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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The strenths and challenges of excellence in COPC
Rapid appraisal as a participatory approach to Community Orientated Primary Care (COPC)
Structural Barriers to Health and the COPC model
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Donald E. Pathman, Chapel Hill, USA Associate Professor, University of North Carolina at Chapel Hill
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Plescia and Groblewski raise the bar for sophistication and excellence in community-oriented primary care, especially in COPC’s second step of problem, needs and assets identification. Their effort in the Northwest Area of their North Carolina city goes far beyond the norm in COPC, where health problems are gleaned usually from a safe computer’s distance perusing on-hand secondary health data or through conversations with a few community leaders. In a much grander effort with a much larger pay-off, Plescia, Groblewski and community members together learned about local health needs through a door-to-door survey, using a questionnaire they assembled with previously validated items and scales and fielded in a rigorous manner that would pass review as a stand-alone scientific undertaking. Even more importantly the community acted as a full partner in this process; grass-roots community activists and local agency representative partners guided all steps in this initiative from planning to evaluation, and trained community residents fielded the questionnaire among their neighbors. To interpret the survey’s findings the academic side of the project’s leadership, who presumably were not from the community themselves, relied on the interpretation of an 18-member community coalition and 15 lay health advisors. Active involvement of the community at the problem identification stage yielded a richer understanding of the data and built trust within the community, which promoted acceptance and dissemination of the survey findings and should contribute to the community’s participation in the interventions that grew from this effort within schools, churches, restaurants, the YMCA and clinics. The greatest challenge of the particular model of COPC undertaken by Plescia and Groblewski is its replicability (N.B. Their paper lists among it limitations only threats to internal study validity). Other practices and communities will be challenged to bring together the skills and financial resources required for the type undertaking they describe in North Carolina. How many communities can match the professional expertise of the COPC team that led this initiative? This effort required expertise with geographically-linked data, survey design, quantitative data interpretation, and qualitative research methods (the latter were applied to understand the community’s views of the survey results). Their effort also required facility with the application of current theories of human behavior—the health locus of control and stages of readiness for change models—to understand community capacity for change in a way apparently never before undertaken within COPC. While some clinical practices with strong academic ties may have the necessary skills in data handling, research and theory application, few also will have staff with the skills and temperament shown in this intervention to truly connect with a community, gain mutual respect and trust and share control. Few academics can step beyond their professional selves to meet a community halfway. Cost is the second challenge for this “Cadillac” model of COPC to be replicated in other communities. Plescia and Groblewski’s initiative in North Carolina was supported by a “large” grant from the U.S. Centers for Disease Control and Prevention and had the advantage of building upon an existing solid relationship with the community established through earlier joint initiatives. Where will other communities find the financial resources to undertake a time- and personnel-intensive effort of this size? Plescia and Groblewski demonstrate innovation and excellence in a COPC intervention, challenging the rest of us to learn to build similar broadly skilled teams and to secure the substantial funds needed for this ambitious model of COPC. Competing interests: Dr. Pathman advised Dr. Plescia on an earlier COPC project in this community. He was not affiliated with the current project. Dr. Pathman is a member of the faculty of the University of North Carolina, where Dr. Plescia also held a faculty appointment when this study was undertaken. |
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Scott A Murray, Edinburgh, Scotland, UK Family Physician and Senior lecturer in General Practice, University of Edinburgh
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I was delighted to read this article (1) which shows that Family Medicine and Public Health can be a marriage made in heaven! COPC is increasingly popular in the UK, Australia and America. This paper confirms the authors’ earlier conclusion that geographic definitions of communities are meaningful to citizens, and institutions that identify local needs have more credibility when engaging in local health provision.(2) The authors are to be congratulated on facilitating interventions which help their patients not only individually but also in community. While a health survey was used to assess needs in the above study, I would like to highlight a participatory approach to data collection and analysis which a multidisciplinary health and social team undertook in a small under serviced community in Edinburgh, Scotland 10 years ago.(3) We used the technique of Rapid Participatory Appraisal to involve the community in identifying its own health related needs. This method can with minimal resourses provide relevant information to place such needs within the community's social, economic and cultural context. It was a method first used in developing countries (4). We collected information in three ways: interviews with key respondents; observing the area as we worked there; and collating information that was routinely available such as from the population census. We used the conceptual format of an “information pyramid” to help collate and analyse data.(3) Having conducted the rapid appraisal we then utilised three other methods of needs assessment - analysis of small area data, analysis of information held by the family doctors concerning the patients registered in their list, and a postal survey. This allowed us to compare the utility of the different methods of needs assessment in primary care. We found that different methods have different strengths and weaknesses.(5) The great advantage of rapid appraisal was, however, that as an action research method it not only identified local resources but started to bring about changes in the community. For instance since the rapid appraisal conducted in 1994, a health forum has continued to meet every few months where local residents and key community workers have met to promote changes for health within the area. As in Charlotte, NC, affordable healthy food was a priority, and a food cooperative was started and continues to this day. Furthermore we recently repeated a rapid appraisal after 10 years and consider that it has utility in assessing outcomes of such community based interventions as well as needs. We wish this project every success as the team practises holistic care at practice and community level. PS the BMJ references are freely available ar www.bmj.com 1. Plescia M, Groblewski M. A Community Orientated Primary Care Demonstration project: refining Interventions for cardiovascular Didease and Diabetes. Ann Fam Med 2004;2:103-109 2. Plescia M, Koontz S, Lorent S. Community assessment in a vertically integrated health care system. Am J Public Health 2001; 91: 811-814. 3. Murray SA, Tapson J, Turnbull L, McCallum J, Little A. Listening to local voices; adapting rapid appraisal to assess health and social needs in general practice. BMJ 1994;308:698-700. 4. Ong BN. Rapid appraisal in health policy. London. Chapman and Hall. 1996. 5. Murray SA, Graham LJC. Practice based health needs assessment: use of four methods in a small neighbourhood. BMJ 1995;310:1443-8. Competing interests: None declared |
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Cheryl A. Bettigole, Philadelphia, USA Family Physician, Philadelphia Dept. of Public Health
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African-Americans, like other minority populations in the U.S., have higher mortality rates and receive less medical care than white patients. They have higher infant mortality, higher rates of HIV infection and death from AIDS, and higher mortality from cardiovascular disease (MMWR 51(15):329, MMWR 53(06):121-5). Plescia and Grobleski's study grapples with the question of how to work with an inner-city community to try to ameliorate these disparities, gaining acceptance by working with lay health advisors and community organizers. They point to structural factors such as poor availability of healthy foods, few public facilities for exercise, etc., that influence their patients' ability to effect change. These physicians then went on to use the knowledge gained to attempt to change these structural factors while continuing their clinical role. This way of thinking "out of the box" of the clinic to see the on-the- ground lives of their patients shows how COPC can function as a clinical tool and enhance the effectiveness of clinical practice. Yet missing from the article is any sense of outrage at the tolerance we have as a society for the structural barriers to health experienced by these patients. No mention is made of the lack of health insurance, although this must surely be of substantial importance in a community as poor as the one described. Similarly, as my own inner-city patients are fond of pointing out to me, the cost of fresh fruits and vegetables is high if they are available at all. In addition, although programs like this one may be of benefit to the local community, they do not affect the vast majority of the population in need. What if federal subsidies covered fruits and vegetables in place of tobacco? What if schools offered only water or milk to drink, instead of balancing budgets by sacrificing the health of their students to obtain money from soda manufacturers? And what if all patients had access to quality health care? The issues raised by the patients and community members in this study challenge all of us to consider these questions as well. Competing interests: None declared |
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