UKZN MMed(FamMed) – COPC MODULE

STUDY GUIDE 2007/8

CONTENTS

1. Introduction

2. Basic Concepts of COPC

3. Linking Personal Care to Community Context

4. Community Definition and Characterization

5. Feedback and Prioritization

6. Intervention Planning

7. References

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1. Introduction - aims and outcomes

Welcome to this module on Community-oriented Primary Care. It is essential that

you read the introductory material before proceeding with the module. After reading
the following introductory material you should understand:

 The module structure and outline

 What you will have to do during the module
 How we will interact and communicate
 How and when you will be assessed

Outcomes for the module

This module aims to cover the principles and some of the practice of community-
oriented primary care in your community.

At the end of this module you should be able to:

 Describe the concept and steps of community-oriented primary care

 Define and characterize a community within which your practice is situated
 Prioritize the major health issues of that community
 Design an intervention that would address one of the high priority health
issues

Module Facilitators:

Prof Steve Reid

Dr Andrew Ross

Ms Sandy Glajchen

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The Course Outline

Months Conceptual stages Practical tasks

Assignment 1: Reading
October – 1. Basic concepts of COPC
November and theoretical framework Discussion 1 : 16 October 08
2007

Assignment 2 : Home visit

Dec 2007 2. Linkage of personal care to
– January community context Discussion 2 : 28 Jan 08
2008

February – 3. Community definition and Assignment 3 : Community survey

May 2008 characterization

May 08 4. Feedback and prioritization Assignment 4: Presentations &

process Prioritization process: 10 June 08

June 08 5. Design an intervention Assignment 5: Intervention planning

6. Summative assessment Hand in composite report : July 08

Marking Schedule

The total module marks allocated to the various types of tasks are shown below.

 Discussion on readings: participation 10%

 Reflection on home visits: written report 20%

 Community survey & prioritization: presentation 20%

 Community survey: written report 30%

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 Intervention plan: written report 20%

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2. BASIC CONCEPTS OF COPC

Introduction

Welcome to the community-oriented primary care (COPC) module. This is a

module in which you will improve your understanding of the community in which
you practice, and start to think about ways of getting involved in order to improve
the health status in a particular area. You have the option of continuing this as an
action research project if you wish.

This module is about making a difference to the context within which your patients
get ill and get better: in other words, acting with and beyond the individual patient
to effect change in the wider factors which affect health. This involves doctors in
preventive and promotive aspects of care, outside of a health facility, with which
they are often uncomfortable. It means using the detailed knowledge of illness and
disease in individuals as a springboard for action on a community level, extending
ones scope of practice to become involved in community-wide health issues as
part of a team.

Simply put, COPC is the combination of frontline clinical medicine with public
health. Note that it is neither one nor the other, but a combination of both. It is
defined as follows:

Definition

“A continuous process by which primary health care is provided to a defined

community on the basis of its assessed health needs, by the planned
integration of primary care practice and public health”.

(Abramson 1988)

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Assignment 1: Reading

Please read the following references thoroughly in order to gain as many

perspectives on COPC as possible. You will need to complete most of the reading
by 16 March so that you can participate in the discussion then.

1. Tollman S, Friedman I. 1994. Community-oriented primary health care – South

African legacy. S Afr Med J; 84 (10): 646

2. Longlett SK, Kruse JE, Wesley RM. Community-Oriented Primary Care:

Historical Perspective. J Am Board Fam Pract 14(1):54-63, 2001.
http://www.familypractice.com/journal/2001/v14.n01/1401.08/art-1401.08.htm

3. Epstein L, Eshed H. 1988. Community-oriented primary health care: the

responsibility of the team for the health of the total population. S Afr Med J 73:
220-223.

4. Reid S. Community-oriented primary care. In: Handbook of Family Medicine,

Mash B (ed). Oxford University Press, SA, 2000.

5. Gruen RL, Pearson SD, Brennan TA, 2004. Physician-Citizens – Public Roles
and Professional Obligations. JAMA 291 (1), 94-98

6. Gofin J, Gofin J, Neumark Y, Epstein L. 1998. The Process of Community-

Oriented Primary Care (COPC): An Overview. Hebrew University of Jerusalem
and Hadassah.

7. Rhyne R, Bogue R, Kukulka G, Fulmer H (eds). 1998. Chapters 3 and 4 from

Community-Oriented Primary Care: Health Care for the 21 st Century.
Washington DC: American Public Health Association.

