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 developed 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, providing promotive, preventive, curative, and rehabilitative services . . . (it) includes at the very least education concerning prevailing health problems and the methods 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, appropriate treatment of common diseases and injuries, and provision of essential drugs. ¹

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 physician. 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 Medicine of the National Academy of Sciences of the United States, ³ are accessibility, 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 members 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, 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 individual patients.

The provision of health care in the community, i.e., the practice of medicine outside the hospital, is sometimes equated with community medicine. We use the term “community medicine” with a different connotation to signify health care focused on population groups rather than on individual patients. So construed, community medicine has its roots in the disciplines of public health and medical administration. In the present context, community 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 following cardinal questions, the asking of which characterizes community medicine:

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;
• 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 defined service; and
• users of a defined service, or repeated users of the service.

Although from a puristic viewpoint the application of the term “community” 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 population at large.

The following can be regarded as the five essential features of COPC:

1.

The use of epidemiologic and clinical skills as complementary functions; 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 responsible. 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 prevention, 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. Community 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 barriers.

The full development of COPC requires a synthesis of all the above elements. Epidemiologic studies alone, or placement of the practice within the neighborhood it serves, are not enough to justify the use of the term “COPC.”

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 multidisciplinary 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 unsatisfactory 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 additional 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 districts.

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 activities—promotive, preventive, curative, and rehabilitative. 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 community 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 by a physician or by 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 parental 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 Jerusalem, we have incorporated this system, and each family nurse working in a family practice (in a prepaid medical insurance framework) has responsibility 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.

Community-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 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 distance 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 responsibility 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 requirements 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 groups ⁴ and health-relevant social networks of the community.

If each practitioner or health team has responsibility for a defined population 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 acceptance of responsibility that distinguishes COPC from much of the primary 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—knowledge that is essential for the use of epidemiologic methods in community diagnosis, in health surveillance, and in the evaluation of health programs focused on changing the community's state of health.

These remarks on defined populations in local communites may be applied to other settings also, e.g., to primary care services for workers in factories or other workplaces and for students and faculty at universities, colleges, and various types of schools.

CLINICAL EPIDEMIOLOGY IN COPC

When examining a patient, primary care practitioners have often to make an initial decision on the problems the patient has posed. The early interviews and various examinations are focused on establishing a positive relationship 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 categories—disease and no disease, illness or wellness—is becoming more difficult to define or even conceptualize. Advances in measurement of various health-relevant characteristics, 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 asymptomatic abnormality are so frequent.

Epidemiology is concerned with population groups. It is commonly defined 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 determinants 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 characteristics 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 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: “The 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 practitioners 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 development, 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 responsibility. 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 infections? 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, especially if different members of the primary care team are involved, and 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-product 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 individuals 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 eligible for the service—the size of the population, its demographic characteristics, 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. 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 occurrence 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. Information 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. ¹⁰ 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 disorders—migraine, chronic bronchitis, congestive heart failure, gallbladder disease, and chronic arthritis. ¹¹ People with one or more of these common conditions made especially heavy use of the primary care service. The clustering was especially strong when people with clear objective evidence of these diseases were removed from consideration; that is, the clustering was essentially between complaint-based disorders. These were frequently associated with emotional symptoms and with family disharmony or other stressful situations. The analysis drew attention to the occurrence of a community health syndrome for which there was no organized program in the primary care service.

When community medicine programs are set up as an integral part of the primary care practice, each program needs to be supported by epidemiologic investigation for (a) community diagnosis related to the problem at which the program is directed, e.g., the particular health condition or group of conditions included in a community syndrome, (b) community health surveillance, and (c) evaluation of the community program.

Information may be required not only about the community as a whole, but also about its various subgroups. This will lead to a need for the organization of continuing epidemiologic surveillance of health and illness of different community groups. For this purpose it is useful to focus on major developmental phases and social groups within the community, such as reproduction and family formation, childhood from infancy and preschool childhood (the under-fives) through school age children and adolescents, adulthood, aging and the aged.

To define health priorities, it is necessary to link clinical and epidemiologic orientations. Thus the care of women through pregnancy and childbirth has to focus on the well-being of individual women, as well as on the progress and outcome of pregnancy in all pregnant women in the community. The two disciplines required for asessing the health state of individual and community, namely clinical practice and epidemiology, are complementary to one another in the devleopment of COPC, the one providing the information needed for individual diagnosis and the other for community diagnosis (Table 1).

