Primary Healthcare

PRIMARY HEALTH CARE IN THE AMERICAS:
CONCEPTUAL FRAMEWORK, EXPERIENCES,

CHALLENGES AND PERSPECTIVES
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 Health
Organization
orld Health Organization
! Pan American Health Organization" 2002
This document is not a formal publication of the Pan American
Health 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 that
full credit is given to the source and that the te!t is not used for
commercial purposes.
AUTHORS
#everly $% &c'lmurry" 'dD" (AA)
Professor" 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" PhD
Assistant Director" /eha*ilitation /esearch and 0raining +enter on
Aging 1ith Developmental Disa*ilities
/osina +ianelli" +)&" &PH" PhD +andidate
Pre2Doctoral 0rainee
A,DS ,nternational 0raining and /esearch Program
+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
0he authors ac.no1ledge the contri*utions of the follo1ing persons in
revie1ing the documents3 )aeema Al24asseer5 Aaron #useh5 4ladys +anaval5
,lta 6ange5 7athryn #% 6emley5 &aricel &anfredi5 $udith Popovitch" and /andy
Spreen Par.er%
TA.LE OF CONTENTS
EXECUTIVE SUMMARY/////////////////////////////////////////////////////////////////////////////////////////////////////////
PRESENTATION///////////////////////////////////////////////////////////////////////////////////////////////////////////////////
0/ INTRODUCTION///////////////////////////////////////////////////////////////////////////////////////////////////////////////
1/ .ACKGROUND////////////////////////////////////////////////////////////////////////////////////////////////////////////////
2/ MODELS OF CARE///////////////////////////////////////////////////////////////////////////////////////////////////////////
8%9 &OD'6S O( +A/' (O/ H'A60H +A/' P/A+0,+'" 'D-+A0,O) A)D /'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'A60H S0A0-S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
5.1.1 Communicable Diseases.....................................................................................................
5.1.2 Non-communicable Diseases..............................................................................................
:%2 H'A60H /,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<,D'/S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$.1.1 Community Health %or"ers&'ides&'ctivitsts( Community Health Motivators&)olunteers.....
$.1.2 Nurses( Mid*ives( and Nurse Practitioners..........................................................................
$.1.3 Physicians...........................................................................................................................
$.1.+ Partnershi,s- Health Proessionals and Community Coalitions............................................
;%2 6O+A0,O) O( S'/<,+'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$.2.1 Church-!ased Health Pro#rams..........................................................................................
$.2.2 School !ased Health Services and Health .ducation..........................................................
$.2.3 %or"-Site Pro#rams............................................................................................................
;%8 0=P'S O( P/O4/A&S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$.3.1 /amily Models.....................................................................................................................
$.3.2 Community Models.............................................................................................................
$.3.3 Health Care Pro#rams.........................................................................................................
;%> H'A60H +O)+'/)S?,SS-'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$.+.1 Primary health care............................................................................................................
$.+.2 'ccess and e0uity...............................................................................................................
$.+.3 Priority areas......................................................................................................................
6/ METHODOLOGICAL AND MEASUREMENT ISSUES///////////////////////////////////////////////////////////////
@%9 P/,&A/= H'A60H +A/' &OD'6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
@%2 0/A)S(O/&,)4 /O6'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
@%8 +/,0'/,A A/'AS%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7/ IMPLICATIONS, CHALLENGES, AND PERSPECTIVES////////////////////////////////////////////////////////////
A%9 A60'/)A0,<' APP/OA+H'S 0O +A/'%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A%2 #A//,'/S 0O +HA)4'%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A%8 P/,O/,0,'S (O/ 0H' )' +')0-/=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A%> 'D-+A0,O)A6 ,SS-'S%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.+.1 .ducational barriers............................................................................................................
1.+.2 .ducational Needs..............................................................................................................
A%: S-&&A/=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.5.1 Su##estions........................................................................................................................
8/ REFERENCES//////////////////////////////////////////////////////////////////////////////////////////////////////////////////
APPENDIX A: THE AMERICAS: 37 COUNTRIES AND TERRITORIES///////////////////////////////////////////
APPENDIX .: PAHO STRATEGIC AND PROGRAM ORIENTATION, 088891::1 /////////////////////////////
APPENDIX C: PRIMARY HEALTH CARE IN .RA;IL///////////////////////////////////////////////////////////////////
EXECUTIVE SUMMARY
Practitioners" educators" and researchers continue to search for innovative
strategies and solutions to address priority areas that are relevant to societal
and community needs% ,n this document for practitioners" researchers" and
educators" 1e present a revie1 of literature reBecting the models of care used
for 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 recognize
that over2arching determinants of preventa*le illness and death are often the
result of poverty" unemployment" and lac. of participatory development" not
*iological?physiological determinants (4ottschal." 9CCC)% &oreover" policies
devoid of the values em*edded in society as 1ell as consideration of the impact
of social and economic policies (&c7night" 9CC:) can negatively aDect health
status on an individual and community level%
0o gain an understanding of the sociopolitical and economic realities as 1ell
as the goals of a community and society" providers of health care services must
familiarize themselves 1ith the concepts that relate to gro1th" development"
and sustaina*ility (4ottschal." 9CCC)% Ho1 these concepts are deEned and
operationalized are critical factors for providers attempting to meet the health
needs of communities and particularly mem*ers considered vulnera*le%
SpeciEcally" providers need to incorporate a *road understanding of the
interconnectedness of these concepts into their daily practice%
e present a Primary Health +are (PH+) &odel that can *e used as a
philosophy and a strategy to promote health and to prevent diseases" through
comprehensive health care" that is colla*oratively and cooperatively provided *y
community mem*ers and multiple" health relevant disciplines% Additionally" the
literature is revie1ed to discuss and to eFamine the types of health care
providers" the mode of service delivery" the location of services" types of health
care programs" and health concerns?issues% e also discuss measurement
criteria issues" evaluation methods" and implications" challenges" and
perspectives% 0his document 1ill *e useful as a guide for practitioners"
educators" and researchers 1ho are interested in health issues and are involved
in decision2ma.ing and policy development for institutions and programs
providing health care services% &any practitioners" educators" and researchers
assume that their practice2*ase is theoretical% e hope to challenge that idea
1ith the suggestion that the PH+ perspective is a useful 1ay to organize
disparate literature" ta.e stoc." and determine a preferred future%
"
PRESENTATION
/eforms of the health sectors in the /egion of the Americas have often
focused on the model of care in the search for ne1 1ays of meeting the needs
and improving the health of the population% 0he need to evaluate these ne1
models and their implementation challenges the health system to ma.e more
eFplicit the conceptual frame1or. used in the approaches *eing considered%
&any pu*lic health leaders vie1 a model of care *ased upon a primary health
care 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 focuses
on the promotion of health and the prevention of disease" through
comprehensive care that is colla*oratively and cooperatively provided *y
community 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 G
medicine" nursing" mid1ifery" pu*lic health2 as 1ell as the models that focus on
age groups or health pro*lems%
0he document" Primary Health +are in the Americas3 +onceptual (rame1or."
'Fperiences" +hallenges and Perspectives" is intended to contri*ute to the
ongoing discussions on designing" implementing and evaluating ne1 models of
care in the conteFt of health sector reform% #ased upon an eFtensive revie1 of
pu*lished literature from around the 1orld" the authors present information on
four components or aspects of care that are often considered in adopting a ne1
model of care% 0hese include provider" location of services" types of programs
and health concerns or issues% 0hey discuss methodological and measurements
issues and propose implications for future 1or.%
&ore than >00 articles pu*lished since 9CC0" including more than half from
the 6,6A+S data*ase" 1ere revie1ed in the preparation of the document% A
maHor diIculty encountered 1as o*taining full teFt articles from the 6atin
American sources% An impressive *ody of literature eFists on these various
aspects of the model of care% 0he research Endings should *e used more
consistently to ma.e decisions regarding practice" education" policy" and to
guide future research%
#
0/ INTRODUCTION
0he ne1 millennium *rings an opportunity to evaluate models of care that
are used for health care service delivery" education" and research% ,n the Pan
American Health Organization (PAHO) /egion" practitioners" educators" and
researchers continue to search for innovative strategies and solutions to address
a myriad of priority areas and issues that are relevant to societal and
community needs% Although the countries and territories in the Americas are
immensely diverse and many diDerent cultures traversed (i%e%" race" ethnicity"
socio2economic status" disa*ility status" political and religious aIliations)"
commonalties do eFist among people and their health care concerns% According
to the 9CC; /eport of the orld Health Organization (HO) Ad Hoc +ommittee
on Health /esearch" the 1orld community faces four critical health issues3
9% ,nfectious diseases" malnutrition" and poor maternal and child health 1ill
continue to account for a signiEcant portion of unnecessary deaths and
illness (particularly in countries 1ith fe1er economic resources)" despite the
health advances and pu*lic education during the past century%
2% ,neJuita*le and ineIcient health care delivery systems prevent access to
health care for many individuals%
8% 'pidemics of non2communica*le diseases" inHuries" and violence such as
cardiovascular diseases" neuro2psychiatric conditions" cancer" dia*etes" and
chronic respiratory infections are aDecting greater num*ers of people%
>% A gro1ing num*er of drug2resistant micro*es are creating ne1 health
emergencies and a resurgence of diseases (e%g%" tu*erculosis" malaria" and
pneumococcal disease) that 1ere once considered to *e under control%
(or practitioners" educators" and researchers" the provision of health care
services to address the a*ove four areas of concern reJuires careful
consideration of the model of care *eing utilized% &odels of health care provide
the foundation for constructing eDective policies and strategies aimed at
improving population health 1ithin the PAHO /egion% Developing frame1or.s for
health care services reJuires an understanding of *oth the critical health issues"
and the determinants of population health (0arlov" 9CCC)% Determinants of
health 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 determine
their eDect on health status" consideration of the dynamic interactions among