8. Boelen C. 2000. Towards Unity for Health: challenges and opportunities for
partnership in health development. World Health Organization, Geneva. The
most useful chapters are "A Challenging View" pages 15-22 and "Innovative
Patterns" pages 23-32.

9. Nickson PJ. 1991. Community Participation in Health Care: who participates

with whom ? Tropical Doctor 21, 75-77.

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Group Discussion 1

Aim:
To explore how the principles of COPC are applicable in your work as a family
physician

Instructions:
Complete the reading on COPC that gives you a number of different perspectives
and theoretical material on COPC. Reflect on how these ideas and concepts could
be applied in your setting. It may be helpful to make notes as you read the
references.

In the group discussion you should discuss the following questions:

1. Are you unclear about any of the principles or ideas in the readings? Do you
need to clarify any terms or concepts?
2. How could these principles and concepts be applied in your setting? What do
you think are the challenges to applying this in your context?
3. What activities have you been involved in previously in your community, and
how do the concepts of COPC relate to these experiences?
4. How will you personally define your community for the purpose of this module?

Grading:
This discussion will count for 10% of the module marks. You will be assessed not
only for your original contribution but also for your interaction with and response to
the other members of the group.

An observer will be present at the discussion in order to score your input in terms
of the following criteria:
Quantity of inputs: how frequently you contribute
Quality of inputs: how appropriate your input is
Related to your own experience
Response to others’ points
Sharing of original insight

If you are unable to attend the discussion for any reason, a written submission
responding to the group discussion questions will gain you a maximum of half
of the 10% module marks available.

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3. LINKING PERSONAL CARE TO COMMUNITY CONTEXT

Assignment 2: Doing a home visit

Aim:
To explore the gap between individual and community care by doing a home visit

Deadlines:
You should complete this task and hand in your written assignment on 28 January
2009.

Grading:
This assignment will count for 20% of the module marks

Instructions:
Home visits were traditionally an important aspect of the work of family physicians
in many countries, but the frequency of home visiting has declined over the years.
The reasons for this are numerous, including rising costs, and the improvement in
communications and emergency services. Nevertheless, the home visit is a crucial
link between clinical practice and comprehensive care, creating the physical and
psychological bridge between facility-based and community-based interventions.
So much insight can be gained from a single home visit that the time spent is not
only justified for that patient, but the effect on other patients is often significant.
McWhinney states as a principle of Family Medicine that “the family physician sees
patients at the office, at their homes and in the hospital”, since he or she is
committed to the person who is the patient.

A home visit can be compared to the time and expense of a common elective
surgical operation, with similarly dramatic results. It can be either diagnostic or
therapeutic, and is often a combination of both. Whereas the ostensible reason
may be that the patient cannot travel, or it is felt to be an emergency, the
experienced practitioner may often take the opportunity to understand a patient’s
context better, or demonstrate his commitment to the patient by making a home
visit. As a learning exercise, you will undertake a home visit primarily as a
“diagnostic” exercise, hoping to learn more about the context of the illness, but you
may be called upon to give advice or intervene.

Before you go out to the home visit, write down what you expect to find based on
what you know about the patient that you have selected. Then compare this after
the visit with what you actually found.

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The choice of patient is entirely up to you, depending on your situation and
relationship with the patient. A good learning opportunity is usually found with a
patient with a chronic disease whom you have known over a period of time.
Whether it is requested by the patient or suggested by the practitioner, entering a
patient’s home and family is an intimate experience, and must be approached with
due respect and consideration.

 Obtain permission and acceptance: explain the purpose of your visit in detail,
and negotiate your entry into the home by appointment.
 Gather all the information that you can: use all your skills of observation and
inquiry to obtain the richest possible understanding of the family and home from
the visit.
 Think family: drawing together all the important findings.
 Make a difference: to the patient, to the family or to any other factor which
influences the illness.

For example, finding other family members coughing at the home of a TB patient
will mean making plans to get the whole family screened. Or finding carpeted floors
or pets in the home of a chronic asthmatic could suggest that specific information
and action is needed for that family.

The following information should be specifically sought if it is not immediately

apparent:

 The illness: What makes it worse? What makes it better? What started it? What
could change? The effect of medication or other medical interventions on the
illness. Help-seeking behaviour-what does this family do when someone is ill?
Who gets involved in caring and who doesn’t? How could this be different?

 The family: structure, dynamics and relationships, values, daily activities,

educational level, sources of income and stability, support systems (extended
family, neighbours, church or other groups) and other resources used by the
family. For example, a traditional healer or a particular friend may be a
significant person to the family. It is often useful to draw a genogram or
ecomap whilst at the home in order to help elicit further information about the
family.

