|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 2 | Page : 74
Towards Unity for Health Utilising Community-Oriented Primary Care in Education and Practice
B Art, L De Roo, J De Maeseneer
Ghent University, University Hospital, Department of Family Medicine and Primary Health Care, Gent, Belgium
|Date of Submission||10-Jul-2007|
|Date of Web Publication||04-Sep-2007|
University Hospital - 1K3, Department of Family Medicine and Primary Health Care, De Pintelaan 185, B-9000 Gent
Source of Support: None, Conflict of Interest: None
Context: Although the evidence is overwhelming that healthcare is delivered more effectively if one involves the targeted communities in decisions concerning their health, top-down programs still rule the world.
Objectives: In order to highlight the benefits of a community-oriented approach, we report the experiences from Ghent, Belgium on COPC styled healthcare initiatives and COPC modelled multidisciplinary education.
Community-oriented Primary Care and Education: COPC is a five-step model combining primary health care, public health and community data and resources. The involvement of community (members) is a crucial element in any effort to effectively enhance health (care) in a given community. Small scale examples from two health centers are given. In order to train future healthcare workers to be able to function with the communities, they participate in a one-week interdisciplinary course based on the COPC cycle at the University of Ghent. The COPC program in relation to Its practical organisation, goals and limitations are presented and discussed.
Conclusion: In order to reach health objectives set out by disease-specific or health promotion programs, a community-sensitive approach is needed, especially for the most deprived communities. The COPC model offers inspiration and can be a practical tool to work with communities. It is also feasible to create a short COPC exercise to prepare future healthcare workers for complex community work. This model is one of the ways to concretise some of the main objectives of TUFH.
Keywords: community-oriented primary care; community-based education; social accountability; health policy
|How to cite this article:|
Art B, De Roo L, De Maeseneer J. Towards Unity for Health Utilising Community-Oriented Primary Care in Education and Practice. Educ Health 2007;20:74
The concept of Towards Unity for Health was developed in the 1990s, in order to improve the coordination of health service delivery through partnerships among the community, health service providers, policy makers, health professionals and academic institutions. Community-oriented Primary Care (COPC) may create an opportunity to put the principles of "Towards Unity for Health" into action. In this paper, we first describe the background and key features of COPC, give examples of the practice and illustrate opportunities in education. We finally reflect on the question as to whether COPC may contribute to "Unity for Health".
Community-Oriented Primary Care: History and Key Features
The importance of the community one lives in for health and well-being has been acknowledged since Hippocrates (5th century BCE). In the 20th century, various initiatives started working with communities to improve health. Samuel and Emily Kark were the first to design a structured model which they implemented in the 1930s and 40s in a rural South African setting (the Pholela Health Centre). Their approach started from a health center which takes responsibility for a given area. To guide their actions, they laid the emphasis on data-gathering and community research (Tollman, 1991). This approach proved successful to address nutritional deficits and infectious diseases. The combination of community involvement and needs assessment is a key feature in all COPC initiatives. As pointed out by Rhyne & Bogue (1998), the name of the model is not important; the principles are what count. COPC essentially takes the individual provider-patient encounter as a starting point and combines individual and practice data with public health data at the community level, leading to a "community diagnosis", intervention and evaluation. Involvement of the community in all phases of the process is mandatory (Henley & Williams, 1999).
From the 1960s, this model was successfully applied in Israel. For nearly three decades in the Hadassah Community Health Center in Jerusalem, a family medicine practice and a Mother and Child Preventive Service provided the frameworks for this programme, which proved to be effective in the increase of hypertension control and reduction of cigarette smoking at the community level (Epstein & Goffin). Later the model spread to other parts of the world, mainly documented in the United States of America (Pickens et al., 2002; Dobbie et al., 2006). The method can provide tools to approach problems encountered by healthcare workers in the community but that only can be addressed on a higher level than the individual patient-healthcare worker contact. There seems to be no widespread implementation of the strategy since the first account in 1952 (Kark, 1952), but when COPC is used as a broader label to describe all efforts by healthcare teams working "in and with" the community, many more examples can be given (Iliffe & Lenihan, 2003).
