Community Oriented Primary Care New Directions for Health Services Delivery (1983) / Chapter Skim
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Health Worker Roles in Community Oriented Primary Care
Health Worker Roles in Community Oriented Primary Care
Pages 138-166
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From page 138... ...
COMMUNITY INVOLVEMENT IN COPC Failure to involve community people in planned change will, at best, limit the potential for service, and, at worst, result in social disorganization and lead to gross compromise in the quality of life. There is evidence that our ability to tolerate stressors within the broader environment is related to the quality of relationships and the degree of social support we receive from those who are closest to US.~-5 Therefore, is it reasonable to believe 138
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From page 139... ...
agree with these statements, then what exactly is the charge of the COPC health team? And more specifically, what is expected of community health workers?
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From page 140... ...
Community health workers are seen as vital members of the COPC team in answering: "What is the state of the community's health? "; "What factors are responsible for this state?
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From page 141... ...
Fortunately, the two approaches need not be mutually exclusive if we believe that community development has a greater influence than medical care on improvements in health status. COPC workers need not feel torn, for they are the link in the middle.
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From page 142... ...
During this period, Hatch was involved in collecting ethnographic data to be used in planning the Tufts-Delta Health Center in Mound Bayou, Mississippi. Returning twice monthly to Boston, he was debriefed in sessions held with Donald Kennedy, a medical anthropologist with the Tufts Medical School, Department of Preventive Medicine.
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From page 143... ...
The credentialed include people trained as nurses, sanitarians, physicians, social workers, economists, lawyers, clergymen, public health workers, political scientists, and horticulturists. Others involved with activism and community development in health care include maids, laborers, farmers, fishermen, construction workers, coal miners, pulpwood cutters, and others representing a fair sampling of occupational groups in the United States.
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From page 144... ...
In an attempt to deal with this situation, the agency agreed to support Hatch, who was a community organizer trained in social work and a newcomer himself, to mobilize community members to work as front-line workers for the organization. Prior to this time, possession of a bachelor's degree had been a prerequisite for employment with the Settlement House.
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From page 145... ...
On various occasions Hatch had observed her negotiate a suspension of sentence for one of her roomers who had been picked up in a corner dice game, provide counsel in lovers' quarrels, place people in jobs, advise police on how best to intervene in cases of domestic conflict, and confer with human service agencies before deciding to refer her people to them. Hatch would sometimes accompany Mrs.
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From page 146... ...
The team of Social Outreach Workers survived these and other conflicts with the established health and human service delivery system. As a result of this process, the known pool of resources had been vastly expanded,
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From page 147... ...
Within 6 months the NAACP, local women's organizations, other health and human service agencies, storefront churches, and fundamentalist evangelical churches joined a planning group to consider the needs of single women migrating to Boston to work as domestics. The up-front, no-nonsense character of the Social Outreach Workers enabled them to cut through bureaucratic protocol and objections that could have been barriers for a professional.
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From page 148... ...
MOUND BAYOU Our second example of meaningful interaction between communities and professionals occurred in 1965, when the Department of Preventive Medicine of the Tufts University School of Medicine gained support from the Office of Economic Opportunity tO develop a health center in Bolivar County, Mississippi—a site 1,400 miles from its home base in Boston. In addition to responding to the desperate needs of the citizens in this county, it was felt that a health center in Mississippi would provide professionals with insights into the social norms, values, health attitudes, beliefs, and behaviors of a population that was becoming increasingly important to health and human service agencies working with the inner-city districts of Roxbury, South End, and Columbia Point.
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From page 149... ...
From his work with Kark in Polela, Geiger brought notions of health worker roles that were considerably more advanced than those held by community oriented practitioners of that day. John Hatch contributed knowledge of organizing strategies from his experience gained through 5 years of neighborhood development work in Boston's South End and Columbia Point.
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From page 150... ...
A brief sketch of the exceptional workers and their roles may help to provide clues for developing more reliable selection criteria and insight into enhancing the role and function of noncredentialed COPC workers. Miss Pearl had been chosen as a community worker by her neighbors and was hired essentially on the strength of their recommendations.
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From page 151... ...
Care for the elderly had declined during the past decade, and, with the advent of the project, there was a basis for them to expect better conditions. However, it became evident that the health center had recruited too many pediatricians and child-oriented health workers who were not able to meet the demand for geriatric services.