 The home: physical infrastructure, hygiene and sanitation, water sources,

distance to schools and shops, means of transport, communications,
environment, security and stability of tenure.

Reading: The College of Family Physicians of Canada:The Role of the Family

Physician in Home Care. A Discussion Paper – December 2000.
http://www.cfpc.ca/English/cfpc/communications/health%20policy/the%20role
%20of%20the%20family%20physician/default.asp?s=1

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Write-up of home visit

After you have conducted a home visit using these principles you should write up
your visit (2 to 4 pages single-spaced) using the following questions as a guide:

What?
What did you expect to find before you visited the home ?
What was the reason for the visit?
What did you plan?
What did you see and hear?
What actually happened? (i.e. that you might not have actually seen or heard)
In what ways was what actually happened different to what you had planned or
expected?
What did you experience or feel yourself?

So what?
So what does this mean ? What does it suggest ?
So what did you learn from the experience?
Why did things happen the way that they did?
In what ways do the issues that this patient or family face reflect those of the whole
community?
What does this experience teach you about the community that you serve?
How does this fit into the bigger picture of the community and wider society at
large?
Did you make a difference?
How do you know if you made a difference?
Did you experience a difference yourself?
What changed for you, if anything?

What next?
How might you do things differently next time if at all?
What needs to happen next?
What questions arise for you for further investigation ?
How could this experience and reflection change the way that you practice
clinically with other patients, whose homes you do not visit?
How could you influence or improve the access to health care of those in your
community who do not come for care?
How might you engage with the social determinants of health in your community
and society?
- as a doctor
- as a citizen

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4. COMMUNITY DEFINITION AND CHARACTERIZATION

Introduction

The community in COPC is the equivalent of the patient in individual care. Knowing
the characteristics of the community both qualitatively and quantitatively is an
essential component of COPC practice. Just as we take a history and examine
individual patients, so we must inquire about and examine the community which we
serve, if we are to make any meaningful interventions beyond the individual level.
This is basically a situational analysis of the community or district.

What is a community? How shall it be defined or described? It could be:

 A group of people residing in a geographically defined area
 Members of a certain ethnic, language, age or other demographically-defined
group who share certain characteristics and have the ability to interact with one
another.
 A group of people brought together by a school, church, workplace, shared
interest or necessity.

An important component of community is the capacity to interact and create an

identity – the clients who use a petrol station or even a medical practice or hospital
are not necessarily a community, unless they come together around a particular
issue.

It is extremely important to define the limits or boundaries of the community that

you are going to work with. This will give you the denominator information that will
enable you to compare whatever you measure with other areas and with national
norms and standards. You are free to define your community in whatever way you
see fit, but we would encourage you to go outside of your known patients (your
practice population) and include the local community in which your practice is
situated.

The community in which you practice will be part of a demarcated municipality,

which in turn will be part of a district. You will need to find out all you can about the
size and shape of these structures. The district health system operates on the
basis of distinct geographical districts, and all health workers within that area share
the responsibility for the health of its residents. This affords us the opportunity in
South Africa to plan the utilization of resources more equitably and rationally than
ever before. The whole population of a geographically defined district is the focus
of the health care services, rather than select individuals within that district, such
as those who can afford to attend private practices, or get to clinics and hospitals.
Those who do not come for care are as important as those who do come for care –
in fact, the most vulnerable groups are often found amongst those who cannot
attend health care facilities.

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Assignment 3: Community survey

Aim:
To complete a situational analysis of the community that you serve as a family
physician

Deadlines:
You have 4 months to engage with this task and write up your findings. A
presentation of a summary of your findings will be given in June 09, and the final
written report should be handed in in July 09.

Grades:
The presentation will count for 30% and the written report will count for 30% of the
module marks.

Instructions:

Complete the reading for this section of the course while you are planning this task.

Your task is first to define the community that you will focus on, by describing its
limits or boundaries – who is included and who is not, with justification for both.
If appropriate, draw a map or diagram that depicts the community that you will
study.

Next, you need to plan to gather information and data about your community from
every available source, over the next 8 weeks. You will need to get an idea of
the size and shape of the whole community that you serve. Census figures are
very useful, and your District Health Information Officer may already have all
the data that you need. The information may be quantitative or qualitative data,
or a combination of both.

You need to start by interviewing key people in your community, and record the
interviews, e.g. the District Health manager, the local Mayor, and the manager
of your nearest hospital or health centre. If a group of students work in the
same district, you could make one appointment and meet with these key
informants together.

