Primary Healthcare

8/11/2019 Primary Healthcare

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PRIMARYHEALTHCAREINTHEAMERICAS:

CONCEPTUALFRAMEWORK, EXPERIENCES,

CHALLENGESANDPERSPECTIVES

August 2002

Organizai!n an" Manag#$#n !% H#a&' S()#$)an" S#r*i+#) HSO-

Division of Health Systems and Services Development(HSP)

Pan American HealthOrganization

orld Health Organization


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! Pan American Health Organization" 2002

This document is not a formal publication of the Pan AmericanHealth Organization (PAHO), and all rights are reserved by the

Organization. This document may, hoever, be freely revieed,

abstracted, reproduced and translated, in part or in hole, provided thatfull credit is given to the source and that the te!t is not used for

commercial purposes.


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AUTHORS

#everly $% &c'lmurry" 'dD" AAProfessor" Pu*lic Health ursing" and Associate Dean"

Director" HO +olla*orating +enter for the,nternational Development of Primary Health +are"

-niversity of ,llinois at +hicago+ollege of ursing

#eth A% &ar.s" PhDAssistant Director" /eha*ilitation /esearch and raining +enter on

Aging 1ith Developmental Disa*ilities

-niversity of ,llinois at +hicago

/osina +ianelli" +&" &PH" PhD +andidatePreDoctoral rainee

A,DS ,nternational raining and /esearch Program-niversity of ,llinois at +hicago

+ollege of ursing

ith contri*ution from &arli &amede" PhD

Professor" HO +olla*orating +entre for ursing /esearch Development-niversity of Sao Paulo+ollege of ursing at /i*eirao Preto

#razil

he authors ac.no1ledge the contri*utions of the follo1ing persons inrevie1ing the documents3 aeema Al4asseer5 Aaron #useh5 4ladys +anaval5,lta 6ange5 7athryn #% 6emley5 &aricel &anfredi5 $udith Popovitch" and /andySpreen Par.er%


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TA.LEOFCONTENTS

EXECUTIVE SUMMARY/////////////////////////////////////////////////////////////////////////////////////////////////////////

PRESENTATION///////////////////////////////////////////////////////////////////////////////////////////////////////////////////

0/ INTRODUCTION///////////////////////////////////////////////////////////////////////////////////////////////////////////////

1/ .ACKGROUND////////////////////////////////////////////////////////////////////////////////////////////////////////////////

2/ MODELS OF CARE///////////////////////////////////////////////////////////////////////////////////////////////////////////8%9 &OD'6SO+A/'O/H'A6H+A/'P/A+,+'" 'D-+A,OAD/'S'A/+H%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

3.1.1 Medical Model.....................................................................................................................

3.1.2 Primary Health Care Model.................................................................................................

3/ METHODOLOGY//////////////////////////////////////////////////////////////////////////////////////////////////////////////

4/ HEALTH STATUS IN THE AMERICAS///////////////////////////////////////////////////////////////////////////////////

:%9 H'A6HSA-S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%5.1.1 Communicable Diseases.....................................................................................................

5.1.2 Non-communicable Diseases..............................................................................................:%2 H'A6H/,S7S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

5.2.1 Socio-economic and environmental actors........................................................................

5.2.2 !ehavioral ris" actors........................................................................................................

5.2.3 !iolo#ical ris" actors..........................................................................................................

5/ COMPONENTS OF CARE///////////////////////////////////////////////////////////////////////////////////////////////////;%9 P/O H'A6H+O+'/S?,SS-'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

$.+.1 Primary health care............................................................................................................

$.+.2 'ccess and e0uity...............................................................................................................$.+.3 Priority areas......................................................................................................................

6/ METHODOLOGICAL AND MEASUREMENT ISSUES///////////////////////////////////////////////////////////////@%9 P/,&A/=H'A6H+A/'&OD'6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%@%2 /ASO/&,4/O6'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%@%8 +/,'/,AA/'AS%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

7/ IMPLICATIONS, CHALLENGES, AND PERSPECTIVES////////////////////////////////////////////////////////////%9 A6'/A,


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%2 #A//,'/SO+HA4'%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%8 P/,O/,,'SO/H''+'-/=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%> 'D-+A,OA6,SS-'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

.+.1 ducational barriers............................................................................................................

.+.2 ducational Needs..............................................................................................................%: S-&&A/=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

.5.1 Su##estions........................................................................................................................

8/ REFERENCES//////////////////////////////////////////////////////////////////////////////////////////////////////////////////

APPENDIX A: THE AMERICAS: 37 COUNTRIES AND TERRITORIES///////////////////////////////////////////

APPENDIX .: PAHO STRATEGIC AND PROGRAM ORIENTATION, 0888911 /////////////////////////////

APPENDIX C: PRIMARY HEALTH CARE IN .RA;IL///////////////////////////////////////////////////////////////////


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EXECUTIVE SUMMARY

Practitioners" educators" and researchers continue to search for innovativestrategies and solutions to address priority areas that are relevant to societal

and community needs% ,n this document for practitioners" researchers" andeducators" 1e present a revie1 of literature reBecting the models of care usedfor practice" research and education in the /egion of the Americas%

e *egin the revie1 1ith a *road" inclusive notion of health% ,n this sense"health is considered more than the a*sence of disease% urther" 1e recognizethat overarching determinants of preventa*le illness and death are often theresult of poverty" unemployment" and lac. of participatory development" not*iological?physiological determinants (4ottschal." 9CCC)% &oreover" policiesdevoid of the values em*edded in society as 1ell as consideration of the impactof social and economic policies (&c7night" 9CC:) can negatively aect healthstatus on an individual and community level%

o gain an understanding of the sociopolitical and economic realities as 1ellas the goals of a community and society" providers of health care services mustfamiliarize themselves 1ith the concepts that relate to gro1th" development"and sustaina*ility (4ottschal." 9CCC)% Ho1 these concepts are deEned andoperationalized are critical factors for providers attempting to meet the healthneeds of communities and particularly mem*ers considered vulnera*le%SpeciEcally" providers need to incorporate a *road understanding of theinterconnectedness of these concepts into their daily practice%

e present a Primary Health +are (PH+) &odel that can *e used as aphilosophy and a strategy to promote health and to prevent diseases" throughcomprehensive health care" that is colla*oratively and cooperatively provided *ycommunity mem*ers and multiple" health relevant disciplines% Additionally" theliterature is revie1ed to discuss and to eFamine the types of health careproviders" the mode of service delivery" the location of services" types of healthcare programs" and health concerns?issues% e also discuss measurementcriteria issues" evaluation methods" and implications" challenges" andperspectives% his document 1ill *e useful as a guide for practitioners"educators" and researchers 1ho are interested in health issues and are involvedin decisionma.ing and policy development for institutions and programsproviding health care services% &any practitioners" educators" and researchersassume that their practice*ase is theoretical% e hope to challenge that idea1ith the suggestion that the PH+ perspective is a useful 1ay to organize

disparate literature" ta.e stoc." and determine a preferred future%

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PRESENTATION

/eforms of the health sectors in the /egion of the Americas have oftenfocused on the model of care in the search for ne1 1ays of meeting the needs

and improving the health of the population% he need to evaluate these ne1models and their implementation challenges the health system to ma.e moreeFplicit the conceptual frame1or. used in the approaches *eing considered%&any pu*lic health leaders vie1 a model of care *ased upon a primary healthcare frame1or. to *e the *est option for addressing the critical health issues*eing faced around the 1orld%

A primary health care model is a useful approach to health care that focuseson the promotion of health and the prevention of disease" throughcomprehensive care that is colla*oratively and cooperatively provided *ycommunity people and health relevant disciplines% As an interactive model"primary health care encourages individuals and communities to *e more

involved in decisions a*out their health and its management% At the same time"primary health care is a*le to accommodate discipline speciEc perspectives Gmedicine" nursing" mid1ifery" pu*lic health as 1ell as the models that focus onage groups or health pro*lems%

he document" Primary Health +are in the Americas3 +onceptual rame1or."'Fperiences" +hallenges and Perspectives" is intended to contri*ute to theongoing discussions on designing" implementing and evaluating ne1 models ofcare in the conteFt of health sector reform% #ased upon an eFtensive revie1 ofpu*lished literature from around the 1orld" the authors present information onfour components or aspects of care that are often considered in adopting a ne1model of care% hese include provider" location of services" types of programs

and health concerns or issues% hey discuss methodological and measurementsissues and propose implications for future 1or.%

&ore than >00 articles pu*lished since 9CC0" including more than half fromthe 6,6A+S data*ase" 1ere revie1ed in the preparation of the document% Amaor diIculty encountered 1as o*taining full teFt articles from the 6atinAmerican sources% An impressive *ody of literature eFists on these variousaspects of the model of care% he research Endings should *e used moreconsistently to ma.e decisions regarding practice" education" policy" and toguide future research%

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0/ INTRODUCTION

he ne1 millennium *rings an opportunity to evaluate models of care thatare used for health care service delivery" education" and research% ,n the Pan

American Health Organization (PAHO) /egion" practitioners" educators" andresearchers continue to search for innovative strategies and solutions to addressa myriad of priority areas and issues that are relevant to societal andcommunity needs% Although the countries and territories in the Americas areimmensely diverse and many dierent cultures traversed (i%e%" race" ethnicity"socioeconomic status" disa*ility status" political and religious aIliations)"commonalties do eFist among people and their health care concerns% Accordingto the 9CC; /eport of the orldHealth Organization (HO) Ad Hoc +ommitteeon Health /esearch" the 1orld community faces four critical health issues3