Figure 1: The Steps in the COPC Process. (Garr, 2005)
The primary care practice is considered by many as the "pivotal element" in any COPC process. A COPC team consists of a varying group of health/welfare workers and community members. The first step is to define the community on which the efforts will be focused. The community can be the population of a certain area (neighbourhood, city, school, district), the patient list of a practice, or a cultural group. Secondly, the community's health problems need to be identified. A combination of primary care knowledge and accessible public health data and socioeconomic and demographic data present a comprehensive image of the health needs of a community. The list of problems a community faces, along with its strengths, defines the "community diagnosis". According to the available resources and priorities, an intervention strategy can be developed. Essential to any process is a thorough cost-utility analysis: is the intervention worth the effort? Therefore the last principal element in any COPC cycle is evaluating the impact of the intervention, allowing the COPC team to adjust.
Whether dealing with substance abuse in an inner-city neighbourhood, or with intersectoral HIV/AIDS approach in a rural area, the sixty year old principles of COPC strategy are the same, even though practical implementation, methods and context may vary widely (Goede, 2005). Obviously, many data are available to a healthcare team, leading to new challenges. A multitude of national and regional data can give information about health problems in a given area, tempting the health team to try to identify different subgroups at higher risk for certain conditions. However, to avoid the ecological fallacy, local data must be gathered to confirm or refine these differences. If only large scale epidemiology is used, important small scale problems remain simply unnoticed. If one relies only on the local knowledge, one can equally miss the target.
COPC at Work: Three Practice Examples from Belgium
The Belgian primary care system is characterised by single-handed fee for service practices. Recently, more primary care physicians form group practices, sometimes multidisciplinary teams, gradually creating a more COPC-friendly environment. The Community Health Centers in Ghent have tried for many years to implement aspects of COPC in their activities.
The University Center for Primary Health Care "Nieuw Gent" is part of an integrated welfare building of the public welfare service, including social service, a social restaurant, the intercultural network, a Well Baby Clinic, and a variety of neighbourhood organisations. In order to start a COPC process, the most important health problems of the neighbourhood were investigated utilising a qualitative approach with focus group discussions, including different "sub-groups" in the neighbourhood: elderly people; mothers from single parent families; migrants; single person families. The aim was to investigate the community’s health needs by involving the community in the process. One of many problems that surfaced was the deficient knowledge and skills concerning adequate baby-feeding. This was confirmed by observations in the health center and by the nurses at the Well Baby Clinic. In collaboration with mothers from the neighbourhood, a video was made giving advice on the adequate feeding of babies. As people from more than 50 nationalities are living in the neighbourhood, the video was language-independent, for individual use and for use with groups of parents, in order to empower them and avoid malnutrition. The video was ‘pre-tested’ with a small group of local mothers, allowing for considerable improvements.
In the Community Health Center “Botermarkt” in Ledeberg, there was an "epidemic" of teenage pregnancies, especially with young poor women living alone. The reason for this epidemic was unclear to the local healthcare workers. In most of the cases, there was no father who wanted to commit himself for the child, a lot of these teenagers had been placed in institutions during a large part of their youth, and none of them had clear occupational plans for the future. In order to define the problem adequately, all girls living in the local communities between 14 and 18 years received an anonymous questionnaire probing their knowledge, behaviour and attitudes with respect to sexuality, contraception and relations (Peersman, 1997). The response rate was 64.5% and showed that accurate knowledge of sexuality decreased with the social class. As far as contraception was concerned, more girls from the lower social class used unsafe methods. We checked the knowledge of the teenage mothers from the "epidemic-group", but there seemed no lack of knowledge. By using group discussions, it became clear that pregnancy was a well-decided choice for these girls: they felt they had failed in so many domains of their life (relations, work, education, family). They wanted to succeed in their fundamental human right to become pregnant and to become a mother.
