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Community Orientecl Primary Care: Meaning and Scope Joseph H. Arson and Sidney L. 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. Health care is usually provided by a variety of discrete and independently functioning services, some of which are located in the community to which they deliver care, while others are not. Most of the major advances in the quality and content of health care have been made in public health services and in hospital medicine, rather than in primary care based in neighborhoods of cities, rural villages, or other local communities. The acute, short-stay hospital with its various departments is regarded by many physicians, nurses, other health personnel, and the public, as the center of health care. Yet its major functions are increasingly directed towards tertiary care. Much less attention has been given to developing the potential of health care in the community. In our view what is needed is a change in the orientation of practice and the practitioner an acceptance of responsibility for care of all the people, not only those with particular medical needs that require the facilities for tertiary care, emergency treatment, or special services such as obstetrics. There is a need for recognition of the full potential of medicine and health care in its capacity to promote health, prevent disease, alleviate the suffering and disability accompanying chronic illness, cure those whose illnesses are curable, and rehabilitate the many whose injuries and illnesses demand a 21

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22 PART I THEORETICAL ISSUES change in life-style and work. For this we need a more integrated approach to health care than is common at present, bringing together different pri- mary care services with certain aspects of community medicine. It is this that we now refer to as community oriented primary care (COPC). GENERAL CONSIDERATIONS PRIMARY HEALTH CARE AND COMMUNITY MEDICINE Community oriented primary care (COPC) is a strategy whereby elements of primary health care and of community medicine are systematically de- veloped and brought together in a coordinated practice. Focus on this kind of integration was one of the features of the declaration on primary health care of the Alma-Ata conference: Primary health care addresses the main health problems in the community, pro- viding promotive, preventive, curative, and rehabilitative services . . . (it) includes at the very least education concerning prevailing health problems and the meth- ods of preventing and controlling them, promotion of food supplies and proper nutrition, an adequate supply of safe water and basic sanitation, maternal and child health care, including family planning, immunization against the major infectious diseases, prevention and control of locally endemic diseases, appro- priate treatment of common diseases and injuries, and provision of essential drugs. ~ COPC unifies two forms of practice the clinical care of individuals in the community and aspects of community medicine.2 In more developed countries the main primary care practitioners are physicians and nurses. For purposes of the present discussion, attention will be focused on the phy- sician. The clinical care provided by primary care physicians may include promotive, preventive, curative, and alleviative functions, but the dominant function is care of the ill or disabled patient who turns to them for treatment. The five attributes that are essential to the practice of good primary care, according to a definition of primary care prepared by the Institute of Med- icine of the National Academy of Sciences of the United States,3 are ac- cessibility, comprehensiveness, coordination, continuity, and accountability. The primary physician is the doctor to whom a patient first turns when ill or when seeking advice on personal health. Another important feature of such primary care in the community is its continuity over long periods of time; this builds a special relationship between practitioners, patients, and their families. Primary care practitioners who come to know several mem- bers of the same family in the course of their practice are more able to use this knowledge of the family's state of health, its resources, relationships,

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Meaning and Scope 23 and perception of health when members of the family turn tO them, from time to time, for care. The doctor's interest often extends to the school and other institutions in the community, as resources in the care of indi- vidual patients. The provision of health care in the community, i.e., the practice of medicine outside the hospital, is sometimes equated with community med- icine. We use the term "community medicine" with a different connotation to signify health care focused on population groups rather than on individual patients. So construed, community medicine has itS roots in the disciplines of public health and medical administration. In the present context, com- munity medicine may be distinguished from other forms of personal health care in the community in that its interest is centered on the community as a whole and on the groups of which communities are composed. Practitioners of community medicine need the skills tO answer the fol- lowing cardinal questions, the asking of which characterizes community . . mec ~lc1ne: 1. What is the state of health of the community? 2. What are the factors responsible for this state of health? 3. What is being done about it by the health service system and by the community itself? 4. What more can be done, what is proposed, and what is the expected outcome? 5. What measures are needed to continue health surveillance of the community and tO evaluate the effects of what is being done? Basic Features of COPC The cardinal features of COPC are: 1. The provision of primary clinical care for individuals and families in the community, with special attention to the continuity of care. Suitable arrangements need to be made for consultative services, specialist care, and hospitalization. 2. A focus on the community as a whole and on itS subgroups when appraising needs, planning and providing services, and evaluating the effects of care. The "community" in COPC may be any of the following (in order of preference): . a"true" community, in the sociological sense;

