Primary Health Care: Module 2

In this module we will, in a sense, go backwards! We have been talking about Primary Health Care and have noted the strong commitment to achieving health goals in, and by including, communities (phrases such as ‘country and community can afford’, ‘acceptable to the community’, and so forth, should come to mind). Now, after using these terms we are going to go back to examine them in more detail. These are indeed foundation concepts. They underpin PHC and a grasp of them is important for establishing sound rationales for practice.

Since we have used the term community many times already, we can leave the definition just a little longer while we consider this point. We need to address a potential difficulty: PHC is meant to permeate the whole health system, which naturally includes hospitals and other institutions, yet it appears that all the attention relates to the community. There is a danger that this will reinforce the idea that the health system is divided, with those who have a hospital focus pitted against those who have a community focus, and that PHC supports the latter.

It is true that PHC aims to achieve a more rational balance in the distribution of health resources and this clearly will involve a shift in favour of the community at the expense of hospitals. This must be a goal of any approach that seeks to achieve "health for all". One must acknowledge though, that for both practical and political reasons there is at present no likelihood that hospitals will stop dominating the health care system in Australia in the foreseeable future.

Indeed, the imbalance has led some to suggest that we have an illness management system rather than a health care system. Wass (1994, 7) reveals, as shown in the diagram below, that hospitals in Australia consume 41.4% of health expenditure while community and public health consume only 4.4%, little more than one-tenth of the cost of hospitals.

Even when one recognises that, as PHC makes clear, many other sectors that have not been included in these computations expend resources in support of health outcomes, this is still clearly a serious imbalance.

It is easy to see how those with a passionate commitment to health promotion, for example, might well become somewhat anti-hospital. It is therefore important to think this through carefully. In practice, admittedly, one can find individuals who choose to align themselves rather forcefully with one focus or the other. Perhaps this is understandable. It is important to realise that division and antipathy are not practices supported or encouraged by PHC.

Whilst PHC seeks to redress the imbalance, it does not have an anti-hospital agenda as such. It has a pro-health care agenda. If this were to be so successful as to put hospitals out of business (a regrettably unachievable situation), surely that would be a welcome outcome to all committed health care workers.

The principles of PHC that you learned about in module one should be applied universally. This means they are as relevant within hospitals as they are outside hospitals. We need to remember that when we consider the wider community, hospitals are very much included as a part of the community. Indeed, we can view a hospital as a community as we shall see.

In this subject you are encouraged to do three things which should help to keep what we might call a healthy perspective in this matter.

Just how to put this together will become clear as you proceed. For now, let’s take a closer look at the term community.

The term or concept "community" can be defined in either simple or elaborate terms, although once an elaborate approach is taken it frequently becomes a classification of types rather than a definition per se. One report for the WHO (1974) stated: "A community is a social group determined by geographic boundaries and/or common values and interests. Its members know and interact with one another. It functions within a particular social structure and exhibits and creates norms, values and social institutions." This is a quite useful definition.

Hanchet (1979, 7) takes a very simple approach and defines community as "people in relationship with others." This has some merit in that it is non-exclusive but this is also a weakness. This definition is so inclusive it would suggest that all groups constitute communities and this seems unwarranted. Stanhope and Lancaster (1992, 254) suggest that a "community is a locality-based entity, composed of systems of formal organizations reflecting societal institutions, informal groups and aggregates." Their own observation is that this definition "includes personal, spatial, and functional dimensions and recognizes interdependence or interaction among systems within a community" (Stanhope & Lancaster 1990, 254).

Spradley and Allender (1996, 5) define community as "a collection of people who interact with one another and whose common interests or characteristics form the basis of a sense of unity or belonging". As we shall see in the next section, requiring a sense of unity or belonging is unnecessary. In the same place they also state that "Broadly defined, a community is a collection of people who share some important feature or features of their lives in common."

If we apply a practice test to the above definitions, that is, find the one that will be most useful in supporting actual practice, it is likely that the last one will be selected. This will accept both geographic and common values or interests as boundaries. Whilst Stanhope and Lancaster (1990, 254) may be correct when they observe that "Most definitions of community include three dimensions: people, place and function", there are clearly communities for which place is not a factor, so it is best avoided in a definition. Further, this favoured definition is one that can be applied by observers, such as practitioners, or adopted by the members of a community themselves. This last point is important since it does not disempower anyone: if people choose to identify themselves as a community, why impose a definition that will deny them validity?