9% ,nfectious diseases" malnutrition" and poor maternal and child health 1illcontinue to account for a signiEcant portion of unnecessary deaths and

illness (particularly in countries 1ith fe1er economic resources)" despite thehealth advances and pu*lic education during the past century%

2% ,neJuita*le and ineIcient health care delivery systems prevent access tohealth care for many individuals%

8% 'pidemics of noncommunica*le diseases" inuries" and violence such ascardiovascular diseases" neuropsychiatric conditions" cancer" dia*etes" andchronic respiratory infections are aecting greater num*ers of people%

>% A gro1ing num*er of drugresistant micro*es are creating ne1 healthemergencies and a resurgence of diseases (e%g%" tu*erculosis" malaria" andpneumococcal disease) that 1ere once considered to *e under control%

or practitioners" educators" and researchers" the provision of health careservices to address the a*ove four areas of concern reJuires carefulconsideration of the model of care *eing utilized% &odels of health care providethe foundation for constructing eective policies and strategies aimed atimproving population health 1ithin the PAHO /egion% Developing frame1or.s forhealth care services reJuires an understanding of *oth the critical health issues"and the determinants of population health (arlov" 9CCC)% Determinants ofhealth status can *e categorized into Eve *road areas3

9% *iology?physiology"

2% health care services"

8% personal health *ehaviors">% the interrelationship of individuals 1ithin their social emotional and physical

environments" and"

:% social?societal inBuences%

hile each of the a*ove areas has *een eFamined discretely to determinetheir eect on health status" consideration of the dynamic interactions amongand *et1een these factors on health status for individuals or communities

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PRIMARYHEALTHCAREINTHEAMERICAS: CHALLENGESANDPERSPECTIVES

remains a challenge% 'Famining the interrelationships *et1een determinants ofhealth and critical health issues reJuires the eFplicit use of models toconceptualize and guide practice" teaching" or research% &odels of care directlyinBuence health care research and the health care services that people receive%&oreover" the framing of the care or the research Juestions 1ill determine1hether the processes and outcomes are e0uitable" accessible( acce,table( oravailable% Partici,ation levelsand cultural relevancyare also determined *y themodelKs philosophical assumptions% hus" understanding a particular model ofhealth care is a crucial component in health care practice" education" andresearch% he use of a model illustrates the factors that determine health statusand esta*lish critical path1ays to address health care concerns%

,n preparing this document" 1e recognize that every segment is integral tothe entire document% Ho1ever" 1e have structured the paper so that eachsection can *e revie1ed individually" if the reader prefers to do so% he ta*le ofcontents is a useful means for readers to locate topics" supporting references"and appendiF documents% urther" 1e have included an appendiF *y Dr%

&amede as a stand along eFample of ho1 a country speciEc eFamination ofmodels of care might *e organized% e hope that readers of this document useit to reBect on means for improving multidisciplinary and participatory activitiesto advance health care in the PAHO /egion%

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1/ .ACKGROUND

he 9CCCG2002 Pan American Health OrganizationKs Strategic andProgrammatic Orientations identiEed Eve Strategic and Programmatic

Orientations to guide health planning and programmatic actions to addresshealth concerns across all levels" local" regional" and national in the PAHO/egion (See AppendiF A)% he strategies include3

9% health and human development5

2% health promotion and protection5

8% environmental protection and development5

>% health systems and services development" and

:% disease prevention and control%

he Eve strategic areas are useful guides for formulating ne1 directions and

o*ectives to *e addressed in models of care in the Americas%he health and human development strategies support the necessity of

deEning conceptual aspects related to ineJuities in health care (PAHO" 9CCC)%&oreover" instruments need to *e developed and reEned for measurement andsurveillance at the regional and national level to document and evaluateineJuities in health% Studies eFamining the health proEles of neglectedpopulation groups must *e conducted to design health interventions addressingthe social ineJuities" and disparities in health status and health care services%

raining for health care providers across all levels must *e upgraded to ena*lethem to analyze the health situation and living conditions of various populationsectors and the prevailing social ineJuitiesLparticularly those pertaining to

health% &odels of care need to address the formation of local" national"su*regional" and regional intersectoral net1or.s to assist in policyma.ing andthe preparation of plans" proects" and programs aimed at *ridging the gaps inhealth%

Health promotion and protection is a po1erful strategy to addresscommunity and individual health concerns (PAHO" 9CCC)% hile health is aprimary component of human development" health promotion must involve amuch *roader scope of action than that customarily handled *y health systemsand services% Additionally" health promotion and protection can *e a useful focalpoint for countries to adopt and implement paradigms aimed at aecting thedeterminants of health in general% &oreover" the factors that are fundamental to

a populationKs health relate to 9) their living conditions5 2) their opportunities tofulEll *asic needs5 8) the Juality of their environment5 >) the culture to 1hichthey *elong5 and :) their .no1ledge" attitudes" and practices 1ith regard tohealth and the political health structure foot health services delivery%

heenvironmental protection and development strategy is critical due to thepotential adverse eects of environmental factors on the health of a community(PAHO" 9CCC)% #y including environmental factors as a component in models ofcare" programs and proects 1ill address the eects of the environment on the

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health of community mem*ers" particularly children" aimed at identifying andeliminating or minimizing due to its greater suscepti*ility% his strategy alsosupports the promotion and implementation of environmental care activities1ithin the conteFt of Health for All" along 1ith active participation amongcommunity mem*ers in identifying their o1n needs and in Ending solutions% hehealth systems and services development strategy supports the developmentand dissemination of methodologies and tools to strengthen capacities foranalysis" policyma.ing" and the implementation and evaluation of sectoralreform programs" along 1ith systematic and ongoing transfer of information toshare eFperiences on a local and national level (PAHO" 9CCC)% hese strategiesare *est implemented *y use of health care models that support a reorientationof health services to satisfy health promotion" health protection" and diseaseprevention criteria% hese criteria emphasize improvement in the Juality andcomprehensiveness of speciEc interventions and strengthen the operational andpro*lemsolving capa*ility of the services at dierent levels of care%

he Enal strategy" disease prevention and control" is useful to address

regional challenges and reduce and control disease (PAHO" 9CCC)% his strategyalso encourages community participation and changes in the *ehavior ofindividuals to insure success% or eFample" national capacities 1ill *estrengthened in order to control" reduce" or eradicate speciEc diseases% his can*e achieved through regional and national partnerships for prevention andsetting priorities regarding intentional and unintentional inuries" including theprevention of violence from a pu*lic health perspective% Additionally" providingsupport for countries in developing policies" models" and 1or.ing partnershipsamong health care 1or.ers" la*oratories" and treatment facilities 1ill preventdiseases (e%g%" helping cervical cancer control programs to understand 1omenKsattitudes and needs5 evaluating demonstration proects5 and planning their

udicious" result*ased eFpansion)%

6imitations in health care resources reJuire an eFamination of methods thatare most eective for promoting healthy lifestyles to communities% A revie1 ofthe literature on eFisting models of care eFamines practice as a 1ay to integrateresearch and education" identify eective models" descri*e the crucial elementsand areas that need to *e addressed" and generate Juestions for futureresearch" education" and practice% his revie1 1ill *e useful for healthauthorities at dierent levels and responsi*ilities for services" includingeducators" providers" and policy ma.ers to analyze current models of care anddetermine future directions% he critical analysis of literature covers thefollo1ing areas3

9% he primary health care model of care in the Americas52% SpeciEc components of care (types of providers" mode of service delivery"

location of services" types of programs" and health concerns?issues)5

8% he challenges and implications associated 1ith models of care5

>% &odels of care used *y practitioners?educators?researchers5 and"

:% Systematic and strategic approaches to understanding models of care%

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BACKGROUND

he revie1 supported the PH+ model as a frame1or. to mo*ilizecommunities and health care providers to move for1ard 1ith health sectorreform on a local" regional" and national level%

Health sector reform recognizes that all mem*ers of a community 1ithhighly diverse interests are directly concerned 1ith health and health care% Such

processes reJuire a gradual and transparent approach to development thatfosters the understanding of those involved directly in the provision of care" as1ell as the recipients of care% &oreover" implementation reJuiresintergovernmental association and cooperation and the participation of theprivate sector" nongovernmental organizations" and individuals involved inhealth and health care% Overall" PH+ models must *e implemented that arecomprehensive" em*race health promotion and disease prevention services" andeFtend health services to all 1ith eIcient use of increasingly scarce resources%

,n order to shift the focus of health delivery systems from acute" curativemedicine to the inclusion of health protection and health promotion" the healthcare system must decentralize some of the decisionma.ing processes to

regional and community levels (4reen" 9CC>)% Health professions trainingprograms must increasingly thin. glo*ally" *ut assume a greater role in thepromotion of health 1ithin their o1n communities% Additionally" health careproviders must engage a *roader range of disciplines" such as dentistry"medicine" nursing and nonmedical groups (e%g%" community health 1or.ers) inpartnerships and coalitions for health research and health care activities%


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2/ MODELS OF CARE

2/0 MODELSOFCAREFORHEALTHCAREPRACTICE, EDUCATION, ANDRESEARCH

heories and models of care are an integral part of healthcare practice"education" and research (Alderson" 9CC)% he choice of models" al*eit oftenunac.no1ledged" shapes the 1ay practitioners" educators" and researcherscollect" analye" inter,ret" and disseminateinformation% o *e eective" 1e mustdeconstruct our 1ays of M.no1ingN and understanding the inBuence of thevalues and philosophies forming the foundation of our practice" teaching" andresearch% As 1e increasingly 1or. 1ith culturally diverse groups" .no1ledgemust *e constructed in a manner that accurately reBects the nature ofdiversities and the conseJuences on responses to health (,m &eleis" 9CCC)%

hile theories in health care may range from eFplicit hypotheses to modelsor frame1or.s that are eFpressly used to guide oneKs practice or research