TABLE 1

Summary of the Complementary Functions of Clinical and Epidemiologic Skills in Development of Community Oriented Primary Health Care.

Very few practitioners can be expected to be skillful both as epidemiologists and as clinicians. In view of the need for a high standard of epidemiologic practice in COPC, it is probably true to say that in general the involvement of an epidemiologist, at least as a part-time co-worker and consultant, is desirable. All COPC practitioners, however, should have been exposed to epidemiology sufficiently to enable them to appreciate its importance, to play their part in the collection of accurate data, and to make proper use of the epidemiologic findings.

Why has the use of epidemiology in the practice of primary care physicians not been fully explored? This seems to be the case despite the increasing attention given by medical schools to the teaching of epidemiology, despite the need for such knowledge in reading current medical journals, and despite the increasing recognition of the importance of epidemiologic thinking as a basis for “clinical judgement” and clinical decisions concerning diagnosis, prognosis, and treatment. ¹² It seems that one of the important reasons is that the epidemiology that is clinically relevant for primary care is not developed by the major teaching centers.

Of special relevance for community diagnosis in primary care are studies of the incidence of common acute illnesses and the prevalence of a number of chronic disorders and disabilities, cigarette smoking, and other health-relevant behaviors, as well as studies of the distribution of continuous variables such as height, weight, and blood pressure. This information may be derived from routine recordings on all persons examined or interviewed or from special surveys of the population eligible to use the practice.

Epidemiologic investigations in primary care practices allow for analysis of the data to determine the health priorities for the practice. In the practice of COPC, the functions of epidemiology include:

• determination of health priorities on which the practice should focus, and the community's interest and involvement;
• the more intensive epidemiologic investigation for community diagnosis of those conditions with high-priority rating;
• subsequent epidemiologic surveillance of the various community health programs established in the framework of primary care; and
• evaluation of the programs by epidemiologic methods to measure their effectiveness in changing the community's state of health.

Case Illustration of Clinical Epidemiology

The use of epidemiology for the control of cardiovascular risk factors is illustrated in a community oriented primary care practice in western Jerusalem. The program is conducted by a health team of primary care physicians and public health nurses, supported by epidemiologists and statisticians and by a community organizer/health educator. It is focused on all the adults eligible for care who live in four housing projects close to the practice. Known as the CHAD program (Community Syndrome of Hypertension, Atherosclerotic Disease, and Diabetes), it aims to modify the frequency distributions of blood pressure, serum cholesterol levels, and weight/height index in the community and to reduce the prevalence of hypertension, hypercholesterolemia, overweight, and cigarette smoking, at the same time as ensuring continuing care and treatment of patients with ischemic heart disease, cerebral vascular and peripheral vascular disease, and diabetes mellitus.

The original aim of the program was to test the feasibility and usefulness of incorporating such a community oriented health program as an integral part of primary care. For this purpose, a control area, immediately adjacent to the CHAD neighborhood, was selected. This control population had access to another primary care center situated in the area, providing a primary medical service to those who turned to it for attention. Thus both populations, “CHAD” and control, had easy access to primary care facilities located in their neighborhoods, the one facility utilizing a COPC approach in the control of cardiovascular disease risk factors and the other providing primary care without a community medicine orientation. Both were prepaid services. The program has been described in a number of publications. ^{2 , 13 , 14 , 15 , 16 , 17 , 18 , 19 and 20} We will confine ourselves to one aspect of the program, namely, hypertension.

Determining Priorities

The impression of the practitioners was that hypertension was common in their practice, more especially in middle-aged and older persons. Extraction and analysis of the relevant data from clinical records of the practice provided information about the proportion of adults eligible for care who had previously had their blood pressure (BP) recorded in their clinical files. ¹³ While only 52 percent of men aged 25-44 years had a record of at least one BP reading, 77 percent of women in this age-group had such a record. There was little difference between the men and women 45 and over, the vast majority having been examined. The percentage of men and women of different ages who had blood pressure measurements in the clinical records was as follows:

Another fact of relevance to the clinicians' impressions of a high prevalence of hypertension was the prevalence of diastolic hypertension (diastolic BP ≥90 mm HG) on at least one occasion, as revealed by analysis of the clinic records: ¹³

As expected in this particular community, there was a sharp rise in prevalence with age, but at that time we were not able to make more specific inferences because of the considerable difference in frequency of BP recordings.