Where appropriate, use an asset-based approach in gathering the information as

described in the readings below.

Don’t limit yourself to health information: get some other perspectives on issues
that affect health, such as social services, housing, water and sanitation,
education, agriculture if you are in a rural area, or traffic control if you are in an
urban area. Use the guide in Gofin et al. to cover the issues.

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You will need to present a summary of the information gathered about your
community on 10 June 2009, in such a way that your audience is able to assist
you in prioritizing the major health issues (See section 4 below).

Finally, you need to write up a report that highlights your findings, including the
limitations of the data. Your reflections on the process of gathering the data
need to be included in a discussion section, in which you need to draw
together the information that you have gathered, and analyse what it means.
Compare your community to others, and to national standards. What are its
major assets, and its major areas of weakness? Try to consolidate this into the
community diagnosis, in an analogous way to the clinical diagnosis of an
individual patient that summarizes the whole situation .

The report should be between 20 and 30 single-spaced pages including figures

and graphs, and should include the following sections:
Introduction
Methodology
Findings
Discussion
Prioritization (see section 4 below)
Intervention plan (see section 5 below)

These reports will be marked using the following criteria

 Presentation and layout
 Validity and accuracy
 Relevance and focus
 Level of analysis
 Appropriateness of the community diagnosis / conclusion

Readings

Community Engagement: Asset-Based Community Development

http://www.health.state.mn.us/communityeng/disparities/asset.html

Engagement: Two Way Communication

http://www.health.state.mn.us/communityeng/disparities/twoway.html

Introduction to "Building Communities from the Inside Out: A Path Toward Finding
and Mobilizing a Community's Assets," by John P. Kretzmann and John L.
McKnight.
http://www.northwestern.edu/ipr/publications/community/introd-building.html

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5. FEEDBACK AND PRIORITIZATION

Introduction

Having described the characteristics of the community, including its health status,
the next step requires that the main health issues be prioritized. Since communities
are complex systems, and face many different health problems simultaneously,
they are forced to compete for limited resources. Decisions regarding what, where,
when and how personnel and other resources should be deployed in a given
community will depend on the identification of the most important health needs. It is
important therefore, that the process of prioritization of health issues is done
inclusively, and with meticulous care.

First, an appropriate group of people needs to be identified in order to feedback the

results of your survey to, and carry out the task of prioritisation with you. Ideally this
should be a group of key people in the community. There may be an existing team,
such as a district or sub-district health management team, that is responsible for
the community that you have studied, and with whom you will be able to interact.
However, for the purposes of this module, we will simulate this experience in
the classroom. You need to be prepared to present the findings of your survey to
your colleagues as if they were the community members, and ask for their
comments.

The identification of health priorities begins by listing all the health issues identified
in the survey and identifying the most compelling problems through an open
discussion between the members of the primary care team. “Brainstorming” in
response to the question: “What are the most important health issues in this
community?” will generate a long list, which can be subsequently whittled down by
the application of criteria.

While health professionals can identify the major causes of morbidity and mortality
by the analysis of health status data, these decisions can not be made in isolation
of the users of the health system, the community itself. In the words of Sidney
Kark, the pioneer of COPC in the 1950’s, we need to “explore what the community
feels, thinks and does about its health needs, since interventions need to be
directed towards those aspects about which people can do much themselves”
(Kark SL, 1981). Thus community involvement in this stage of identification and
prioritization is considered to be essential. Community representatives from formal
representative structures such as local councils, district or tribal councils, should be
invited to participate, as well as key figures in the community, such as the
ministers, or school principals if appropriate. Without community involvement, any
subsequent intervention is unlikely to succeed. So, if you do decide to carry
through this exercise into real life, you would need to meet with or convene such a
group of people to plan the way forward together.

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Assignment 4: Feedback and prioritisation

Aim:
To present the findings of your community survey to your colleagues (in lieu of a
community forum) and together to prioritise the health issues.

Deadlines:
This will be done on one presentation day on 10 June 2009. Each student will be
given an opportunity to present and ask for feedback.

Grades:
The presentations will count for 30% of the module marks. You will be assessed
not only for your original contribution but also for your interaction with and
response to the other members of your group.

 Present your findings to them

 Ask for validation and feedback
 Present the criteria for prioritisation
 Draw up a ranked list of health issues from highest to lowest priority, through
discussion and debate, or voting if necessary.