All classification systems have faults. One fundamental fault is that, being artificial and always to some extent either arbitrary or subjective, the purpose of discrimination eventually breaks down and the items begin to overlap. As expressed elsewhere (Tylee 1988, 2) the classifications tend to ‘run together’ or blur or lose focus. Nevertheless, classification systems can assist with communication among people who understand the system and they can be very helpful in learning about complex phenomena.

Significant work was contributed by Archer and Fleshman (1975, 18-24) who described the following community types and subtypes.

Emotional Communities

These centre on a sense or feeling of community.

Belonging Community: a place where you feel you belong or have ‘roots’. Diminished by a fondness for mobility, privacy or convenience.
Special Interest Community: short or long term and bound by a common interest, eg. A group of parents seeking to have school road crossings patrolled, or all nursing administrators.

Structural Communities

These involve time and space relationships among people and relate to geographic placement.

Aggregates: any aggregate, regardless of why they are gathered, eg. Anything from a nation to a casual crowd.
Face to Face Community: closely knit and relatively small, eg. Group of families, neighbourhood or parish.
Community of Problem Ecology: a geographical area where people share an ecological problem; either physical or social.
Geopolitical Community: units of political jurisdiction with definite legal and geographic boundaries, eg. Towns, cities, states, nations.
Organisations: eg. Health departments, hospitals, churches, trade unions, etc.
Community of Solution: boundaries within which a community health problem can be defined, dealt with and solved.

Functional Communities

These assume community to be an achievement, not merely the result of geographic placement.

Community of Identifiable Need: based on a common problem.
Critical Mass Community: one in which there are sufficient resources (money, personnel, influence, materials, etc) to do something about a problem, need or situation.

As you can see there is plenty of overlap between categories. Nevertheless, such schemas are useful for extending and enriching our understanding of the concept of community.

A common classification used by community nurses is presented by Spradley and Allender (1996, 5-6). Simply put, it includes the following.

Geographic community
Eg. A town or suburb or city
Community of common interest
Eg. The diabetics in a given area

Or perhaps all mastectomy patients
Community of solution
Eg. Those in an effected water supply area

5.1 Introduction

Quite obviously "health" is a central concept. We have already encountered it in Primary Health Care, health promotion, community health, and so on. Presumably it is doubly important to you because you have both a concern to maintain and promote your own health (hopefully!) and you are preparing for or are already following a career in which you will be concerned with the health of others. It is important though, not to make the assumption that you really know what health is. In this section then, we shall explore this complex and abstract concept.

5.2 What is health?

Think about health and write your definition in the space below. Just answer the question: What is health? This information will be submitted for review.

5.3 The WHO definition

The definition of health from the WHO Charter has had many critics. The chief complaint is that it is an unachievable state and is therefore impractical, which one might consider less than ideal given the important and immensely practical role of the WHO. Recognising the limitations of relying on this general statement, in 1957 the WHO released this as their official definition: "Health is a condition or quality of the human organism which expresses adequate functioning under given genetic and environmental conditions" (WHO 1957 in Hetzel 1980, 16).

Here was a definition that seemed more useful. Yet there were problems here too. Over time, it came to feel somewhat negative given its recognition of apparently inevitable genetic and environmental limitations. Then there is the concern that it does not specify the nature of the environment, which must include at least the physical and social domains. The idea of ‘adequate functioning’ also seems awkward. Who decides or can define what is adequate. In the area of health we sometimes see some of the finest evidence of the ability of the human spirit to transcend. Seemingly impossible situations and conditions which have beaten many can be overcome by some.

As a result, the WHO today promotes its original Charter definition, which has the virtues that it:

5.4 A state of being: a total/holistic view

As indicated above, the WHO definition is based on state theory. As a state of being health can be viewed as holistic. This is perfectly consistent with the current views that underpin the way various health professions practice (at least ideally or in their rhetoric). It means that health involves the whole person or whole community (depending on your client focus). It involves the:

domains, and then more. Remember holism means that anything is always more than the sum of its parts.

It also means that, as well as the traditional language, it is also appropriate to describe health in language such as, for example:

This diagram illustrates the issue of whether or not health can be understood as an absolute achievement or something one experiences in relative terms. If health is a ‘complete’ state, as the WHO definition suggests, must it be at the extreme right on the above diagram? If we see the diagram as a continuum, this implies that there can be degrees of health status; that one may move from a position on the continuum towards either higher or lower levels of health.

Since this is consistent with our experience and observations we can, at least tentatively, conclude that health is indeed a relative concept. This is quite important for health carers since the focus of much intervention is to improve health, to work towards optimal health, but we need not feel abject failures if we do not always deliver our patients or clients in a condition of optimal wellness. Thankfully!

