Primary Health Care Philosophy Research Articles

An overview of Iran's actions in response to the COVID-19 pandemic and in building health system resilience.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The considerable human, social, and economic impacts of COVID-19 have demonstrated a global lack of health system resilience, highlighting gaps in health system capacities due to fragmented approaches to health system financing, planning, and implementation. One of the key actions for ensuring equitable essential health services in all countries in normal situations as well as emergencies is through strengthening the primary healthcare (PHC) system. In the context of the unfolding pandemic, the Iranian Ministry of Health and Medical Education (MoHME) undertook a variety of strategic actions to ensure the sustainability of health services during the current health emergency and to promote health system resilience against future shocks. Right after the Alma-Ata declaration in 1978, MoHME pursued the PHC philosophy incorporating the principles within the WHO health system framework and its six building blocks. In response to the evolving pandemic, MoHME put in place several interventions to ensure the maintenance of essential health services in addition to the provision of response. Some interventions were new, informed by global experience with COVID-19, while others leveraged existing strengths within the existing health system. Those were taking a whole-of-government approach; leveraging the PHC capacity; supporting the workforce; strengthening preparedness and response; improving access to medicines, vaccines, and health products; and leveraging the health information system into the pandemic response. Health system strengthening that promotes resilience is imperative for governments as health systems are fundamental to sustainable socioeconomic development. In recognition of this, the WHO Eastern Mediterranean Regional Office (EMRO) has recently outlined regional priorities for advancing universal health coverage (UHC) and ensuring health security. Iran's approach both prior to and during the pandemic is strongly aligned with those regional priorities, which are "primary health care-oriented models; enhancing health workforce; promoting equity; enabling environment for research; improving access to countermeasures; and fostering health system resilience."

What are the roles of community health workers? Looking back at the philosophies of primary health care.

This commentary discusses the different roles of community health workers (CHWs), their challenges and limitations in a historical perspective of primary health care (PHC). We first try to show that the comprehensive philosophy of PHC promulgated in Alma-Ata proposed the role of CHWs as actors who work in community development. On the other hand, in the 1980s, with the emergence of the selective philosophy of PHC, CHWs' role was more affiliated with the health system. We conclude our pitch about the balance that can exist between these different roles by suggesting that CHWs can work in continuity with the health system, but they should not be considered as affordable labor. Also, they must be supported in their activities to develop their communities, allowing them to participate effectively in programs and policies that concern them and their community.

Conceptualization of competency based curricula in pre-service nursing and midwifery education: A grounded theory approach.

In health professional education, the competency-based curriculum concept has been an important driver of reform in the training of competent graduates for the 21st century. In African countries, although there has been implementing it in pre-service nursing and midwifery education and the literature reports a lack of understanding of what is it on the part of the implementers. This article explores the meaning of competency based curriculum in pre-service nursing and midwifery education in Rwanda. A grounded theory approach, following Corbin and Strauss, was used. Following ethical clearance by the university ethical committee, data was collected from 17 participants through in-depth individual interviews of staff. Four categories emerged: (a) transformation, (b) tool for primary health care philosophy, (c) technological approach to education, (d) and modular system. Competency-based curriculum is confirmed as an appropriate educational tool in producing competent graduates for today and the future.

Mapping primary health care renewal in South America.

Primary health care (PHC) renewal processes are currently ongoing in South America (SA), but their characteristics have not been systematically described. The study aimed to describe and contrast the PHC approaches being implemented in SA to provide knowledge of current conceptions, models and challenges. This multiple case study used a qualitative approach with technical visits to health ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53 local managers, as well as field observation of 57 selected PHC providers and document analysis, using a common matrix for data collection and analysis. PHC approaches were analysed by triangulating sources using the following categories: PHC philosophy and conception, service provision organization, intersectoral collaboration and social participation. Primary health care models were identified in association with existing health system types and the dynamics of PHC renewal in each country. A neo-selective model was found in three countries where coverage is segmented by private and public regimes; here, individual and collective care are separated. A comprehensive approach similar to the Alma-Ata model was found in seven countries where the public sector predominates and individual, family and community care are coordinated under the responsibility of the same health care team. The process of implementing a renewed PHC approach is affected by how health systems are funded and organized. Both models face many obstacles. In addition, care system organization, intersectoral coordination and social participation are weak in most of the countries.