and *et1een these factors on health status for individuals or communities
$
PRIMARY HEALTH CARE IN THE AMERICAS: CHALLENGES AND PERSPECTIVES
remains a challenge% 'Famining the inter2relationships *et1een determinants of
health and critical health issues reJuires the eFplicit use of models to
conceptualize and guide practice" teaching" or research% &odels of care directly
inBuence health care research and the health care services that people receive%
&oreover" the framing of the care or the research Juestions 1ill determine
1hether the processes and outcomes are e0uitable" accessible( acce,table( or
available% Partici,ation levels and cultural relevancy are also determined *y the
modelKs philosophical assumptions% 0hus" understanding a particular model of
health care is a crucial component in health care practice" education" and
research% 0he use of a model illustrates the factors that determine health status
and esta*lish critical path1ays to address health care concerns%
,n preparing this document" 1e recognize that every segment is integral to
the entire document% Ho1ever" 1e have structured the paper so that each
section can *e revie1ed individually" if the reader prefers to do so% 0he ta*le of
contents 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 of
models of care might *e organized% e hope that readers of this document use
it to reBect on means for improving multidisciplinary and participatory activities
to advance health care in the PAHO /egion%
%
1/ .ACKGROUND
0he 9CCCG2002 Pan American Health OrganizationKs Strategic and
Programmatic Orientations identiEed Eve Strategic and Programmatic
Orientations to guide health planning and programmatic actions to address
health concerns across all levels" local" regional" and national in the PAHO
/egion (See AppendiF A)% 0he 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%
0he Eve strategic areas are useful guides for formulating ne1 directions and
o*Hectives to *e addressed in models of care in the Americas%
0he 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 and
surveillance at the regional and national level to document and evaluate
ineJuities in health% Studies eFamining the health proEles of neglected
population groups must *e conducted to design health interventions addressing
the social ineJuities" and disparities in health status and health care services%
0raining for health care providers across all levels must *e upgraded to ena*le
them to analyze the health situation and living conditions of various population
sectors 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 policy2ma.ing and
the preparation of plans" proHects" and programs aimed at *ridging the gaps in
health%
Health promotion and protection is a po1erful strategy to address
community and individual health concerns (PAHO" 9CCC)% hile health is a
primary component of human development" health promotion must involve a
much *roader scope of action than that customarily handled *y health systems
and services% Additionally" health promotion and protection can *e a useful focal
point for countries to adopt and implement paradigms aimed at aDecting the
determinants of health in general% &oreover" the factors that are fundamental to
a populationKs health relate to 9) their living conditions5 2) their opportunities to
fulEll *asic needs5 8) the Juality of their environment5 >) the culture to 1hich
they *elong5 and :) their .no1ledge" attitudes" and practices 1ith regard to
health and the political health structure foot health services delivery%
0he environmental protection and development strategy is critical due to the
potential adverse eDects of environmental factors on the health of a community
(PAHO" 9CCC)% #y including environmental factors as a component in models of
care" programs and proHects 1ill address the eDects of the environment on the
&
health of community mem*ers" particularly children" aimed at identifying and
eliminating or minimizing due to its greater suscepti*ility% 0his strategy also
supports the promotion and implementation of environmental care activities
1ithin the conteFt of Health for All" along 1ith active participation among
community mem*ers in identifying their o1n needs and in Ending solutions% 0he
health systems and services development strategy supports the development
and dissemination of methodologies and tools to strengthen capacities for
analysis" policy2ma.ing" and the implementation and evaluation of sectoral
reform programs" along 1ith systematic and ongoing transfer of information to
share eFperiences on a local and national level (PAHO" 9CCC)% 0hese strategies
are *est implemented *y use of health care models that support a reorientation
of health services to satisfy health promotion" health protection" and disease
prevention criteria% 0hese criteria emphasize improvement in the Juality and
comprehensiveness of speciEc interventions and strengthen the operational and
pro*lem2solving capa*ility of the services at diDerent levels of care%
0he Enal strategy" disease prevention and control" is useful to address
regional challenges and reduce and control disease (PAHO" 9CCC)% 0his strategy
also encourages community participation and changes in the *ehavior of
individuals to insure success% (or eFample" national capacities 1ill *e
strengthened in order to control" reduce" or eradicate speciEc diseases% 0his can
*e achieved through regional and national partnerships for prevention and
setting priorities regarding intentional and unintentional inHuries" including the
prevention of violence from a pu*lic health perspective% Additionally" providing
support for countries in developing policies" models" and 1or.ing partnerships
among health care 1or.ers" la*oratories" and treatment facilities 1ill prevent
diseases (e%g%" helping cervical cancer control programs to understand 1omenKs
attitudes and needs5 evaluating demonstration proHects5 and planning their
Hudicious" result2*ased eFpansion)%
6imitations in health care resources reJuire an eFamination of methods that
are most eDective for promoting healthy lifestyles to communities% A revie1 of
the literature on eFisting models of care eFamines practice as a 1ay to integrate
research and education" identify eDective models" descri*e the crucial elements
and areas that need to *e addressed" and generate Juestions for future
research" education" and practice% 0his revie1 1ill *e useful for health
authorities at diDerent levels and responsi*ilities for services" including
educators" providers" and policy ma.ers to analyze current models of care and
determine future directions% 0he critical analysis of literature covers the
follo1ing areas3
9% 0he primary health care model of care in the Americas5
2% SpeciEc components of care (types of providers" mode of service delivery"
location of services" types of programs" and health concerns?issues)5
8% 0he 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%
'
BACKGROUND
0he revie1 supported the PH+ model as a frame1or. to mo*ilize
communities and health care providers to move for1ard 1ith health sector
reform on a local" regional" and national level%
Health sector reform recognizes that all mem*ers of a community 1ith
highly diverse interests are directly concerned 1ith health and health care% Such
processes reJuire a gradual and transparent approach to development that
fosters the understanding of those involved directly in the provision of care" as
1ell as the recipients of care% &oreover" implementation reJuires
intergovernmental association and cooperation and the participation of the
private sector" non2governmental organizations" and individuals involved in
health and health care% Overall" PH+ models must *e implemented that are
comprehensive" em*race health promotion and disease prevention services" and
eFtend health services to all 1ith eIcient use of increasingly scarce resources%
,n order to shift the focus of health delivery systems from acute" curative
medicine to the inclusion of health protection and health promotion" the health
care system must decentralize some of the decision2ma.ing processes to
regional and community levels (4reen" 9CC>)% Health professions training
programs must increasingly thin. glo*ally" *ut assume a greater role in the
promotion of health 1ithin their o1n communities% Additionally" health care
providers must engage a *roader range of disciplines" such as dentistry"
medicine" nursing and non2medical groups (e%g%" community health 1or.ers) in
partnerships and coalitions for health research and health care activities%
(
2/ MODELS OF CARE
2/0 MODELS OF CARE FOR HEALTH CARE PRACTICE, EDUCATION, AND
RESEARCH
0heories and models of care are an integral part of healthcare practice"
education" and research (Alderson" 9CCA)% 0he choice of models" al*eit often
unac.no1ledged" shapes the 1ay practitioners" educators" and researchers
collect" analy2e" inter,ret" and disseminate information% 0o *e eDective" 1e must
deconstruct our 1ays of M.no1ingN and understanding the inBuence of the
values and philosophies forming the foundation of our practice" teaching" and
research% As 1e increasingly 1or. 1ith culturally diverse groups" .no1ledge
must *e constructed in a manner that accurately reBects the nature of
diversities and the conseJuences on responses to health (,m O &eleis" 9CCC)%
hile theories in health care may range from eFplicit hypotheses to models
or frame1or.s that are eFpressly used to guide oneKs practice or research
(Alderson" 9CCA)" conventional approaches to .no1ledge development in health
care practice" research" and education are grounded in positivist theories
(Oliver" 9CCA)% Over the past century" the medical model has *een the implicit"
default model of care%
3.1.1 Medical Model
0he conventional medical model uses a logical positivism philosophy" or
empiricism" to verify cause and aDect relationships for all human eFperiences
(ilson20homas" 9CC:)% ith this approach" the goal is to descri*e" predict" and
control human responses% (or eFample" practitioners and researchers use this
approach to locate the Mpro*lemN 1ithin the individual and orient health care
to1ard amelioration of disease rather than health% ,f Mo*serva*leN physiological
Endings are identiEed" then a prescri*ed course of action is underta.en%
0he medical model places the health2care professional as the eFpert
responsi*le for curing disease and dysfunction and MhelpingN people to achieve
Mhealth and normalcyN (Oliver" 9CCA)% 0he professional role is legitimized and
professionals are authorized to la*el people as deEcient and in need of care%
Provision of care (interventions) 1ithin the medical model focus on remediation
of personal health *ehaviors or curing *iological factors (i%e%" physical or mental
a*normality or impairment) to restore health status5 1here prevailing research
methods include controlled trials" random statistical samples" and structured
Juestionnaires% #ecause the medical model focuses primarily on individual
impairments and diseases" health is usually implicitly conceptualized as the
a*sence of disease (Peters" 9CCA)% +onseJuently" a limited perspective often
fails to eFplain many of the social and environmental factors that account for
todayKs health concerns and ineJuities around the glo*e (Parsons" 9CCC)% 0he
traditional *iomedical model does not consider the values em*edded in society"
nor onePs social positionLa reBection of socioeconomic status and povertyLas
an over2arching determinant of health status%
)
MODELS OF CARE
Practitioners and researchers often consider health care rooted in positivist
philosophy as value2free" reduci*le and isolata*le5 yet" personal histories and
eFperiences are not validated" and dialogue and sharing appear to *e irrelevant
in the process (ilson20homas" 9CC:)% /esearch and practice rooted in
traditional" empiricist methods that have separated the mind" *ody" and
eFternal environment are intrinsically pro*lematic% /irst" traditional approaches
to .no1ledge development that depend on assumptions of homogeneity"
normality" and statistical relia*ility" rather than coherent reBections of diverse
human eFperiences" have limitations in generating comprehensive models of
care (Hall" Stevens" O &eleis" 9CC>)% 0he .no1ledge gained from traditional
research produces a limited understanding a*out the inter2relationships *et1een
people" their environment" their health and their relationship 1ith their health
care provider% Secondly" o*taining *alanced po1er relationships is diIcult 1hen
research and practice is *ased on logical positivist philosophy% 3astly" a
reductionist approach to1ard research and practice can perpetuate the
underlying 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 onePs health status%
