to further your understanding. If possible, contact a librarian at your local academic institution and request a systematic literature review; this will accelerate the process of finding relevant, high-quality information.
We took an eclectic approach to our learning, speaking to local people, reading textbooks and peer-reviewed articles, recounting medical school lectures, contacting experts in metals and environmental contamination, and even watching relevant movies.19
Catalyze the action.
At some point, your community will take independent action. You cannot be the cause of the action, but you can be the catalyst to drive it further and strengthen it, or relieve the action of its barriers. Do whatever you can within the boundaries of your role.
The rallying cry by community residents was impeded by confusing and relatively costly water-testing processes. We stepped in to coordinate and subsidize the initial water analysis (the cost of later analyses was covered by the citizens); the results of which precipitated further action from community residents, as some of them conducted independent well water testing.
Analyze the action.
Consider the outcomes from the community action and how they will come to bear on the community itself. Be prepared for both positive and negative outcomes. Either way, the effect of these results will not wait for an ideal time, so do not procrastinate on this step.
We found that most of the tested wells exceeded the recommended limits for arsenic in drinking water. The magnitude of this finding for citizens’ quality of life, health, and safety was immediately clear, and our role required us to share this news with the communities.
Break the news.
Depending on the outcomes and your role, you might need to act as a knowledge broker, conveying information and its meaning to citizens and other stakeholders. You will need to communicate the news simply and clearly to inform the broadest number of community members, and communicate the relevant outcomes to stakeholders with whom community members are not connected.
We immediately communicated each test result and information about safe water use to the respective well owners and conveyed the findings to government officials, the local health authority, and the provincial university.
Assist an informed decision.
At this point, the community members will need to make important decisions. Again, your job is not to make these decisions for them, but to help community residents make an informed decision in the greatest capacity that your role allows. This might culminate in you moderating a dialogue between the community and stakeholders to further the CE process.
We were asked to organize a public meeting with all relevant stakeholders from the government office, the local health authority, and the provincial university. This meeting, attended by more than 200 citizens, precipitated further decisive action from the communities.
Provide ongoing support.
This step permeates all others and symbolizes that your support is crucial throughout the CE process. Be prepared to repeat some or all steps to further CE and seek to engage stakeholders as early as possible, understanding that the extent of their involvement should also be decided by the community. Remember that you might not have complete commitment from stakeholders immediately; throughout history it has often taken the actions of a few to inspire this level of stakeholder commitment on even the most important issues (recall Rosa Parks and Mahatma Gandhi). Do not be discouraged; as the movement builds momentum stakeholders will take notice and their involvement might prove invaluable.
Our support from the medical community and government and non-government organizations snowballed over time. Although the initial opinion of these stakeholders was that their existing, optional recommendation that private well owners test their water every 3 to 5 years20 was adequate and constituted the extent of their involvement, we had dedicated relationships with all of the stakeholders by the end of the process. Further community action alongside these stakeholders has resulted in more water test results, local media coverage, new health policy, and community residents adopting safe alternate water use practices.
Conclusion
As a physician (D.H.) with no past experience supporting CE, it was challenging to work through the process without a practical guide or being able to follow in the footsteps of a previous, successful example. The 8-step strategy was derived from the richness of a CE experience in a rural setting but might also have merit in urban areas or locations with limited resources. It provides a framework for family physicians to catalyze CE but does not negate joining other such initiatives led by public health, regional health care authorities, or others. Figure 8 is complementary to these initiatives and processes. We hope it will help other physicians find their place in a CE initiative and experience the power of CE to create change.
Acknowledgments
We express our deep respect for the New World Island communities, particularly Moreton’s Harbour and Valley Pond, for their wisdom, hard work, and patience. We thank Memorial University’s Centre for Rural Health Studies, 6for6 program members, and faculty of Memorial University, as well as colleagues from Central Health, for their support. We also extend our gratitude to Michelle Swab, Public Services Librarian, for her literature review expertise. Figure 8 was partially inspired by Dr John Sheldon, a mentor to the lead author (D.H.) and others, whose philosophy of starting patient interactions with “How can I help you?” and never “What problems are you having?” embodies the spirit of the family physician in a community-helping role.
Footnotes
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 590.
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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