Community Diagnosis and Epidemiologic Surveillance

The CHAD program is founded on epidemiologic surveillance of the practice population as a whole and not only on those who use the practice for care when sick. The program was initally developed through analysis of existing clinic records of the practice together with a comprehensive picture of the health status of the community provided by a community health survey. The latter included the prevalence of cardiovascular disorders and diabetes mellitus as well as the frequency distribution of blood preassure and other risk factors for these disorders. The survey added to the knowledge we had of the prevalence of hypertension, revealing a considerably higher percentage of men and women with diastolic BP ≥90 mm Hg, as shown by the following data: ¹³

Over a period of time every adult with evidence of possible hypertension (at least one measurement with systolic ≥140 mm Hg and/or diastolic ≥90 mm Hg, according to the clinic records or the community health survey) was invited to attend for a series of new measurements in order to determine whether standard criteria for the diagnosis of hypertension were met and whether treatment was required.

Registers are now in common use in epidemiologic studies of hypertension and cardiovascular disease. ²¹ In this COPC practice the presence of hypertension is recorded on a card register that is maintained for all CHAD subjects and available for use by the nurse coordinator of the program and for each nurse and physician in the practice team. This card register is used for reviewing the progress of the program in measuring the compliance of persons at risk and the response to treatment. It thus becomes the key to the monitoring of individual patient care and to the surveillance of the community as a whole. Almost 90 percent of people who have resided in the neighborhood for at least 2-3 years have come into the program, and almost all known hypertensives receive medicinal treatment. For these purposes the community program defines a hypertensive as a person found consistently to have a systolic BP ≥160 mm Hg and/or diastolic ≥95 mm Hg.

Evaluation

The use of epidemiology in primary care evaluation requires rigorous attention to the use of standardized methods in the practice. These have been described elsewhere. ^{2 , 14 , 19} The care is based on standardized examination procedures, uniform methods of treatment and advice, and defined monitoring of regimes for people at different, specified risk levels. Thus hypertensive patients are put on a stepped-care regime that commences with a diuretic and the addition of other drugs (propanolol, methyldopa, etc.); if necessary dietary advice is given on calorie reduction for overweight subjects and on salt restriction. Other aspects of the program include advice to cigarette smokers to stop smoking, a cholesterol-lowering diet, weight control, and increase in physical exercise where this is advisable.

The program has been evaluated by comparing the outcome with the findings in a control population. This was done by means of community health surveys of the total CHAD (COPC practice) population and the control population at the commencement of the program and 5 years later. The same methods of interview and examination were used in both surveys and for both populations. ^{16 , 17 , 18 , 19 and 20}

The analysis included 2,036 men and women, 35 years and over, 524 in the CHAD population and 1,512 in the control population, who were examined on both occasions. The respective response rates were 91 percent and 83 percent of the eligible population at the second examination.

The comparison of change in prevalence with respect to several risk factors, namely, hypertension, cigarette smoking, weight, and serum cholesterol levels, was encouraging. ²⁰ There was a reduction in the prevalence of hypertension in the COPC population of 8.2 per 100, from a rate of 25.0, to 16.8 per 100. The reduction in the control population was 3.2 per 100 (Table 2).

TABLE 2

Changes in Blood Pressure and Hypertension Prevalence in a COPC Practice as Compared With a PC Practice Not Community Oriented (Standardized for Age, and Sex Where Men and Women Are Analyzed Together).

Especially striking was the reduction in prevalence of diastolic hypertension from 17.3 per 100 to 7.1, a reduction of nearly 60 percent affecting men and women equally. Another interesting finding was the impact of the community program on the younger and middle-aged adult groups of 35-44 and 45-54 years (Table 3). In men and women aged 35-44 at the time of the initial survey, the reductions in prevalence were from 11.3 to 6.5 and from 13.6 to 6.2 per 100 men and women, respectively. In the agegroup 45-54, the reductions were from 22.9 to 8.9 and from 23.9 to 15.9 per 100 men and women, respectively. The impact on outcome as measured by mortality or morbidity from hypertensive disease, cerebral vascular disease, and possibly ischemic heart disease may thus be expected to reflect itself only after some years, with the further aging of these groups. As yet, 9 years after initiation of the program, no change in this direction has been noted. ²²

TABLE 3

Change in the Prevalence Rates of Hypertension by Age and Sex in the COPC and the Control Populations.