If the hypothesis of "lack of knowledge" had not been discussed with the community of young mothers, the more fundamental cause of the epidemic would have remained unknown. To simply try to increase knowledge on sexuality would not have worked. Instead, a project was designed to help the girls be successful in their new role as mothers. To prevent future pregnancies by raising the girls’ self-esteem seems an obvious but hard to reach goal.
The confrontation with the bad quality of the teeth in a lot of children, observed by family physicians and nurses during their consultations, was the starting point for a project on "dental health". Together with the local Well Baby Clinics and the Department of Dentistry of Ghent University, a project was implemented to examine all the toddlers at the age of 30 months at the different Well Baby Clinics in the city of Ghent. There were clear relationships between poverty, ethnicity and the presence of early childhood caries (Willems & Vanobbergen, 2005). These findings led to a campaign on dental hygiene involving all the stakeholders: the mothers; the Well Baby Clinics; dentists.
Now, the screening for caries at the age of 30 months is part of the official programme of the Well Baby Clinics in Flanders.
In all these projects, the starting point is a well-defined community, where an important health problem shows up and is recognised in the daily activities of the healthcare providers, or in the framework of a screening programme, or following "incidents". Data are collected at different levels (e.g. practice, existing or new surveys). The three examples show us that COPC involves a complex and time-consuming approach (needs assessment, discussion groups, new collaborations, sometimes evaluations) but that this work can be very relevant. This extra work can only be done by a competent team (where possible supported by university departments), and cannot be expected from the average primary care practice. As the example of the teenager mothers demonstrates, it is always worthwhile to investigate the community’s priorities even if the ‘diagnosis’ seems obvious.
The last step in the cycle - ‘measure outcomes and monitor impact’ - often proves to be the most problematic one, by its absence. To measure outcomes requires extra time and specific competencies, both of which are often not available. Moreover, especially in deprived areas, other factors may partly overrule the positive results of projects: unstable populations; increasing unemployment; and decreasing funding may contribute to the difficulties of tracing ‘real progress’. This risks leaving the COPC team ultimately unsatisfied and uncertain about the invested energy. On the other hand, our experiences show us signs of a positive commitment of local stakeholders to healthy communities, and increased empowerment of the reached communities.
COPC: An Educational Experience
To integrate the COPC concept into daily practice, it is important to introduce the concept during (medical) education. To take responsibility for the community is an essential feature of the "Five-Star Doctor" concept (Boelen, 1993): the doctor that enhances quality of care, makes appropriate use of new technologies, contributes to health promotion and works in multidisciplinary teams. Reports on how medical students in their undergraduate training can be exposed to community experiences are provided from different settings (Dowell & Crompton, 2001; Lennox & Petersen, 1998; Davison & Capewell, 1999).
In the medical curriculum at Ghent University, a COPC-based exercise has been integrated into the unit "Health and Society pt II" since 2002. During this four-day course, students work together to formulate a "community diagnosis" of deprived areas in Ghent.
Students work in groups of twenty, attached to a neighbourhood and a tutor (a local healthcare worker). They start in smaller groups by visiting a family living in the neighbourhood, which they interview focussing on health and social problems. Afterwards, they visit the different care providers that surround this family. Through the interviews with the providers, students get insight into the professional domains of family physicians, nurses, social workers, physiotherapists, and others, and how the care networks are organised around families. Moreover, the providers give insight into the broader context of the community’s problems. The findings from these interviews are then combined with epidemiological, sociodemographic and other data retrieved from health needs assessment surveys, police-reports, the city’s database on socioeconomic status, reports from local agencies, etc., leading to a tentative ‘community diagnosis’. This is discussed with community workers and refined.