Needs-based public health service provision ensures equity

We welcome the contribution of Iversen, Hope, and McVeigh (2016) to the debate about the allocation of scarce HIV prevention resources. In our paper we raised the dilemma posed by competing demands for the Kirketon Road Centre’s needle syringe program (NSP) in Sydney’s Kings Cross. Iversen et al. suggest that the more targeted approach we adopted recently to preventing blood borne infections (BBIs) among people who inject performance and image enhancing drugs (PIEDs) is inequitable and discriminatory (Iversen et al., 2016). We feel they may have over interpreted its ‘‘restrictiveness’’. They also appear to conflate demand with need for such services, and being discriminatory with being discriminating in the use of scarce resources. While Iversen et al. point to the WHO/UNODC/UNAIDS Technical Guide, which advocates universal access among people who inject drugs (PWID) and recommends that services should be equitable and non-discriminatory (without exclusion criteria), being inequitable and discriminatory would also contravene KRC’s own longstanding explicit commitment to WHO’s Primary Health Care philosophy stating that health care should be accessible, acceptable, affordable and equitable (van Beek, 1994, 2007; World Health Organization, 1978). We would like to point out that this Technical Guide goes on to state that: ‘supply should be determined by need’ (World Health Organization, 2012), which we strongly endorse. We suggest that the Needle Syringe Program (NSP) supply to PIEDs injectors in Australia has primarily been driven by demand, which does not necessarily coincide with need, and can even be inversely proportional in the case of socially marginalised populations. A R T I C L E I N F O

Promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective

Background. Community-based education (CBE) serves as a primordial instrument in the implementation of primary healthcare (PHC). Learning experiences in community-based settings provide students with learning opportunities, as they are actively engaged in PHC-associated activities in under-resourced communities. Many nursing schools in higher education integrated and implemented a CBE programme with an end-goal of becoming healthcare practitioners who are responsive to the needs of the community. Objectives. To establish how PHC philosophy is promoted through a community-based nursing education programme. Methods. The study was non-experimental and cross-sectional with a quantitative approach and was done at a selected higher education institution in KwaZulu-Natal, South Africa. A total of 118 participants were selected using the non-probability convenience sampling technique. A self-report questionnaire was distributed to the participants; 91 questionnaires were completed and returned – a response rate of 73.3%. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Committee. Participation was voluntary, informed consent was obtained, and other ethical principles were respected. Data were analysed with the Statistical Package for Social Sciences (SPSS). Descriptive and analytical analysis was used to analyse the data. Results. The participants reported exposure to community-based learning from the first until the fourth year of their study programme. Participants (69.9%) indicated that their learning activities had involved members of the community. The community-based learning projects, which mostly promoted a PHC philosophy, included prevention of illness, injuries and social problems (90.1%), health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%). Conclusion . Findings revealed that the community-based learning experiences of students promoted a PHC philosophy and that underprivileged community settings provided a rich learning environment.

Abstract: Promotion of Primary Health Care Philosophy in a Community-Based Nursing Education Program: Students’ Perspective

Abstract Background Community-based education (CBE) serves as a primordial instrument in the implementation of Primary Health Care (PHC). Learning experiences in community-based settings provide the students with opportunities to learn by means of being actively engaged in primary health care associated activities to under-resourced communities (Mtshali, 2009, 2005; World Health Organization ,2011a; World Health Organization, 2011b). International Council of Nurses (ICN) (2009) and World Health Organization (1993) recommends this educational approach as means of implementing PHC and responsive education. In response, many of the nursing schools in higher education integrated and implemented a community-based education programme with an end goal of becoming healthcare practitioners who are responsive to the needs of the community and promoting PHC. Aim This study explored how Primary Health Care philosophy is promoted through a community-based nursing education program. Methodology A non-experimental, cross-sectional study with a quantitative approach was carried out at a selected higher education institution in KwaZulu-Natal. A total of 118 participants were selected using the non-probability convenience sampling technique. A self-report questionnaire was distributed to the participants and 91 questionnaires were completed and returned with a response rate of 73.3%. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Committee. The participation was voluntary and informed consent was obtained and other ethical principles were respected. Data were analyzed descriptively and analytically with the Statistical Package for Social Sciences (SPSS). Results The participants reported exposure to community-based service learning (CBSL) throughout their study program. Findings revealed that 69.9% of participants indicated that their learning activities had involved members of the community. The community-based learning projects which mostly promoted a primary health care philosophy ranged from prevention of illness, injuries and social problems (90.1%); health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%). The findings indicated that 98.9% had positive perceptions about CBE and overall 79.5% of participants strongly perceived CBE as a tool to promote PHC philosophy. Conclusion The findings of the study revealed that the community-based learning experiences of students promoted primary health care philosophy and that underprivileged community settings provided a rich learning environment. Community -Based Service Learning should be included in nursing education programs as a responsive educational approach in order to prepare graduates who are competent and willing to work in, and serve underserved communities. Key words : nursing education, community-based education, community-based learning, primary health care, community-service learning