Despite the technological eFcellence and sophisticated medical care that has
*een advanced *y using the medical model" its usefulness is *ecoming
increasingly limited in the current health care delivery system% Several issues
suggest a need to move *eyond the medical model and to use eFisting theories
and models that develop and employ models of care suIcient to achieve PH+
criteria%
hen health is narro1ly deEned 1ithin the medical model" diDerences in
cultural 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 and
scientiEcally constructed% ,ncreasingly" this po1er ineJuity is vie1ed as a
mechanism of control and oppression for disenfranchised groups% ith a
restricted vie1 of health" clients are seen as passive recipients of medical care"
rather than active participants 1or.ing colla*oratively and cooperatively 1ith
multiple health relevant disciplines% S.yroc.eting medical care costs" decreasing
access to health care and increasing disparities in health care status among
groups of people (1omen" aging adults" racial?ethnic minorities" disa*led people"
and children) also suggest a need to create ne1 models of care% ,deally" useful
models of care delineate the su*Hectivity and social construction of reality"
sociopolitical and economic inBuences on health care research and practice" and
the prevalence of discrimination against marginalized groups (,m O &eleis"
9CCC)% &odels that capture the compleFities of multiple determinants of health
status and the diversity and sociopolitical and historical conteFts inherent
among persons are more li.ely to achieve the desired connections *et1een
factors 1hich inBuence our understanding of health%
Philosophies and models of health care are increasingly used to address the
sociopolitical" cultural" and economic forces that may impact onePs health and to
address po1er im*alances eFperienced *y disenfranchised groups and
individuals% 0hese philosophies and models are posing important Juestions for
*
health care and health care research% 0he use of more comprehensive models
that incorporate a focus on promoting health and disease prevention 1ill allo1
practitioners to identify critical issues that are important to an individual and
avoid overloo.ing or minimizing the impact of societal attitudes and values on
the dynamic state of health% A Primary Health +are (PH+) model is a useful
approach to health2care that focuses on the promotion of health and the
prevention of disease" through comprehensive care that is colla*oratively and
cooperatively provided *y community people and multiple health relevant
disciplines%
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 in
their health care management% &oreover" PH+ addresses self2care practices for
physical and mental aspects of community health as 1ell as community social
and 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 all
se#ments o a community5
&a5imi2ation o individual and community involvement in the ,lannin# and
o,eration o health care services to ensure that services are a,,ro,riate and
acce,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 economic
develo,ment o the community6
Provision o culturally acce,table( a,,licable( and e0uitable health services
and ,ro#rams6
/ocus on health concerns that are identi9ed and ,rioriti2ed by community
members so that essential services are available6 and(
7se o strate#ies that ma5imi2e 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 of
literature on models of care in the Americas% 0he disparate literature on PH+ can
*e considered *y using (igure 9 as a map for developing an action plan% ,n other
1ords" 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 or
perspective% e deEne PH+ as a participatory approach to healthcare delivery
that encourages a partnership *et1een community residents and health
professionals to achieve a mutual goal of improved health (&c'lmurry" 9CCC)%
0his approach is consistent 1ith the HO tradition that 1as initiated in 9C@A
"+
MODELS OF CARE
and 1ith the current agenda% ,n the Americas" the nursing community deEnes
PH+ (&c'lmurry O #rum*augh27eeney" 9CCA) as presented in the 9C@A HO
document% Ho1ever" the deEnition of primary care is used 1ithin the pu*lic
health model of primary" secondary" and tertiary levels of care% Primary care is
oriented to the care and prevention of illness among individuals and families% ,n
the -%S%" primary care is perceived as the entrance to secondary and tertiary
levels of care (&arion" 9CCA)% hile diDerences eFist *et1een the M1orldvie1sN
enmeshed in diDerent perspectives" they are not mutually eFclusive and can *e
incorporated in the HOKs current strategic directions as captured in the
follo1ing3
9% 0o reduce eFcess mortality of poor and marginalized populations%
2% 0o eDectively respond to leading ris. factors%
2% 0o strengthen sustaina*le health systems%
8% 0o place health at the center of the *roader development agenda (HO"
2000)%
""
3/ METHODOLOGY
6iterature 1as retrieved from 9CC0 through 2000 for the follo1ing languages
in the PAHO /egion3 'nglish" Spanish and Portuguese% 0he 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%
0o develop the search strategy used 1ith the )ational 6i*rary of &edicine for
identifying models of care in the Americas" 1e used a Primary Health +are
deEnition that focused on the follo1ing service areas3
9% 0ypes of services provided (health promotion" health education" and
health care interventions Q 29"AA2 a*stracts)5
2% 0ype 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 A9"@9:
a*stracts)5
>% &easurement criteria and issues (aDorda*ility" accessi*ility" availa*ility"
applica*ility" accepta*ility" eJuita*ility Q 2>">@@ a*stracts)5 and"
:% &ethodological issues (Jualitative" Juantitative" evaluation" or
methodology Q 9AA"022 a*stracts)%
0o capture the concepts included in models o care" the follo1ing search
terms 1ere used3
+ommunity Health Planning or Health Planning Organization or
Health 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 Health
Services Accessi*ility or Health +are Delivery or Health +are &odel
or Health +are Sector or Health Planning or Health Planning
4uidelines or Health Policy or Health Priorities or Health /esource
Allocation or Health +are &odels or Primary Health +are or Pu*lic
Health Practice or <oluntary Health Agencies or <oluntary Health
Administration (9CC022009 Q :C"90: a*stracts)
0o narro1 the search further" models o care terms 1ere crossed 1ith ty,es
o service provided 1ith a Primary Health +are (PH+) perspective3
&odels of care *y type of service Q >"9C2 a*stracts5
&odels of care *y type of service *y ty,e o ,rovider < 2A8 a*stracts5
&odels of care *y type of service *y mode o service delivery < 8:@
a*stracts5
&odels of care *y type of service *y measurement criteria and issues < 982
a*stracts5 and"
&odels of care *y type of service *y methodolo#ical issues < >@8 a*stracts%
"#
METHODOLOGY
0he 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 of
the 6atin American and +ari**ean +enter on Health Sciences (#,/'&') a*stract
li*rary% ,t is a cooperative data*ase that covers literature related to the health
sciences since 9CA2% /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 maHority of them do not have
a*stracts in 'nglish% 0he access to this data*ase from the -S is achieved *y
accessing the 1e* page R111% *ireme%*rS
0he Erst search to identify models of care in the Americas" using Primary
Health +are as a term resulted in 9@"98> citations from the aforementioned
data*ase% -se of the services provided search deEnition resulted in the neFt
display:
0/ 0ypes of services provided (health promotion" health education" and
health care interventions Q 9"CAC a*stracts)5
1/ 0ype 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 (aDorda*ility" accessi*ility" availa*ility"
applica*ility" accepta*ility" eJuita*ility Q 9";A: a*stracts)5 and"
4/ &ethodological issues (Jualitative" Juantitative" evaluation" or
methodology Q 2"0:8 a*stracts)%
0o further narro1 the search" models o care 1as crossed 1ith ty,es o
service provided 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 ,rovider Q 90 a*stracts5
&odels of care *y type of service *y mode o service delivery Q ;8 a*stracts5
&odels of care *y type of service *y measurement criteria and issues Q 9:
a*stracts5 and"
&odels of care *y type of service *y methodolo#ical issues Q 2@ a*stracts%
0he 6,6A+S a*stracts 1ere read (9>@)" and the articles that meet the search
criteria 1ere incorporated for Enal analysis% ,t 1as diIcult to reach the complete
document selected from 6,6A+S since the articles cannot *e do1nloaded
automatically as full teFt from the ,nternet% &any li*raries in the -S do not have
an agreement 1ith 6,6A+S" and so in some cases" document retrieval too.
approFimately a month" 1hile in other instances the documents 1ere
uno*taina*le%
0hus" the more limited num*er of references a*ove *ecame the data*ase
included in the revie1 of literature from the 6,6A+S% Overall" several Juestions
"$
emerged from a revie1 of the composite literature% 0he 'nglish" Spanish and
Portuguese language a*stracts for this data*ase 1ere read 1ith attention to the
follo1ing types of Juestions3
9% ho are the diDerent 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" seFual
practices" alcohol and drug use" safety practices)T
@% Are services accessi*le" aDorda*le" accepta*le" applica*le" and availa*leT
A% hat are the *iological ris. factors (genetic conditions" age"
race?ethnicity" gender2speciEc conditions)T
C% 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.ers
in 6atin America and +ari**ean /egionT
99% Ho1 can 1e improve access to 6,6A+S for 'nglish spea.ers in the -S 1ho
need 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 1ith
community heath 1or.ers is an important and successful component of the
health care system 1hile other countries do not have this eFperienceT
"%
4/ HEALTH STATUS IN THE AMERICAS
4/0 HEALTH STATUS
,n general" health status across the lifespan of individuals in the Americas
has improved over the past decade as a result of enhanced social" political"
environmental" cultural and technical factors (PAHO" 9CCA)% &oreover" the
eFpansion of health care systems from an emphasis on treatment of diseases to
a focus on health promotion through health education" disease prevention" and
supportive socio2environmental conditions is improving health status%
Despite improvements in health care status and health care services" the
characteristics and speed of the improvements have not *een the same across
countries or in all population groups 1ithin any one country (PAHO" 9CCA)% ,nfant
mortality in the Americas has declined steadily (PAHO" 9CCA)% hile the ris. of
dying in adulthood (>:2;> year old group) across countries is relatively sta*le for
males *et1een 9CA0 and 9CC>" the mortality pattern for 1omen sho1s a long2
term do1n1ard trend that is systematically higher in lo1er2income country
groups" 1hich suggests gender ineJuality% SpeciEcally" adult males in the
Americas seem to have achieved greater access to preventive" curative" or
palliative care services" 1hereas" access for adult 1omen may still *e inBuenced
*y their economic level% Ho1ever" the ris. of dying due to eFternal causes
across the Americas is higher for males >:2;> years of age compared to
females% ,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 have
enhanced child and adolescent health status in many countries (4racey" 9CCA)%
e have learned the elements that reduce ris. for children and adolescents3
parental caring and connectedness5 parental eFpectations for school and parent
availa*ility all out1eigh family structure5 ethnicity and" income (#lum" 9CCA)%
,n the -%S%" mortality rates" overall" are decreasing and many mor*idity rates
have declined (#lum" 9CCA)% ,n the PAHO /egion" although the prevalence of lo1
1eight2for2age and lo1 1eight2for2height has declined for children (PAHO" 9CCA)"
lo1 height2for2age resulting from periods of inadeJuate nutrition continues to *e
seen in approFimately :0V of preschool and school2age children in some
countries% +onversely" o*esity has rapidly increased in the /egion" particularly
among 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 progress
has *een made in slo1ing the spread of +hagasK disease (PAHO" 9CCA)%
Ho1ever" after an a*sence of almost 900 years" cholera returned to the PAHO
/egion in 9CC9% &oreover" dengue and other vector2*orne diseases are still
occurring at epidemic rates in many countries throughout the Hemisphere%
0u*erculosis has also re2emerged" along 1ith anti*iotic resistant diseases%
"&
6astly" approFimately" half of the 9%; million A,DS cases reported 1orld1ide"
