Primary Health Care Delivery System Research Articles

The ayurveda education in India: how well are the graduates exposed to basic clinical skills?

“Ayurveda” is an ancient system of healthcare that is native to India. At present, in India, there are more than 240 colleges that offer a graduate-level degree (Bachelor of Ayurvedic Medicine and Surgery—BAMS) in Ayurveda. Even though the Central Council of Indian Medicine, the governing body that monitors the matters related to Ayurveda education, has imposed various educational norms and regulations, the standard of education has been a cause of concern in recent years. The mushrooming of substandard Ayurvedic colleges is the most important factor that is being held responsible for this kind of erosion in the standards. The present study is a mailed survey, which was carried out to evaluate the “Extent of exposure to basic clinical skills during BAMS course” as perceived by the sample groups of students and teachers drawn from 32 Ayurvedic educational institutions spread all over India. A methodically validated questionnaire was used as the tool in the study, to which 1022 participants responded. The study indicates that there are some serious flaws in the existing system of the graduate-level Ayurveda education. Since the Ayurvedic graduates play an important role in the primary healthcare delivery system of the country, governing bodies are required to take necessary steps to ensure the adequate exposure of the students to basic clinical skills. Along with the strict implementation of all the regulatory norms during the process of recognition of the colleges, introducing some changes in the policy model may also be required to tackle the situation.

Integrating syndromic case management of sexually transmitted diseases in primary healthcare services in Nigeria

Sexually transmitted diseases (STDs) are a huge public health problem; both the aetiological and clinical approaches to management have limitations. WHO has therefore developed an alternative strategy--the syndromic case management approach. This paper reports a training of healthcare providers at the Primary Health Centers aimed at integrating STD care into other services in the PHCs to improve management at the community level. Sixteen nurses, from eight PHCs were trained on this new strategy. The training included: identification of STDs, use of flow charts, patient education and counseling, clinic management issues and record keeping and reporting. Over a period of eight weeks post training, about 731 clients were attended to, 451 (61.7%) had signs and symptoms of various STDs (genital discharge, genital ulcer, genital warts and lower abdominal pains). They were treated using the syndromic case approach. About 18.6% (84/451) were males and 81.4% (367/451) were Females. Singles (never married) constituted 32.8% (148/451) while 28.6% were married. About 26.6% and 12.0% were divorced and separated respectively. Age group 20-35 years was at highest risk of infection Syndromic case management of STDs can be conveniently integrated into the primary health care delivery system in Nigeria.

Global Health Assistance for Chronic Illness: A Look at the Practical

The changing pattern of disease in the developing world calls for a change in the structure, goals, and personnel of global health assistance. Chronic diseases are now the dominant threat to health and are becoming a challenge to economic advancement in developing economies. Because confronting these diseases, heart disease and diabetes mellitus in particular, requires long-tem, ongoing programs, the support and funding must come from within and therefore must reflect a nation's commitment to combat them. One model for this change is a 3-legged stool or platform upon which an assault on chronic disease can be built. The 3 legs are (1) an effective primary health care delivery system, (2) effective health promotion, and (3) a macroeconomic repositioning of health within the government bureaucracy and the world of commerce. To construct each of these legs requires changes in the structure and roles of global health assistance organizations.