Age-standardized mean values of blood pressure and prevalence rates of hypertension are shown in Table 2. The mean values of blood pressure declined in both the COPC and control populations, except for women in the latter. The changes were more marked in the COPC population and were significant in both sexes for systolic and diastolic BP. Thus the net reduction in mean values, that is, the difference between the reduction in the COPC population and the reduction in the control primary care population, was significant for systolic and diastolic BP for each sex. The net changes did not alter appreciably when the data were standardized by education or region of birth, used as an indicator of ethnic group.

Although there were favorable changes in the control population also, these were much smaller than in the COPC population. The changes in the control population might be expressions of an increasing awareness by the medical profession during recent years of the importance of treating hypertension. According to the survey results, the proportion of all adults aged 45 years in the control population who were receiving treatment for high blood pressure rose from 9 percent to 14 percent during the 5 years of the comparative study. ²⁰ In the COPC population the corresponding rise was from 10 percent to 19 percent. Among patients who had ever received treatment for high blood pressure, the proportion who reported discontinuation of treatment when questioned in the second survey was 9 percent in the COPC population and 29 percent in the control population.

The results of this controlled evaluation provided encouraging evidence that the integration of this community focus into primary care was having an appreciable effect on cardiovascular risk factors in the population served. Ongoing surveillance findings support this conclusion. A recent check revealed that 76 percent of known hypertensives were under control, i.e., had blood pressures below 160/95 mm Hg.

A Note on Other Programs in This COPC

Improvements in the prevalence of several other cardiovascular disease risk factors have also been reported in the course of this CHAD program. ²⁰ These improvements are summarized in Figure 1, which contrasts the changes observed during a 5-year period in the CHAD population and the control population. This figure shows the rates in 1975, expressed as percentages of the initial rates (in the same population) in 1970. The decrease in prevalence was greater in the CHAD population for each of the risk factors shown—systolic and diastolic hypertension, hypercholesterolemia, cigarette smoking, and overweight. The decrease in the CHAD population was most marked for diastolic hypertension and least marked for overweight. The figure (which is based on data for both sexes) underestimates the change in smoking observed among men. The decreases observed in the control population (smaller than those in the CHAD population) were ascribed to a general increase of awareness of the importance of the prevention of heart disease, in both the population and the medical profession. The evaluation of the CHAD program also pointed to improvements in relation to diet.

FIGURE 1

1 Prevalence of risk factors in 1975 expressed as a percentage of prevalence in 1970, for CHAD and control populations.

Maternal and child health constitutes a most important aspect of family and community health to which COPC has important contributions. In addition to the adult community health programs focused on CHAD, the neighborhood primary care center in western Jerusalem focuses on several aspects of maternal and child health care. The community programs have included surveillance of health through pregnancy and its outcome. Associated with this, several community programs have been developed, such as the prevention and/or treatment of anemia in pregnancy, asymptomatic bacteriuria, cigarette smoking, initiation of breast feeding, and family spacing. The first of these introduced was that concerned with anemia in pregnancy. Program reviews indicated a rapid decline in the occurrence of anemia with general improvement in the distribution of hemoglobin levels of the women at different phases of pregnancy. This anemia is now relatively uncommon. Within a decade of the start of the program, the rate declined from an initial level of 12.0 percent of women exhibiting a hemoglobin level of less than 10 gm/100 ml at any time during pregnancy to 1.6 percent. With this change the intensity of the program has been reduced and the number of blood determinations has been considerably lessened.