(Alderson" 9CC)" conventional approaches to .no1ledge development in healthcare practice" research" and education are grounded in positivist theories(Oliver" 9CC)% Over the past century" the medical model has *een the implicit"default model of care%

3.1.1 Medical Model

he conventional medical model uses a logical positivism philosophy" orempiricism" to verify cause and aect relationships for all human eFperiences(ilsonhomas" 9CC:)% ith this approach" the goal is to descri*e" predict" andcontrol human responses% or eFample" practitioners and researchers use thisapproach to locate the Mpro*lemN 1ithin the individual and orient health care

to1ard amelioration of disease rather than health% ,f Mo*serva*leN physiologicalEndings are identiEed" then a prescri*ed course of action is underta.en%

he medical model places the healthcare professional as the eFpertresponsi*le for curing disease and dysfunction and MhelpingN people to achieveMhealth and normalcyN (Oliver" 9CC)% he professional role is legitimized andprofessionals are authorized to la*el people as deEcient and in need of care%Provision of care (interventions) 1ithin the medical model focus on remediationof personal health *ehaviors or curing *iological factors (i%e%" physical or mentala*normality or impairment) to restore health status5 1here prevailing researchmethods include controlled trials" random statistical samples" and structuredJuestionnaires% #ecause the medical model focuses primarily on individual

impairments and diseases" health is usually implicitly conceptualized as thea*sence of disease (Peters" 9CC)% +onseJuently" a limited perspective oftenfails to eFplain many of the social and environmental factors that account fortodayKs health concerns and ineJuities around the glo*e (Parsons" 9CCC)% hetraditional *iomedical model does not consider the values em*edded in society"nor ones social positionLa reBection of socioeconomic status and povertyLasan overarching determinant of health status%


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MODELSOFCARE

Practitioners and researchers often consider health care rooted in positivistphilosophy as valuefree" reduci*le and isolata*le5 yet" personal histories andeFperiences are not validated" and dialogue and sharing appear to *e irrelevantin the process (ilsonhomas" 9CC:)% /esearch and practice rooted intraditional" empiricist methods that have separated the mind" *ody" andeFternal environment are intrinsically pro*lematic% /irst" traditional approachesto .no1ledge development that depend on assumptions of homogeneity"normality" and statistical relia*ility" rather than coherent reBections of diversehuman eFperiences" have limitations in generating comprehensive models ofcare (Hall" Stevens" &eleis" 9CC>)% he .no1ledge gained from traditionalresearch produces a limited understanding a*out the interrelationships *et1eenpeople" their environment" their health and their relationship 1ith their healthcare provider% Secondly" o*taining *alanced po1er relationships is diIcult 1henresearch and practice is *ased on logical positivist philosophy% astly" areductionist approach to1ard research and practice can perpetuate theunderlying assumptions that one has a*out gender" race" ethnicity" disa*ility"and class% Such an approach inhi*its gaining an understanding of critical

eFternal factors that may impact ones health status%Despite the technological eFcellence and sophisticated medical care that has

*een advanced *y using the medical model" its usefulness is *ecomingincreasingly limited in the current health care delivery system% Several issuessuggest a need to move *eyond the medical model and to use eFisting theoriesand models that develop and employ models of care suIcient to achieve PH+criteria%

hen health is narro1ly deEned 1ithin the medical model" dierences incultural attitudes and values regarding deEnitions of MhealthN are often ignored%&oreover" the use of diagnoses creates patient dependency on the eFpertise of

the health care professional to treat the Mpro*lemN that has *een socially andscientiEcally constructed% ,ncreasingly" this po1er ineJuity is vie1ed as amechanism of control and oppression for disenfranchised groups% ith arestricted vie1 of health" clients are seen as passive recipients of medical care"rather than active participants 1or.ing colla*oratively and cooperatively 1ithmultiple health relevant disciplines% S.yroc.eting medical care costs" decreasingaccess to health care and increasing disparities in health care status amonggroups of people (1omen" aging adults" racial?ethnic minorities" disa*led people"and children) also suggest a need to create ne1 models of care% ,deally" usefulmodels of care delineate the su*ectivity and social construction of reality"sociopolitical and economic inBuences on health care research and practice" andthe prevalence of discrimination against marginalized groups (,m &eleis"

9CCC)% &odels that capture the compleFities of multiple determinants of healthstatus and the diversity and sociopolitical and historical conteFts inherentamong persons are more li.ely to achieve the desired connections *et1eenfactors 1hich inBuence our understanding of health%

Philosophies and models of health care are increasingly used to address thesociopolitical" cultural" and economic forces that may impact ones health and toaddress po1er im*alances eFperienced *y disenfranchised groups andindividuals% hese philosophies and models are posing important Juestions for

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health care and health care research% he use of more comprehensive modelsthat incorporate a focus on promoting health and disease prevention 1ill allo1practitioners to identify critical issues that are important to an individual andavoid overloo.ing or minimizing the impact of societal attitudes and values onthe dynamic state of health% A Primary Health +are (PH+) model is a usefulapproach to healthcare that focuses on the promotion of health and theprevention of disease" through comprehensive care that is colla*oratively andcooperatively provided *y community people and multiple health relevantdisciplines%

3.1.2 Primary Health Care Model

As an interactive model" PH+ encourages individuals and communities to *e.no1ledgea*le in health matters and to have an opportunity to participate intheir health care management% &oreover" PH+ addresses selfcare practices forphysical and mental aspects of community health as 1ell as community socialand environmental conditions% A *asic goal of PH+ is to ensure that essential

health care is availa*le to everyone in the community% ,mplementation of PH+emphasizes several concepts3

Provision o accessible and a4ordable essential health services or allse#ments o a community5

&aimiation o individual and community involvement in the ,lannin# ando,eration o health care servicesto ensure that services are a,,ro,riate andacce,table to ,artici,ants6

m,hasis on services that are ,reventive and ,romotive as *ell as curative6

7se o a,,ro,riate technolo#y unded by local resources and su,,orted by#overnment structures6

8nte#ration o health develo,ment *ithin the overall social and economicdevelo,mento the community6

Provision o culturally acce,table( a,,licable( and e0uitable health servicesand ,ro#rams6

/ocus on health concerns that are identi9ed and ,rioritied by communitymembers so that essential services are available6 and(

7se o strate#ies that maimie sel-learnin#( sel-determination( sel-care(and sel-reliance( on the ,art o the ,eo,le.

,n this document" a PH+ perspective 1as used to organize the revie1 ofliterature on models of care in the Americas% he disparate literature on PH+ can*e considered *y using igure 9 as a map for developing an action plan% ,n other1ords" 1e often have insuIcient resources to ta.e on a comprehensive PH+study" *ut 1e can situate the 1or. *eing underta.en 1ithin a larger conteFt orperspective% e deEne PH+ as a participatory approach to healthcare deliverythat encourages a partnership *et1een community residents and healthprofessionals to achieve a mutual goal of improved health (&c'lmurry" 9CCC)%

his approach is consistent 1ith the HO tradition that 1as initiated in 9C@

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MODELSOFCARE

and 1ith the current agenda% ,n the Americas" the nursing community deEnesPH+ (&c'lmurry #rum*augh7eeney" 9CC) as presented in the 9C@ HOdocument% Ho1ever" the deEnition of primary care is used 1ithin the pu*lichealth model of primary" secondary" and tertiary levels of care% Primary care isoriented to the care and prevention of illness among individuals and families% ,nthe -%S%" primary care is perceived as the entrance to secondary and tertiarylevels of care (&arion" 9CC)% hile dierences eFist *et1een the M1orldvie1sNenmeshed in dierent perspectives" they are not mutually eFclusive and can *eincorporated in the HOKs current strategic directions as captured in thefollo1ing3

9% o reduce eFcess mortality of poor and marginalized populations%

2% o eectively respond to leading ris. factors%

2% o strengthen sustaina*le health systems%

8% o place health at the center of the *roader development agenda (HO"2000)%

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3/ METHODOLOGY

6iterature 1as retrieved from 9CC0 through 2000 for the follo1ing languagesin the PAHO /egion3 'nglish" Spanish and Portuguese% he data*ases searched

included the &'D6,' and +,AH6 data*ases of the -S ational 6i*rary of&edicine and the 6,6A+S data*ase for South America and the +ari**ean /egion%o develop the search strategy used 1ith the ational 6i*rary of &edicine foridentifying models of care in the Americas" 1e used a Primary Health +aredeEnition that focused on the follo1ing service areas3

9% ypes of services provided (health promotion" health education" andhealth care interventions Q 29"2a*stracts)5

2% ype of provider (mid1ife" nurse" physician" rural health motivator"community health aides" and community health 1or.er Q >8"9:2 a*stracts)5

8% &ode of service delivery (mid1ifery" nursing" and medicine Q 9"@9:

a*stracts)5>% &easurement criteria and issues (aorda*ility" accessi*ility" availa*ility"

applica*ility" accepta*ility" eJuita*ility Q 2>">@@ a*stracts)5 and"

:% &ethodological issues (Jualitative" Juantitative" evaluation" ormethodology Q 9"022 a*stracts)%

o capture the concepts included in models o care" the follo1ing searchterms 1ere used3

+ommunity Health Planning or Health Planning Organization orHealth Planning Administration or +ommunity Health Services or+ommunity et1or.s or +onsumer Participation or Delivery of