since the *eginning of the epidemic" are in the Americas%
5.1.2 Non-communicable diseases.
Deaths from chronic and degenerative diseases are increasingly
outnum*ering deaths from infectious and parasitic diseases in the /egion% 0he
ratio 1as estimated to increase from :39 in 9CA: to 9039 *y the year 2000
(PAHO" 2000)% Deaths from nutritional deEciencies and anemia have decreased
among individuals under the age of 2:" *ut have increased in varying degrees
among people over the age of 2: in almost all of the countries in the /egion%
Additionally" the total num*er of deaths due to malignant neoplasms has *een
rising at a much faster rate than the overall population gro1th" resulting in
higher speciEc mortality rates in the general population% SpeciEcally" this
increase is noted *eginning at 2: or 80 years of age and is greatest among
1omen% 0hese Endings are due in part to the decline of deaths at earlier ages
due to avoida*le causes% #ecause people are living longer" they are eFposed to
ris. factors leading to malignant neoplasms for a longer length of time" and
therefore" more deaths at later ages are occurring% 0he most common sites for
malignant neoplasms for men are the lungs" digestive system (primarily
esophagus and stomach)" and the prostate% ,n developed countries" lung cancer
is the leading cause of death" 1hile neoplasms of the digestive system are more
common in developing countries% (or 1omen" the leading causes of death are
malignant neoplasms of the digestive system (primarily colon and rectal)" *reast
cancer" and cancer of the uterus% #reast cancer is more common in developed
countries and cancer of the uterus is more common in less developed countries%
Deaths related to dia*etes mellitus also increased across the /egion"
especially among the population over 2: years of age" and in the 'nglish2
spea.ing +ari**ean" Andean Area (see AppendiF A" #razil" and &eFico (PAHO"
9CCA)% 0he lo1est increases 1ere in the Southern +one and )orth America%
Additionally" the Southern +one and )orth America sa1 a decrease in ischemic
heart disease" 1hich is a trend seen across many developed countries around
the 1orld% Ho1ever" in &eFico and other su*regions" mortality related to
ischemic heart disease increased% 0his trend is reversed for pulmonary
circulation and other forms of heart disease that increased in the Southern +one
and )orth America" *ut decreased in other su*regions%
,n )orth America" cere*rovascular disease has decreased as a cause of
death" and the num*er of deaths has remained the same from 9CA0 to 9CC> in
other su*regions (PAHO" 9CCA)% Ho1ever" cirrhosis has increased across four
su*regions" +entral America and the 6atin +ari**ean" the Andean Area" #razil"
and &eFico% Additionally" mortality related to cirrhosis in all the su*regions is
approFimately three times greater for men compared to 1omen%
&ortality associated 1ith *ronchitis" emphysema" and asthma declined
across many of the /egions" eFcept in )orth America and the Southern +one
1here rates are unchanged *et1een 9CA0 and 9CC> for population groups under
the age of 8:% Ho1ever" the over28: age group eFperienced a signiEcant
increase% &or*idity related to psychiatric disa*ilities has also increased in almost
"'
HEALTH STATUS IN THE AMERICAS
all of the countries in the /egion% &oreover" mortality related to smo.ing and
alcoholism has increased in the /egion%
4/1 HEALTH RISKS
0he maHor factors associated 1ith mor*idity and mortality in the Americas
varies across regions and countries% Social" political" economic" and
environmental factors" along 1ith *ehavioral ris. factors" are a large component
of health ris.s (4reen O 7reuter" 9CC9)% ith a decrease in mortality and
mor*idity rates in the Americas" a greater interest in preventing diseases related
to lifestyle and social environment has emerged%
5.2.1 Socio-economic and environmental factors
Socio2economic and environmental factors play a pivotal role in health
status ((ernandez" 0ate" #onet" +anizares" &as" O =assi" 2000)% (or eFample"
inadeJuate Enancial resources can constrain people from o*taining necessary
health care services5 and" health insurance programs may impose reJuirements
and restrictions that limit access to needed services% PAHO uses a variety of
indicators to measure socio2economic status (S'S) including3 4ross )ational
Product (4)P) per capita" annual 4)P gro1th rate" percentage of population in
poverty" and the highest 20V to lo1est 20V income ratio% As 4ross Domestic
Product (4DP) per capita falls" accessi*ility" coverage" and availa*ility of medical
care decrease (PAHO" 9CCC)% All of these varia*les are also dependent on a
populationKs geographic location% PAHO also trac.s literacy rate" percentage
population 1ith drin.ing 1ater supply services" percentage of population 1ith
se1age and eFcreta disposal services" and the ratio of diDerent types of health
care providers compared to the population
6iving conditions in the Americas have generally seen a gradual
improvement among *asic S'S indicators (PAHO" 9CCA)% Access to safe 1ater
increased from ;0V in 9CA0 to @:V in 9CC:5 and" sanitation coverage rose from
>8V to ;AV5 and" vaccination coverage increased from >@V to AAV *et1een
9CA> and 9CC;% &oreover" adult literacy increased from @2V to C2V *et1een
9C@0 and 9CC:% Despite these improvements" *et1een 9CC0 and 9CC>"
countries 1ith the lo1est 4)P rate consist of +u*a" Haiti" Puerto /ico" 0rinidad"
(rench 4uyana" 0o*ago" )icaragua" and #ahamas5 and" the percentage of
population living in poverty is highest in #olivia" Haiti" Honduras" 'cuador"
4uatemala" Peru" Panama" and #razil% &en and 1omen are at greatest ris. of
lo1 literacy rates if they live in #razil" St% 6ucia" 'l Salvador" Honduras"
)icaragua" 4uatemala" and Haiti% omen living in #olivia also have eFtremely
lo1 literacy rates% 6astly" the ratio of physicians" professional nurses" and
dentists per 90"000 population rose from 98%@ to 9A%2" from 28%@ to 8>%@" and
from 8%8 to :%8" respectively" *et1een 9CA0 and 9CC: (PAHO" 9CCA)%
'nvironmental factors also may determine 1hether health2care services and
health2related information are accessi*le" aDorda*le" accepta*le" or availa*le%
(or eFample" a study *y Dellasega" #ro1n" and hite (9CC:) found that older
adults living in rural areas 1ere concerned a*out the accessi*ility of health
promotion activities" such as cholesterol screening" along 1ith *eing a*le to
have the results of screening eFplained and dietary interventions taught in an
"(
accessi*le format% 0hus" health care programs need to consider and incorporate
factors that aDect access and accepta*ility to community mem*ers%
0he environment is a critical determinant in the level of ris. for violence and
the amount of opportunities to engage in healthy *ehaviors% hile some
countries still face *asic health care issues associated 1ith poverty"
environmental degradation" and deteriorating living conditions" other nations
are eFperiencing health issues related to aging populations" rapid ur*anization"
and unhealthy lifestyles (PAHO" 9CCA)%
+hildren around the 1orld eFperience a vast array of social pressures and
health ris.s (4racey" 9CCA)% ,n the PAHO /egion" childrenKs eFperiences include
the follo1ing3 9) those 1ho are living in 1ealthy" industrialized countries5 2)
those living in rapidly industrialized countries that are eFperiencing rapid
changes in their health care systems (4racey" 9CCA5 #ossert" 6arranaga" /uiz
Peir" 2000)5 8) minority groups including recently arrived immigrants in
other1ise aUuent and healthy societies5 >) previously traditional people in rapid
transition to ur*anized" estern lifestyles5 and" :) many millions living in
grinding poverty in overcro1ded" unhygienic conditions 1here child mortality is
high" often due to malnutrition and infections (4racey" 9CCA)%
Health care delivery systems are constantly changing and have signiEcant
implications for access to health services and health information% +urrently"
many health care systems 1orld1ide are consolidating services" 1hile availa*le
resources and funding for health care and health2related programs are
increasingly limited% ,ncreased time pressures are especially pro*lematic for
people 1ith disa*ilities 1ho have needs that reJuire eFtra time for
eFaminations" tests" procedures" and health teaching (Heller O &ar.s" in press)%
Despite the improvements in health status among children in the PAHO
/egion" the gains are *eing oDset *y o*esity" smo.ing" alcohol and drug a*use
and social disruption" mental disease and high rates of violence" including
homicide and suicide% &oreover" these Wne1 mor*iditiesK are magniEed among
minorities and in populations undergoing rapid social change" as 1ell as those
eFperiencing social pressures" such as unemployment and family dysfunction%
Deaths related to accidents and violence have essentially remained the
same for the PAHO /egion (PAHO" 9CCA)% Ho1ever" some countries have
eFperienced a mar.ed increase in the num*er of deaths due to homicide" 1hile
accidental deaths are decreasing% 0he -%)% Population (und (Septem*er 20"
2000) report states that discrimination and violence against 1omen Mremain
Ermly rooted in cultures around the 1orld"N stopping 1omen from reaching their
full potential% 4lo*ally" girls and 1omen are still routinely denied access to
education 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 suggest
that 1omen 1ith intellectual disa*ilities are four to ten times more li.ely than
other 1omen to *e targets of seFual assault and other violence (So*sy" 2000)5
and" greater than @: percent of mentally disa*led 1omen are victims of seFual
a*use%
")
HEALTH STATUS IN THE AMERICAS
5.2.2 ehavioral ris! factors
#ehavioral ris. factors can consist of inadeJuate eFercise" poor nutritional
ha*its" cigarette smo.ing" drug and alcohol a*use" unsafe seFual practices" or
living in a psychological state of helplessness" 1ithout options for maHor life
choices and decisions% 0o*acco use is the leading preventa*le cause of death in
the 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" *et1een
9CC; and 9CCC to*acco prevalence in the population ranged from a high of
approFimately >0V in Argentina and +hile" to a lo1 of 22V in +olom*ia% ,n some
ur*an areas" more than half of the young people smo.e% ,n 6atin America" more
people already die of non2communica*le diseases" many of 1hich are caused *y
to*acco" than of communica*le diseases" maternal and perinatal conditions and
nutritional deEciencies%
0he trend to1ard non2communica*le diseases is eFpected to continue%
0o*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 from
infectious to non2communica*le diseases (PAHO" 2000)% #ehavior can directly
inBuence health and it can have an indirect aDect on health *y inBuencing
environmental factors% Health *ehaviors also can maintain or enhance health
status and Juality of life" control or remove deleterious ris. factors" and prevent
the onset of chronic conditions%
)on2communica*le diseases are responsi*le for approFimately t1o2thirds of
all deaths in 6atin America and in the +ari**ean (PAHO" 9CCA)% Additionally"
deaths from chronic and degenerative diseases 1ere proHected to outnum*er
deaths 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 or
social and environmental changes may *e reJuired% Health promotion strategies
are primarily concerned 1ith creating *ehavior change through modiEcation of
lifestyles and living conditions to increase 1ell2*eing% 6ifestyle changes can *e
facilitated *y a com*ination of eDorts to enhance a1areness" change *ehavior"
and create environments that support good health practices% Ho1ever" the
inBuence of lifestyle and living conditions on the state of 1ell2*eing reportedly
varies among diDerent socioeconomic levels (HO" 9CAA)% (or eFample" 1hile
personal lifestyles may dramatically aDect the development of a state of 1ell2
*eing among the aUuent" social and environmental conditions may *e larger
determinants of 1ell2*eing among the less aUuent%
5.2.3 iolo"ical ris! factors
/is. factors related to *iological factors can include genetic
predisposition" age and gender% Although health promotion activities are
directed to1ard factors that are changea*le" consideration must *e given to the
*iological ris. factors that are not changea*le (4reen O 7reuter" 9CC9)%
#iological ris. factors include genetic predisposition" age" gender" race or
ethnicity" and climate% hile many of these factors do not lend themselves to
direct intervention" they must *e ta.en into account 1hen identifying high2ris.