Similarly, community oriented programs have been a feature of child health care in this primary care center. These have involved rheumatic fever and rheumatic heart disease, now uncommon in the area of western Jerusalem, and promotion of the physical growth and behavior development in infants and young children with special reference to children of lesser educated mothers and hence of lower social class families. Community diagnosis of child growth and development is an ongoing process in this COPC center. These have been described in some detail in a number of publications. Encouraging has been the fact that the gap between children of better-off and poorer families is closing. And here we would emphasize that this trend is now evident in behavior, including fields such as language and social development. The routine of the child health programs has included attention to ways of improving social interaction and stimulation of infants by their mothers, as well as the nutritional and more physical aspects of child health care. The main somatic defect requiring further attention at this time is that of anemia in infancy, and for this a community program of surveillance and treatment has been conducted over several years, with evidence of satisfactory responses. ^{23 , 24 and 25}

SOCIAL AND BEHAVIORAL ASPECTS OF COPC

As long ago as the mid-nineteenth century, medicine was said to be a social science by Virchow and his colleague Neuman. And here we are in the 1980s of the twentieth century, witness to the fact that the social and behavioral aspects of medicine still receive scant attention in the practice of medicine. It is true that there have been considerable advances in social policy affecting health services and public health; however, it is the social component of care itself that is being considered here.

A central feature of primary health care of patients or others seeking advice is the relationship between practitioner and patient. Since T. Parson's pioneering analysis of modern medical practice as a case illustration of social structure and dynamic process, a number of medical sociologists have focused on different aspects of medical care, the role of the physician, the sick role, the doctor's functioning in legitimizing it, and patient-doctor relationships. ^{26 , 27 , 28 and 29} It is not surprising that the revitalization of primary medical care that is now taking place in many more developed countries is emphasizing the key role of the consultation when a patient turns to his or her doctor for care and advice. ³⁰

No less important for COPC is the knowledge that the practitioner builds up about the community. The use of social and behavioral variables has become common place in clinical and epidemiologic studies. Many of these are relevant to COPC.

Measures of social process and of basic cultural characteristics are much less commonly used. This includes important areas such as people's belief systems and practices and value attitudes. COPC practitioners could contribute considerably in improving this situation, because of their close and ongoing relationship with patients and small communities. The methods of social anthropology, as carried out in small communities, incorporated with those of epidemiology, could lead to fruitful, innovative investigations, such as the study of the relationship between culture, personality, and common diseases like coronary heart disease. ³¹

The way in which communities function, their social system and culture, has been studied by social scientists in different disciplines of these sciences. But such investigations have not yet been accepted as an integral element of ongoing community health care. A COPC team should have knowledge of social health relevance that will not only define community health in epidemiologic terms, but will also help stimulate a community's involvement in its own care. Such knowledge includes community networks of relationships and social support systems, occupations and activities of daily living, family structure and kinship in the community, and its formal and informal leadership. Each situation in which a member of the health team meets an individual or group of the community provides an opportunity for such observations. Planned surveys, including KAP (knowledge, attitudes, and practices) studies, may be especially helpful when carried out with the participation of members of the community, or even conducted by them.

Community Involvement in COPC

The individual's active interest in treatment of his or her illness is often a sine qua non of successful treatment. This is especially true for patients who need medication or other treatment over long periods of time. For example, one of the first measures of effectiveness of a program to control hypertension is the extent of compliance with the recommendations. The individual's sovereignty is involved in the decisions that have to be made in his or her own interests. Recognition of this would lead physicians and other practitioners to give more attention to patients' perceptions of their health condition and the possible effects of treatment. Cooperation in the program of care is influenced by a number of interrelated factors. Did the patient with hypertension seek care because of illness, or was the hypertension found on a screening survey in which he or she was passively involved by virtue of being a member of a group that was being screened? Was the screening survey conducted by the personal doctor as part of his/ her practice, or was it a mass screening survey organized by an impersonal health authority? The answers to such questions and others relating to patients' involvement in decision making about their care must surely influence their response to advice and treatment.

While participation in decision making by the individual patient is important for satisfactory care, it is perhaps even more so in community health care. Study of the determinants of community involvement and participation in its health care is a function of the social sciences in medicine and public health. For the past 30 years or so there has been increasing awareness and a number of reports on the community processes involved in failure to apply our increasing body of knowledge about health to the promotion of community health. The earliest of these reports are still worthy of reading by all those interested in COPC. ^{32 , 33} Not only do practitioners need to know suitable epidemiologic methods for studying the state of health of the community, but also social science methods for understanding the community's health-relevant behavior, the people's varied perceptions of health and disease, and their attitudes towards, and expectations from, the health team. What was so well said by George Rosen about the health officer and the community is equally apt for those now moving into COPC, “A knowledge of the community and its people . . . is just as important for successful public health work as is a knowledge of epidemiology or medicine. . . . The first principle in community organization is to start with the people as they are, and with the community as it is.” ³⁴

The problems that have arisen, and the failure of well-intentioned health programs, have been more readily observed in cross-cultural situations, where the health team aimed to produce change of behavior in communities whose way of life, technology, and value-attitudes differed markedly from those of the team. Enthusiasm in attaining objectives for better health is often not matched by understanding of the community and hence lack of sensitivity to possible adverse reactions to the various activities generated by the health program.

