Drawing on lessons from a variety of current activities, the committee brings to community health improvement an approach that focuses on integrating the roles of clinical personal health services, public health, and a broad array of other elements in the community, and on developing monitoring systems that can function in this integrated context. The committee is not attempting to prescribe what communities should do to address their health concerns or who should be responsible for what, but it is encouraging communities to adopt a systematic approach to health improvement that makes use of performance monitoring tools to help them achieve their goals.
Contributing to the interest in health improvement and performance monitoring is a wider recognition that health embraces well-being as well as the absence of illness. For both individuals and populations, health depends not only on health care but also on other factors including individual behavior, genetic makeup, exposure to health threats, and social and economic conditions. The health field model , as described by Evans and Stoddart (1994) and discussed further in Chapter 2, presents these multiple determinants of health in a dynamic relationship. The model's feedback loops link social environment, physical environment, genetic endowment, an individual's behavioral and biologic responses, disease, health care, health and function, well-being, and prosperity. The committee found this model to be an effective basis for its work.
Health in the community can be seen as the product of the changing mix and interactions of these factors over time. The multidimensional perspective reinforces the value of public health's traditional emphasis on a population-based approach to community health issues. It also provides a basis for looking to many segments of the community to address factors affecting health and well-being, making it appropriate to bring a wide array of parties to the table as interested stakeholders and accountable partners.
The committee adopted as a starting point for its discussions of ''community" a definition offered by Labonte (1988): individuals with shared affinity, and perhaps a shared geography, who orga-