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24 PART I: THEORETICAL ISSUES . a defined neighborhood; . workers in a defined factory or company, students . In a defined school, etc; . people registered as potential users of a physicians' group practice, health maintenance organization, neighborhood health center, or other de- fined service; and users of a defined service, or repeated users of the service. Although from a puristic viewpoint the application of the term "com- munity" to a group of patients may rightly be criticized, especially when these patients constitute a small selected part of a population, there is little doubt that the principles and practice of COPC can profitably be applied to such groups, although its full development may not be possible. At this stage it would not be constructive to suggest that COPC should be confined to "true" communities and defined neighborhoods. When COPC is applied to a selected part of a population, an effort should be made to determine how the characteristics of this subgroup compare with those of the popu- lation at large. The following can be regarded as the five essential features of COPC: 1. The use of epidemiologic and clinical skills as complementary func- tions; both the epidemiologic and the clinical activities should be of as high a standard as possible. 2. Definition of the population for which the service is or feels respon- sible. This defined population is the target population for surveillance and care and the denominator population for the measurement of health status and needs and the evaluation of the service. 3. Defined programs to deal with the health problems of the community or its subgroups, within the framework of primary care. These community health programs may involve health promotion, primary or secondary pre- vention, curative, alleviative or rehabilitative care, or any combinations of these activities. The programs are based on the epidemiologic findings. 4. Involvement of the community in the promotion of its health. Com- munity involvement may be seen as a prerequisite for the satisfactory and continued functioning of a COPC service. 5. Accessibility that is not limited to geographic accessibility (the COPC practice should ideally be located in the community it serves) but that refers also to the absence of fiscal, social, cultural, communication, or other bar- r~ers. The full development of COPC requires a synthesis of all the above ele- ments. Epidemiologic studies alone, or placement of the practice within the

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Meaning and Scope 25 neighborhood it serves, are not enough to justify the use of the term ``COPC.7, At least five other elements can be regarded as highly desirable features of COPC, although not essential: 1. The integration, or at least the coordination, of curative, rehabilitative, preventive, and promotive health care. Even if different agencies provide these services, COPC practitioners should be concerned with ensuring their coordination and the continuity of care, at least of the individual patient, the family and other small groups, and where possible in the development of health programs focused on the community as a whole. 2. A comprehensive approach to health care, encompassing social and mental as well as physical aspects of health, and extending to behavioral, social, environmental, and other determinants of health. 3. A multidisciplinary health team. While some features of COPC can be introduced into the practice of a motivated solo practitioner with the necessary epidemiologic skills, the complementary functions of a multidis- ciplinary group will obviously enhance effectiveness. 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. 5. Extension of community health programs beyond the framework of primary care, e.g., by promoting health education programs in schools or community centers, or by participating in broad programs of community development that are not aimed solely at health advancement but that deal with the root causes of health and disease in the community. The Need for Coordination or Integration of Community Health Services In more developed countries, health and welfare services are often provided by separate agencies having little, if any, accountability to one another, tO a central authority, or to the community itself. Some of the more unsat- isfactory aspects of a nonunified health care system are the problems created by the ready access to so many varied health and medical care facilities; the limited relationships and the lack of coordination between agencies; the absence of responsibility by any single agency for the overall health of individuals, families, or community resulting in gaps in care; and the ad- ditional costs of duplication or overlapping of services. This multiplicity of services and its consequent problems may be found even in relatively small localities of metropolitan areas, in smaller towns or cities, and in rural . . c .lstrlcts.