Rapid urbanization - Its impact on mental health: A South Asian perspective

Rapid increase in urban population as a proportion of total population is resulting in rapid urbanization of the world. By the end of 2008, a majority of the world's population will be living in the cities. This paradigm shift in the dynamics of human population is attracting attention of demographers, sociologists, scientists, and politicians alike. Urbanization brings with it a unique set of advantages and disadvantages. Though it is driving the economies of most of the nations of the world, a serious concern regarding the impact of urbanization on mental health is warranted. The impact of urbanization on mental health in South-Asian countries needs to be examined. These countries by virtue of their developing economies and a significant proportion of population still living below poverty line are particularly vulnerable and tend to have a higher burden of diseases with an already compromised primary health care delivery system. The range of disorders and deviancies associated with urbanization is enormous and includes psychoses, depression, sociopathy, substance abuse, alcoholism, crime, delinquency, vandalism, family disintegration, and alienation. Thus, it is a heterogenous mix of problems and categorizing them to one particular subtype seems daunting and undesirable. Urbanization is affecting the entire gamut of population especially the vulnerable sections of society - elderly, children and adolescents, and women. Rapid urbanization has also led to creation of “fringe population” mostly living from hand to mouth which further adds to poverty. Poverty and mental health have a complex and multidimensional relationship. Urban population is heavily influenced by changing cultural dynamics leading to particular psychiatric problems like depression, alcoholism, and delinquency. Judicious use of resources, balanced approach to development, and sound government policies are advocated for appropriate growth of advancing economies of South-Asian region.

Vulnerable Populations in Thailand: Giving Voice to Women Living With HIV/AIDS

Thailand was the first Asian country hit by the AIDS epidemic, and in the 1990s reported the fastest spread of HIV/AIDS in the world. According to Thailand's Ministry of Public Health, women, primarily between the child-bearing ages of 15 and 49, are increasingly becoming infected with HIV. A number of factors contribute to the increasing AIDS epidemic, including the rise of the commercial sex industry in Thailand; social disparities that have existed between men and women throughout Thailand's history; and the gender-expectations faced by Thai women toward family and society. Thailand enjoys one of the oldest, reputedly successful primary health care delivery systems in the world; one that relies on community health workers to reach the most rural of populations. In the mid-1990s, day care centers were established at district hospitals by the Thai government to provide medical, psychological, and social care to people living with HIV/AIDS (PWA). Buddhist temples also provide a source of alternative care for PWAs. However, the AIDS policy of the Thai government relies on families to care for the country's sick. Although poor women are a vulnerable population in Thailand, they are changing the paradigm of AIDS stigma while providing a significant cost-savings to the Thai government in their caregiving activities. Based on existing nursing studies on Thailand, this chapter gives voice to poor Thai women living with HIV/AIDS, and examines how they make sense of their gendered contract with society and religion while being HIV/AIDS caregivers, patients, or both.

Health Sector Reforms: A Study of Primary Health Care Delivery System in Tribal Areas of Andhra Pradesh

Health Sector Reforms: A Study of Primary Health Care Delivery System in Tribal Areas of Andhra Pradesh

Traditional medicine development for medical and dental primary health care delivery system in Africa

Traditional African Medicine (TAM) is our socio-economic and socio-cultural heritage, servicing over 80% of the populations in Africa. Although, it has come a long way from the times of our ancestors, not much significant progress on its development and utilization had taken place due to colonial suppression on one hand, foreign religions in particular, absolute lack of patriotism and political will of our Governments, and then on the other hand, the carefree attitudes of most African medical scientists of all categories. It is incontrovertible that TAM exhibits far more merits than demerits and its values can be exploited provided the Africans themselves can approach it with an open mind and scientific mentality. The degree of sensitization and mobilization by the World Health Organization (WHO) has encouraged some African countries to commence serious development on TAM. The African Regional Director of the WHO has outlined a few guidelines on the responsibilities of all African nations for the realistic development of TAM, in order to sustain our health agenda and perpetuate our culture. The gradual extinction of the forests and the inevitable disappearance of the aged Traditional Medical Practitioner should pose an impending deadline for us to learn, acquire and document our medical cultural endowment for the benefit of all Africans and indeed the entire mankind. Key Words: Traditional African Medicine practice, TAM and PHC, WHO and TAM, herbal production, herbal dentistry Afr. J. Trad. Comp. Alt. Med. , 2005, 2 (1): 46-61

Developing school health services in Massachusetts: a public health model.