Following the COPC model, the students brainstorm about possible ways to address one of the problems they encountered. They also look at ways to monitor the impact of the intervention. On the final day, the students present their findings to policy makers, community health and welfare workers, sometimes amazing them by the accuracy of the diagnosis and the originality of their proposals. The students’ findings or suggestions are also designed as a poster, to be used in the community.
Students mostly corroborate findings and suggestions known to local residents, but sometimes they unearth ‘new’ problems or solutions: green spaces that were unknown to the inhabitants of one neighbourhood; the lack of an appropriate meeting place for young teenagers in another.
Since 2003, the course has involved not only third-year medical students but also students from the master in social welfare studies. The confrontation between the two disciplines, each with their own frame of reference leads to a genuine ‘culture-clash’, but is always an added value and stimulates students to reflect on their professional roles - medical students being more oriented towards the immediate needs of the individual patient and social welfare students looking at the broader societal context and being very careful when looking at community involvement.
After five years of experience, a lot of trust has been created between all the stakeholders: the local communities; academics; healthcare agencies and providers; politicians; and students. Evaluation reveals that students learn to make a broader contextual diagnosis of problems related to health and welfare at the level of the community. They are challenged to be critical about their attitudes towards these communities and towards priority setting in healthcare delivery. Skills, such as interviewing, working as an interdisciplinary team to solve problems, presenting the results and communicating their findings with local stakeholders are learned during the week. Most students value the experience, while criticising its shortcomings (mostly time constraints). Structural problems are the lack of time to actively contribute to a community partnership and the absence of any real student participation in the intervention and monitoring.
Community-based education confronts us with ethical problems: are students not "social tourists" when visiting patients? By giving a voice to the needs of those most in need, we try to “give something back” to the community. First, every student has to write a letter to a provider or an agency, making suggestions to improve the condition of the family they visited. On the neighbourhood level, the community diagnosis is shared with both policy makers and fieldworkers as with the community itself via the poster. Finally, it is hoped that in professional life the students will take the role of "advocacy" whenever they are able to contribute to improvement of the situation of individuals, families and the communities they live in.
COPC: A Strategy Towards Unity for Health
In this article, we have illustrated that the COPC strategy is a good way of putting the "Towards Unity for Health" principles into practice (Boelen, 2000). The examples from our practices illustrate that it helps to orient a health system towards peoples needs, involving the "partnership": policy makers: health professions: academic institutions; communities; health managers (De Maeseneer & Derese, 1998; Moosa, 2006). Primary healthcare is the most adequate context to put COPC into practice, as it is situated in the communities. Continuity as a team and in time, as a basic primary care element, allows us to follow-up the community over a large period of time and to become its partner. The Belgian healthcare system is not the most favourable environment to develop COPC. First of all, there is almost no territorial organisation of health services. Moreover, there is still need for development of the primary health care system: there are no formal patient lists and patients can directly contact either family physicians or specialists (no gate-keeping). The fee-for-service system does not stimulate comprehensive community orientation, prevention, interdisciplinary cooperation and patient empowerment. Therefore, the community health centers have adopted a “mixed capitation” payment (for family physicians, nurses and physiotherapists). Scaling up COPC will require a fundamental reorientation of the Belgian healthcare system towards primary care.
Currently, vertical disease-oriented programmes utilise much of the resources, but very often fail to reach the populations most in need due to a top-down approach. This approach may add to the dual society, making the not-so-sick healthier and the underserved more burdened by disease (Unger & D’Alessandro, 2006). A COPC strategy may contribute to the integration of vertical programmes in the local healthcare delivery system, utilising a bottom-up approach and involving the community. Alternative models, blending the databases, experiences and resources of some of the fragmented disease-specific programmes, with methods that are adapted to meet the needs of the most vulnerable parts of society, may lead to more effective and equitable healthcare delivery and results. In order to address these challenges, a TUFH environment is needed: skilled healthcare staff; socially accountable academic institutions; policy makers at different levels; health managers to provide efficient functioning; and communities involved at all levels. Learning from international experiences, at the Ghent University we have tried to apply this model.
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