Community Oriented Primary Care New Directions for Health Services Delivery (1983) / Chapter Skim
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Community Oriented Primary Care: Meaning and Scope
Community Oriented Primary Care: Meaning and Scope
Pages 21-59
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From page 21... ...
Kick Health protection is increasingly seen as a responsibility of society and health care as a right of individuals. The system of financing and organizing health services varies considerably, not only between different countries, but also for different health conditions, income groups, and aspects of health care in the same locality.
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From page 22... ...
. GENERAL CONSIDERATIONS PRIMARY HEALTH CARE AND COMMUNITY MEDICINE Community oriented primary care (COPC)
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From page 23... ...
The provision of health care in the community, i.e., the practice of medicine outside the hospital, is sometimes equated with community medicine. We use the term "community medicine" with a different connotation to signify health care focused on population groups rather than on individual patients.
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From page 24... ...
These community health programs may involve health promotion, primary or secondary prevention, curative, alleviative or rehabilitative care, or any combinations of these activities. The programs are based on the epidemiologic findings.
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From page 25... ...
4. Mobility of the health teams "outreach" activities, such as going out into the community to become acquainted with the people and their health problems and identifying people at risk and inviting them to attend for surveillance or care.
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From page 26... ...
Commanity-Based Primary Health Care Primary care services that are situated in the communities they serve are in the main concerned with the health care of people who live nearby.
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From page 27... ...
This definition of an area or population for which the practitioner or team is responsible makes it possible to go further and to characterize the community in terms of itS demographic and other characteristics knowledge that is essential for the use of epidemiologic methods in community diagnosis, in health surveillance, and in the evaluation of health programs focused on changing the community's state of health. These remarks on defined populations in local communites may be applied to other settings also, e.g., to primary care services for workers in factories or other workplaces and for students and faculty at universities, colleges, and various types of schools.
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From page 28... ...
Critical to the diagnosis is a judgment as to whether the patient has a disease or not. If so, what is the nature of the disease, its natural history and hence the patient's prognosis, and the management needed?
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From page 29... ...
What are their social and environmental conditions, especially in the home and family? " The answers tO these questions may lead the practitioner or health team to consider the desirability of inviting visits by certain parents with infants and children registered in the practice, or otherwise eligible for care, or to go further and explore the possibility of inviting children to attend for health care and advice at fixed ages.
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From page 30... ...
The primary aim is not to advance medical science by providing new knowledge about the causation or natural history of a state of health or disease or about the value of a treatment or type of health care although this may be a secondary gain but to contribute to the health care of the specific group or population for whom the primary care service is responsible. This kind of epidemiology is probably best referred to as "clinical epidemiology," as a natural extension of a term usually confined tO small-scale investigations centered around patients, their families, and other small groups of people receiving clinical care.8 A notable feature of clinical epidemiology is that in many or even most instances the collection of data fulfills a double function and meets the dual responsibilities of the clinician who is concerned both with the care of specific individuals and with the care of a total community.
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From page 31... ...
N Pickles, a general practitioner in Yorkshire, England, provide a simple means of infectious disease surveillance.9 Registers of important long-term disorders such as ischemic heart disease and cerebrovascular disease and maps showing the distribution of house-bound patients or of patients with certain acute infections may be useful.
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From page 32... ...
. When community medicine programs are set up as an integral part of the primary care practice, each program needs to be supported by epidemiologic investigation for (a)
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From page 33... ...
It seems that one of the important reasons is that the epidemiology that is clinically relevant for primary care is not developed by the major teaching centers. Of special relevance for community diagnosis in primary care are studies of the incidence of common acute illnesses and the prevalence of a number of chronic disorders and disabilities, cigarette smoking, and other healthrelevant behaviors, as well as studies of the distribution of continuous variables such as height, weight, and blood pressure.
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From page 34... ...
Known as the CHAD program (Community Syndrome of Hypertension, Atherosclerotic Disease, and DiabetesJ, it aims tO modify the frequency distributions of blood pressure, serum cholesterol levels, and weight/height index in the community and tO reduce the prevalence of hypertension, hypercholesterolemia, overweight, and cigarette smoking, at the same time as ensuring continuing care and treatment of patients with ischemic heart disease, cerebral vascular and peripheral vascular disease, and diabetes mellitus. The original aim of the program was tO test the feasibility and usefulness of incorporating such a community oriented health program as an integral part of primary care.
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From page 35... ...
Community Diagnosis and Epidemiologic Surveillance The CHAD program is founded on epidemiologic surveillance of the practice population as a whole and not only on those who use the practice for care when sick. The program was initally developed through analysis of existing clinic records of the practice together with a comprehensive picture of the health status of the community provided by a community health survey.
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From page 36... ...
was invited to attend for a series of new measurements in order to determine whether standard criteria for the diagnosis of hypertension were met and whether treatment was required. Registers are now in comrr~on use in epidemiologic studies of hypertension and cardiovascular disease.2i In this COPC practice the presence of hypertension is recorded on a card register that is maintained for all CHAD subjects and available for use by the nurse coordinator of the program and for each nurse and physician in the practice team.
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From page 37... ...
As yet, 9 years after initiation of the program, no change in this direction has been noted.22 Age-standardized mean values of blood pressure and prevalence rates of hypertension are shown in Table 2. The mean values of blood pressure declined in both the COPC and control populations, except for women in the latter.
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From page 38... ...
