The social revolution in health services.

In the past, health care was predominantly curative and was directed mostly at the individual. It largely neglected the community and the true object of health services, i.e. to improve the health of the entire population. A comprehensive health service should meet all the health needs of a community and should not be orientated solely towards disease and hospital care. The importance of community participation in the social rehabilitation of individuals recovering from mental or organic diseases is emphasized, and the role of primary health care in helping to relieve pressure on hospital services by caring for more people at the community level should be recognized. In training health personnel greater emphasis needs to be placed on promoting more flexible attitudes of mind to fit professional skills covering all problems confronting the community. The social function of health services should be recognized and accepted in order to ensure that health technology is developed and applied in harmony with this social function.     

Policy and strategy for occupational health services in South Africa

Recent events in South Africa have spurred policy thinking in many areas, including occupational health. Strategic thinking needs to take account of current and likely future economic and political conditions in the new South Africa. The present occupational health system, considered as a network of health services, educational and research facilities along with a mechanism of legal regulation of workplace conditions, and compensation for occupationally-related disability, is reviewed and found to be inadequate in several respects. A possible structure for an integrated occupational health system is outlined at national, regional and local levels. Both service provision and financing arrangements are addressed. The interrelation between occupational health services and general health services for workers and their dependants is approached from the point of view of the desirability of comprehensive primary health care services catering to all health needs of all workers and their dependants. Appropriate linkages between levels of care (primary, secondary and tertiary), and between relevant institutions required for an efficient occupational health system are outlined.     

Presidential address 1996: “Dear ministers of health....”

The Canadian Association of General Surgeons, representing community and academic general surgeons throughout Canada, is concerned about the widespread effects of health care restructuring on clinical care, education and research. The general surgeon remains one of the critical members of the health care team and should have an adequate voice in ongoing discussions regarding health care reform.     

Strategies to support families of children with end-stage renal failure

The burden of care for families looking after children with end-stage renal failure can be considerable, especially when it involves home peritoneal dialysis and supplementary feeding. Good communication with the family and between team members delivering the multidisciplinary care is essential. Stress may be partly reduced by meeting the information needs and supplementing the spoken word with booklets, videos, tape-recorded interviews and play preparation for children. Families greatly appreciate a continuum of care between the hospital and community which is enhanced by team members visiting the home, nursery/school and primary care physician to impart and update knowledge. Respite care is essential for home dialysis patients. It can be enhanced by an evening baby-sitting service and the involvement of a home care renal nurse, as well as a holiday support strategy. Participation of the families in a regular parents support group provides not only an opportunity to integrate families into the unit, but also allows direct feedback on issues affecting the quality of care.     

基于CLHLS的老年人社区养老服务需求及影响因素研究

目的分析社区现有养老服务内容以及老年人对社区养老服务的护理需求,为政府合理分配社区养老服务资源,提高老年人生活质量提供参考。方法基于2017~2018年中国老年人健康长寿影响因素追踪调查数据(CLHLS),采集有关老年人期望社区提供的养老服务需求与社区供给情况,以及老年人人口学、社会经济状况、健康状况相关数据,运用Logistic回归分析方法,探究老年人社区养老服务需求的影响因素。结果共采集到11981名老年人数据资料。75.7%的老年人希望得到保健知识教育服务,42.2%的老年人报告其社区会提供该类服务;64.3%的老年人希望得到居家护理服务,但仅10.2%的老年人报告其社区会提供此类服务;81.0%的老年人希望得到家访照顾,35.0%的老年人报告其社区会提供此类服务;67.3%老年人希望提供心理咨询服务,但仅12.1%的老年人报告其社区会提供此类服务。老年人的年龄、居住地、居住现状、经济情况及健康状况等是影响其社区养老服务需求的主要因素(P<0.05,P<0.01)。结论老年人对社区养老服务需求较大,但我国社区养老仍存在供需不平衡、城乡差距明显以及老年人生活水平差异等。社区养老应以老年人需求为导向,建立多层次、全方位、多元化的养老服务体系,提高社区养老服务质量,满足老年人社区养老服务需求。     

Reducing health care costs--potential and limitations of local authority health services