In 1993 the Massachusetts Department of Public Health (MDPH) began defining essential components of school health service programs, consistent with the public health model. The MDPH designed and funded the Enhanced School Health Service Programs to develop 4 core components of local school health services: (a) strengthening the administrative infrastructure; (b) promoting health education, including tobacco control activities; (c) linking school health services with health care providers; and (d) implementing management information systems. Funds were appropriated in 1992 from the tobacco excise tax. With additional funding appropriated in 1999 and 2000 from the Tobacco Settlement Fund, these school nurse-managed programs have increased in number. The goal is to develop a statewide system of high-quality school health service programs responsive to the specific needs of students in each community. To be effective, these programs must be recognized as essential components of the primary health care delivery system serving children.

Defining primary care and the chiropractic physicians' role in the evolving health care system

Objective To review the literature assessing current trends within primary health care and its delivery and the role of the chiropractic primary care physician. Data Sources Select papers which offer definitions of primary care. Data Synthesis Several influential papers offer criteria necessary to be considered primary care practitioners. Results Primary care is comprehensive, coordinated, continuous and accessible. Chiropractic care meets this definition. Conclusion The primary care chiropractic physician is a viable and important part of the primary health care delivery system, with many chiropractic physicians currently prepared to participate effectively and competently in primary care.

Planetary Health

This paper is an exercise in integrative thinking. Accepting the perilous decline of the environment as a given, and accepting the growing evidence of serious damage to human health, Planetary Health suggests a philosophy of environmental health that implies deep societal and educational change. It presents a conceptual framework for understanding human health as a dynamic condition of sustainability arising from successful integration of ecological sub–systems, of which the human species is but one. Human health and planetary health are fundamentally inseparable. The environment is the primary health care delivery system: the disruption of the environment threatens us with a health crises beyond our experience. As a species priority, we need a vision of how to sustain the planetary health care system. What are the broadest contextual determinants of individual and societal health? What are the behavioral implications of profound interdependence? Planetary Health attempts to synthesize multiple aspects of human health - physical, economic, behavioral, and cognitive into a vision of human sustainability. It proposes the phenomenon of human health as one aspect of a unifying ecological principle. It proposes this reality as the appropriate foundation of educational and social policy.

Physicians' preferences for specialty involvement in the care of patients with neurological conditions.

Recent changes in the US health care system have produced questions about the appropriate roles and responsibilities of generalist and specialist physicians within a primary care-centered health care delivery system. To determine neurologists' and primary care physicians' preferences for specialist involvement in the management of common neurologic conditions and the factors influencing these preferences. A self-administered questionnaire was developed with the assistance of a multispecialty Advisory Board and sent to a stratified probability sample of 608 family physicians, 624 general internists, and 492 neurologists. The questionnaire contained three clinical scenarios, each followed by questions regarding respondent preferences for the primary care physician to manage alone, curbside, or refer to a specialist. The questionnaire also contained knowledge questions corresponding to each scenario and physician and practice characteristics questions. Response rate was 60%. For all three scenarios, primary care physicians' preferences to involve a specialist differed substantially from neurologists' preferences, with nearly all neurologists preferring involvement of a specialist. Primary care physicians with less knowledge were more likely to prefer assistance from a neurologist. Physician age and practice setting influenced the type of assistance preferred (curbside vs. referral). Utilization management techniques and financial incentives had little influence on physician preferences to involve a specialist. The extensive disagreement between primary care physicians' and specialists' preferences for specialty involvement represents cause for considerable concern, supporting further efforts to identify where inappropriate referral processes are occurring and to implement mechanisms for improving the coordination and quality of primary and specialty care.

An integrative review illuminates curricular applications of primary health care.