You need to consider the following criteria for prioritisation:

1. How common is it? This is measured by the prevalence or incidence

2. How serious is it? This is measured by the case-fatality rate
3. To what extent is the community concerned about it?
4. Is it feasible to intervene?
5. Will an intervention be effective?

Taking the main health issues identified in your community assessment, subject
each of these to each of the above criteria, and weigh them up relative to one
another. Each participant needs to justify their priority ranking of each issue. You
could use a scoring system for each issue, and add up the total score.

The findings or outcome of your prioritization process needs to be presented as

part of your written assignment on intervention planning that is described in section
5 and is also due at the end of the module.

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6. INTERVENTION PLANNING

Introduction

The final task in this process is to take one of the high priority issues identified by
your team, and design an appropriate intervention to address that issue. For the
purposes of the requirements of this module, this planning process is a paper
exercise. However you could elect to take the project further as an action research
project next year, or you might want to implement it outside of the course
requirements. In the latter case, the establishment and integrity of the team that
you work with will be crucial to the success of the project.

Aim:
To plan an appropriate intervention to address one of the identified priority issues

Deadlines:
This written task should be incorporated into the final report and handed in at the
end of the module in Julu 2009.

Grades:
This assignment will count 20% towards the final module mark.

Instructions:

This written assignment should include the outcome of the team prioritisation
process that you completed in the previous section.

This subsequent planning process is a paper exercise that you will think through
individually for yourself and write down in your written assignment. You are NOT
required to actually organise a team to complete this planning process
during the module, but you could do this electively outside of the module, or take
it through into your research project.

The first step must be to identify in theory the most appropriate members of a new
team who would be prepared to work on the chosen issue. Be sure to include all
role-players, including representatives of those most affected by the issue that you
are addressing. For example, if alcoholism is a major problem, try to identify
reformed alcoholics in the community who would be willing to help. If the issue is
HIV/AIDS, invite people living with AIDS to join the team.

The planning cycle needs to start by answering the following questions:

 What is it that we can envisage in a few years’ time ? (a vision)
 What is the broad aim of the project?
 What are the specific objectives, or components of the broader aim?

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These will determine the specific activities, which need deadlines and people
identified to carry them out.

You need to give thought to how the progress of the project could be monitored, i.e.
what indicators could be measured before, during and at the end of the project to
be able to know whether it is making any difference or not?

The basic components of a comprehensive intervention plan include the following:

1. A name or title for the project

2. The team members
3. A vision
4. The overall aim
5. The objectives to reach that aim
6. Activities for each objective
7. Identifying who will do what
8. Deadlines and timelines
9. Indicators for monitoring and evaluation
10. Ethical considerations

Composite Final Report

In summary, the final report should include the following chapters:

Community survey
Prioritization process
Intervention Plan

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 REFERENCES

1. Tollman S, Friedman I. 1994. Community-oriented primary health care – South

African legacy. S Afr Med J; 84 (10): 646

2. Longlett SK, Kruse JE, Wesley RM. Community-Oriented Primary Care:

Historical Perspective. J Am Board Fam Pract 14(1):54-63, 2001.

3. Epstein L, Eshed H. 1988. Community-oriented primary health care: the

responsibility of the team for the health of the total population. S Afr Med J 73:
220-223.

4. Reid S. Community-oriented primary care. In: Handbook of Family Medicine,

Mash B (ed). Oxford University Press, SA, 2000. Prescribed book.

5. Gruen RL, Pearson SD, Brennan TA, 2004. Physician-Citizens – Public Roles
and Professional Obligations. JAMA 291 (1), 94-98

6. Rhyne R, Bogue R, Kukulka G, Fulmer H (eds). 1998. Community-Oriented

Primary Care: Health Care for the 21 st Century. Washington DC: American
Public Health Association. Recommended book.

7. Gofin J, Gofin J, Neumark Y, Epstein L. 1998. The Process of Community-

Oriented Primary Care (COPC): An Overview. Hebrew University of Jerusalem
and Hadassah.

8. Boelen C. 2000. Towards Unity for Health: challenges and opportunities for
partnership in health development. World Health Organization, Geneva.

9. Nickson PJ. 1991. Community Participation in Health Care: who participates

with whom ? Tropical Doctor 21, 75-77.

10. The College of Family Physicians of Canada:The Role of the Family Physician
in Home Care. A Discussion Paper – December 2000.

11. Community Engagement: Asset-Based Community Development

12. Engagement: Two Way Communication

13. Kretzmann JP and McKnight. JL. Introduction to "Building Communities from

the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets".

18