One of the major reactions to this increasing body of experience has been recognition of the need for community involvement in the initiation and provision of community health care. What does this mean for the COPC health team and for the community's health? Primary care physicians and their colleagues in practice have had a professional training that not only prepares them for their special role, but also differentiates them from the population and their patients. This difference is not only in their “medical culture,” but often also in their educational and socioeconomic status. Attempts to bridge the social distance between practitioners and their patients have included the appointment by the community, or by the health practice, of community health workers who are members of the community. ^{35 , 36 and 37}

Understanding the community is essential for a health team that expects to work with, and encourage the active participation of, the community in its own health care. The basic education of COPC team members should include special study with those epidemiologists, health educators, community organizers, and behavioral scientists who have a special interest in the application of their disciplines to the health of communities and individuals.

Community health workers have become the main primary care practitioners in many societies. The “barefoot doctor” of China is an example of this in a large country. ³⁸ Equally interesting but on a more modest scale is the concept of community members themselves functioning within their own communities, not as community members of a primary care health center, but as workers relatively independent of medical services. An example of this is the Community Health Participation Program (CHPP), which is directed by the Department of Social Medicine of the Montefiore Hospital and Medical Center in the Bronx, New York City. ³⁹ Volunteers in the community undergo a training program in the CHPP that includes first aid, with cardiopulmonary resuscitation and emergency handling of persons choking on food, and advocacy and counselling of individuals, families, and other community groups regarding the use of various agencies and their rights in the use of different facilities. These volunteers also learn about systems of social support for those members of the community who are not well integrated in a social network, such as aged persons living alone, disabled persons, teenagers in need of help, and new immigrants.

The potential contribution to community health and well-being of such a resource is considerable, especially if well coordinated with other community focused health care, such as COPC. Much depends on the attitude of physicians and other health professionals to such a CHPP program and the particular community workers living in the community in which the COPC is being practiced. The extent of mutual respect and trust between a COPC health team and the community will be reflected in their reciprocal functioning. Furthermore, a community health council of a primary care center will be more likely to become an effective advisory and involved group if its representatives are well accepted by the professional health team and if it is recognized as representative by the community.

Community involvement in health activities varies from community to community. The variation depends on the nature of the community and the way in which the health service system perceives community participation in health care activities. While action by the community has become a feature of the approach to primary health care that is now being advocated by WHO and UNICEF for developing countries, its usefulness is often questioned in more developed countries, especially in metropolitan cities. Our experience in rural peasant communities and in cities relatively small and very large has indicated that the potential of community involvement is equally great in all settings.

If health is about the quality of life, promoting community involvement is not only for the purpose of achieving specific goals, such as building protected water supplies in a rural community, or organizing a hypertensive program in different settings. Community involvement is in itself a health activity, promotive of social well-being and mental health. The sense of being able to influence the development of one's own community is especially relevant in communities alienated from the dominant social, cultural, and economic classes. It may be difficult to achieve community involvement in those more developed societies where highly organized services are conducted within the framework of bureaucratic decision making and direction. However, the difficulty should not deter community health researchers from studying the impact that community involvement might have on the effectiveness of health services.

TRAINING FOR COPC

The development of a unified practice of community medicine and primary health care, that is COPC, requires practitioners who have had training for such practice. While some aspects of community health care are beginning to receive more attention in the experience provided for medical students, practical clerkships still have little place in the curricula of medical schools in more developed countries. The multidepartmental hospital, mainly catering to short-stay patients, is the major field of clinical practice for undergraduate and postgraduate students in medicine and nursing. This has been so in developed countries for many years, so that the clinical professors in the teaching centers of today were themselves educated in the setting of the hospital institutions. An encouraging reaction has been the appointment of professors of community health, general practice, and family medicine in a rapidly increasing number of medical schools, and the attachment of students to general and family practices, as well as other primary care practitioners, pediatricians, internists, and in some cases group practices. However, this is still far from the training and experience needed for COPC.