Health +are or Developing +ountries or amily Health or HealthServices Accessi*ility or Health +are Delivery or Health +are &odelor Health +are Sector or Health Planning or Health Planning4uidelines or Health Policy or Health Priorities or Health /esourceAllocation or Health +are &odels or Primary Health +are or Pu*licHealth Practice or "9C2 a*stracts5

&odels of care *y type of service*yty,e o ,rovider< 28a*stracts5 &odels of care *y type of service *y mode o service delivery < 8:@

a*stracts5

&odels of care *y type of service*ymeasurement criteria and issues< 982a*stracts5 and"

&odels of care *y type of service*ymethodolo#ical issues< >@8a*stracts%

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METHODOLOGY

he eJuivalent strategy and .ey 1ords used to retrieve literature from&'D6,' and +,AH6 1ere used for the 6,6A+S search% 6,6A+S is a component ofthe 6atin American and +ari**ean +enter on Health Sciences (#,/'&') a*stractli*rary% ,t is a cooperative data*ase that covers literature related to the healthsciences since 9C2% /esearch articles 1ere o*tained from 6,6A+S in 'nglish"Spanish" and Portuguese% Some of the articles have the title in Portuguese and'nglish or in Spanish and 'nglish" ho1ever the maority of them do not havea*stracts in 'nglish% he access to this data*ase from the -S is achieved *yaccessing the 1e* page R111% *ireme%*r

he Erst search to identify models of care in the Americas" using PrimaryHealth +are as a term resulted in 9@"98> citations from the aforementioneddata*ase% -se of the services provided search deEnition resulted in the neFtdisplay:

0/ ypes of services provided (health promotion" health education" andhealth care interventions Q 9"CCa*stracts)5

1/ ype of provider (mid1ife" nurse" physician" rural health motivator"community health aides" and community health 1or.er Q C";90 a*stracts)5

2/ &ode of service delivery (mid1ifery" nursing" and medicine Q 9"@C@a*stracts)5

3/ &easurement criteria and issues (aorda*ility" accessi*ility" availa*ility"applica*ility" accepta*ility" eJuita*ility Q 9";: a*stracts)5 and"

4/ &ethodological issues (Jualitative" Juantitative" evaluation" ormethodology Q 2"0:8 a*stracts)%

o further narro1 the search" models o care 1as crossed 1ith ty,es oserviceprovided and concepts associated 1ith a Primary Health +are (PH+)

perspective% A total of 9>@ articles 1ere retrieved3 &odels of care *y type of service Q 82 a*stracts5

&odels of care *y type of service *y ty,e o ,roviderQ 90 a*stracts5

&odels of care *y type of service *y mode o service deliveryQ ;8 a*stracts5

&odels of care *y type of service *y measurement criteria and issuesQ 9:a*stracts5 and"

&odels of care *y type of service *y methodolo#ical issuesQ 2@a*stracts%

he 6,6A+S a*stracts 1ere read (9>@)" and the articles that meet the searchcriteria 1ere incorporated for Enal analysis% ,t 1as diIcult to reach the completedocument selected from 6,6A+S since the articles cannot *e do1nloadedautomatically as full teFt from the ,nternet% &any li*raries in the -S do not havean agreement 1ith 6,6A+S" and so in some cases" document retrieval too.approFimately a month" 1hile in other instances the documents 1ereuno*taina*le%

hus" the more limited num*er of references a*ove *ecame the data*aseincluded in the revie1 of literature from the 6,6A+S% Overall" several Juestions

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emerged from a revie1 of the composite literature% he 'nglish" Spanish andPortuguese language a*stracts for this data*ase 1ere read 1ith attention to thefollo1ing types of Juestions3

9% ho are the dierent types of providersT

2% hat are the various modes and levels of service deliveryT

8% here are the services provided" such as" health promotion" education"treatment" and prevention servicesT

>% hat are the environmental health ris. factorsT

:% hat are the socioeconomic ris. factorsT

;% hat are the *ehavioral ris. factors (physical Etness" nutrition" seFualpractices" alcohol and drug use" safety practices)T

@% Are services accessi*le" aorda*le" accepta*le" applica*le" and availa*leT

% hat are the *iological ris. factors (genetic conditions" age"

race?ethnicity" genderspeciEc conditions)TC% Ho1 do health providers in the AmericaKs /egion vie1 PH+T

90% Ho1 can 1e improve access to full teFt documents for the health 1or.ersin 6atin America and +ari**ean /egionT

99% Ho1 can 1e improve access to 6,6A+S for 'nglish spea.ers in the -S 1honeed to o*tain information a*out the 6atin America and +ari**ean /egionT

92% Ho1 can the curriculum of health professionals *e oriented to PH+T

98% hy is it that in some countries the eFperience of 1or.ing 1ithcommunity heath 1or.ers is an important and successful component of thehealth care system 1hile other countries do not have this eFperienceT

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4/ HEALTHSTATUSINTHEAMERICAS

4/0 HEALTHSTATUS

,n general" health status across the lifespan of individuals in the Americashas improved over the past decade as a result of enhanced social" political"environmental" cultural and technical factors (PAHO" 9CC)% &oreover" theeFpansion of health care systems from an emphasis on treatment of diseases toa focus on health promotion through health education" disease prevention" andsupportive socioenvironmental conditions is improving health status%

Despite improvements in health care status and health care services" thecharacteristics and speed of the improvements have not *een the same acrosscountries or in all population groups 1ithin any one country (PAHO" 9CC)% ,nfantmortality in the Americas has declined steadily (PAHO" 9CC)% hile the ris. ofdying in adulthood (>:;> year old group) across countries is relatively sta*le formales *et1een 9C0 and 9CC>" the mortality pattern for 1omen sho1s a long

term do1n1ard trend that is systematically higher in lo1erincome countrygroups" 1hich suggests gender ineJuality% SpeciEcally" adult males in theAmericas seem to have achieved greater access to preventive" curative" orpalliative care services" 1hereas" access for adult 1omen may still *e inBuenced*y their economic level% Ho1ever" the ris. of dying due to eFternal causesacross the Americas is higher for males >:;> years of age compared tofemales% ,n particular" men have a greater ris. of dying from eFternal causes in+olom*ia" +hile" 'l Salvador" &eFico" and icaragua%

Over the past century" improvements in industrialization" aUuence" housing"hygiene and nutrition" clinical care" and disease prevention initiatives haveenhanced child and adolescent health status in many countries (4racey" 9CC)%

e have learned the elements that reduce ris. for children and adolescents3parental caring and connectedness5 parental eFpectations for school and parentavaila*ility all out1eigh family structure5 ethnicity and" income (#lum" 9CC)%

,n the -%S%" mortality rates" overall" are decreasing and many mor*idity rateshave declined (#lum" 9CC)% ,n the PAHO /egion" although the prevalence of lo11eightforage and lo1 1eightforheight has declined for children (PAHO" 9CC)"lo1 heightforage resulting from periods of inadeJuate nutrition continues to *eseen in approFimately :0V of preschool and schoolage children in somecountries% +onversely" o*esity has rapidly increased in the /egion" particularlyamong lo1er socioeconomic groups" ur*an communities" and 1omen%

5.1.1 Communicable diseases

+ommunica*le diseases vary across countries% +urrently" poliomyelitis has*een nearly eradicated" the spread of measles is under control" and progresshas *een made in slo1ing the spread of +hagasK disease (PAHO" 9CC)%Ho1ever" after an a*sence of almost 900 years" cholera returned to the PAHO/egion in 9CC9% &oreover" dengue and other vector*orne diseases are stilloccurring at epidemic rates in many countries throughout the Hemisphere%

u*erculosis has also reemerged" along 1ith anti*iotic resistant diseases%

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22/101

HEALTHSTATUSINTHEAMERICAS

all of the countries in the /egion% &oreover" mortality related to smo.ing andalcoholism has increased in the /egion%

4/1 HEALTHRISKS

he maor factors associated 1ith mor*idity and mortality in the Americasvaries across regions and countries% Social" political" economic" andenvironmental factors" along 1ith *ehavioral ris. factors" are a large componentof health ris.s (4reen 7reuter" 9CC9)% ith a decrease in mortality andmor*idity rates in the Americas" a greater interest in preventing diseases relatedto lifestyle and social environment has emerged%

5.2.1 Socio-economic and environmental factors

Socioeconomic and environmental factors play a pivotal role in healthstatus (ernandez" ate" #onet" +anizares" &as" =assi" 2000)% or eFample"inadeJuate Enancial resources can constrain people from o*taining necessaryhealth care services5 and" health insurance programs may impose reJuirementsand restrictions that limit access to needed services% PAHO uses a variety of

indicators to measure socioeconomic status (S'S) including3 4ross ationalProduct (4P) per capita" annual 4P gro1th rate" percentage of population inpoverty" and the highest 20V to lo1est 20V income ratio% As 4ross DomesticProduct (4DP) per capita falls" accessi*ility" coverage" and availa*ility of medicalcare decrease (PAHO" 9CCC)% All of these varia*les are also dependent on apopulationKs geographic location% PAHO also trac.s literacy rate" percentagepopulation 1ith drin.ing 1ater supply services" percentage of population 1ithse1age and eFcreta disposal services" and the ratio of dierent types of healthcare providers compared to the population