"*
population groups% #iological ris. factors play a role in several leading causes of
mortality" including heart disease" cancer" stro.e" dia*etes" and cirrhosis%
#+
5/ COMPONENTS OF CARE
0he follo1ing components of health care are revie1ed in this section3 types
of providers" modes of service delivery" location of services" and types of
programs% ,n the PAHO /egion" a variety of health care providers deliver primary
health care services% Although many disciplines provide health care services" the
discussions in the literature center on community health 1or.ers" nurses" and
physicians% 0hus" for the purpose of this paper" the revie1 is limited to these
speciEc providers%
Along 1ith the various types of providers" the diDerent modes of service
delivery are discussed here% Service delivery modes consist of medical care"
nursing care" health education" health promotion" and health protection
services% 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% 0ypes of
health care programs may also vary depending on location of services and types
of providers% 0he follo1ing revie1 of literature descri*es the myriad of health2
related programs that have *een implemented in the Americas /egion%
5/0 PROVIDERS
Dramatic changes in the health care system have occurred over the past
century% #ecause of the increasing compleFity of health2related concerns and
health care delivery systems" interdisci,linary a,,roaches are critical for
designing and implementing services across a variety of settings% Additionally"
current trends in health care delivery are moving us to1ard a system 1ith less
com,ulsory and more arbitrary standards and services delivered *y Juasi2
oIcial and voluntary *odies (Halperin" 9CCA)" including a variety of health
delivery providers (e%g%" community health aides?1or.ers" mid1ives" nurses"
physicians" rural health motivators)% 0hese standards are developed in response
to speciEc needs that are driven *y sociopolitical and economic agendas (Silva O
4omes" 9CCA)% As ne1 standards are developed in an age of increasing
technology and rapid information eFchange" issues related to the rights of
access must *e *alanced 1ith protection from unsafe" ineDective" and poor
Juality services and products% Additionally" standards must incorporate BeFi*ility
to ena*le consumers to choose their level of protection% ,n order to develop
participatory services and programs" health care professionals must em*race
the value of multidisciplinary and interdisciplinary approaches for individuals
and communities%
Despite the increasing emphasis on interdisciplinary approaches"
professionals and academicians still resist team1or. and .no1ledge sharing
across disciplines ()aHera O Perez" 9CCC)% 0hese o*stacles often stem from the
persistent over2valuing of speciEc eFperiences of particular disciplines%
Professional training needs to shift educational programs from a
compartmentalized model of care to a model of comprehensive care that
includes a variety of care providers 1ith a range of s.ills that are situation2
speciEc and eJually valued% (or eFample" depending on the health care issues"
#"
certain health care providers may *e most appropriate (e%g%" community health
aides?advisors" community health motivators?volunteers" nurses" mid1ives"
nurse practitioners" physicians" etc%)% 0his section revie1s research related to
speciEc types of providers%
#.1.1 Community Health $or!ers%&ides%&ctivists' Community Health Motivators%(olunteers
+ommunity health 1or.ers (+H) is Hust one of many terms used throughout
the 1orld to descri*e an indigenous outreach health 1or.er 1ho is trusted and
respected in his or her community (/odney" +lasen" 4oldman" &ar.ert" O Deane"
9CCA)% 0hey are also .no1n as community health aides or advisors" lay health
advisors" community health motivators" community health advocates"
community health volunteers" or ethnic minority lin. 1or.ers% ,n general" +Hs
are local lay community mem*ers 1ho interface directly 1ith residents in the
community as Mhealth activistsN to convey a variety of health messages that
promote health (#ental O Paran" 9CC0) and to improve access to and utilization
of 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 and
may share their ethnic racial *ac.ground (6ove" 4ardner" O 6egion" 9CC@)% As
frontline health care professionals" +Hs are increasingly vie1ed as health
agents 1ith .ey roles in the primary health care model as the +H programs are
designed to *uild on the strength of eFisting community relationships to improve
health (#a.er" et al%" 9CC@)% 0he role that +Hs play in *rea.ing do1n social and
cultural *arriers *et1een the formal health care system and the client
community is a pivotal factor in access to health care services for community
mem*ers (0omas Sancho" 7ennedy" O +olomer /evuelta" 9CCA)% +H volunteers
often have the a*ility to administer more personalized services to community
mem*ers and can *ridge the gap *et1een community residents and the health
agency (Dic. O Schoeman" 9CC;)%
+Hs also have diDerent activities and settings across the Americas /egion
(6opez" 9CCC)% ,n developed countries" activities for +Hs are developed in
response to a lac. of responsiveness 1ithin the formal health care system to
facilitate health promotion and illness prevention (0omas Sancho" 7ennedy" O
+olomer /evuelta" 9CCA)% ,n developing countries" the primary goal of +H
activities is to implement primary health care services in areas 1ith limited
professional resources% +Hs also provide services for a variety of community
mem*ers in settings ranging from ur*an areas (Par.er" Schulz" ,srael" O Hollis"
9CCA5 Schulz" ,srael" #ec.er" O Hollis" 9CC@5 Solla" &edina" O Dantas" 9CC;))"
rural areas ('arp" 9CC@5 #erner" 9CC25 /o*inson O 6arsen" 9CC0)" schools
(#er.ley2Patton" (a1cett" Paine2Andre1s" O $ohns" 9CC@5 Olvera" /odriguez"
Perez" 'i*enschutz" O <illal*a" 20005 <elasJuez" 9CC8))" churches (Simpson O
7ing" 9CCC)" and migrant camps (#oo.er" /o*inson" 7ay" )aHera" O Ste1art"
9CC@)%
&any +Hs are adult 1omen volunteers (Peru" 9CC;5 6ange" AguilX" O
#arros" 9CC>)% 6ove" 4ardner O 6egion (9CC@) reported the maHority of +Hs in
eight #ay Area counties in +alifornia are 1omen (;;V)" of color (@@V)" 1ith a
high school degree or less (:AV)% Ho1ever" depending on the target population"
ne1er models of care are training diDerent groups of people to 1or. as +Hs"
##
COMPONENTS OF CARE
such as" adolescents (#er.ley2Patton" (a1cett" Paine2Andre1s" O $ohns" 9CC@5
4arEeld" 9CC;)" older adults ('arp" et al%" 9CC@)" church mem*ers" mothers
($ohnson" Ho1ell" O &olloy" 9CC854utierrez O Paredes" 2000)" and mem*ers of
racial?ethnic minorities ($ac.son O Par.s" 9CC@)% hile the location of services
and goals may vary across the /egion" the processes that are fundamental to
+Hs performance are similar% 0hese factors include recruitment" training
(4utierrez O 4avilano" 2000)" monitoring" ongoing support" and evaluation%
Health care activities
6ay health 1or.ers have essentially three primary functions3 9) to serve as
mediators *et1een community mem*ers and health agencies" 2) to esta*lish a
social net1or." and 8) to oDer a range of services from emergency care to
health protection and social support (#erner" 9CC25 #ro1nstein" +heal"
Ac.ermann" #assford" O +ampos2Outcalt" 9CC2)% SpeciEcally" +Hs are trained
to participate in a variety of health education programs including smo"in#
cessation (6acey" 0u.es" &anfredi" arnec.e" (9CC9)" cardiovascular health
education (#ental O Paran" 9CC0)" ,rovidin# vaccinations (Solorzano &oguel O
Alvarez +uevas" 9CC9)" violence ,revention education (Davies" Harris" /o*erts"
&annion" &c+os.er" O Anderson" 9CC@5 Anderson" Harris" &c+os.er" 9CC@)"
cancer screenin# and education ()avarro" Senn" &c)icholas" 7aplan" /oppe" O
+ampo" 9CCA5 'arp" et al%" 9CC@5 )avarro" Senn" 7aplan" &c)icholas" +ampo" O
/oppe" 9CC:)" enhancin# sel-care and advocacy s"ills or *omen (&c'lmurry"
S1ider" 4rimes" Dan" ,rvin" O 6ourenco" 9CA@)" and surveillance and treatment
activities or tro,ical or communicable diseases (+airncross" #raide" O #ugri"
9CC;5 /ue*ush" Yeissig" 7oplan" 7lein" O 4odoy" 9CC>5 'ngel.es" 9CC25
Solorzano &oguel O Alvarez +uevas" 9CC9)% One study in +alifornia reported that
the maHor foci of the +HKs activities 1ere A,DS and maternal child health (6ove"
4ardner O 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 transmitted
disease testing and perform *reast eFaminations to increase access to 1omenKs
health 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 improve
the eIciency of health promotion programs to increase pu*lic a1areness of
health ris.s related to diseases (e%g%" cardiovascular disease" cancer screening"
0# prevention" emergency care)% #ecause a fundamental tenet 1ithin +Hs
training focuses on improving access to essential primary health care services of
community mem*ers" they are often eDective in getting people to engage in
health promoting *ehaviors and activities that prevent illness% Additionally" use
of +Hs can signiEcantly increase the use of the availa*le pu*lic health care
services (+hristensen O 7arlJvist" 9CC0)% 0his in turn reduces the overall cost of
health care services 1ithin a community% Despite the positive *eneEts that front2
line community 1or.ers have in inBuencing health status" successful
implementation of +H programs remains challenging (/o*inson O 6arsen"
9CC0)% /eports have suggested that high turnover rates" a*senteeism" poor
Juality of 1or." and lo1 morale among 1or.ers in +H programs is associated
#$
Ta=&# 0/ M!"#& Pr!gra$) D#*#&!>#" =( N?r)#)
0he +ool 7ids +oalition (+orrarino" alsh" #oyle" O Anselmo" 2000)
'Fperiencia de enfermerZa en la atenciXn materno infantile (+ampos" $aimovich"