Identifying student knowledge and perception of what is valuable to professional practice: A mixed method study

Bachelor of Nursing programmes are designed to prepare Registered Nurses for professional practice. The Bachelor of Nursing curriculum under discussion was shaped by the conceptual framework of primary health care philosophy, including themes of social justice, Indigenous health, caring philosophy, and the advancement of the discipline through research, scholarship and application of nursing knowledge and evidence-based practice. This study was designed to identify what students and graduates found valuable in a Bachelor of Nursing curriculum conceptual framework and what value they placed on a conceptual framework and underpinning themes. A small study was designed to identify the student perceptions of themes which may be valuable to the new curriculum of the Bachelor of Nursing. A mixed methodology was selected as being appropriate to allow students to indicate the value that previous and completing students placed on each of these items and to explore their perceptions. The setting for this small study was a regional university in NSW, Australia. Previous and completing (final year) students were invited to complete the online survey and any who were willing to be interviewed were asked to provide their contact details. The research was conducted via a questionnaire through Survey Monkey, using a Likert scale and open responses and follow up interviews were conducted with willing participants. A total of 128 responses to the survey were received and ten were interviewed. Overall responses were positive. Students were aware of and valued all aspects of the current and proposed conceptual framework. There were some themes; however which were better understood than others. The majority of graduated students indicated that they were well prepared for the workforce. All aspects of the conceptual framework of the curriculum were valued by the majority of students.

Rainbows: A primary health care initiative for primary schools

Within the current Australian health system is the understanding of a need to change from the predominate biomedical model to incorporate a comprehensive primary health care centred approach, embracing the social contexts of health and wellbeing. Recent research investigated the benefits of the primary health care philosophy and strategies in relation to the Rainbows programme which addresses grief and loss in primary school aged students in Western Australia. A multidisciplinary collaboration between the Western Australian Departments of Health and Education enabled community school health nurse coordinators to train teacher facilitators in the implementation of Rainbows, enabling support for students and their parents. The results of this qualitative study indicate that all participants regard Rainbows as effective, with many perceived benefits to students and their families.

Primary health care as a philosophical and practical framework for nursing education: Rhetoric or reality?

At least three decades after primary health care (PHC) took nursing by storm it is time to re-examine the philosophical shift to a PHC framework in pre-registration nursing curricula and overview factors which may hinder or promote full integration of PHC as a course philosophy and a contemporary approach to professional practice. Whilst nurse education has traditionally focused on preparing graduates for practice in the acute care setting, there is continuing emphasis on preparing nurses for community based primary health roles, with a focus on illness prevention and health promotion. This is driven by growing evidence that health systems are not responding adequately to the needs and challenges of diverse populations, as well as economic imperatives to reduce the burden of disease associated with the growth of chronic and complex diseases and to reduce the costs associated with the provision of health care. Nursing pre-registration programs in Australia and internationally have philosophically adopted PHC as a curriculum model for preparing graduates with the necessary competencies to function effectively across a range of settings. Anecdotal evidence, however, suggests that when adopted as a program philosophy PHC is not always well integrated across the curriculum. In order to develop a strong and resilient contemporary nursing workforce prepared for practice in both acute and community settings, pre-registration nursing programs need to comprehensively consider and address the factors impacting on the curricula integration of PHC philosophy.

Primary health services at district level in South Africa: a critique of the primary health care approach.

BackgroundThe rhetoric of primary health care philosophy in the district health system is widely cited as a fundamental component of the health transformation process in post-apartheid South Africa. Despite South Africa’s progress and attempts at implementing primary health care, various factors still limit its success.DiscussionInconsistencies and poor understanding of primary care and primary health care raises unrealistic expectations in service delivery and health outcomes, and blame is apportioned when expectations are not met. It is important for all health practitioners to consider the contextual influences on health and ill-health and to recognise the role of the underlying determinants of ill-health, namely, social, economic and environmental influences. The primary health care approach provides a strong framework for this delivery but it is not widely applied.There is a need for renewed political and policy commitments toward quality primary health care delivery, re-orientation of health care workers, integration of primary health care activities into other community-based development, improved management skills and effective coordination at all levels of the health system. There should also be optimal capacity building, and skills development in problem-solving, communication, networking and community participation.SummaryA well-functioning district health system is required for the re-engineering of primary health care. This strategy requires a strong leadership, a strengthening of the current district heath system and a greater emphasis on health promotion, prevention, and community participation and empowerment.