6iving conditions in the Americas have generally seen a gradualimprovement among *asic S'S indicators (PAHO" 9CC)% Access to safe 1ater

increased from ;0V in 9C0 to @:V in 9CC:5 and" sanitation coverage rose from>8V to ;V5 and" vaccination coverage increased from >@V to V *et1een9C> and 9CC;% &oreover" adult literacy increased from @2V to C2V *et1een9C@0 and 9CC:% Despite these improvements" *et1een 9CC0 and 9CC>"countries 1ith the lo1est 4P rate consist of +u*a" Haiti" Puerto /ico" rinidad"rench 4uyana" o*ago" icaragua" and #ahamas5 and" the percentage ofpopulation living in poverty is highest in #olivia" Haiti" Honduras" 'cuador"4uatemala" Peru" Panama" and #razil% &en and 1omen are at greatest ris. oflo1 literacy rates if they live in #razil" St% 6ucia" 'l Salvador" Honduras"icaragua" 4uatemala" and Haiti% omen living in #olivia also have eFtremelylo1 literacy rates% 6astly" the ratio of physicians" professional nurses" and

dentists per 90"000 population rose from 98%@ to 9%2" from 28%@ to 8>%@" andfrom 8%8 to :%8" respectively" *et1een 9C0 and 9CC: (PAHO" 9CC)%

'nvironmental factors also may determine 1hether healthcare services andhealthrelated information are accessi*le" aorda*le" accepta*le" or availa*le%or eFample" a study *y Dellasega" #ro1n" and hite (9CC:) found that olderadults living in rural areas 1ere concerned a*out the accessi*ility of healthpromotion activities" such as cholesterol screening" along 1ith *eing a*le tohave the results of screening eFplained and dietary interventions taught in an

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accessi*le format% hus" health care programs need to consider and incorporatefactors that aect access and accepta*ility to community mem*ers%

he environment is a critical determinant in the level of ris. for violence andthe amount of opportunities to engage in healthy *ehaviors% hile somecountries still face *asic health care issues associated 1ith poverty"

environmental degradation" and deteriorating living conditions" other nationsare eFperiencing health issues related to aging populations" rapid ur*anization"and unhealthy lifestyles (PAHO" 9CC)%

+hildren around the 1orld eFperience a vast array of social pressures andhealth ris.s (4racey" 9CC)% ,n the PAHO /egion" childrenKs eFperiences includethe follo1ing3 9) those 1ho are living in 1ealthy" industrialized countries5 2)those living in rapidly industrialized countries that are eFperiencing rapidchanges in their health care systems (4racey" 9CC5 #ossert" 6arranaga" /uizPeir" 2000)5 8) minority groups including recently arrived immigrants inother1ise aUuent and healthy societies5 >) previously traditional people in rapidtransition to ur*anized" estern lifestyles5 and" :) many millions living in

grinding poverty in overcro1ded" unhygienic conditions 1here child mortality ishigh" often due to malnutrition and infections (4racey" 9CC)%

Health care delivery systems are constantly changing and have signiEcantimplications for access to health services and health information% +urrently"many health care systems 1orld1ide are consolidating services" 1hile availa*leresources and funding for health care and healthrelated programs areincreasingly limited% ,ncreased time pressures are especially pro*lematic forpeople 1ith disa*ilities 1ho have needs that reJuire eFtra time foreFaminations" tests" procedures" and health teaching (Heller &ar.s" in press)%

Despite the improvements in health status among children in the PAHO/egion" the gains are *eing oset *y o*esity" smo.ing" alcohol and drug a*useand social disruption" mental disease and high rates of violence" includinghomicide and suicide% &oreover" these Wne1 mor*iditiesK are magniEed amongminorities and in populations undergoing rapid social change" as 1ell as thoseeFperiencing social pressures" such as unemployment and family dysfunction%

Deaths related to accidents and violence have essentially remained thesame for the PAHO /egion (PAHO" 9CC)% Ho1ever" some countries haveeFperienced a mar.ed increase in the num*er of deaths due to homicide" 1hileaccidental deaths are decreasing% he -%% Population und (Septem*er 20"2000) report states that discrimination and violence against 1omen MremainErmly rooted in cultures around the 1orld"N stopping 1omen from reaching theirfull potential% 4lo*ally" girls and 1omen are still routinely denied access toeducation and health care" including control over their reproductive activity"eJual pay" and legal rights% At least one in three 1omen has *een *eaten"coerced into seF" or a*used in some 1ay% Studies over the past decade suggestthat 1omen 1ith intellectual disa*ilities are four to ten times more li.ely thanother 1omen to *e targets of seFual assault and other violence (So*sy" 2000)5and" greater than @: percent of mentally disa*led 1omen are victims of seFuala*use%

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HEALTHSTATUSINTHEAMERICAS

5.2.2 ehavioral ris! factors

#ehavioral ris. factors can consist of inadeJuate eFercise" poor nutritionalha*its" cigarette smo.ing" drug and alcohol a*use" unsafe seFual practices" orliving in a psychological state of helplessness" 1ithout options for maor lifechoices and decisions% o*acco use is the leading preventa*le cause of death inthe Americas" .illing an estimated ;2:"000 people every year (>80"000 in the-S" 9:0"000 in 6atin America and the +ari**ean" and >:"000 in +anada) (PAHO"2000)% According to availa*le data in orth America and 6atin America" *et1een9CC; and 9CCC to*acco prevalence in the population ranged from a high ofapproFimately >0V in Argentina and +hile" to a lo1 of 22V in +olom*ia% ,n someur*an areas" more than half of the young people smo.e% ,n 6atin America" morepeople already die of noncommunica*le diseases" many of 1hich are caused *yto*acco" than of communica*le diseases" maternal and perinatal conditions andnutritional deEciencies%

he trend to1ard noncommunica*le diseases is eFpected to continue%

o*acco use" 1hich .ills through chronic diseases such as heart disease" cancer"and lung disease" has contri*uted to a regional shift in causes of death frominfectious to noncommunica*le diseases (PAHO" 2000)% #ehavior can directlyinBuence health and it can have an indirect aect on health *y inBuencingenvironmental factors% Health *ehaviors also can maintain or enhance healthstatus and Juality of life" control or remove deleterious ris. factors" and preventthe onset of chronic conditions%

oncommunica*le diseases are responsi*le for approFimately t1othirds ofall deaths in 6atin America and in the +ari**ean (PAHO" 9CC)% Additionally"deaths from chronic and degenerative diseases 1ere proected to outnum*erdeaths from infectious and parasitic diseases *y a ratio of 9039 *y the year

2000% ,n order to control or remove harmful ris. factors" personal choice orsocial and environmental changes may *e reJuired% Health promotion strategiesare primarily concerned 1ith creating *ehavior change through modiEcation oflifestyles and living conditions to increase 1ell*eing% 6ifestyle changes can *efacilitated *y a com*ination of eorts to enhance a1areness" change *ehavior"and create environments that support good health practices% Ho1ever" theinBuence of lifestyle and living conditions on the state of 1ell*eing reportedlyvaries among dierent socioeconomic levels (HO" 9C)% or eFample" 1hilepersonal lifestyles may dramatically aect the development of a state of 1ell*eing among the aUuent" social and environmental conditions may *e largerdeterminants of 1ell*eing among the less aUuent%

5.2.3 iolo"ical ris! factors

/is. factors related to *iological factors can include geneticpredisposition" age and gender% Although health promotion activities aredirected to1ard factors that are changea*le" consideration must *e given to the*iological ris. factors that are not changea*le (4reen 7reuter" 9CC9)%#iological ris. factors include genetic predisposition" age" gender" race orethnicity" and climate% hile many of these factors do not lend themselves todirect intervention" they must *e ta.en into account 1hen identifying highris.

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population groups% #iological ris. factors play a role in several leading causes ofmortality" including heart disease" cancer" stro.e" dia*etes" and cirrhosis%

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5/ COMPONENTS OF CARE

he follo1ing components of health care are revie1ed in this section3 typesof providers" modes of service delivery" location of services" and types of

programs% ,n the PAHO /egion" a variety of health care providers deliver primaryhealth care services% Although many disciplines provide health care services" thediscussions in the literature center on community health 1or.ers" nurses" andphysicians% hus" for the purpose of this paper" the revie1 is limited to thesespeciEc providers%

Along 1ith the various types of providers" the dierent modes of servicedelivery are discussed here% Service delivery modes consist of medical care"nursing care" health education" health promotion" and health protectionservices% 6ocations of health care services are also delineated% or eFample"Services may *e delivered in churches" clinics" schools" 1or.places" prisons"homeless shelters" nursing homes" and community recreational centers% ypes of

health care programs may also vary depending on location of services and typesof providers% he follo1ing revie1 of literature descri*es the myriad of healthrelated programs that have *een implemented in the Americas /egion%

5/0 PROVIDERS

Dramatic changes in the health care system have occurred over the pastcentury% #ecause of the increasing compleFity of healthrelated concerns andhealth care delivery systems" interdisci,linary a,,roaches are critical fordesigning and implementing services across a variety of settings% Additionally"current trends in health care delivery are moving us to1ard a system 1ith lesscom,ulsory and more arbitrary standards and services delivered *y JuasioIcial and voluntary *odies (Halperin" 9CC)" including a variety of healthdelivery providers (e%g%" community health aides?1or.ers" mid1ives" nurses"physicians" rural health motivators)% hese standards are developed in responseto speciEc needs that are driven *y sociopolitical and economic agendas (Silva 4omes" 9CC)% As ne1 standards are developed in an age of increasingtechnology and rapid information eFchange" issues related to the rights ofaccess must *e *alanced 1ith protection from unsafe" ineective" and poorJuality services and products% Additionally" standards must incorporate BeFi*ilityto ena*le consumers to choose their level of protection% ,n order to developparticipatory services and programs" health care professionals must em*racethe value of multidisciplinary and interdisciplinary approaches for individualsand communities%

Despite the increasing emphasis on interdisciplinary approaches"professionals and academicians still resist team1or. and .no1ledge sharingacross disciplines (aera Perez" 9CCC)% hese o*stacles often stem from thepersistent overvaluing of speciEc eFperiences of particular disciplines%Professional training needs to shift educational programs from acompartmentalized model of care to a model of comprehensive care thatincludes a variety of care providers 1ith a range of s.ills that are situationspeciEc and eJually valued% or eFample" depending on the health care issues"

