Community care and health promotion: primary care at a crossroads
One of the difficulties in addressing the issue of community care is confusion with some concepts. For we understand that community care that aims attention to an entire population of a defined community and seeks health outcomes. Requires intervention on the determinants of health and disease, it is necessary to identify the health needs in the population under care and the factors that determine them. It is known that many of the emerging health problems (dependence, immigration, social exclusion, mental health, cardiovascular risk, among others) have a multicausal origin, one of the essential characteristics of community care is needed multisectoral intervention and not only from health services.
The importance of knowing and analyzing the foreseeable future health needs and the role they should play the primary care is addressed in an article of this monograph (“The future of the health needs and primary care”).
Community care has a close relationship with health promotion, meaning this action to provide people with the means to improve their health and exercise greater control over misma1. Since the concept of health as well transcends the idea of healthy lifestyles, promoting health concerns not only the health sector. The health promotion is carried out by and with people and not imposed on them; It improves the ability of individuals to act and the capacity of groups, organizations or communities to influence the determinants of health2. That is why community care implies the active participation of citizens and their organizations, so that the community is not a passive object but an active subject of intervention in the care and health promotion. The concepts of intervention and community participation yrelacionan closely intertwine, complementing each other.
The current situation of the development of community care in primary care teams, although very heterogeneous, is deficient or non-existent in general. However, there are also many intervention activities and community involvement taking place throughout Spain, some of which can be known through the Network of Community Activities (RAC) Program Community Activities in Primary Care SEMFYC (PACAP ) and it is important to understand and analyze the causes.
Relevance of community care as part of primary care and its relation to health promotion.
Since several decades emphasizes the need to strengthen the primary care level of public health systems and their reorientation to achieve health outcomes. The oft-mentioned and influential First International Conference on Primary Health Care in Alma-Ata (Kazakhstan, 1978) celebrated its 25th anniversary and five years ago, confirming not only in full force but the need to strengthen and deepen their recommendations. In the Ottawa Charter for Health Promotion conclusions of the First International Conference on Health Promotion (Ottawa, 1986) one with emphasis, among other recommendations (Table I) collected in the necessary reorientation of health services and strengthening community action, encouraging the development of personal skills. In that conference it concluded that the health sector should play an increasing role in promoting health, beyond the mere responsibility for providing clinical and medical services and stresses the importance of creating communication channels between the health sector and social, political and economic sectors, assigning health workers the responsibility to act as mediators between conflicting interests and for health. Proof of the validity and future prospects of these approaches is the Jakarta Declaration on Health Promotion in the XXI century as a result of the Fourth International Conference on Health Promotion held in 1997.2 In this Fourth Conference call attention to the new challenges posed by the determinants of health and the need to develop intersectoral actions, within families and local communities, establishing priorities for a global alliance to promote health (Table II).
Health equity is one of the fundamental objectives of almost all strategies for health promotion and this does not mean that everyone has the same condition. Health equity focuses on the ideal that all people enjoy equal opportunities to enable them to lead a healthy life in all its potencial3. It is wrong to believe that the search for equity in health makes sense primarily in developing countries and not in developed countries. Evidence indicates that the “relative deprivation” and not absolute poverty is critical to understanding health inequalities in a Europe that is far from living in crushing poverty in other regions element. Many interventions in equity in the field of health have their most important impact at the community level. Evidence shows that people acquire a greater ability to define and solve local problems and the participation or involvement of the local community is a key factor éxito3. The strategy of Health for All in the XXI century WHO4 proposed as targets not only reduce health differences between European countries but also within each country, as health differences related to income level is one of the most important determinants of health. Also local primary care & corporate team building events by community care interventions, must take into account health inequalities, identifying disadvantaged population groups and social exclusion, looking for effective and targeted interventions for them, seeking equity required .
In Spain there is every normative arguments that determine which community care is one of the powers and responsibilities of primary care teams. Royal Decree 137/84 on basic health structures that initiated the reform of the primary care level and initiated the development of primary care and subsequent decrees of the regions state that depends on the first level of health care promotion and community care. The General Health Law 14/1986 clearly establishes a new model of primary care that emphasizes the integration of care activities with prevention and health promotion. In the most recent Act Calida Cohesion and the National Health System 16/2003 reiterates that are a function of primary care activities in health promotion and community care. Referring specifically to family physicians, Royal Decree 3303/78 which develops specialty training program and clearly define responsibilities in health promotion and community care and treaties aimed consulted by family doctors always include chapters on competences of comunitaria5,6 attention. Likewise, magazines continuing education aimed at family doctors continue to publish articles that review strategies and metodologías7.