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26 PART I: THEORETICAL ISSUES One of the major aims of COPC is to remedy these unsatisfactory features of present-day health care by integrating or coordinating the various primary ., . . . . care activitiespromotlve, preventive, curative, anc re na ~llltatlve. . in many communities a main feature of existing personal services is that the initiative for care comes from patient or family only, or depends on referral from one practitioner or agency to another. Staff members of the health services are relatively static. They do not go out into the community to identify and explore health problems. In contrast to this, a COPC practice in which mobility of staff is a feature develops programs for going out to the com- munity to conduct investigations of its health status, health attitudes, and health-relevant practices. On the basis of the findings, action is initiated by the practice with the concurrence and active cooperation of the community. The extension of interest to the community as a whole and to all its members, with the assumption of responsibility for surveillance at least, if not for comprehensive health care, is a key to the introduction of COPC into existing primary care practices. This is so whether they are conducted by family physicians, by pediatricians or internists, or by other practitioners, in solo practice, or in a group practice, or in a community health center. Generally, such practices provide services in response to patients who turn to them for care or advice. If they conduct home visits it is in response to a call or a follow-up visit for care of a patient. This visit might be conducted . . . . . . fly a physician or fly a visiting nurse. This approach to COPC may be contrasted with the traditional practice of public health nurses in their maternal and child health work. The public health nurse was responsible for the care of all the babies in a defined geographic area. Surveillance of the health of these babies and of the pa- rental care received at home was and, in many places, still is a central function of the public health nurse's work. In our own approach to COPC in Je- rusalem, we have incorporated this system, and each family nurse working in a family practice (in a prepaid medical insurance framework) has re- sponsibility for the nursing care in health and illness and for surveillance of all members of the households living in a defined area allocated to her.2 This requires ongoing contact with each family and necessitates home visits when there has been no contact for some time. This surveillance assists the nurse and family physician to help the family to make the best use of the various services available. 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. This

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Meaning and Scope 27 proximity is important; it makes it easier for people to come for personal health care or to attend group discussions or community meetings. For older or disabled people and for mothers with their babies and toddlers, it is especially important that the service should be within easy walking dis- tance or within easy reach by public transport. Proximity facilitates home visits by the health team, for home care of the sick, for family and group health discussions, and as part of preventive and promotive programs. These relationships may promote community involvement in accepting respon- sibility for important aspects of its own health. The insecurity felt by health professionals in many neighborhoods of large cities may also be reduced by their increasing familiarity with many residents in the neighborhood and their consequent recognition by people in the local streets and buildings. When a service is located within the community, the area or people for whom a practitioner or health team is responsible may be relatively easy to define. If the population is large or dense, as in many city neighborhoods, the primary care unit might be divided into a number of health teams, each providing service tO one section of the neighborhood. In a rural area with scattered small homesteads, a single health team might meet the require- ments of a large area by traveling from a central station or by setting up subcenters. A health team that works with a small defined population may readily come to know the primary groups4 and health-relevant social net- works of the community. If each practitioner or health team has responsibility for a defined pop- ulation or geographic area, this may counteract one of the major deficiencies of modern health care. Generally no one person or institution accepts the responsibility for the health of a community or population. It is this ac- ceptance of responsibility that distinguishes COPC from much of the pri- mary care that is so common today, characterized by the episodic care of those patients who seek care when sick. 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 knowl- edge 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 ap- plied 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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28 SOME SPECIAL FEATURES OF COPC CLINICAL EPIDEMIOLOGY IN COPC PART I THEORETICAL ISSUES When examining a patient, primary care practitioners have often to make an initial decision on the problems the patient has posed. The early inter- views and various examinations are focused on establishing a positive re- lationship between practitioner and patient, making a diagnosis, deciding on treatment and care, and considering the expected outcome. 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? If not, the patient is often reassured, and the practitioner's task is ended for that particular event. This division of health into two distinct categoriesdisease and no dis- ease, illness or wellnessis becoming more difficult to define or even conceptualize. Advances in measurement of various health-relevant char- acteristics, somatic, psychological, or social, make it increasingly difficult to divide the universe into two discrete groups, the healthy and the sick. This is especially true in present-day medical care where patients with long-term and chronic diseases represent such a large part of practice and where long periods of Symptomatic abnormality are so frequent. Epidemiology is concerned with population groups. It is commonly de- fined as the study of the distribution of disease in population groups and the determinants of this distribution. This definition is too restrictive and limiting for the full use of epidemiology in COPC, which is not limited to treatment of disease but which includes promotion of health through changes in behavior, protection from exposure to potentially harmful infections and other substances, the prevention and treatment of disease, and care of the disabled. We therefore emphasize epidemiology as a health science and define it as "the science concerned with the occurrence, distribution and determi- nants of states of health and disease in human groups and populations."5 This extends epidemiology beyond the study of disease to the study of health and well-being and the investigation of differences in such charac- teristics as growth and development through infancy and childhood. Further, we consider health care to be one of the "determinants" of health mentioned in the above definition and hence regard the collection and analysis of information about the use, the provision, and effects of health care as a legitimate concern of epidemiology. In his book on the uses of epidemiology, J. N. Morris writes of an "epidemiology of health services as well as of health," and stresses the importance of information