Enhancing decolonization and knowledge transfer in nursing research with non-western populations: examining the congruence between primary healthcare and postcolonial feminist approaches

This article is a call for reflection from two distinct programs of research which converge on common interests pertaining to issues of health, social justice, and globalization. One of the authors has developed a research program related to the health and well-being of non-western populations, while the other author has expanded the field of Aboriginal and international research in Canada and abroad. Based on examples drawn from our respective programs of research, we suggest conciliating the philosophy of primary healthcare to postcolonial feminism for decolonizing research and enhancing knowledge transfer with non-western populations. We contend that applying the theoretical and methodological strengths of these two approaches is a means to decolonize nursing research and to avoid western neocolonization. In conciliating primary health care and postcolonial feminism, the goal is to enhance the pragmatic relevance of postcolonial feminism to generate resistance through transformative research for achieving social justice. In tapping into the synergistic and complementary epistemological assumptions of the philosophy of primary health care and postcolonial 'feminisms', nurse researchers reinforce the anti-oppresive goals of postcolonial feminist research. Consequently, this approach may enhance both decolonization and knowledge transfer through strategies like photovoice.

A Partnership Model Evolves from a Living Inventory of Engagement

This university-community partnership developed when practitioners at a community health centre within a regional health authority collaborated with nursing faculty at the University of New Brunswick in Saint John, New Brunswick, Canada. A philosophical match and work context facilitated this collaboration. Partners acknowledged that continued maintenance of the partnership, or its termination, was dependent on the acceptance of principles of partnership engagement. Even though the common philosophy of primary healthcare brought these partners together and reciprocal capacity building was the glue that nurtured their partnership, the tensions that arose fuelled its continued growth and development. Roles and responsibilities of members were discerned and space was created to acknowledge and integrate the lessons learned when tensions were examined. Within this environmental context, a model of partnership emerged. Tensions within this model were accepted as opportunities that resulted in beliefs being challenged, relevant questions generated and partnership alliances strengthened. In this spiral process, new relevant knowledge was constructed and new norms for best practice and policy were developed. The utility of this inter-professional Partnership Model: Living Inventory of Engagement is demonstrated through case examples.

Models of health service delivery in remote or isolated areas of Queensland: a multiple case study

Objective: This paper reports on models of health service delivery in remote or isolated areas of Queensland. Background: There is little research that investigates current models of health service delivery in remote or isolated areas of Australia. Design: A multiple case study research design was employed that included interviews and focus groups. Setting: Three types of health care facilities in remote or isolated Queensland. Subjects: Thirty-five registered nurses. Results: Findings indicated that nurses and Indigenous health workers are predominantly resident and provide health services in this environment, while medical and allied health care services are usually provided by non‑resident visiting specialists. Conclusions: Findings suggest that meeting the needs of communities in remote and isolated areas of Queensland requires a change in the focus of health service delivery to accommodate a primary health care philosophy. The introduction of a new model of health service delivery is recommended; however this will only occur if resources are harnessed to prepare staff to reprioritise services offered. Implications for Health Service Management: Supporting community partnerships with shared responsibility between health service providers and community members for increasing primary care prevention practices is advocated.

Health promotion perceptions among community pharmacists in Nigeria

AbstractObjectiveTo explore the attitudes of Nigerian community pharmacists towards health promotion, to determine the importance pharmacists attach to health promotion behaviours and their perceived involvement in promoting them among their clients.MethodsWe conducted a cross-sectional survey of community pharmacists in two Nigerian cities. Attitudes toward health promotion were assessed using a 24-item instrument. The importance pharmacists attach to healthy behaviours as well as their perceived involvement was assessed using a 23-item standard instrument. Interval data on questionnaire items were gathered on a Likert-type scale, and the demographic characteristics of the respondents were also profiled. Principal factor analysis employed Varimax rotation with Kaiser normalisation. Associations between demographic profile and responses were evaluated using Student's t test and one-way ANOVA.ResultsAbout 84% of the respondents indicated a favourable attitude towards health promotion. Nearly all the respondents (98%) were interested in health promotion services, and 94% indicated willingness to devote extra time to talk to patients. A majority (93%) reported willingness to retrain on health promotion. Lack of health promotion policy for pharmacists, and negative attitude towards the utilisation of pharmacy technicians were potential barriers. Pharmacists that were studied attached very high importance to 12 of the 23 widely advocated health promotion behaviours, and felt they should be very involved in seven of them. Medication-related counselling, use of condoms, and maintenance of blood pressure were perceived to be top priorities. Rating attitudinal scores, importance of healthy behaviours, and level of involvement were 94.07 ± 20.77, 99.22 ± 21.78, and 93.33 ± 24.01 respectively (range 23 to 115; midpoint 69). Perceived involvement had moderate correlation with the importance attached, r = 0.6488 (P = 0.0008).ConclusionThere is an indication that the Nigerian community pharmacists in this survey perceived an extended role in health promotion, especially medication-related activities. This is consistent with the philosophy of primary healthcare and pharmaceutical care.