The justification for the development of community care from primary care part of a premises that provide a general framework on which there should be consensus among professionals and administrations sanitarias7 (Table III). Moreover, a must to argue the relevance of the involvement and participation activities that will shape the community care provided is to know your eficacia8. A preliminary analysis on the appropriate methods to investigate the effectiveness of health promotion and community care is required. Without underestimating the value of randomized double-blind clinical trials to demonstrate the efficacy of certain interventions (ideally pharmacological treatments), in most cases this is not the appropriate methodology to determine the effectiveness of health promotion interventions. The limited application of appropriate methodologies and testing community as qualitative techniques determine the need for further development of community care research to generate new knowledge. Still, there are several interesting sources for current evidence, which is discussed in another article in this special issue (“Building Bridges: From evidence to practice in community-oriented activities”). In a rigorous report of the International Union of Health Promotion and Health Education of the European Commission (parts 1 and 2) systematically reviewed the evidence of the effectiveness of health promotion, often from different sectors the sanitario3.
Current situation and difficulties in community care in the field of Primary Care
The current situation of the development of community care team building in primary care teams, although very heterogeneous, is deficient or non-existent in general. However, there are also many intervention activities and community involvement taking place throughout Spain, some of which can be known through the Network of Community Activities (RAC) Program Community Activities in Primary Care SEMFYC (PACAP ) 9. To make proposals to improve the current situation is first necessary to understand and analyze the difficulties, both originated in health systems such as those that come from the professionals themselves, often little aware, if not skeptical, about the interest of the community care (Table IV). The subject is of sufficient interest to address it at length in the third article of this monograph (“Current context of Primary Care: Challenges and opportunities for community activities”).
Does the Primary Care at a crossroads?
Often in the past and has raised community care as opposed to individual attention, with statements such as “we must emerge from the consultations.” It seemed that the crossroads where primary care could be found was the choice between individual attention outside consultation or community health center. For many years we reflect and debate on the relationship between the individual attention in consultation and comunitaria10 and even today are still opposing both like two little related practices. One of the most important and difficult challenges of family medicine and community is precisely not to give to community care without neglecting individual attention. One strategy for achieving this is to recognize and utilize the many concrete relations be established between them in everyday practice (Table V). All health problems that affect patients occur in a particular social and community context that influences both the causes of the problem and the circumstances that favor or impede its correct approach, and knowledge must guide their best care. There is talk of “focused on the community context medicine” and “medical history focused on the community,” noting that it can be done medical care to each person in consultation with a community approach, favoring “community micro-processes” to care for patients11. The interesting and useful to keep in mind the community context in the care of people in the office is covered in depth in the last article of this monograph (“individual health care community oriented contextualized note. The figure is the bottom”).
The crossroads at which is now the primary care is not therefore the need to choose between individual and community care, establishing priorities among ambas.La true crossroads is to continue to pose a Primary Focus on the provision of care services patient demand, based on a portfolio of services and prescribed uniform, in which the patient participates only through individual demand for these services and adopts a passive attitude as a consumer of them, while professionals position themselves as providers of those services you require. It would be a primary care focused on improving the health of people requiring care and those problems mainly by consulting with opportunistic specific prevention interventions, using a model of care that has inevitably affects not biomédicay guidance the determinants of disease and health outcomes searches of the entire population it serves.
By contrast, the other way is the crossroads posed opt for a primary care whose object of attention is the whole community it serves and, of course, people who are part of it, searching health outcomes by identifying problems and priority needs, trying deinfluir on their (usually multicausal) not only determinants through health care interventions (necessarily with a biopsychosocial approach) but also prevention and health promotion (necessarily intersectoral and active citizen participation). It would be a primary care posed a different model of relationship between professionals and citizens trying to avoid dependence on the latter to the former, avoiding the false belief that health depends primarily on doctors and trying to overcome the concept of citizen as a mere consumer and professional health services as a provider of these. It would be a primary care that ensures that citizens and their organizations occupy a leading role in promoting and health care. Professional flee from paternalistic attitudes grounded in scientific and technical knowledge, ensuring the empowerment of citizens, so that it is capable and has the power to modify and improve the determinants of their own health, so that citizens would be objects passive recipients to active participants care for their own health. And all this must be remembered equally for both individual care in consultation (with community orientation) and developing community involvement and participation activities.