+ampos" 9CCC)
0he Ar.ansas AH'+ model of community2oriented primary care (Hart1ig O 6andis"
9CCC)
0he 'Fpanded +are for Healthy Outcomes ('+HO) ProHect3 addressing the spiritual care
needs of homeless men in recovery (#rush O &c4ee" 9CCC)
0he &c4ill &odel and 6ocal +ommunity Service +enters3 A (etching +om*ination (&alo"
+ote" 4iguere" O OP/eilly 9CCA)
Shuler )urse Practitioner Practice &odel (Shuler O Hue*scher" 9CCA)
Put Prevention into Practice (4rey" 9CCA)
Partners in colla*oration3 0he Homan SJuare ProHect (Hollinger2Smith" 9CCA)
0he ;0 and #etter Program3 A Primary Health +are Program for the Aged ()ay" 9CC@)
Health +are Delivery in (aith +ommunities3 0he Parish )urse &odel (eis" &atheus" O
Schan." 9CC@)
0he +omoF <alley )ursing +entre (Attridge" et al%" 9CC@)
Selfcare nursing as a contri*ution to Juality improvement in health3 A 6atin American
eFperience (6ange" O $aimovich" 9CC@)
A +omprehensive School2*ased +linic3 -niversity and +ommunity Partnership
(&c+lo1ry" et al%" 9CC;)
1ith 1ea. organizational and managerial capacity 1ithin the government health
systems% 0o address these issues" studies have sho1n that good supervision" in
service training and adeJuate logistic support are necessary components in
maintaining +HsP s.ills and participation (Ash1ell O (reeman% 9CC:)%
#.1.2 Nurses' Mid)ives' and Nurse Practitioners
)urses throughout the PAHO /egion have a vital role in community
activities" and have *een instrumental forces *ehind the development of many
types of community2*ased model programs to address community health
concerns (see 0a*le 9)% Additionally" nurses have a long history of forming
partnerships 1ith a variety of health care providers and 1ith community groups
in response to health care educational needs eFpressed *y community
mem*ers% (or eFample" nurses assem*led a multidisciplinary tas. force in
response to several 1omen 1ho presented 1ith post2partum depression in order
to educate health care professionals to identify 1omen eFperiencing depression
(Strau*" et al%" 9CCA)%
)urses in the PAHO /egion continue (lorence )ightingaleKs tradition of
integrating scholarly 1or. 1ith political activism (/afael" 9CC@)% $ust as
)ightingale *ecame 1ell versed in maHor areas of pu*lic policy and lo**ied
eFtensively to create policies that integrated factors in the *iophysical
environment 1ith social and economic factors" nurses today assume leadership
roles to advocate for critical issues aDecting speciEc communities% One such
#%
COMPONENTS OF CARE
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 directed
a leading +enter for ,ndependent 6iving" since it 1as esta*lished in 9CA0% ,ts
mission includes service" advocacy and promotion of social change for people 1ith
disa*ilities% 0he +enter *rought disa*ility to the forefront in +hicago and nationally%
#ecause nurses are often informally sought out for education and health care
information" they have a critical role in promoting health *ehaviors *y acting as
health educators and change agents outside" as 1ell as 1ithin" their professional
roles (0essaro" 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 providing
training and supervision of community health aides (#erner" 9CC2) and other
paraprofessionals 1ho provide direct care services%
Services provided *y nurses occur in a variety of community settings
including the follo1ing3 schools (&c+lo1ry" et al%" 9CC;)" churches (eis"
&atheus" O Schan." 9CC@)" correctional facilities (&iller" 9CCC)" home care
(7eating" 9CC:5#andeira" 9CC@))" rural and ur*an areas (Dumas" 9CC25 +uEno
Svitone" 4arEeld" <asconcelos" O ArauHo +raveiro" 2000)" and physician oIce2
*ased practices (Hill O #ec.er" 9CC:)% )urses are also committed to providing
services to a variety of population groups% (or eFample" nurses in the /egion
1or. 1ith lo1 income 1omen (7ozlo1s.i O Yotti" 9CC>)" immigrants and
refugees (DeSantis" 9CC@)" prisoners (&iller" 9CCC)" children (+orrarino" alsh"
#oyle" O Anselmo" 2000)" people 1ho are homeless (#rush O &c4ee" 9CCC)"
older adults (hite O )ezey" 9CC;)" 1omen 1ith chemical addictions (Dumas"
9CC2)" 1or.places (Parrish" 9CC:5 assel" 9CC:)" O adult day care (Dunham2
0aylor" Olda.er" De+apua" &anley" Oprian" O restler" 9CC8)%
SpeciEc topics covered *y nurse2developed programs include the follo1ing3
education in speciEc content areas" such as cardiovascular health promotion
(Hill O #ec.er" 9CC:)" assessment" screening and treatment for various
conditions" including mental health issues (Strau*" et al%" 9CCA) and cancer
screening (Ansell" 6acey" hitman" +hen" O Phillips" 9CC>)" scald *urn
prevention education for parents (+orrarino" alsh" #oyle" O Anselmo" 2000)"
individualized health promotion services (&alo" +ote" 4iguere" O OK/eilly" 9CCA)"
empo1erment strategies and promotion of eJuity and access for older adults
(eis" &atheus" O Schan." 9CC@5 )ay" 9CC@)" maternal" child health (Hollinger2
Smith" 9CCA)" and lead screening (#loc." Sze.ely" O 'sco*ar" 9CC;)%
Nurses im,act in Primary Health Care activities
/esearch documenting the clinical2 and cost2eDectiveness of community2
*ased nursing services is limited% hile anecdotal evidence suggests nurses do
contri*ute to improvements in health status and to reducing health care costs"
nurse leaders in .ey community positions 1ill reJuire more support for
addressing eDectiveness (Dunham20aylor" Olda.er" De+apua" &anley" Oprian" O
restler 9CC8)% Additionally" more research2*ased demonstration proHects need
to *e conducted in communities to document the clinical eDectiveness of nurse2
run health promotion and prevention programs% ,f more nurses 1ere a*le to *ill
#&
and?or *e directly reim*ursed for their services" this picture might change as
most eDectiveness studies are tied to costs rather than the social value of their
services%
+ommunity health nurses are in a strategic position in the PAHO /egion to
maintain" promote" and protect the health of populations *oth no1 and in the
future (7uss" ProulF24irouard" 6ovitt" 7atz" O 7ennelly" 9CC@)% As the health care
environment increasing emphasizes the protection and promotion of health"
access to health services" and prevention of illness" pu*lic health nurses given
their training and historical roots are paramount in the changing focus to
primary prevention% )urses also have the *readth of .no1ledge to interface 1ith
many diDerent levels of service delivery professionals and to translate this
information to community mem*ers" to *uild community capacity for health
promotion" and to facilitate community participation *y enhancing community
health services and coordinating pu*lic policy to achieve core pu*lic health
responsi*ilities of assessment" policy" and assurance (7ang" 9CC:)%
#.1.3 Physicians
,n the PAHO /egion" physicians have focused on curing and restoring health
to individuals 1ho eFperience speciEc disease states% &uch of the eFtant
literature revie1ed demonstrates that the primary goal for physicians to change
the individual *y replacing disease or impairment 1ith MhealthN or MnormalityN
(4ill" 2009)% Additionally" the M.ey pro*lemN in many of the studies in the
physician2*ased primary health care literature 1as seen as a physical or
functional impairment% 0he interface *et1een the environment and the
individual 1as for the most part neglected in these studies% &oreover"
incorporation of the cultural" political" social" and economic factors into the
analysis of the Mpro*lemN 1as virtually a*sent%
An important conclusion cited in a meeting *et1een the orld Health
Organization (HO) and the orld Organization of (amily Doctors (O)+A) in
9CC> 1as3 MOptimal medical practice is responsive to individuals and
communities" *eing person2centered" health oriented" and community *ased the
systems 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" a
paucity of literature eFists relating to models of care for primary health care
activities among physicians%
&uch of the literature a*out health care services provided *y physicians
centers on teaching them more eDective 1ays to provide oIce2*ased health
promotion counseling for their patients% (or eFample" studies revie1 counseling
activities for nutrition (Oc.ene" He*ert" Oc.ene" &erriam" Hurley" O Saperia"
9CC;)" smo.ing" drug a*use" o*esity" contraception" *reast self eFamination"
cholesterol chec.s" diet" eFercise" hormonal replacement" Papanicoloaou
smears" and glaucoma chec.s (Davies" 9CC9)% Studies also eFamined factors
associated 1ith preventing lo1 *irth 1eight *a*ies (Ste1art O )imrod" 9CC8)"
accidents in children (+arter O $ones" 9CC8)" sports2related inHuries (/ouzier"
#'
COMPONENTS OF CARE
9CC:)" cancer ((rame O erth" 9CC8)" and preventive care measures for
patients 1ith dia*etes (StreHa O /a*.in" 9CCC)%
0he studies also addressed treatment issues for patients in providing health
promotion and prevention services% (or eFample" research studies eFamined the
patient2physician interaction (alsh O PcPhee" 9CC2) and the impact of
physician cooperation 1ith a community2*ased prevention and health promotion
program for older adults (#ula" Alessi" Arono1" =u*as" 4old" )isen*aum" #ec." O
/u*enstein" 9CC:)% ,n sum" the literature revie1 found that" on a community
level" physicians are involved 1ith activities that omit attention to the social
realities that often have a much greater impact than the presenting physical or
psychological concerns% +onseJuently" this contri*utes to health care services
from physicians that are internalized as oppressive" rather than helpful%
#.1.* Partnershi+s, Health Professionals and Community Coalitions
,nterdisciplinary and multidisciplinary 1or. creates an opportunity to
develop partnerships 1ith other health professionals (+ourtney" #allard" (auver"