Caring for a marginalised community: the costs of engaging with culture and complexity

The Care and Prevention Programme (CPP) began in 1998. It is based on the philosophy of primary health care, and has improved health among homosexually active men, including about a third of HIV-positive South Australians. The CPP was assessed using financial analysis and qualitative methods. Participants wanted to access care where they could feel comfortable and safe to talk about issues of sexuality and lifestyle. The CPP model is "economically" sustainable, but not "financially" sustainable within the Medicare Benefits Schedule. It is vulnerable to changes in political environment. The financing model for the CPP has been adapted by including state funding. General practitioners have adapted by lowering their personal incomes (but not quality of care). These adaptations have achieved fragile financial viability. Facilitators of sustainability for the CPP included: It is part of the community that it serves; The creation of deeply integrated networks of diversity-competent service providers; and "Virtuous non-adaptability" of service providers in refusing to compromise care standards despite financial pressure to do so. Threats to sustainability included: Difficulty maintaining a diversity-competent workforce skilled in HIV medicine; Marginal financial viability; and Political vulnerability.

General practice — chaos, complexity and innovation

Primary health care (PHC) reforms focus on improving access to and effectiveness of general practice services, with greater emphasis on health promotion, prevention and chronic disease management, and integration with population health approaches. Currently, reforms are often based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood. Complexity theory is based on understanding patterns that are not predictable by traditional evidence and social knowledge, within a complex adaptive system. Complexity knowledge provides a way of understanding the general practitioner's role in PHC in self-organising local networks, with a capacity to generate new solutions integrated through historical and social connections. Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies.

Taking a systematic approach to addressing health inequality in Primary Health Care

The history and philosophy of primary health care (PHC) in Australia is strongly linked to achieving ?Health for All?. As can be seen from the range of papers in this edition of the Australian Journal of Primary Health, considerations of equity, participation and action to address the underlying causes of poor health drive many programs and research endeavours. We have reason to be proud of the energy, enthusiasm and innovation that is demonstrated in the work presented, and heartened that there is an ever-increasing body of work which demonstrates the effectiveness of a comprehensive PHC approach in improving health and quality of life.

Priorities in oral health care in non-EME countries

This paper describes the prevailing problems pertaining to oral care in non-established market economy (non-EME) countries. The current situation with large numbers of untreated cases of oral diseases, the inequality in delivery systems and the virtual non-existence of an adequate community oriented prevention calls for action. What is needed is a turn towards an oral care system that meets the principles of primary health care (PHC). This implies an oral health care system which makes use of the existing health care infrastructures and which applies an appropriate technology with emphasis on community oriented prevention directed to all at an affordable price. Four components of oral care are proposed as priorities in basic oral care, aiming to achieve the objectives of the PHC philosophy. These four components are: emergency care; exposure to fluoride; oral health education (OHE); atraumatic restorative treatment (ART). These components should be available for all. The exact content and extent of each component in various countries depends on local existing supporting conditions and on the level of development as well as on specific perceived needs of the population. Therefore, small-scale demonstration projects containing one or more of the described components should firstly be launched in various countries to evaluate the acceptability, effectiveness and sustainability of the proposed basic oral care programme.

Learning in the field: curriculum issues in a diploma in public health nursing

Illuminative evaluation of a public health nursing curriculum shows that there was a gap between theory and practice, originating in the ways in which public health nursing was understood in the field, and therefore during students’ placements, and in the university. The difference was chiefly in how the community staff and the lecturers understood primary health care. The former had a ‘medical/professional’ understanding of primary health care, implying that the professional knows best and that the client is an individual, a family or a group. The lecturers held a philosophy of primary health care with special emphasis on partnership with clients at all levels: individual, family, group and community; the partnership approach was intended to permeate the entire curriculum. Besides philosophical differences, there were other features of the theory practice gap demonstrated elsewhere. Fieldwork practice is integral to learning public health nursing so these contrasts created a serious disjunction within the curriculum. Actual and potential ways of improving curriculum integration are discussed.