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Meaning and Scope 29 on "the people's needs and demands; how these are being met; and the success of services in lifting the burden of disability and improving health."6 This interpretation of epidemiology, broader than that of many academic epidemiologists, has come increasingly into the forefront, and a handbook recently sponsored by the International Epidemiological Association and the World Health Organization extends it still further: '7he epidemiologist is concerned not solely with the monitoring and evaluation of existing services ... but with the planning process in its entirety, including the assessment of needs, the formulation of and choice between alternative policies and objectives, with evaluation, with the design of experimental services, and with the implementation and development of definitive ones."7 As a simple example of the use of epidemiology, primary care practi- tioners who wish to extend their work with children to include community pediatrics will require some of the skills of community medicine, of which epidemiology is a foundation science. They will need not only to make routine measurements of such variables as length or height, weight, head circumference, skinfold thickness, motor, adaptive, language and social de- velopment, and intellectual development, but also to analyze the findings at a group level. Practitioners need to investigate and answer questions concerned with the community of children for whom they have responsi- bility. Among the critical questions are: "Who are the infants and children registered in my practice and which of them have I seen and examined this past year? What is their state of health, growth, and development? What acute illnesses have they had, and what chronic illnesses or disabilities? Are they all under care, and, if not through my practice, by other agencies? Have all the children been immunized against the major childhood infec- tions? What are the major determinants of their state of health? 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. In this way the practice establishes routines that provide the information required to assess the state of health of individual children, as well as that of the community of children. If information is to be used in this way, the methods by which it is collected should be as rigorously defined as in any epidemiologic survey.5 Standardized diagnostic criteria should be decided upon for common or important diseases, and standard operational definitions should be used for other relevant variables. Uniform examination methods must be used, es- pecially if different members of the primary care team are involved, and

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30 PART I: THEORETICAL ISSUES data that are to be analyzed should be accurately and completely recorded. Record forms and systems should be designed with an eye to the easy retrieval of data. The information required for epidemiologic purposes may be a by-prod- uct of the diagnostic investigation and surveillance of patients, it may be derived from routines specially added to clinical procedures, or it may require special surveys. The characteristic feature of this application of epidemiology is not the source of its data, but its purpose. 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. This is obviously so when the results of clinical tests, performed as part of the management of patients, are used as data for subsequent analysis at a group level. It is also true if the test is performed in the course of routine community surveillance or during a screening or case-finding survey of the practice population. Similarly, information on immunizations may be used both for the quantitative evaluation of an immunization program and to pinpoint specific children who have not yet been fully immunized. A register of patients with a specific disease may be useful not only as a basis for the calculation of prevalence or incidence rates, but also as a tool for ensuring that particular patients get the care they need. A list or register of the total eligible population may be invaluable not only for epidemiological planning and organizational purposes, but also for the identification of specific in- dividuals who may require follow-up or care, such as elderly people with whom there has been no contact for some time. The information that may be collected includes the following: 1. Demographic information on the community or the population eli- gible for the service the size of the population, its demographic charac- teristics, such as its age, sex, and ethnic distribution, and its mobility. These data have obvious implications for the planning of services and provide the denominators required for the measurement or morbidity and other rates.