4ariota" O Holland" 9CC;5 Dos Santos" 9CC@)% As 1e shift from a
compartmentalized model of care to a model of comprehensive care" health
professionals must maFimize their relationships 1ith providers across disciplines
in the health care system and em*race partnership relationships 1ith clients
and their communities (4oulart" 9CC@5 Stoc.ins O PantoHa" 9CC@)% Partnership
relationships can transform the ,roessional and the client roles% As
professionals relinJuish their positions of authority to partner 1ith clients" clients
? families ? communities shift from *eing passive recipients of care to *ecoming
active participants in maintaining health and preventing disease (&c'lmurry"
0ys.a" O Par.er" 9CCC)% Additionally" partnerships *uild capacity among
individuals and communities (7ang" 9CC:)5 and" are particularly *eneEcial for
communities that have *een under2represented and?or minority populations
(+ourtney" #allard" (auver" 4ariota" O Holland" 9CC;)% (or eFample" 6ough (9CCC)
descri*ed an academic2community partnership *et1een a college of nursing
and a neigh*orhood grade school and parish% 0his partnership actually achieved
t1o goals% (irst" the provision of needed health care services improved health
status and increased access to health promotion services% Secondly" similar to
other academic community health centers (#eauchesne O &eservey" 9CCC)"
nursing students are given an opportunity to provide services using a
community2*ased primary care model%
0he formation of multiple partnerships 1ithin communities fosters
community empo1erment and mutual accounta*ility (6a*onte" 9CCC5 'isen"
9CC>)% &oreover" including Mout2of2the2mainstreamN groups as partners" such as
youths (Harper O +arver" 9CCC)" farmers ('hlers O Palermo" 9CCC)" religious
groups (Simpson O 7ing" 9CCC)" and minority populations (6evine" et al%" 9CC2)
can result in informative health service programs" along 1ith a uniJue
opportunity to *uild community coalitions as change agents% ithin a
community" coalitions encourage *road community involvement and
Mo1nershipN in the planning and implementation of needed health promotion
and health education services (6evine" et al%" 9CC25 Arm*ruster O 4ale" O #rady"
9CCC)% (or eFample" a coalition of consumer organizations" health care
#(
providers" and activists in /hode ,sland directed their activities to1ard
improving maternal and infant health (Aaronson" 9CC9)% ith multiple inputs
from people 1ith varied areas of eFpertise" the /hode ,sland coalition achieved
important legislative initiatives to improve maternal and infant health" such as"
health insurance for uninsured pregnant 1omen and promotion of mid1ifery
services% 0hus" the po1er of coalitions can enhance perceived o1nership" 1hich
in turn can result in greater community participation and interest in health
promotion and protection activities%
5/1 LOCATION OF SERVICES
0he acute" inpatient2oriented illness model of health care is *eing replaced
1ith a health protection" health2promotion" and primary health care model
(Shortell" 4illies" O Devers" 9CC:)% As the location of health care services moves
into the community (e%g%" 1or.site" schools" churches" healthcare sites)"
Juestions emerge concerning the dimensions of health education?health
promotion programs and policies (&ullen" et al%" 9CC:)% /esearch a*out program
needs" feasi*ility" eIcacy" and eDectiveness also must *e underta.en%
Although care is shifting to a primary health care model" models outside of
the formal health care arena eFist% (or eFample" Minformal careN is one strategy
that is *eing used to empo1er minority communities 1ith respect to health care
and health promotion and is a signiEcant force in health maintenance" health
promotion" and disease prevention (+hen" 9CCC)% ,nformal care is deEned as the
practice of alleviating physiological and psychological distress through others
(e%g% traditional healers" family mem*ers" self" etc%) using measures that do not
reJuire a physicianPs prescription or intervention (e%g% lifestyle modiEcations)
(erner" 9CC>)% 0hese actions are usually outside of formal" institutionally *ased
care mechanisms (e%g% homes and communities) ()igenda" 6oc.ett" &anca" O
/odriguez" 9CC@5 Seravalle O #oo." 9CC;)% ,n the -%S%" at least one2third of the
population is estimated to engage in unconventional medical practices" and
approFimately one2half of racial?ethnic populations use informal care% -se of
informal care is advantageous *ecause it is often more culturally compati*le"
relatively lo1 in cost" and BeFi*le%
+ommunity2*ased programs located 1here people freJuently congregate
can play a valua*le role in health promotion activities% (or eFample" health
promotion and health protection programs can *e implemented in churches"
schools" nursing homes" 1or.sites" +enters for ,ndependent 6iving for persons
1ith disa*ilities (+,6s)" Erehouses" supermar.ets" military systems" housing
proHects" *ar*ershops and *eauty salons" and other community settings% (or the
purpose of this paper" ho1ever" only churches" schools" and 1or.2site programs
1ill *e discussed in2depth%
#.2.1 Church-ased Health Pro"rams
+hurches are increasingly used as sites for health promotion and health
protection activities% A partnership *et1een religious groups and health
providers ena*les incorporation of the culture of the community into health
promotion eDorts to reach vulnera*le populations (Simpson O 7ing" 9CCC)% A
#)
COMPONENTS OF CARE
church2*ased model focuses on using the faith community to inBuence the
*ehavior and lifestyle of persons 1ithin an organized pu*lic health model" 1hich
provides a ne1 model of ministry (+oo." 9CC@)%
+hurch2*ased health programs oDer an innovative response to achieve
health policy as 1ell as address the changing health needs and altering social
and economic trends of a community (van 6oon" 9CCA)% )urses are often the .ey
providers in many of the faith2*ased community programs% 0hese programs
have the a*ility to foster community participation in health and promote health
from a holistic perspective" 1ithin the supported social and culturally speciEc
conteFt of a faith community% /eligious leaders may also play an instrumental
role in initiating health promoting and protecting messages (Anonymous" 9CC8)%
/esearch has sho1n that the religious community is more 1illing to accept
health messages" 1hen the church2*ased programs stress 1ays to improve the
Juality of life in .eeping 1ith the messages conveyed *y the church" rather than
framing health issues in mortality statistics (Sanders" 9CC@)%
A variety of health messages have *een promoted in church2*ased
programs% (or eFample" program aims have included the follo1ing3 reduction of
*reast" cervical" and diet related cancers in 1omen (+astro" et al%" 9CC:)5
smo.ing cessation (Anonymous" 9CC8)5 nutrition2related programs (Demar.2
ahnefried" Ho*en" Hars" $ennings" &iller" O &c+lelland" 9CCC)5 cardiovascular
ris. reduction programs (OeFmann" 2000)5 and" stro.e prevention (O.1uma*ua"
&artin" +layton2Davis" O Pearson" 9CC@)%
Health promotion programs in churches have targeted diDerent groups of
people% (or eFample" population groups have included3 people living in rural
areas (Simpson O 7ing" 9CCC5 Demar.2ahnefried" Ho*en" Hars" $ennings" &iller"
O &c+lelland" 9CCC)5 6atino?Hispanic 1omen (+astro" et al%" 9CC:)5 and" African2
American men and 1omen (O.1uma*ua" &artin" +layton2Davis" O Pearson"
9CC@5 0homas" [uinn" #illingsley" O +ald1ell" 9CC>)% /esearch is limited
concerning the interconnections among pu*lic health" health education" and
faith2*ased communities (+hatters" 6evin" O 'llison" 9CCA)% Ho1ever"
researchers and practitioners are increasingly interested in theoretical issues
and frame1or.s eFplaining the relationships *et1een religious involvement and
health% Additionally" research studies are increasingly eFploring the associations
*et1een religious involvement and health attitudes" *eliefs" and *ehaviors%
6astly" future eDorts need to evaluate health education programs in faith
communities and eFamine the contri*utions of religious institutions to the
development of health policy%
#.2.2 School-based Health Services and Health -ducation
School2*ased health clinics in
the -S have gro1n from a fe1
programs in the early 9C@0s to
more than ;00 in the 9CC0s (7lein
O+oF" 9CC:)% ,mplementation of
comprehensive school health
education and integrated school
#*
Ta=&# 1/ S+'!!&9=a)#" C&ini+)
&ariner ProHect3 A coordinated school
health pilot program (<alois O Hoyle"
(2000)%
School2#ased?School26in.ed Health
+entersK (illis" 2000)%
A comprehensive school2*ased clinic3
university and community partnership
(&c+lo1ry" 9CC;)
A colla*orative eDort for seF education
in rural school settings ((aul. O
&ancuso" 9CCA)
health services *ased on an assessment of community needs and resources can
improve access to health care for millions of underserved school2aged children
(Anonymous" 9CC>)% 4reater attention to health promotion and protection
services provides an optimal setting for improving health for all children and
adolescents *y focusing on health *ehaviors in school settings (#rindis" 9CC8)%
See 0a*le 2 for eFamples of school2*ased clinics%
A variety of conteFtual factors may facilitate or impede the provision of
school health services% (or eFample" schools 1hose students eFperienced more
health ris.s 1ere generally more li"ely to provide related services than schools
1hose students eFperienced fe1er ris.s (#illy" 4rady" enzlo1" #rener" +ollins"
O 7ann" 2000)% Schools 1ithin states that had strong state policies and
reJuirements for health2related programs and services 1ere also associated 1ith
#reater school2*ased provision of services% Additionally" schools 1ere less li"ely