Local authorities (LAs) currently provide preventive and promotive services. It is argued that, by extending the role of the LA to the provision of comprehensive services, including ambulatory and hospital curative care, both the quality and the cost-effectiveness of health care would be improved. Making health care the responsibility of the LA would minimise fragmentation, allow for the provision of a number of services that currently are neglected because they fall through the gap that exists between preventive and curative services, and result in the more effective use of personnel currently restricted to providing preventive care only. LAs offer an appropriate structure for effective community control over the health services, and are more likely to be sensitive to local needs and demands. In addition, their administrative proximity to other LA departments responsible for housing, town planning and parks and recreation allows for an effective multisectoral approach to health. The positive aspects of LA care can only be achieved in the context of racially integrated services provided by an LA elected by universal adult franchise. Smaller LAs may need to be grouped together in larger units for the purpose of achieving satisfactory economies of scale in the provision of health care.     

"Oh, that's a bit of a nuisance": community-dwelling clients ' perspectives of urinary continence health service provision.

OBJECTIVE: This study explored clients' perspectives of urinary continence service provision for community-dwelling people from a primary health care perspective. DESIGN: For this interpretive study, data were collected from 11 clients via in-depth interviews and a questionnaire eliciting demographic details and written comment. A focus group was also held with 7 people belonging to an existing continence self-help group. RESULTS: Clients indicated that appropriate and acceptable continence care was accessible, affordable, and based on accurate knowledge. They valued practitioners who were empathetic, interested, had good networks, and could assist in practical ways. They looked for explanation, information, and discussion, often finding this when they accessed continence specialists. However, they often found it difficult to access this type of care, with many clients finding that urinary incontinence was treated as a secondary issue or a nuisance by generalist health practitioners. Clients believed that many health practitioners lacked knowledge and/or interest in urinary incontinence. In particular, there was very poor transitional care between hospital and community. The cost of consulting a health practitioner was seen as secondary to the cost of continence equipment and aids. CONCLUSIONS: This study found that the principles of primary health care were not being realized in generalist continence care. Client- centered services that address individual needs, relationships, psychological factors, emotional needs, financial circumstances, social contexts, and lifestyle factors, particularly in transition between sectors, are needed.     

A health status and health service utilization study of a peri-urban community in Kwazulu

A community survey was undertaken in a district in Kwazulu, adjacent to Pietermaritzburg. Natal, in order to determine health status and health service utilization patterns at a local level. This low-cost survey was labour-efficient and yielded useful data for the evaluation and planning of local health services. It was found that child health and delivery services were under-utilized while family planning and antenatal care services were comparatively well used. 'Traditional' practitioners' services were used regularly by 51% of the mothers and childminders interviewed. The use of the services of general medical practitioners was less significant. Some 36% of the children under 5 years of age were found to be malnourished, and 29% had conditions requiring medical treatment. The findings of this study indicate that a major discrepancy exists between the local need for health services and utilization of the available services. The introduction of community health workers is proposed as a possible solution.     

Launching a problem service--the organisation of an occupational health service in the primary health care context. The case of the Alexandra Workers' Health Outreach Programme

The planning and development of an occupational health service (OHS) in a primary health care setting is described. A number of questions are addressed, including the relevance of an OHS for a developing country, the appropriate base for OHSs, and how to go about developing them. On the basis of early experiences with the Alexandra Health Centre project, it seems that the primary health care is an appropriate base for OHS provision and that it is possible to develop the service as a model for future OHS provision.     

Thai men's health and sexual attitude

Men's health awareness, including the research and study of quality of life, sexual desires and risk factors, has increased worldwide. In Thailand, this advancement is made possible by cooperation, research and sponsorship from the local Thai community. This article aims to illustrate the sexual attitudes of Thai people, to determine the degree of erectile dysfunction (ED) and to investigate how to manage and cope with ED in a Thai community. We reviewed the relevant literature from Thai-based articles and surveys in regard to men's health, sexual attitudes, the prevalence of ED and common risk factors in the Thai community. The primary risk factor for ED in Thai men was age-related health decline and the presence of vascular disease. Most Thai men will seek consultation from their partner in regard to ED. The main presentation of metabolic disease in Thai patients was dyslipidemia. New selective serotonin reuptake inhibitors are not available for premature ejaculation in Thai communities. The debate in regard to malpractice compensation is an issue that should be closely monitored. There is currently a shortage of home care for the elderly in Thailand. The insights provided by the articles helped recruit the study patients and in turn, helped us gain knowledge that can be translated into improved men's health care in Thailand.     