According to the survey results, the proportion of all adults aged 45 years in the control population who were receiving treatment for high blood pressure rose from 9 percent to 14 percent during the 5 years of the comparative study.20 In the COPC population the corresponding
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From page 39... ...
A recent check revealed that 76 percent of known hypertensives were under control, i.e., had blood pressures below 160/95 mm Hg. A Note on Other Programs in This COPC Improvements in the prevalence of several other cardiovascular disease risk factors have also been reported in the course of this CHAD program.20 These improvements are summarized in Figure 1, which contrasts the changes observed during a 5-year period in the CHAD population and the control population.
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From page 40... ...
Maternal and child health constitutes a most important aspect of family and community health to which COPC has important contributions. In addition to the adult community health programs focused on CHAD, the neighborhood primary care center in western Jerusalem focuses on several aspects of maternal and child health care.
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From page 41... ...
The routine of the child health programs has included attention to ways of improving social interaction and stimulation of infants by their mothers, as well as the nutritional and more physical aspects of child health care. The main somatic defect requiring further attention at this time is that of anemia in infancy, and for this a community program of surveillance and treatment has been conducted over several years, with evidence of satisfactory responses.23~25 SOCIAL AND BEHAVIORAL ASPECTS OF COPC As long ago as the mid-nineteenth century, medicine was said tO be a social science by Virchow and his colleague Neuman.
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From page 42... ...
Such knowledge includes community networks of relationships and social support systems, occupations and activities of daily living, family structure and kinship in the community, and its formal and informal leadership. Each situation in which a member of the health team meets an individual or group of the community provides an opportunity for such observations.
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From page 43... ...
Attempts to bridge the social distance between practitioners and their patients have included the appointment by the community, or by the health practice, of community health workers who are members of the community.35~37 Understanding the community is essential for a health team that expects to work with, and encourage the active participation of, the community in its own health care. The basic education of COPC team members should
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From page 44... ...
The extent of mutual respect and trust between a COPC health team and the community will be reflected in their reciprocal functioning. Furthermore, a community health council of a primary care center will be more likely to become an effective advisory and involved group if its representatives are well accepted by the professional health team and if it is recognized as representative by the community.
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From page 45... ...
However, the difficulty should not deter community health researchers from studying the impact that community involvement might have on the effectiveness of health services. TRAINING FOR COPC The development of a unified practice of community medicine and primary health care, that is COPC, requires practitioners who have had training for such practice.
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From page 46... ...
The group may be composed of a number of specialists, or of general practitioners, each having additional knowledge and special interest in a particular field of practice. Whatever the type of group practice, it iS clear that redefinition of the practitioners' functions will be needed if the group is to combine the practice of community medicine with that of primary health care focused on the individual patient.
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From page 47... ...
Thus, the health recorder will be required to maintain a record system not only for case identification and follow-up, but also for epidemiologic purposes, such as community diagnosis, health surveillance, and program evaluation.
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From page 48... ...
Firstly, the community health workers require special training to help them perform their roles. Secondly, some members of the health team need training in methods of educating these community health workers, together with experience in formulating the content of the curriculum suited to the needs and wishes of the particular community.
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From page 49... ...
in community diagnosis and health surveillance; . in evaluation of community programs; and .
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From page 50... ...
Within the framework of primary care of individuals and families, practical experience in the community medicine aspects of COPC should proceed. These aspects should include the conduct of community health surveys, epidemiologic investigation of specific health conditions allowing for community health diagnosis, planning community programs for the promotion of health (e.g., growth and development of infants and children)
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While each of these developments has involved health teams, composed of varying groups, they have differed considerably in the nature of the professional groups. Perhaps the most developed in its teaching function is that of the Hebrew University-Hadassah Community Health Center.
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From page 52... ...
PROCESSES IN THE DEVELOPMENT OF COPC In more developed countries the establishment of COPC involves a process of introducing community medicine orientations and methods into ongoing primary health care practices. In less developed countries, and in any community that is poorly served, it is possible tO establish a COPC program ab initio.
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From page 53... ...
However, this does not meet the needs of present-day COPC. Helpful as it may be in providing a subjective picture of the community and itS main health problems, the systematic development of demographic, social, health, and other relevant data is essential for community medicine in primary care.
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From page 54... ...
Planning and gathering the data needed for epidemiologic diagnosis is a function of various members of the health team, physicians, nurses, and community health workers. In initiating community health diagnosis in a primary care practice, the data to be gathered should be obtained from
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From page 55... ...
This requires ongoing health surveillance in the community, and in fact what has happened in various COPC practices with which we have been involved is that the early community diagnosis of particular health conditions will be followed by built-in routines in the practice allowing for health surveillance of these conditions and their determinants. PLANNING OF INTERVENTION The formulation of a plan for a community program in the framework of primary health care will thus be based on knowledge gathered through the preliminary steps and community diagnosis that have been outlined.
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From page 56... ...
IMPLEMENTATION The ways in which the planned program may be implemented include treatment and counselling of individuals, community health education, and community organization, with special emphasis on community involvement in the promotion of its own health. The activities may be of various kinds: .
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From page 57... ...
All health programs should be submitted to this kind of review. The review is usually based mainly on information on the performance of planned activities, on the achievement of easily measurable shortterm outcomes, and on the occurrence of any obvious undesirable effects.
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From page 58... ...
(1981) Evaluation of a Community Program for the Control of Cardiovascular Risk Factors The CHAD Program in Jerusalem.
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From page 59... ...
(1973) Community Medicine and Primary Health Care: A Field Workshop on the Use of Epidemiology in Practice.
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