They are politicians, managers, health professionals and the citizens themselves who ultimately influence decisions that determine which path is taken at the crossroads that presenta12.
The challenges ahead.
The real and major challenge of the future will decide precisely the path that will travel at the crossroads described. By choosing the option community-oriented and provides community care and health promotion skills of primary care some important elements shall be taken into account.
It is necessary to adapt health services and priority to the real needs of each community it serves and is a function of identifying health centers in collaboration with other services and with the participation of the citizens themselves, using methods proven in methodology Oriented Primary Care Community (APOC), which takes place in an article of this monograph (“Methodology Oriented Primary Care Community (APOC). Elements to practice”). The need for a portfolio of common services is not questioned at all health centers in the territory of the State to ensure equity precise, but it must be compatible with the necessary flexibility for the development of interventions and services that respond to the needs of each population. The portfolios of uniform and inflexible services common to all corporate team building events and for all populations represent a barrier to the adequacy of services to changing needs. It is imperative formal recognition of community activities and services to include among the performance of primary care teams, always adapting to needs identified.
It is essential to achieve the aforementioned integration and complementarity of individual care and community, getting their mutual strengthening and seeing them as inseparable parts and closely related Primary Health Care. Individual attention in consultation must have a biopsychosocial approach and be contextualized, allowing startup “Community micro-processes”. In the clinical practice of the family doctor is daily how many patients come to the consultation by problems for which often do not have effective, so the doctor is limited to efforts to curb, if not medicalized problem away It is an organic disease, so an important inefficient use of resources and a worrying wear and professional frustration is generated. A major challenge for all family physician is to identify the real demands and needs of each patient that we see and recognize the real problem is hidden behind that which is made explicit and socially legitimizing go to the doctor (dizziness, pain , weakness, sadness). Improving the above problems can not be addressed primarily in the space of medical consultation, since it can only be shared with the patient possible ways to start. That is when the need and interest of the use of other community services and resources that have previously known and that the health center is coordinated arises. The correct use of the leadership of family physicians and other health professionals in the community they serve must be directed towards strengthening associations and civic organizations, as potential health workers, and medical consultation is adequate space for reporting patients about their usefulness.
Primary attention should allocate more resources and more professional efforts to promote health, efforts to increase training and access to decision-making of citizens and their organizations for health care and improvement proposals health services. As future horizon should be encouraged effective and concrete community participation in setting priorities, making decisions and the development and implementation of planning strategies to achieve a better standard of health (Ottawa Charter, 1986) 1 .
One of the main outstanding issues is to achieve intersectoral coordination and cooperation for both the identification and prioritization of health needs to intervene on them. It is also essential to achieve mutual engagement and collaboration with local governments. In any community process involving the health sector is to procure the joint and coordinated participation of professionals of different services, different administrations and ciudadanos13,14 own.
For the start of any process of intervention and community participation it is essential to use appropriate methodologies and cover some steps that must necessarily go through reflection and internal consensus within the primary care team, as described in an article of this monograph (“Primary Care and community processes: intervention and community participation”). Another major challenge is to know that there are different methodologies for high quality team building and corporate community care and that they are not only exclusive, but must be supplemented, as, in addition to others already mentioned, with the methodology of Community Correction processes described in another article in this monograph (“The Methodology of Community Process correctors (ProcC).
One of the main barriers and limitations for Community Care are training deficiencies for its development, sometimes provoking interventions without the necessary methodological rigor, making them ineffective and causing frustration among professionals. Continued training and very primarily postgraduate training program in family medicine training is one of the great challenges of the immediate future and will be crucial to the development of community care in the short term corporate team building. Formation must be directed not only to the acquisition of knowledge and skills, being fundamental attitudes also generate flattering.
The experience of the development of primary care in Spain has shown the important role they can play the professionals themselves and their most representative scientific organizations. That is why the SEMFYC been developing since 1996 Community Activities Program in Primary Care (PACAP) 9 as favorable development strategy of the Community Care.