Primary health care strategies for the prevention of end-stage renal disease in Cuba

End-stage renal disease (ESRD) is a major health problem in the world, including Cuba. There is an increasing trend in both the incidence and prevalence of ESRD. Global projections consistently show an increase of patients in maintenance dialysis, and also an epidemic trend in diabetes mellitus and hypertension, two diseases that are leading causes of ESRD in most countries. A new paradigm is necessary to handle this major health problem, such as a public health model that integrates health promotion and disease prevention. In 1996, the Ministry of Public Health of Cuba launched a national program for the prevention of chronic renal failure (CRF). The progressive implementation of this program follows several steps: the analysis of the resources and health situation in the country; epidemiological research to define the burden of CRF; continuing education for nephrologists, family doctors, and other health professionals; and reorientation of primary health care toward increased nephrology services, intervention, and surveillance. The main outcomes of the program have been: a rational redistribution of nephrology services in corresponding health areas of primary health care; nephrologists being brought closer to the community; an improvement in the knowledge and ability of family doctors and nephrologists in the prevention of chronic renal disease; an increase in the number of patients with CRF (serum creatinine > or = 133 micromol/L or > or = 1.5 mg/dL, or a glomerular filtration rate < 60 mL/min) who are registered in primary health care every year, from a prevalence of 0.59 per 1,000 inhabitants at the beginning of the program in 1996 to 0.92 per 1,000 inhabitants in 2002, with a mean prevalence growth of 9.2% per year; a significant reduction (0.1%) in the incidence of viral hepatitis B in dialysis patients after the implementation of vaccination against viral hepatitis B in CRF patients who are registered in primary health care; and the implementation of CRF surveillance in primary health care, which provides periodic information on CRF burden, patterns, and trends to assist evidence-based public-health decision making, and measures the impact of interventions in the population. Primary health care is an essential tool, and the community is an appropriate social space for health promotion and the prevention of CRF and ESRD.     

Financing health care for all--is national health insurance the first step?

Political changes are likely to lead to demands for a more equitable health care system. It will be necessary to pay for more health care for more people without a substantial increase in the resources available. If a substantial proportion of the funds continue to come from private sources, then inequity in access to and the distribution of health care is inevitable. Consequently, it is argued that this can best be achieved if the resources that are available to pay for health care are controlled by a single, centralised co-ordinating body. It is suggested that it will be more feasible to generate sufficient funds under central control through taxation supplemented by a national health insurance scheme, rather than through simply expanding the contribution to health care that comes out of general tax revenue. Given that private ownership of health care facilities and services is likely to continue for the foreseeable future, central control of the funding of health care will make it possible to regulate the private sector, and bring it into a national health plan to provide health care for all.     

The phoenix physician: defining a pathway toward leadership in patient-centered care

Health care delivery has evolved in reaction to scientific and technological discoveries, emergent patient needs, and market forces. A current focus on patient-centered care has pointed to the need for the reallocation of resources to improve access to and delivery of efficient, cost-effective, quality care. In response to this need, primary care physicians will find themselves in a new role as team leader. The American College of Osteopathic Internists has developed the Phoenix Physician, a training program that will prepare primary care residents and practicing physicians for the changes in health care delivery and provide them with skills such as understanding the contributions of all team members (including an empowered and educated patient), evaluating and treating patients, and applying performance metrics and information technology to measure and improve patient care and satisfaction. Through the program, physicians will also develop personal leadership and communication skills.     

Patient-centered approaches to creating understandable health information

As care delivery shifts to further include patients in shared decision-making, patient-centered health information can balance the information asymmetry between patients and providers. Patient health literacy, numeracy, and graph literacy must match that of health information materials to create understandable health information that empowers patients to participate in shared decision-making. We consider an iterative approach focused on three key steps: assessment of the specific information needs of the selected patient community, assessment of that community’s ability to receive and understand health information, and evaluation of the materials developed to assess effectiveness. This structured approach using validated tools maximizes the likelihood of meeting patient needs to improve health outcomes.     