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Meaning and Scope 31 Registration of known pregnancies and of births, deaths, and movements in and out may have immediate practical relevance. 2. Information on illnesses and disabilities. Charts showing the occur- rence of selected acute illnesses, using the technique developed by W. 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. 3. Information about health-relevant characteristics, such as the growth and development of children and blood pressures of the adult population. 4. Information about the utilization of services and their differential use by various groups of the community. 5. Information about health-relevant behavior, such as cigarette smoking, family planning practices, and compliance with medical advice. 6. Information about the presence of risk markers or known risk factors as a basis for the identification of vulnerable individuals and groups; "at- risk" registers may be helpful. 7. Prompt reporting of deaths or other stressful events that may warrant the adoption of crisis intervention procedures. 8. Information on the performance of activities by the primary care practitioners, such as screening tests, home visits, etc. 9. Information, often not quantifiable, on the community's interests and concerns, its demand for services, and its satisfaction with its health care. An analytic as well as a descriptive approach may be used in clinical epidemiology by directing attention at relationships between variables. In- formation about the differential occurrence of a disease in different groups of the population, for example, may be helpful both in the delineation of vulnerable groups and as a pointer to the etiological processes operative in the community. In a primary care health center where a program for the treatment and control of anemia in pregnancy was initiated,2 we found a differential distribution of hemoglobin levels and of anemia, according to ethnic group and socioeconomic status. In the same center, a comparison of the characteristics of elderly men who died or remained alive during a 5-year period revealed a simple set of risk markers that might be used to identify men with a high risk of dying. it An examination of the coprevalence of diseases, i.e., the tendency of different diseases to affect the same people, revealed an unexpected cluster of mutually associated disordersmigraine, chronic bronchitis, congestive heart failure, gallbladder disease, and chronic arthritis. People with one or more of these common conditions made especially heavy use of the primary care service. The clustering was espe-

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Meaning and Scope 49 for medical students, residency training for specialization, or limited grad- . . uate training. There are many doctors who have not had training in COPC or its related sciences, whether in the form of systematic courses (lectures, seminars, and exercises) or of clerkships and workshops. Thus, what might be a basic course for such physicians is also a basic course for medical students in a medical school. We will therefore not divide our discussion into various phases of medical experience, student, internship and residency speciali- zation, or other graduate studies, but rather focus on the subject matter and experience, which is in our view essential for COPC. Further, our emphasis will be on those fields that are essential to the fuller development of COPC and not the medical student curriculum as a whole. Among the courses needed to ensure a well-founded community ori- entation in primary health care are epidemiology and biostatistics, medical sociology, community health education, and health behavior. Practical ex- perience in workshops, clerkships, and residencies in a suitable COPC training center should be a feature of the curriculum. Epidemiology should include general basic courses: Principles and uses of epidemiology, graded courses in survey methods, and exercises in the use of biostatistics in epidemiologic studies. Special attention should be . . given to its uses: 1 1. ~ r . in ceclulng on priorities tor community programs; . in community diagnosis and health surveillance; . in evaluation of community programs; and . in the more immediate clinical situation with consideration of the ep- idemiologic significance of the findings in a particular patient, in relation to the family and other groups in the community. This might involve more systematic diagnosis of the state of health of small groups, such as family diagnosis and significant changes in life situation. Biostatistics should include basic courses about statistical inference and descriptive statistics in community health and the use of statistics in epi- demiologic investigations of special relevance in COPC. Medical sociology, which for our purposes includes the social and be- havioral sciences, in health care should be offered. Basic courses should embrace sociology, social/cultural anthropology, and social psychology. Their relevance tO medicine and public health should be stressed throughout. Elementary courses in economics and political science should similarly be focused on their implications for the health of populations and the organ- ization of health services. Of relevance to health and COPC are more specific studies on community characteristics that would focus on various