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certain health care providers may *e most appropriate (e%g%" community healthaides?advisors" community health motivators?volunteers" nurses" mid1ives"nurse practitioners" physicians" etc%)% his section revie1s research related tospeciEc types of providers%

#.1.1 Community Health $or!ers%&ides%&ctivists' Community Health Motivators%(olunteers

+ommunity health 1or.ers (+H) is ust one of many terms used throughoutthe 1orld to descri*e an indigenous outreach health 1or.er 1ho is trusted andrespected in his or her community (/odney" +lasen" 4oldman" &ar.ert" Deane"9CC)% hey are also .no1n as community health aides or advisors" lay healthadvisors" community health motivators" community health advocates"community health volunteers" or ethnic minority lin. 1or.ers% ,n general" +Hsare local lay community mem*ers 1ho interface directly 1ith residents in thecommunity as Mhealth activistsN to convey a variety of health messages thatpromote health (#ental Paran" 9CC0) and to improve access to and utilizationof health and human services (#a.er" et al%" 9CC@)% +Hs are often indigenous

to the community and 1or. 1ith community mem*ers 1ho are underserved andmay share their ethnic racial *ac.ground (6ove" 4ardner" 6egion" 9CC@)% Asfrontline health care professionals" +Hs are increasingly vie1ed as healthagents 1ith .ey roles in the primary health care model as the +H programs aredesigned to *uild on the strength of eFisting community relationships to improvehealth (#a.er" et al%" 9CC@)% he role that +Hs play in *rea.ing do1n social andcultural *arriers *et1een the formal health care system and the clientcommunity is a pivotal factor in access to health care services for communitymem*ers (omas Sancho" 7ennedy" +olomer /evuelta" 9CC)% +H volunteersoften have the a*ility to administer more personalized services to communitymem*ers and can *ridge the gap *et1een community residents and the healthagency (Dic. Schoeman" 9CC;)%

+Hs also have dierent activities and settings across the Americas /egion(6opez" 9CCC)% ,n developed countries" activities for +Hs are developed inresponse to a lac. of responsiveness 1ithin the formal health care system tofacilitate health promotion and illness prevention (omas Sancho" 7ennedy" +olomer /evuelta" 9CC)% ,n developing countries" the primary goal of +Hactivities is to implement primary health care services in areas 1ith limitedprofessional resources% +Hs also provide services for a variety of communitymem*ers in settings ranging from ur*an areas (Par.er" Schulz" ,srael" Hollis"9CC5 Schulz" ,srael" #ec.er" Hollis" 9CC@5 Solla" &edina" Dantas" 9CC;))"rural areas ('arp" 9CC@5 #erner" 9CC25 /o*inson 6arsen" 9CC0)" schools(#er.leyPatton" a1cett" PaineAndre1s" $ohns" 9CC@5 Olvera" /odriguez"

Perez" 'i*enschutz" )% 6ove" 4ardner 6egion (9CC@) reported the maority of +Hs ineight #ay Area counties in +alifornia are 1omen (;;V)" of color (@@V)" 1ith ahigh school degree or less (:V)% Ho1ever" depending on the target population"ne1er models of care are training dierent groups of people to 1or. as +Hs"

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COMPONENTSOFCARE

such as" adolescents (#er.leyPatton" a1cett" PaineAndre1s" $ohns" 9CC@54arEeld" 9CC;)" older adults ('arp" et al%" 9CC@)" church mem*ers" mothers($ohnson" Ho1ell" &olloy" 9CC854utierrez Paredes" 2000)" and mem*ers ofracial?ethnic minorities ($ac.son Par.s" 9CC@)% hile the location of servicesand goals may vary across the /egion" the processes that are fundamental to+Hs performance are similar% hese factors include recruitment" training(4utierrez 4avilano" 2000)" monitoring" ongoing support" and evaluation%

Health care activities

6ay health 1or.ers have essentially three primary functions3 9) to serve asmediators *et1een community mem*ers and health agencies" 2) to esta*lish asocial net1or." and 8) to oer a range of services from emergency care tohealth protection and social support (#erner" 9CC25 #ro1nstein" +heal"Ac.ermann" #assford" +amposOutcalt" 9CC2)% SpeciEcally" +Hs are trainedto participate in a variety of health education programs including smo"in#cessation (6acey" u.es" &anfredi" arnec.e" (9CC9)" cardiovascular healtheducation (#ental Paran" 9CC0)",rovidin# vaccinations(Solorzano &oguel

Alvarez +uevas" 9CC9)" violence ,revention education (Davies" Harris" /o*erts"&annion" &c+os.er" Anderson" 9CC@5 Anderson" Harris" &c+os.er" 9CC@)"cancer screenin# and education(avarro" Senn" &cicholas" 7aplan" /oppe" +ampo" 9CC5 'arp" et al%" 9CC@5 avarro" Senn" 7aplan" &cicholas" +ampo" /oppe" 9CC:)" enhancin# sel-care and advocacy s"ills or *omen(&c'lmurry"S1ider" 4rimes" Dan" ,rvin" 6ourenco" 9C@)" and surveillance and treatmentactivities or tro,ical or communicable diseases (+airncross" #raide" #ugri"9CC;5 /ue*ush" Yeissig" 7oplan" 7lein" 4odoy" 9CC>5 'ngel.es" 9CC25Solorzano &oguel Alvarez +uevas" 9CC9)% One study in +alifornia reported thatthe maor foci of the +HKs activities 1ere A,DS and maternal child health (6ove"4ardner 6egion" 9CC@)% +ommunity Health Aides (+HAs) have a vital role in

improving access to preventive health services (SoF" 9CCC)% or eFample"1omen +HAs 1ere trained to collect specimens for Pap and seFually transmitteddisease testing and perform *reast eFaminations to increase access to 1omenKshealth services for Alas.an natives%

Community Health %or"ers 8m,act in Primary Health Care activities

/esearch suggests that services provided *y lay health activists can improvethe eIciency of health promotion programs to increase pu*lic a1areness ofhealth ris.s related to diseases (e%g%" cardiovascular disease" cancer screening"

# prevention" emergency care)% #ecause a fundamental tenet 1ithin +Hstraining focuses on improving access to essential primary health care services ofcommunity mem*ers" they are often eective in getting people to engage in

health promoting *ehaviors and activities that prevent illness% Additionally" useof +Hs can signiEcantly increase the use of the availa*le pu*lic health careservices (+hristensen 7arlJvist" 9CC0)% his in turn reduces the overall cost ofhealth care services 1ithin a community% Despite the positive *eneEts that frontline community 1or.ers have in inBuencing health status" successfulimplementation of +H programs remains challenging (/o*inson 6arsen"9CC0)% /eports have suggested that high turnover rates" a*senteeism" poorJuality of 1or." and lo1 morale among 1or.ers in +H programs is associated

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Ta= 0/ M!"#& Pr!gra$) D#*#&!>#" =( N?r)#)

he +ool 7ids +oalition (+orrarino" alsh" #oyle" Anselmo" 2000) 'Fperiencia de enfermerZa en la atenciXn materno infantile (+ampos" $aimovich"

+ampos" 9CCC) he Ar.ansas AH'+ model of communityoriented primary care (Hart1ig 6andis"

9CCC) he 'Fpanded +are for Healthy Outcomes ('+HO) Proect3 addressing the spiritual care

needs of homeless men in recovery (#rush &c4ee" 9CCC) he &c4ill &odel and 6ocal +ommunity Service +enters3 A etching +om*ination (&alo"

+ote" 4iguere" O/eilly 9CC) Shuler urse Practitioner Practice &odel (Shuler Hue*scher" 9CC) Put Prevention into Practice (4rey" 9CC) Partners in colla*oration3 he Homan SJuare Proect (HollingerSmith" 9CC) he ;0 and #etter Program3 A Primary Health +are Program for the Aged (ay" 9CC@) Health +are Delivery in aith +ommunities3 he Parish urse &odel (eis" &atheus"

Schan." 9CC@) he +omoF


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COMPONENTSOFCARE

nursing leader (1ho also is disa*led) in the Disa*ility +ommunity is &arca #risto%A highly respected leader in the Disa*ility /ights &ovement" #risto has directeda leading +enter for ,ndependent 6iving" since it 1as esta*lished in 9C0% ,tsmission includes service" advocacy and promotion of social change for people 1ithdisa*ilities% he +enter *rought disa*ility to the forefront in +hicago and nationally%#ecause nurses are often informally sought out for education and health careinformation" they have a critical role in promoting health *ehaviors *y acting ashealth educators and change agents outside" as 1ell as 1ithin" their professionalroles (essaro" 9CC@)% Oftentimes" nurses have to step outside normal roles and*ureaucratic eFpectations to achieve resolution of the issues that people are*ringing to them from the community% urses also are instrumental in providingtraining and supervision of community health aides (#erner" 9CC2) and otherparaprofessionals 1ho provide direct care services%

Health care activities

Services provided *y nurses occur in a variety of community settingsincluding the follo1ing3 schools (&c+lo1ry" et al%" 9CC;)" churches (eis"