It is also important to think about wholeness here. We accept the tenets of holistic practice. We accept the reality that it is absolutely impossible to change any one part of a person or community without in some way changing them as a whole. This means that if we were to situate a person or community at some point on the continuum above, their position reflects their state of being, not their piecemeal functioning.

Let me illustrate this. Take a fit and well young person who has a motor cycle crash and sustains a fractured femur and some minor abrasions. Whilst it may be tempting to imagine this person’s physical dimension has temporarily moved to the left but they are in other dimensions just the same, this would be wrong. The reality of holism, and ‘being’, is that there will clearly be a move to the left but it is made by the whole person, not just a part. In fact this person will have changes in their psychological and social domains and maybe they feel they also just had a spiritual experience! The event has changed them as a whole person, even if the most obvious change is quite physical.

5.5 Subjective and objective: feeling and function

We need to acknowledge that health can have both subjective and objective dimensions. This is particularly important for health practitioners. When enquiring about a person’s health it is common practice to say: "How do you feel?" This acknowledges the subjective nature of health. A person may feel generally well or unwell, better or worse than five minutes ago or yesterday or last year, and so on.

We know however, that whilst it is important to include this subjective data, it will not suffice for a professional assessment. One can encounter individuals, who for reasons ranging from personality to cultural expectations, will report that they are feeling very ill when they appear to be reasonably well, while others claim to be quite fine when they appear most unwell. The experience of these discrepancies alerts us to the fact that we can also conceptualise an objective dimension to health.

When nurses and other health workers make observations of the health status of clients, we know that the process can be highly sophisticated and almost impossible to fully describe, based as it can be on considerable expertise in relating to others. You may recall here the work of Benner (1984) in describing the transition from novice to expert in nursing practice. However, at a simpler level, we can all make reference to normative data about functioning. Accordingly, we see tools used to assess activities of daily living, level of pain, post-natal adjustment, etc.

5.6 Health relates to values and beliefs

The concept of health does have an objective element as we have discussed, but it is also significantly culturally determined. What one culture accepts and defines as healthy may not be a feature in another culture. It is quite healthy and normative in some European countries for adult males to express their feeling rather publicly, even openly weeping, for example. If adult males weep publicly in Australia (notwithstanding the example of a recent Prime Minister) they would probably be considered seriously disturbed. So much so, that without a convincing context they would make many observers feel uncomfortable.

It is also true that what one culture clearly views as health may be considered disease in another. For example, there is a tribe in an African country which lives in a region where a spirochaete is endemic in the ground. Each year in the wet season it becomes active and as people walk about without footwear it enters via fine abrasions in the soft area between the toes. In our terms they become infected and the only evidence of this is the development of blotches on the skin which are permanent.

In our culture this infection would be seen as unhealthy; the blotches as pathology. We would seek treatment (although hopefully you would recommend prevention!). In the other culture though it is different. When occasionally an individual has a level of natural immunity that prevents the pathology from progressing to produce the blotches, you guessed it, they are considered unhealthy and are ‘treated’ to help produce the blotches.

You may feel that we are right and they are wrong. Be careful; such feelings merely betray ethnocentrism and that is a disorder of values and belief that you can do without. They are simply different and any input we may offer in the form of education or treatment would need to be very culturally sensitive. For now, we simply want to make the point that health is a concept that is culturally determined, at least to some degree.

5.7 Resource or asset

Another way the concept of health is used is to view it as an asset or resource. One does not have to be an economic rationalist or to suffer from economism (ie the tendency to view everything in economic terms) to think this way. Perhaps you have heard someone who has perhaps just sustained the loss of a great opportunity or their job, remark: "Oh well, I still have my health!" This is recognition that health is something that can be regarded as a possession, an asset.

Even in our ‘generous’ welfare state in Australia, the capacity to work and be gainfully employed is important. This capacity is dependent on a certain level of health. This is clearly recognised by such things as pre-employment health examinations, compensation schemes, and so on.

What is true for individuals is also true for whole communities or countries. If the overall population has a relatively high level of health then public money which would otherwise have to be spent on health care (usually illness care) can be spent on other standard-of-living enhancements (perhaps free tertiary education would be nice or safer roads or more parks!). A high level of health in the population is therefore a significant resource.

To conclude, you need to complete the activity below and then follow-up with some extra reading.

Once again, think about health and write your definition in the space below. Just answer the question: What is health? This information will be submitted for review.