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50 PART I: THEORETICAL ISSUES components of the social system of communities, namely: . structure and various relational and categorical groupings; . customary practices, patterns of health-relevant behavior; and . value-attitudes, belief systems, and framework of health knowledge. Practical work for physicians in COPC may be organized for medical students or for residents specializing in any of the specialities relevant to primary care practice, such as family medicine, internal medicine, pediatrics, geriatrics, or psychiatry. To ensure a meaningful experience for students or residents in the practice of COPC, the aim should be to provide the following: . clinical studies in COPC; . family health care; and . community health care. Clinical studies in COPC should include varied case problems, empha- sizing common problems of daily practice in a community and ensuring exposure to care of people of different age, sex, and social groups, with acute and chronic diseases, and in different states of physical, mental, and social well-being, illness, or disability. They should also provide continuing relationships with individual patients, and with groups of which these pa- tients are members, more especially their families. Family health care should involve follow-through of patients' care by further contact with their families, allowing for family health assessment (family diagnosis) and planning family health care. Family health care ex- perience should be so provided as to improve the practitioner's understand- ing of the family as the most important primary care provider, a key de- terminant of its members' health, and hence, a focus of attention in maternal and child health, parenting, and care of the aged, with emphasis on nutrition, mental health and social adjustment, and COPC in general. 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 com- munity health diagnosis, planning community programs for the promotion of health (e.g., growth and development of infants and children), the pre- vention of disease (e.g., immunization, the control and treatment of hy- pertension or anemia), and the treatment and care of the sick (e.g., home care of the disabled; control, treatment, and health education of patients and families with tuberculosis, rheumatic heart disease). Students and res- idents should participate in the planning and implementation of such pro-

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Meaning and Scope 51 grams in COPC, ensuring the development of skills in community diagnosis, health surveillance, and methods of evaluation of these community pro- grams. They should also be required to initiate and develop at least one program in the course of their practical experience, a program that will be integrated into the COPC practice so that it continues when their period of clerkship or residency training is completed. With the growing appre- ciation of the importance of community involvement in such programs, their experience in this should include working with community groups in deciding on priorities and in formulating and implementing programs. They should have experience in advocacy and health education in the community and become familiar with agencies in that community. Trozinir~g Centers The teaching objectives of a COPC center require that it be linked with suitable university faculties and schools, such as medical and nursing schools, schools of public health, or other recognized teaching institutions. Over many years the authors have been concerned with the initiation and direc- tion of several such teaching centers in different countries, such as the Institute of Family and Community Health in Durban, linked with the Faculty of Medicine of the University of Natal. This institute was responsible for establishing a network of health centers in rural, urban, and periurban communities of differing socioeconomic groups and races. Differing very markedly from this institute, both in its social setting and size, is the Had- assah Community Health Center in Terusalem, which is an integral part of the Department of Social Medicine of the School of Public Health and Community Medicine. This school is itself one of the schools of the Faculty of Medicine of the Hebrew University-Hadassah Campus for the Health Sciences. Most recently we have been helping in the development of COPC practicing centers in New York City. Some of these are planned to be part of the teaching campus in community health of the Sophie Davis School of Biomedical Education, City College, CUNY (City University of New York). Others are practicing neighborhood centers of the Residency Train- ing Program in Social Medicine and Family Medicine of the Montefiore Hospital and Medical Center. 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. The number of students of all kinds who pass though the center has been some 200 or more per year during recent years. The amount of time and depth

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52 PART I: THEORETICAL ISSUES of study has varied from several weeks to full-time block periods of study over several months. The teaching objectives of the health center are to provide learning experiences in community health care for different students and to develop suitable teaching methods for this purpose. Observations of different aspects of the practice, integrated into workshop-seminars such as the workshop in COPC are conducted at the center for students in the Master of Public Health degree course of the Hebrew University.44 Active participation and practical experience in the form of clerkships for medical students, nursing students, and physicians specializing in public health and community med- icine are also offered. The physicians' residency training program in this setting includes COPC practice over 3 years and the COPC workshop of the masters degree course referred to above. As in all teaching centers, the most important factor for success in de- veloping a teaching program in COPC is an adequately trained and expe- rienced health team. However, they must be given the support they need to develop fresh approaches to primary medical care practice and teaching. Hospital-based training of the present day is not a suitable foundation for the high-quality community health practitioners required for COPC. New approaches need new forms of practice. New kinds of institutions, such as community-based health centers, group practices, and clinics, need new types of personnel. Schools of medicine, nursing, and public health have a great responsibility for this to happen, but first they need conviction and motivation for COPC. 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 com- munity that is poorly served, it is possible tO establish a COPC program ab initio. We will focus attention on the process of developing COPC by integrating community orientations into existing primary care practices.45 The process will be considered in some detail along the following lines: . . . preliminary steps; . community health diagnosis and health surveillance planning of intervention; . . Imp. .ementatlon; . evaluation; and decision making for future action. .