Among the pioneering innovative explorations in medical education of this kind was that of John Grant, who was appointed in 1921 as head of the Department of Hygiene of the Peking University Medical College in China, which had been taken over by the Rockefeller Foundation. Based on his argument that “preventive medicine” must be provided in facilities comparable with those of the teaching hospital, he established a “demonstration health station” in Peking. In this center health maintenance and preventive and curative medicine were brought together and used in the teaching of medical and nursing undergraduate students, as well as public health nurses.

Despite this and other innovative approaches in medical education and practice, ^{40 , 41} the vast majority of medical schools of today do not provide suitable training for the development of COPC. The same is true of public health schools, which have neither generated fresh approaches in the development of combined promotive, preventive, and curative care, nor pioneered a unified practice of individual and community health care. If COPC is to progress, university health science faculties must have COPC facilities attached to them in much the same way as teaching hospitals are now affiliated. The staff of such facilities require special preparation in practice, research, and teaching for COPC, and relevant textbooks are needed. ^{5 , 14 , 42 , 43}

From Solo Practice to Group Practice and the Health Team

In answer to the question who needs training for COPC, we have to face the reality of who provides primary care today, because it is these practices that we may want to extend from Primary Health Care (PHC) to COPC. Among physicians, solo practice is still very common, despite the frequently made statement that this type of practice is on its way out. While this is probably true, solo practice is sufficiently widespread to compel the attention of teaching institutions. Such practitioners attend postgraduate courses and grand rounds offered by many hospitals. There is every reason to extend similar facilities for courses in subjects relevant to COPC. Likewise they may be encouraged to participate in the COPC rounds at community-based teaching centers where these exist.

There are trends, however, in delivery of health care in the community that offer opportunities for COPC and hence for the training of the practitioners. One modern feature is that increasingly physicians are working in groups, whether in a group practice clinic or in a health center. The group may be composed of a number of specialists, or of general practitioners, each having additional knowledge and special interest in a particular field of practice. Whatever the type of group practice, it is clear that redefinition of the practitioners' functions will be needed if the group is to combine the practice of community medicine with that of primary health care focused on the individual patient. The development of community medicine in primary care is influenced by, and in fact depends on, the orientation of the physicians who are key members of the practice teams. Without ensuring their training in COPC and its related health sciences and community orientations, the team will make little progress toward community-focused primary health care.

It is probably true to say that there will not be sufficient numbers of physicians to provide future clinical primary care services. How then can we ask those practitioners to extend their clinical practice functions by adding an important role for them in community medicine? We believe that the answer is to provide them with assistants for clinical work, as well as for community health. Thus a community health care team, made up of different professional groups, is the answer, rather than separating the services along the lines of the traditional separation of personal public health services and curative medical practice. This being so, we need to provide training facilities for various members of the COPC health team. Such action does presuppose that a unified COPC is the desired practice of the future.

Training programs need to take account of various functions fulfilled by members of the health team so that the training is relevant and appropriate. It is useful to consider these as follows:

• central or nuclear members;
• supportive members;
• consultative members; and
• community and the health team.

The central team might consist of at least four groups: physicians, nurses, social case workers, and community organizers/health educators. The physicians and nurses, or their less skilled alternates where circumstances so dictate, should be trained in clinical and community health skills. These skills may be effectively combined by some physicians and nurses who have had clinical and epidemiologic training. However, these skills can also be brought together by complementary functioning of different members of the central team, providing all have had a basic training in the various skills needed for COPC. As key personal “health care givers” in COPC, doctors and nurses need to understand health-related behavior and community determinants of health, since an important part of their work is directed towards changing behavior when necessary. Nevertheless, there is little doubt that the behavioral aspects of community health care also need the attention of special workers, such as the social caseworker and the community organizer/health educator. These, too, need special training for their roles in COPC.

Supportive members of the team include administrators, as well as others whose functions are supportive of the central team's activities, such as laboratory, pharmacy, secretarial work, and health records. Their training needs to take account of their role in COPC, with respect to individual care and community health. Thus, the health recorder will be required to maintain a record system not only for case identification and follow-up, but also for epidemiologic purposes, such as community diagnosis, health surveillance, and program evaluation.