The International Council of Nurses supported primary health care and advocated its acceptance by other intersectorial stakeholders. Nurse educators involved in curriculum development have respected this direction. To pursue the primary health care vision and influence the adoption of primary health care delivery systems, all principles of primary health care must be implemented simultaneously. An integrative review was conducted to ascertain the interpretation of primary health care held by nurse authors. A content analysis of the nursing literature revealed that 184 of the 254 articles retrieved (72%), applied primary health care in a manner that is consistent with the World Health Organization (WHO) definition. Through curricular applications of different interpretations of the primary health care principles, differences in the created learning environment are discussed. The Declaration of Alma Ata, evolving from beliefs and values shared by 134 member nations present at the Assembly, delineated that primary health care was the accepted infrastructure to guide policies that direct health care delivery systems regardless of the context in the country (WHO, 1978). Even with this overwhelming endorsement, very few countries have made changes in policies and infrastructure for implementing the underlying values and beliefs ascribed in primary health care. Changes that have occurred have not been organized around the vision or the principles of primary health care. This delay has had, and will continue to have, a huge impact on nursing education, practice, and research. Nurses are interested in helping people attain, maintain, or regain health; primary health care has the potential to achieve health for all citizens of the world.

REVIEW OF A COMMUNITY ORAL HEALTH PROGRAMME IN NIGERIA AFTER TEN YEARS

This paper reviews the activities of a model community oral health programme (COHP) which is situated in Idikan, a low income urban community in Ibadan, south western Nigeria. The programme which has been in existence since 1988, is part of a comprehensive primary health care (PHC) delivery system that caters for the basic health needs of members of the community. The programme was designed to prevent diseases of the oral cavity and to provide basic oral care services. It comprises school health programmes, health education programmes for specific target groups, examination for early detection of diseases and provision of dental services at the clinic located on site. Within the first ten years under review (1988-1997), a total of 780 patients were seen at the dental clinic. Three hundred and eighty one were(381) males, while 399 were females and their ages spanned a wide range. Many were petty traders(43.3%), 187(23.9%) were students and 131(16.8%) were skilled artisans. Pain was almost invariably the presenting complaint. In many instances, pain was accompanied by dento-alveolar abscess. Only in a few cases did patients present for routine check-ups or for aesthetic purposes. Periodontal disease in varying degrees of severity was the most prevalent diagnosis (37.2%), and this was followed by dental caries (21.9%). Apart from these, a wide spectrum of conditions such as trauma, chronic gingivitis and necrotising ulcerative gingivitis were treated. An early diagnosis of squamous cell carcinoma was made amongst the patients attending the clinic. Extraction and dental prophylaxis were the treatments most frequently carried out. In many cases, antibiotics and analgesics were administered before the definitive treatment or referral. The clinic utilisation pattern indicates that the majority of the patients attend only once except in cases where the pain is not relieved after the first visit. Even though this programme is considered effective and appropriate, more effort is required in the area of health education to enable residents adopt more prevention oriented behaviour. Keywords : Primary Health Care, Community Health, Oral Health

Medical services in community mental health programs.

Considerable attention has focused on the recent decline in the numben of psychiatrists working in community mental health centers (1) and the fact that the role of psychiatrists in many CMHCs has changed from one of leadership to one of little authority (2). It has been reported that psychiatrists are very dissatisfied with their roles in CMHCs, partly because of their inability to provide adequate medical care for their patients (3). In addition, the impact of deinstitutionalization on the severely and chronically mentally ill has generated increasing concern about how to meet the major medical and psychiatric needs of patients in the community (4). Despite this concern, there are only a few reports of how individual CMHCs have attempted to meet the medical needs of their patients or have related to primary health care delivery systems (5-7). To the best of our knowledge, the nature of medical services within an entire community mental health system has not been described.

A heuristic for direct consumer participation in primary health care planning

Recent attempts at consumer participation in the health care planning process have proved weak in their ability to responsively account for consumer health welfare. This can be attributed, in large part, to the mechanisms employed for identifying and utilizing the consumer's health care views and preferences. A heuristic planning procedure designed to overcome these problems by directly incorporating consumer preferences is developed. It identifies that (primary) health care delivery system which maximizes total incremental health benefit to a community subject to a prespecified budget constraint. The model assumes a methodology (previously developed by the author) for measuring, in aggregable units, the benefit, B ip , from some health care facility p as perceived by some consumer i. Application of the procedure and subsequent sensitivity analyses demonstrate its ability to generate valid solutions that are robust to disturbances in the planning system.