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Meaning and Scope PRELIMINARY STEPS 53 Traditional primary care practitioners of Western societies, family or village doctors, were renowned for their knowledge about the people they doc- tored. It was wisdom born of the experience in day-to-day practice and participation in activities of the social world of which they were a part. 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. The information needed concerns the primary care practice itself, the com- munity it serves, and the state of health of the community. Defining the community included in a particular practice is an important step in the development of COPC in the practice. In some settings the communities are relatively easily defined as in many rural villages, in smaller towns, and even larger cities that have grown to their present size through the incorporation of previously separate villages. Large and crowded inner- city populations offer a considerable challenge to the organization of COPC, more especially in defining the population. Our experience suggests several approaches to this probem. Studies of patient origin often show that geo- graphic proximity of a practice or clinic to the homes of patients is a major determinant of utilization patterns. Beginning with an area immediately adjacent to the practice, an initial defined area (IDA) may be demarcated. The records of all patients using the practice should then clearly indicate whether their household is in the IDA. A body of knowledge is thus built up of the population using the service, or registered to use it in the case of insurance programs such as the HMO's of the United States, Kupat Holim of Israel (Workers' Sick Fund), and doctors lists in the National Health Service of the United Kingdom. As previously mentioned, the registration list may itself be a useful way of defining the population involved in COPC, more especially if it can be related to locality of residence. We have found it useful tO begin with a relatively small defined area (DA) and widen it annually until the total population eligible or likely to use the service is included. The IDA should be related to the census tract in which it is situated, and, as the DA is widened to include more homes, it may be helpful to relate this to census tracts. In this way data available from the census authorities may be used as denominator information for epidemiologic purposes. Initiating a community program within a primary care practice depends on a number of factors. Clinical impressions of the extent and importance of the problems in the particular population, supported whenever possible by epidemiologic and statistical reports of their prevalence and impact in

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54 PART I: THEORETICAL ISSUES the region in which the greatest part of the practice population lives, are important at this stage. It is wise to determine the possibility that inter- vention focused on the community as a whole, or on a particular group, will be acceptable to the community and can be expected to have an effective outcome. And, the feasibility of carrying out a suitable community health program in the framework of the primary care practice needs to be assessed. The planning of programs requires decisions on priorities in the practice, which will be determined by the above considerations and the skills, in- terests, and motivation of the practitioners concerned. No less important are the interest and involvement of the community. COMMUNITY HEALTH DIAGNOSIS Having decided on the priority of specific disorders, or other health con- ditions and problems, a more detailed community health diagnosis may proceed. This requires epidemiologic study of the differential distribution of particular health conditions and the factors that determine their distri- bution For these purposes the record system of a COPC practice should include information on the characteristics of the "denominator" population, i.e., the people eligible to use the practice. Similar information should be available from clinical records of patients, which will provide "numerator" data. The minimal inclusions in the denominator and numerator information systems are sex and date of birth for all individuals in the practice. Other desirable social and demographic data include occupation; education; family, kinship, and ethnic group; religion; social class or socioeconomic status; locality of living; length of stay in the area; and migration. We have previously reviewed the important role of epidemiology in COPC. Determining a community diagnosis may require training in epi- demiology, both formal and in-service, on the part of the primary care physicians, nurses, and other team members. However, this is not always possible. Whatever the reason, the ready use of epidemiologic skills is achieved by only a very few primary care practitioners. This should not deter us from exposing all practitioners of the health team to principles and uses of epidemiology in primary care practice. At the same time at least one epidemiologist should be appointed to function with the primary care health team, or one or more members of the team might be interested in becoming knowledgeable in this field, with special reference to its po- tential for COPC. 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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Meaning and Scope 55 patients' records, household surveys, and other programs of the practice, such as on-site school health services and senior citizens clubs. Definitions and methods of data collection and recording should be standardized, to ensure comparability in the appraisal of change in a specific individual or in groups and in the comparison of different individuals or groups. The process of community diagnosis may be concerned with a broad spectrum, e.g., a community health syndrome involving a number of dis- orders and their causal factors and effects, or it may be narrowed down to a very specific problem. It may include the identification of high-risk groups or other groups who require special care. Community diagnosis is a continuing process, along with planning, de- cision making, and implementation of intervention programs. As the state of health of a community changes, so do the determinants of these changes, hence the community diagnosis changes. This requires ongoing health sur- veillance 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. In addition, answers to the following questions must be obtained. 1. What is already being done about the health condition (or other defined problem) . by health and other services, more especially by the primary care practice itself? and . by the community itself? 2. What can be done within the framework of primary health care, in the light of current knowledge and practical constraints? More specifically, what are the resources of the health team for initiating and carrying out a community program? . A case for intervention exists when a problem is considered tO be of sufficient importance to warrant action, taking account of competing prob- lems, and there is reason to believe that intervention is feasible and likely to be effective. The planning process includes decisions on general and specific goals, subgoals, and their relative practicability and priorities. It