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From page 152... ...
She found office space, involved other agencies, gained support from private donors, developed health care monitoring services, organized entertainment for the elderly, and managed the entire operation very well. More importantly, she convinced the professionals at the center that some community workers were able to far exceed the helper roles usually designed for community residents.
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From page 153... ...
Eugenia Eng worked as a health educator in three rural health dispensaries in Togo, a tiny country in West Africa, to develop an outreach program with each of the dispensaries' staff, which consisted of one male nurse and one auxiliary midwife. The health conditions of Togo in 1970 would not be considered unusual to anyone who has lived and worked in a developing nation a 50 percent infant mortality rate, 1:9,000 nurse to population ratio, and clinics so poorly equipped that needles were only sterilized after every fifth injection due to lack of alcohol, or with a bit of ingenuity used locally distilled spirits as a substitute.
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From page 154... ...
An afternoon program of home ViSitS was also established to follow up on pregnant women who were at high risk, to meet with pregnant women who were not receiving prenatal care, and to talk to nursing mothers. Again, the auxiliary midwife was doing the translating of the words and concepts.
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From page 155... ...
If, indeed, two-way dialogue between communities and professionals as peers is weak, then perhaps COPC workers should share their technical knowledge of basic epidemiology, biostatistics, and health education with community people to enable them tO participate more adequately as partners in planning. Additionally, COPC workers need to admit that there is a lot they do not know about the community and pose questions to the people themselves rather than~to totally rely on published materials.
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From page 156... ...
By arranging the meeting between the director and their traditional village leader, the community was actively involved in the entire process of conflict resolution with the health care system. The health workers did not intervene on the community's behalf by either writing letters for them or going directly to the director to present him with the problem to arrive at a solution about input from those who are experiencing it.
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From page 157... ...
If COPC truly believes that changes in the environment, standards of education, and social status have a greater effect than the medical care system on health improvements, then are COPC workers ready tO go beyond the use of biostatistics, clinical epidemiology, and biomedical services for defining the problem? As we stated in the beginning of this paper, poor health status is an indicator and a symptom of inequality, not its cause.
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From page 158... ...
Discussants Richard Smith I have been, and continue to be, critical of primary health care (PHC) or community oriented primary care (COPC)
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From page 159... ...
And there is much for those of us in developed countries to learn from the Third World, as many developing countries are opting for primary health care as a guiding force. PHC overseas is defined with much more community involvement in the health system.
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From page 160... ...
The history I am talking about reading refers to the efforts that have been made to identify the character of"working-together behavior," demonstrating that health professionals can and will work on a large scale with people in their communities who are prepared to assume their rightful role in responsibility for their own well-being. It is an investment behavior that is different when one is part of a truly COPC program, one characterized by responsibilities that "bubble up" as well as "trickle down." The history I am talking about is the experience with extenders of health services over the past two decades (e.g., physician extenders, nurse practitioners)
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From page 161... ...
Hatch and Ms. Eng's paper is disarmingly broad for a nurse who views all patient contacts in primary care as health care contacts, thereby defining all who deliver care as "health workers." Their emphasis is upon the community-based person who may or may not be a formally trained health professional, but who is used to help integrate primary health care services into an existing community.
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From page 162... ...
Nurses are edgy and angry when patients return and have not "complied" with "what they were told." Dr. Hatch has suggested that community health workers can perform at least three tasks: (1)
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From page 163... ...
Often, in this situation, the provider becomes the liaison, the translator, and the linker. They are effective only if they have maintained appropriate relationships with the power structures outside and inside the community and can bring credence to the situaton based on understanding and power within that structure.
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From page 164... ...
To Steve Joseph's four pillars, I would add a fifth—other health workers. As David Kindig suggests, studies of communities will help define services, and, I would add, not unless the kind and number of providers available for particular purposes .
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From page 165... ...
If we are to look at health care as part and parcel of the social and environmental structure of the community, we cannot continue to weave a fiber that has only one dominant profession, a single answer, or an economic and organizational structure that is neither efficient nor effective. Use of community health workers, nurses, physicians, social workers, home health aides, respite programs, day care centers, elder programs, and the like will be a better approach to team solving of complex issues in the community.
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From page 166... ...
U.S. Department of Health and Human Services, Health Resource Administration, Graduate Medical Education National Advisory Committee, Alvin Tarlov, Chairman (1981)
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