Emergency care in South Asia: challenges and opportunities

One of the striking deficiencies in the current health delivery structure is lack of focus on emergency care in primary health systems, which are ill-equipped to offer appropriate care in emergency situations resulting in a high burden of preventable deaths and disability. Emergency medical systems (EMS) encompass a much wider spectrum from recognition of the emergency, access to the system, provision of pre-hospital care, through definitive hospital care. The burden of death and disability resulting from lack of appropriate emergency care is very high in low- and middle-income countries. In South Asia, health services in general, and emergency care in particular, have failed to attract priority, investments and efforts for a variety of reasons. It has to be emphasized that integrating EMS with other health system components improves health care for the entire community, including children, the elderly, and other vulnerable groups with special needs. Out-of-facility care is an integral component of the health care system in South Asia. EMS focuses on out-of-facility care and also supports efforts to implement cost-effective community health care. There is a possibility of integration of other health services and programmes with an innovative, cost-effective EMS in the region.     

The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon

Disparities in health care access, quality, and outcomes for pediatric patients, and their relationship to race and socioeconomic status (SES) have been extensively documented. The underlying causes behind such disparities have been less carefully studied, as clinicians and researchers often fail to look past immutable features such as race, into modifiable factors like social determinants of health (SDOH). A child's environment affects their patterns of social engagement, sense of security, and overall well-being. Resources such as affordable housing, access to education, public safety, and availability of healthy foods and safe play spaces impact and enhance quality of life, and have significant influence on both health and health care outcomes. These upstream indicators are often unrecognized or misidentified as health concerns. Few pediatric surgery publications discuss SDOH and their effects on children. This paper aims to introduce the five domains of SDOH (economic stability, education, social and community context, health and healthcare, and neighborhood and built environment) along with strategies to identify and address needs in these domains from a provider, hospital, and health system's perspective. It is anticipated that this information will serve as a foundation for pediatric surgeons to understand and develop processes that ameliorate disparities related to SDOH and improve surgical outcomes and the well-being of all children.     

家庭医生服务团队在社区糖尿病健康教育中效果分析

目的：探讨家庭医生服务团队在社区糖尿病健康教育中的效果。方法以2011年12月~2013年5月社区300例糖尿病患者为研究对象,在药物治疗的基础上给予家庭医生团队服务,对服务前后的疾病控制、生活质量和满意度进行调查。结果300例患者经家庭医生团队服务后的空腹血糖、餐后2h血糖和体重指数分别为（6.5±1.1）mmol、（9.1±2.1）mmol和（23.1±1.8）kg/m2,均好于服务前（P＜0.01）;服务后的SF-36健康量表评分明显好于服务前,差异有统计学意义（P＜0.01）;患者对本次服务的满意度为97.33%。结论家庭医生服务团队利于社区糖尿病患者的病情控制,对生活质量的改善效果显著,值得进步推广实施。     

流动老年人社区健康管理利用行为影响因素研究

目的探讨流动老年人社区健康管理利用行为现状及影响因素,建立其作用关系模型,为社区护士开展流动老年人健康管理提供参考。方法便利抽取杭州市6个社区的流动老年人636人,采用自行设计的流动老年人社区健康管理利用情况影响因素问卷进行调查,应用结构方程模型分析相关影响因素与路径。结果流动老年人社区健康管理利用行为总分为(8.65±3.58)分,其中高利用者40人,中等利用者173人,低利用者423人。流动老年人社区健康管理利用行为的影响因素中健康需要的效应值最大(总效应值为0.51),其次是政策影响和环境可及性(总效应值分别为-0.45和-0.35),而社会支持、健康信念和环境影响性仅对利用行为水平有间接影响(总效应值分别为0.26、0.16、-0.08)。结论流动老年人社区健康管理利用行为受健康需要、政策、环境可及性、利用意愿、社会支持、健康信念、环境影响性的影响较大,需从提升流动老年人健康管理需要意识、完善社区卫生资源分配等多方面入手,以提高其社区健康管理利用行为。     

The role of the private general practitioner in the clinic-based primary health care service in KwaZulu

Attitudes of practising private general practitioners to limited integration in the primary health care team in KwaZulu are evaluated and presented in the light of need, draft policy and experience in other parts of the world.     

The paediatric primary health care nurse project in Soweto

The in-service training of paediatric primary health care nurses at Baragwanath Hospital, and the implementation of this project with health care teams in the Soweto clinics, is discussed. Appropriately trained members of the community can provide better comprehensive primary care, and optimal use is made of available manpower. Similar schemes in other parts of the world are briefly considered.