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56 PART I: THEORETICAL ISSUES thus involves consideration of alternative strategies, their feasibility and likely outcomes, decision on procedures, sequence, and timing, allocation of resources, roles of health team members, and design of records. Lastly, it includes the planning of systems for monitoring progress of the program, to answer such questions as "Are we doing what we said we would do?" and "Is the community responding in the ways hoped for?", as well as systems for the surveillance of changes in community health and the factors determining itS health, and formulation of the criteria and methods by which the program will be evaluated. 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: . clinical and individual health care in office practice and home calls; . laboratory and other special investigations; . household visits and other group situations for household surveys, health education, and stimulation of family and community interest and involvement; . initiating and maintaining interagency functioning promotive of the community health programs; . use of health recording procedures suitable for community analysis, as well as for individual care. There should be built-in procedures for the surveillance of changes in health status and in determinants of health, and for monitoring the activities of the health team and of members of the community, including their utilization of services and their compliance with advice. EVALUATION Evaluation may be based on measures of outcome, including both desirable and undesirable changes in health status and in factors that may affect it, and on measures of the care provided, including the extent to which planned activities were performed and the quality of the performance. The program may also be evaluated by measurement of community response, the com- munity's satisfaction, and in terms of economic efficiency. The COPC practice as a whole may be evaluated or specified aspects of

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Meaning and Scope 57 it may be appraised, such as the immunization of infants and children, a program for the control of anemia or hypertension, screening for case- finding of a particular condition, or an antismoking campaign in the practice. Evaluative studies of health programs may be classified as program re- views and program trials.46 These are characterized by differences in their aims and methods. The aim of a program review, like that of clinical epi- demiology, is to provide information that will contribute to the health and welfare of the community or population served by the program. It is per- formed in order tO provide a basis for decisions on changes and on the continuance of the program, in the same way as a clinician repeatedly reviews treatment of a specific patient in order to decide whether to continue, stop, or make changes. All health programs should be submitted to this kind of review. The review is usually based mainly on information on the perform- ance of planned activities, on the achievement of easily measurable short- term outcomes, and on the occurrence of any obvious undesirable effects. A program trial, on the other hand, is designed to yield generalizable conclusions concerning the value of a program of the kind under evaluation. For this purpose it is not enough to show improvement in the health of the population, but there must be evidence that this or other favorable outcomes can be ascribed to the program rather than to other influences. This requires the use of methods as rigorous as those used in clinical trials, such as the use of control groups and other procedures aimed at eliminating or measuring the influence of confounding factors. Program trials are es- sential, especially for a new form of practice like COPC. They require very careful planning and meticulous measurement and usually necessitate pro- cedures that go beyond those that might normally be undertaken in the practice. DECISION MAKING FOR FUTURE ACTION The process now comes full circle. Following surveillance and evaluation the situation is reappraised and new decisions are made for continuation or modification of various elements of the program. Modifications may be introduced at various stages of the program in the light of advances in relevant medical knowledge, methods of changing behavior, and as a result of the surveillance carried out as an integral part of the program. Evaluation of the program as a whole, more especially its effectiveness, offers periodic opportunities for review and modification, or in some cases discontinuing the program. The further development of COPC requires that it be researched as a fresh and exciting approach to an important area of medical and health care.

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