The consultants are of two kinds, those for care of patients and those for the community medicine aspects of the practice. The latter include consultants in epidemiology, biostatistics, medical sociology, and health-related behavior, as well as consultants in planning and implementing specific community programs, such as growth and development, mental health, hypertension, or cancer. Most of these consultants would be more interested and able to function more effectively in the setting of COPC if they had some experience in this field. Thus in the case of epidemiologists, the application of their skills to the relatively small populations involved in COPC, a situation to which they are seldom exposed, may require extra experience. In the case of clinicians, there is need for more knowledge of epidemiology and population medicine.

The community's role in relation to the team needs further mention here. As we have indicated there is a growing movement toward a degree of community participation and involvement in the conduct of community-based health services. Community health workers are often recruited from among the people served by the community health service. There is a movement for communities themselves to elect persons from their own communities as community health workers. These workers then undergo various periods of training. They may become members of the health team, or they may be accountable to the community and as such be seen as the spearhead of community involvement in its health care.

There are at least three important elements in training that emerge from this movement towards community involvement. Firstly, the community health workers require special training to help them perform their roles. Secondly, some members of the health team need training in methods of educating these community health workers, together with experience in formulating the content of the curriculum suited to the needs and wishes of the particular community. Lastly, the community itself needs to be introduced to COPC as a modified way of providing primary health care. This is especially important in countries with long-established modern health services. The present image of the physician is in accord with experience of established practice, and this is different from COPC.

The Preparation of Physicians for COPC

We have been concerned with the training of various professional and nonprofessional groups for COPC, more especially physicians, nurses, social workers, community health workers/health educators, and health recorders. This has involved basic or undergraduate programs as well as postbasic and postgraduate training. In this discussion, we propose to focus on some of the more important aspects of physicians' education for COPC, whether for medical students, residency training for specialization, or limited graduate 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 specialization, 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 orientation in primary health care are epidemiology and biostatistics, medical sociology, community health education, and health behavior. Practical experience 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:

• in deciding on priorities for community programs;
• in community diagnosis and health surveillance;
• in evaluation of community programs; and
• in the more immediate clinical situation with consideration of the epidemiologic 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 epidemiologic investigations of special relevance in COPC.

Medical sociology, which for our purposes includes the social and behavioral 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 organization of health services. Of relevance to health and COPC are more specific studies on community characteristics that would focus on various 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, emphasizing 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 patients 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 experience should be so provided as to improve the practitioner's understanding of the family as the most important primary care provider, a key determinant 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 community health diagnosis, planning community programs for the promotion of health (e.g., growth and development of infants and children), the prevention of disease (e.g., immunization, the control and treatment of hypertension 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 residents should participate in the planning and implementation of such programs in COPC, ensuring the development of skills in community diagnosis, health surveillance, and methods of evaluation of these community programs. 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 appreciation 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.

Training 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 direction 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 Hadassah Community Health Center in Jerusalem, 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 Training 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 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 medicine 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 developing a teaching program in COPC is an adequately trained and experienced 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.

PRELIMINARY STEPS

Traditional primary care practitioners of Western societies, family or village doctors, were renowned for their knowledge about the people they doctored. 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 community 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 innercity 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 geographic 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 (Workersr' 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 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 intervention 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, interests, 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 conditions 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 distribution 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 epidemiology, 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 potential 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 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 disorders 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, decision 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 surveillance in the community, and in fact what has happened in various COPC practices with which we have been involved is that the early community diagnosis of particular health conditions will be followed by built-in routines in the practice allowing for health surveillance of these conditions and their determinants.

PLANNING OF INTERVENTION

The formulation of a plan for a community program in the framework of primary health care will thus be based on knowledge gathered through the preliminary steps and community diagnosis that have been outlined. 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 problems, 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 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 community's satisfaction, and in terms of economic efficiency.

The COPC practice as a whole may be evaluated or specified aspects of 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 reviews and program trials. ⁴⁶ These are characterized by differences in their aims and methods. The aim of a program review, like that of clinical epidemiology, is to provide information that will contribute to the health and welfare of the community or population served by the program. It is performed 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 performance 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 essential, especially for a new form of practice like COPC. They require very careful planning and meticulous measurement and usually necessitate procedures 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.