&atheus" Schan." 9CC@)" correctional facilities (&iller" 9CCC)" home care(7eating" 9CC:5#andeira" 9CC@))" rural and ur*an areas (Dumas" 9CC25 +uEnoSvitone" 4arEeld" )" immigrants andrefugees (DeSantis" 9CC@)" prisoners (&iller" 9CCC)" children (+orrarino" alsh"#oyle" Anselmo" 2000)" people 1ho are homeless (#rush &c4ee" 9CCC)"older adults (hite ezey" 9CC;)" 1omen 1ith chemical addictions (Dumas"9CC2)" 1or.places (Parrish" 9CC:5 assel" 9CC:)" adult day care (Dunham

aylor" Olda.er" De+apua" &anley" Oprian" restler" 9CC8)%

SpeciEc topics covered *y nursedeveloped programs include the follo1ing3education in speciEc content areas" such as cardiovascular health promotion(Hill #ec.er" 9CC:)" assessment" screening and treatment for variousconditions" including mental health issues (Strau*" et al%" 9CC) and cancerscreening (Ansell" 6acey" hitman" +hen" Phillips" 9CC>)" scald *urnprevention education for parents (+orrarino" alsh" #oyle" Anselmo" 2000)"individualized health promotion services (&alo" +ote" 4iguere" OK/eilly" 9CC)"empo1erment strategies and promotion of eJuity and access for older adults(eis" &atheus" Schan." 9CC@5 ay" 9CC@)" maternal" child health (HollingerSmith" 9CC)" and lead screening (#loc." Sze.ely" 'sco*ar" 9CC;)%

Nurses im,act in Primary Health Care activities

/esearch documenting the clinical and costeectiveness of community*ased nursing services is limited% hile anecdotal evidence suggests nurses docontri*ute to improvements in health status and to reducing health care costs"nurse leaders in .ey community positions 1ill reJuire more support foraddressing eectiveness (Dunhamaylor" Olda.er" De+apua" &anley" Oprian" restler 9CC8)% Additionally" more research*ased demonstration proects needto *e conducted in communities to document the clinical eectiveness of nurserun health promotion and prevention programs% ,f more nurses 1ere a*le to *ill

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and?or *e directly reim*ursed for their services" this picture might change asmost eectiveness studies are tied to costs rather than the social value of theirservices%

+ommunity health nurses are in a strategic position in the PAHO /egion tomaintain" promote" and protect the health of populations *oth no1 and in the

future (7uss" ProulF4irouard" 6ovitt" 7atz" 7ennelly" 9CC@)% As the health careenvironment increasing emphasizes the protection and promotion of health"access to health services" and prevention of illness" pu*lic health nurses giventheir training and historical roots are paramount in the changing focus toprimary prevention% urses also have the *readth of .no1ledge to interface 1ithmany dierent levels of service delivery professionals and to translate thisinformation to community mem*ers" to *uild community capacity for healthpromotion" and to facilitate community participation *y enhancing communityhealth services and coordinating pu*lic policy to achieve core pu*lic healthresponsi*ilities of assessment" policy" and assurance (7ang" 9CC:)%

#.1.3 Physicians

,n the PAHO /egion" physicians have focused on curing and restoring healthto individuals 1ho eFperience speciEc disease states% &uch of the eFtantliterature revie1ed demonstrates that the primary goal for physicians to changethe individual *y replacing disease or impairment 1ith MhealthN or MnormalityN(4ill" 2009)% Additionally" the M.ey pro*lemN in many of the studies in thephysician*ased primary health care literature 1as seen as a physical orfunctional impairment% he interface *et1een the environment and theindividual 1as for the most part neglected in these studies% &oreover"incorporation of the cultural" political" social" and economic factors into theanalysis of the Mpro*lemN 1as virtually a*sent%

Health care activitiesAn important conclusion cited in a meeting *et1een the orld Health

Organization (HO) and the orld Organization of amily Doctors (O+A) in9CC> 1as3 MOptimal medical practice is responsive to individuals andcommunities" *eing personcentered" health oriented" and community *ased thesystems of medical practice and pu*lic health should *e closely lin.edN (HO"9CC>)% hile this conclusion supports the use of a primary health care model"unfortunately" compared 1ith the depth of literature for nurses and +Hs" apaucity of literature eFists relating to models of care for primary health careactivities among physicians%

&uch of the literature a*out health care services provided *y physicianscenters on teaching them more eective 1ays to provide oIce*ased healthpromotion counseling for their patients% or eFample" studies revie1 counselingactivities for nutrition (Oc.ene" He*ert" Oc.ene" &erriam" Hurley" Saperia"9CC;)" smo.ing" drug a*use" o*esity" contraception" *reast self eFamination"cholesterol chec.s" diet" eFercise" hormonal replacement" Papanicoloaousmears" and glaucoma chec.s (Davies" 9CC9)% Studies also eFamined factorsassociated 1ith preventing lo1 *irth 1eight *a*ies (Ste1art imrod" 9CC8)"accidents in children (+arter $ones" 9CC8)" sportsrelated inuries (/ouzier"

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COMPONENTSOFCARE

9CC:)" cancer (rame erth" 9CC8)" and preventive care measures forpatients 1ith dia*etes (Strea /a*.in" 9CCC)%

he studies also addressed treatment issues for patients in providing healthpromotion and prevention services% or eFample" research studies eFamined thepatientphysician interaction (alsh PcPhee" 9CC2) and the impact of

physician cooperation 1ith a community*ased prevention and health promotionprogram for older adults (#ula" Alessi" Arono1" =u*as" 4old" isen*aum" #ec." /u*enstein" 9CC:)% ,n sum" the literature revie1 found that" on a communitylevel" physicians are involved 1ith activities that omit attention to the socialrealities that often have a much greater impact than the presenting physical orpsychological concerns% +onseJuently" this contri*utes to health care servicesfrom physicians that are internalized as oppressive" rather than helpful%

#.1.* Partnershi+s, Health Professionals and Community Coalitions

,nterdisciplinary and multidisciplinary 1or. creates an opportunity todevelop partnerships 1ith other health professionals (+ourtney" #allard" auver"

4ariota" Holland" 9CC;5 Dos Santos" 9CC@)% As 1e shift from acompartmentalized model of care to a model of comprehensive care" healthprofessionals must maFimize their relationships 1ith providers across disciplinesin the health care system and em*race partnership relationships 1ith clientsand their communities (4oulart" 9CC@5 Stoc.ins Pantoa" 9CC@)% Partnershiprelationships can transform the ,roessional and the client roles% Asprofessionals relinJuish their positions of authority to partner 1ith clients" clients? families ? communities shift from *eing passive recipients of care to *ecomingactive participants in maintaining health and preventing disease (&c'lmurry"

ys.a" Par.er" 9CCC)% Additionally" partnerships *uild capacity amongindividuals and communities (7ang" 9CC:)5 and" are particularly *eneEcial for

communities that have *een underrepresented and?or minority populations(+ourtney" #allard" auver" 4ariota" Holland" 9CC;)% or eFample" 6ough (9CCC)descri*ed an academiccommunity partnership *et1een a college of nursingand a neigh*orhood grade school and parish% his partnership actually achievedt1o goals% irst" the provision of needed health care services improved healthstatus and increased access to health promotion services% Secondly" similar toother academic community health centers (#eauchesne &eservey" 9CCC)"nursing students are given an opportunity to provide services using acommunity*ased primary care model%

he formation of multiple partnerships 1ithin communities fosterscommunity empo1erment and mutual accounta*ility (6a*onte" 9CCC5 'isen"

9CC>)% &oreover" including MoutofthemainstreamN groups as partners" such asyouths (Harper +arver" 9CCC)" farmers ('hlers Palermo" 9CCC)" religiousgroups (Simpson 7ing" 9CCC)" and minority populations (6evine" et al%" 9CC2)can result in informative health service programs" along 1ith a uniJueopportunity to *uild community coalitions as change agents% ithin acommunity" coalitions encourage *road community involvement andMo1nershipN in the planning and implementation of needed health promotionand health education services (6evine" et al%" 9CC25 Arm*ruster 4ale" #rady"9CCC)% or eFample" a coalition of consumer organizations" health care

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providers" and activists in /hode ,sland directed their activities to1ardimproving maternal and infant health (Aaronson" 9CC9)% ith multiple inputsfrom people 1ith varied areas of eFpertise" the /hode ,sland coalition achievedimportant legislative initiatives to improve maternal and infant health" such as"health insurance for uninsured pregnant 1omen and promotion of mid1iferyservices% hus" the po1er of coalitions can enhance perceived o1nership" 1hichin turn can result in greater community participation and interest in healthpromotion and protection activities%

5/1 LOCATIONOFSERVICES

he acute" inpatientoriented illness model of health care is *eing replaced1ith a health protection" healthpromotion" and primary health care model(Shortell" 4illies" Devers" 9CC:)% As the location of health care services movesinto the community (e%g%" 1or.site" schools" churches" healthcare sites)"Juestions emerge concerning the dimensions of health education?healthpromotion programs and policies (&ullen" et al%" 9CC:)% /esearch a*out programneeds" feasi*ility" eIcacy" and eectiveness also must *e underta.en%

Although care is shifting to a primary health care model" models outside ofthe formal health care arena eFist% or eFample" Minformal careN is one strategythat is *eing used to empo1er minority communities 1ith respect to health careand health promotion and is a signiEcant force in health maintenance" healthpromotion" and disease prevention (+hen" 9CCC)% ,nformal care is deEned as thepractice of alleviating physiological and psychological distress through others(e%g% traditional healers" family mem*ers" self" etc%) using measures that do notreJuire a physicians prescription or intervention (e%g% lifestyle modiEcations)(erner" 9CC>)% hese actions are usually outside of formal" institutionally *asedcare mechanisms (e%g% homes and communities) (igenda" 6oc.ett" &anca" /odriguez" 9CC@5 Seravalle #oo." 9CC;)% ,n the -%S%" at least onethird of the

population is estimated to engage in unconventional medical practices" andapproFimately onehalf of racial?ethnic populations use informal care% -se ofinformal care is advantageous *ecause it is often more culturally compati*le"relatively lo1 in cost" and BeFi*le%