A methodology for the analysis of rural primary health care delivery systems

A methodology for the analysis of rural primary health care delivery systems is presented. The basic approach is that the dynamics of rural primary health care delivery systems can be understood as an interaction between consumer and provider models. Computer modelling techniques can be used to analyze the efficiency of particular rural health care systems based on site-specific geographical data and economic data regarding the cost of gasoline and other costs to the consumer and provider. The methodology is relevant in developing countries as well as in the United States.

Trends in primary health care.

There are many problems related to the planning and delivery of primary health care services. Shortage of appropriately trained health personnel is a principal obstacle to delivery of primary health care services. Expanding the training of traditional health workers has failed to solve the service delivery problem. Health services need to be provided according to a progressive system of increasing expertise and skills from front-line care to base hospital care. A countrys stage of socioeconomic development will dictate the overall structure of a health care delivery team and will determine the standards that can be afforded at the primary health care level. The guiding factor in health personnel planning and recruitment should be what the area can train and sustain and not the population/personnel ratios. The 3 person team covering maternal and child health/family planning medical care and communicable diseases/environmental sanitation offers the optimum for a balanced integrated curative-preventive-promotive primary health care delivery system. The major block to expanding the number of trained auxiliary health care workers is a totally inadequate supply of informed knowledgeable and trained instructors. A series of coordinated actions is needed to overcome this block. In developing a curriculum for training health auxiliaries an interdisciplinary systems-analysis approach should be used. The concept of primary health care should be integrated into other sectors of national development. Another obstacle to the expansion of primary health care is a deficiency in field supervision and management.

The Wholistic Health Center Project: an action-research model for providing preventive, whole-person health care at the primary level.

The Wholistic Health Center action-research project is designed to stimulate new approaches for rectifying a variety of maladies present in the nation's primary health care delivery system. In response to the call for an increase in health education programs, for availability of care in early stages of illness, for care focused on life stress factors, and for better coordination of care-the church-based Wholistic Health Centers utilize a unique multidisciplinary teamwork approach for diagnosis and treatment planning. The patient is involved as an active participant in this process. In conjunction with the University of Illinois, Department of Preventive Medicine and Community Health, the project has developed from its inception as a free clinic in Springfield, Ohio, to the establishment of two potentially self-supporting centers in middle and upper-income suburbs west of Chicago, Illinois.

A Consumer Preference Approach to the Planning of Rural Primary Health-Care Facilities

A problem in planning the expansion of a rural primary health-care delivery system is to determine the set of facilities to be added to an existing system so as to maximize the incremental benefit to the community subject to a cost constraint. The proposed approach involves the following five steps: (1) identification of facility attributes relevant to patients in their choice of health-care facilities, (2) modeling of an individual's overall preference for alternate facilities as a weighted linear function of these facility attributes, (3) transformation of each consumer's preference model into a benefit function expressing the individual's benefit in dollars/year for an existing or potential facility, (4) provision of a method for determining the total incremental benefit to the community from a set of proposed health-care facilities, and (5) use of a heuristic procedure to determine a set of facilities that yields near-optimum total incremental benefit subject to the cost constraint. A practical application of the proposed approach reveals that the consumer preference model has substantial reliability and predictive validity.

Evaluative research design for a health manpower innovation

An evaluative research approach to health innovations involving physician's assistants is necessary if effective and rational policies for future health manpower allocation are desired. The paper develops an ecological framework encompassing the multiple regression approach to data analysis to allow determination of the “community impact” and acceptance of a physician's assistant in doctorless rural communities. Recognition of the complexity of many research problems has led to the specification of a flexible structure which allows modifications and accommodates the measurement of change. This approach provides an improved methodological framework for studying the effectiveness of preplanned changes in the primary health care delivery system.