+ommunity*ased programs located 1here people freJuently congregatecan play a valua*le role in health promotion activities% or eFample" healthpromotion and health protection programs can *e implemented in churches"schools" nursing homes" 1or.sites" +enters for ,ndependent 6iving for persons1ith disa*ilities (+,6s)" Erehouses" supermar.ets" military systems" housingproects" *ar*ershops and *eauty salons" and other community settings% or thepurpose of this paper" ho1ever" only churches" schools" and 1or.site programs

1ill *e discussed indepth%#.2.1 Church-ased Health Pro"rams

+hurches are increasingly used as sites for health promotion and healthprotection activities% A partnership *et1een religious groups and healthproviders ena*les incorporation of the culture of the community into healthpromotion eorts to reach vulnera*le populations (Simpson 7ing" 9CCC)% A

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COMPONENTSOFCARE

church*ased model focuses on using the faith community to inBuence the*ehavior and lifestyle of persons 1ithin an organized pu*lic health model" 1hichprovides a ne1 model of ministry (+oo." 9CC@)%

+hurch*ased health programs oer an innovative response to achievehealth policy as 1ell as address the changing health needs and altering social

and economic trends of a community (van 6oon" 9CC)% urses are often the .eyproviders in many of the faith*ased community programs% hese programshave the a*ility to foster community participation in health and promote healthfrom a holistic perspective" 1ithin the supported social and culturally speciEcconteFt of a faith community% /eligious leaders may also play an instrumentalrole in initiating health promoting and protecting messages (Anonymous" 9CC8)%/esearch has sho1n that the religious community is more 1illing to accepthealth messages" 1hen the church*ased programs stress 1ays to improve theJuality of life in .eeping 1ith the messages conveyed *y the church" rather thanframing health issues in mortality statistics (Sanders" 9CC@)%

A variety of health messages have *een promoted in church*ased

programs% or eFample" program aims have included the follo1ing3 reduction of*reast" cervical" and diet related cancers in 1omen (+astro" et al%" 9CC:)5smo.ing cessation (Anonymous" 9CC8)5 nutritionrelated programs (Demar.ahnefried" Ho*en" Hars" $ennings" &iller" &c+lelland" 9CCC)5 cardiovascularris. reduction programs (OeFmann" 2000)5 and" stro.e prevention (O.1uma*ua"&artin" +laytonDavis" Pearson" 9CC@)%

Health promotion programs in churches have targeted dierent groups ofpeople% or eFample" population groups have included3 people living in ruralareas (Simpson 7ing" 9CCC5 Demar.ahnefried" Ho*en" Hars" $ennings" &iller" &c+lelland" 9CCC)5 6atino?Hispanic 1omen (+astro" et al%" 9CC:)5 and" AfricanAmerican men and 1omen (O.1uma*ua" &artin" +laytonDavis" Pearson"

9CC@5 homas" [uinn" #illingsley" +ald1ell" 9CC>)% /esearch is limitedconcerning the interconnections among pu*lic health" health education" andfaith*ased communities (+hatters" 6evin" 'llison" 9CC)% Ho1ever"researchers and practitioners are increasingly interested in theoretical issuesand frame1or.s eFplaining the relationships *et1een religious involvement andhealth% Additionally" research studies are increasingly eFploring the associations*et1een religious involvement and health attitudes" *eliefs" and *ehaviors%6astly" future eorts need to evaluate health education programs in faithcommunities and eFamine the contri*utions of religious institutions to thedevelopment of health policy%

#.2.2 School-based Health Services and Health ducation

School*ased health clinics inthe -S have gro1n from a fe1programs in the early 9C@0s tomore than ;00 in the 9CC0s (7lein+oF" 9CC:)% ,mplementation ofcomprehensive school healtheducation and integrated school

#*

Ta= 1/ S+'!!&9=a)#" C&ini+)

&ariner Proect3 A coordinated schoolhealth pilot program (


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health services *ased on an assessment of community needs and resources canimprove access to health care for millions of underserved schoolaged children(Anonymous" 9CC>)% 4reater attention to health promotion and protectionservices provides an optimal setting for improving health for all children andadolescents *y focusing on health *ehaviors in school settings (#rindis" 9CC8)%See a*le 2 for eFamples of school*ased clinics%

A variety of conteFtual factors may facilitate or impede the provision ofschool health services% or eFample" schools 1hose students eFperienced morehealth ris.s 1ere generally more li"elyto provide related services than schools1hose students eFperienced fe1er ris.s (#illy" 4rady" enzlo1" #rener" +ollins" 7ann" 2000)% Schools 1ithin states that had strong state policies andreJuirements for healthrelated programs and services 1ere also associated 1ith#reaterschool*ased provision of services% Additionally" schools 1ere less li"elyto provide services on site 1hen communities had readily availa*le andaccessi*le health care services% 6astly" more aUuent communities 1ere moreli"elyto provide school health services than less aUuent communities% Similarly"

pu*lic schools 1eremore li"ely

to provide school health services than privateschools% Pu*lic schools may have more access to pu*lic dollars" 1hich couldaccount for the greater li.elihood of providing school health services%

he inclusion of a multidisciplinary approach (e%g%" school nurses"nutritionists" eFercise physiologists" social 1or.ers" occupational therapists" andpediatricians) in the continuum of health care delivery promotes eective"timely" accessi*le" costeective services for children (4arey #ergren" 9CC)%&oreover" the success of school*ased programs reJuires colla*orative lin.agesacross many levels of systems and individuals% +olla*oration can increase pointsof access for children" *y mo*ilizing community resources among local leaders"parents" and state1ide health systems (illis" 2000)% hile the development of

colla*orative net1or.s for comprehensive school health programs remainslargely untapped" common dimensions of colla*oration have *een identiEed(4ottlie*" 9CCC)% hese dimensions include3

9% Having interpersonal and organizational interactions5

2% A1areness and understanding of comprehensive school health programs5

8% -nderstanding organizational priorities and re1ard systems5

>% ,dentifying political forces5

:% Having resources availa*le" and

;% Sharing resources%

/esearch supports the suggestion that many elements are critical to thesuccess of a school*ased health program3

9% Administrative support?*uyin5

2% +oordination of the school*ased health promotion team5

8% Program liaison?facilitator5 and

>% Sta 1ellness coordinator (


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COMPONENTSOFCARE

,mplementation of a comprehensive school health education programreJuires that teachers feel comforta*le and prepared to teach speciEc healthtopics% Ongoing training and reinforcement for teachers can increase theteachersK feelings of preparedness" 1hich in turn can have a signiEcant eect onthe students (Hausman /uze." 9CC:)%

School*ased health care services in the -S are often delivered *y APs(Advanced Practice urses) (al.er" #a.er" +hiverton" 9CC5 aul. &ancuso"9CC)% A primary focus of school*ased services is the provision of primaryhealth care and psychosocial counseling to children and adolescents in schools(7lein +oF" 9CC:)% Additional services often include health promotion"screening" and anticipatory guidance (al.er" #a.er" +hiverton" 9CC)% -se ofan integrated approach to school*ased health care services and healtheducation can provide programs to reduce to*acco use (&ac.ie Oic.le" 9CC:)and provide seF education to reduce the incidence of teen pregnancy andseFually transmitted diseases (aul. &ancuso" 9CC)%

he availa*ility of school*ased health care services can *e eFpanded *y

institutional partnerships and capitalizing on each otherKs strengths (&c+lo1ry"et al%" 9CC;)% &ore research needs to *e conducted to document the most costeective and costeIcient manner" and determining the needed sta andresources (#rindis" 9CC8)%

PAHO is developing a document that includes an overvie1 of the currentstatus" diIculties" and constraints of school health services in the Americas/egion in 2002% ,ssues of availa*ility" coverage" inconsistent Juality" design"content of care" coordination *et1een the school health services and the localnet1or. of services" Enancing" management" and the scarcity of trainedpersonnel designated for the management and provision of care in the schoolsetting are addressed% 'Fperiences from +hile" +u*a" $amaica" 'cuador Peru" and

the -%S% are also discussed% (o o*tain more information a*out MStatus of SchoolHealth Services in the Americas /egion 2002N document" contact Dr% /% /oas"PAHO" HSP?HSO)%

#.2.3 $or!-Site Pro"rams

or.site health promotion programs freJuently implement healthpromotion and protection strategies to reduce o*esity and the prevalence ofcigarette smo.ing ($eery" et al%" 9CC8)% or.site programs have traditionallyfocused on individually oriented 1ellness programs (provided at the 1or.siteand aimed primarily at changing employees health *ehavior) (Sto.ols" Pelletier" ielding" 9CC;)% Ho1ever" current programs are emphasizing the oint impact

of the physical and social environment at 1or." o*person Et" and 1or. policieson employee 1ell*eing%

5/2 TYPESOFPROGRAMS

Health care interventions are typically directed across three areas3individual" family" or community interventions% o manage ne1 causes ofmor*idity and mortality" traditional health services must move *eyond theindividual level and su*sume greater focus on health protection and health

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promotion (4uldan" 9CC;)% #ecause most common health pro*lems amena*le toprevention have strong environmental" cultural" lifestyle" and *ehavioralcomponents" community1ide or population approaches are imperative in mosthealth promotion and prevention strategies (6uep.er" 9CC>)% ,ndividuals"communities" and countries ma.e choices a*out 1hether or not to consumealcohol and drive" smo.e cigarettes" eFercise" or have their children immunized%hile all of these involve personal choices" they also involv

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