to provide services on site 1hen communities had readily availa*le and
accessi*le health care services% 6astly" more aUuent communities 1ere more
li"ely to provide school health services than less aUuent communities% Similarly"
pu*lic schools 1ere more li"ely to provide school health services than private
schools% Pu*lic schools may have more access to pu*lic dollars" 1hich could
account for the greater li.elihood of providing school health services%
0he inclusion of a multidisciplinary approach (e%g%" school nurses"
nutritionists" eFercise physiologists" social 1or.ers" occupational therapists" and
pediatricians) in the continuum of health care delivery promotes eDective"
timely" accessi*le" cost2eDective services for children (4aDrey O #ergren" 9CCA)%
&oreover" the success of school2*ased programs reJuires colla*orative lin.ages
across many levels of systems and individuals% +olla*oration can increase points
of 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 remains
largely untapped" common dimensions of colla*oration have *een identiEed
(4ottlie*" 9CCC)% 0hese 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 the
success of a school2*ased health program3
9% Administrative support?*uy2in5
2% +oordination of the school2*ased health promotion team5
8% Program liaison?facilitator5 and
>% StaD 1ellness coordinator (<alois O Hoyle" 2000)%
$+
COMPONENTS OF CARE
,mplementation of a comprehensive school health education program
reJuires that teachers feel comforta*le and prepared to teach speciEc health
topics% On2going training and reinforcement for teachers can increase the
teachersK feelings of preparedness" 1hich in turn can have a signiEcant eDect on
the students (Hausman O /uze." 9CC:)%
School2*ased health care services in the -S are often delivered *y AP)s
(Advanced Practice )urses) (al.er" #a.er" O +hiverton" 9CCA5 (aul. O &ancuso"
9CCA)% A primary focus of school2*ased services is the provision of primary
health care and psychosocial counseling to children and adolescents in schools
(7lein O+oF" 9CC:)% Additional services often include health promotion"
screening" and anticipatory guidance (al.er" #a.er" O +hiverton" 9CCA)% -se of
an integrated approach to school2*ased health care services and health
education can provide programs to reduce to*acco use (&ac.ie O Oic.le" 9CC:)
and provide seF education to reduce the incidence of teen pregnancy and
seFually transmitted diseases ((aul. O &ancuso" 9CCA)%
0he availa*ility of school2*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 cost2
eDective and cost2eIcient manner" and determining the needed staD and
resources (#rindis" 9CC8)%
PAHO is developing a document that includes an overvie1 of the current
status" 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 local
net1or. of services" Enancing" management" and the scarcity of trained
personnel designated for the management and provision of care in the school
setting are addressed% 'Fperiences from +hile" +u*a" $amaica" 'cuador Peru" and
the -%S% are also discussed% (0o o*tain more information a*out MStatus of School
Health Services in the Americas /egion 2002N document" contact Dr% /% /oHas"
PAHO" HSP?HSO)%
#.2.3 $or!-Site Pro"rams
or.2site health promotion programs freJuently implement health
promotion and protection strategies to reduce o*esity and the prevalence of
cigarette smo.ing ($eDery" et al%" 9CC8)% or.2site programs have traditionally
focused on individually oriented 1ellness programs (provided at the 1or.site
and aimed primarily at changing employeesP health *ehavior) (Sto.ols" Pelletier"
O (ielding" 9CC;)% Ho1ever" current programs are emphasizing the Hoint impact
of the physical and social environment at 1or." Ho*2person Et" and 1or. policies
on employee 1ell2*eing%
5/2 TYPES OF PROGRAMS
Health care interventions are typically directed across three areas3
individual" family" or community interventions% 0o manage ne1 causes of
mor*idity and mortality" traditional health services must move *eyond the
individual level and su*sume greater focus on health protection and health
$"
promotion (4uldan" 9CC;)% #ecause most common health pro*lems amena*le to
prevention have strong environmental" cultural" lifestyle" and *ehavioral
components" community21ide or population approaches are imperative in most
health promotion and prevention strategies (6uep.er" 9CC>)% ,ndividuals"
communities" and countries ma.e choices a*out 1hether or not to consume
alcohol and drive" smo.e cigarettes" eFercise" or have their children immunized%
hile all of these involve personal choices" they also involve societal or cultural
*arriers and enticements" access" and availa*ility" monetary and opportunity
costs" la1s" and other community21ide factors (6uep.er" 9CC>)% Although some
prevention issues respond to traditional clinical approaches" many do not% 0hus"
a coordinated community approach to support the preventive eDorts of the
health care system and develop a healthy environment and health literate
population is reJuired%
#.3.1 .amily Models
A ne1 model of health proposed *y &endoza O (uentes2AUic. (9CCC) is the
family2community health promotion model% 0his model attempts to account for
the paradoF that 6atino children do not seem to have a consistent association
*et1een poverty and poor health% hile a maHority of 6atino children in the -S
live in poverty" many poor 6atino children have uneFpectedly good health
outcomes% 0he family2community health promotion model emphasizes the
family2community milieu of the child% ,nstead of focusing on traditional models
of health" the family2community model eFpands the outcome measures from
physical health to functional health status" 1hile incorporating the contri*utions
of cultural factors to functional health outcomes%
#.3.2 Community Models
+urrently" the focus of health promotion is shifting from the individual level
to organizations" communities" and *roader social policy areas (&c7inlay" 9CC85
&c7inlay" 9CC2)% +ommunity2*ased health promotion and protection services
emphasize community participation" along 1ith empo1erment of community
mem*ers to address ineJuities and increase control over their health (4uldan"
9CC;)%
+ommunity2*ased educational programs are often conducted to promote
healthy lifestyles (/eger" ootan" O #ooth2#utterEeld" S% 2000)% (or eFample"
the M9V Or 6essN message used pu*lic relations and community2*ased
educational activities in supermar.ets" schools" 1or.sites" and other community
settings to encourage community mem*ers to s1itch from high2fat (1hole or
2V) to lo12fat (9V or fat2free) mil.% 0he +anadian Heart Health ,nitiative2Ontario
ProHect (+HH,OP) used an ecological approach to health promotion 1ithin 1hich
pu*lic health agencies are seen to play a central role in implementing
community2*ased heart health promotion activities (0aylor" 'lliott" O /iley" 9CCA5
6othrop" 9CCC)%
+ommunity coalitions are a popular tool for promoting community2*ased
solutions to health pro*lems" such as alcohol" to*acco" and other drug a*use
(#utterfoss" 4oodman" O andersman" 9CC;)% &em*er satisfaction and
$#
COMPONENTS OF CARE
participation are critical components in community coalitions that are providing
health promotion and protection programs% &oreover" community leadership"
shared decision2ma.ing" lin.ages 1ith other organizations" and a positive
organizational climate are factors that predict satisfaction" participation" and
planning%
#.3.3 Health Care Pro"rams
0he eFtent and type of services depend on the location of the services%
hile there is a 1ide variety of health promotion and health protection
programs in the /egion" for the purpose of this paper the programs eFamined
1ere categorized as follo1s3 asthma treatment" cardiovascular health" eFercise
and physical activity" 1eight reduction" eye care" dental treatment" inHury
prevention" maternal child health" mental health" reproductive health?1omenKs
health" seFually transmitted diseases" su*stance a*use programs" and
un1anted pregnancy%
Schools and community programs have tremendous opportunity to help
children and adolescents adopt lifelong" physical activity patterns (Anonymous"
9CC@)% 7ey components of school and community programs for encouraging
physical activity include3 9) policies that promote enHoya*le physical activity and
social environments5 2) physical education curricula and instruction5 8) health
education curricula and instruction5 >) eFtracurricular physical activity programs
that meet the needs and interests of students5 :) involvement of parents and
guardians in physical activity instruction and programs for young people5 ;)
personnel training5 @) health services for children and adolescents5 A)
developmentally appropriate community sports and recreation programs that
are attractive to young people5 and" C) regular evaluation of physical activity
instruction" programs" and facilities%
&any of the asthma and inHury prevention programs are developed for
children and adolescents% (or eFample" su*standard housing and lac. of
resources often result in asthma triggers for many lo12income ur*an children
1ith asthma (7rieger" Song" 0a.aro" O Stout" 2000)% Health educators" outreach
1or.ers" medical providers" health care insurers" housing agencies" and elected
oIcials have developed various programs to address issues related to asthma
and asthma triggers ((isher" 9CC>5 Diaz <azJuez" Alonso #ernardo" 4arcia
&unoz" del 'Hido &ayo" Sordo 'spina O Alonso" 9CC@5 7ohler" 9CC8)%
#ehavior and environment have *een found to *e .ey determinants of *oth
unintentional and intentional inHuries in childhood and adolescence (4rossman O
/ivara" 9CC2)% ,nHury prevention programs have focused on violence
(#orze.o1s.i O Poussaint" 20005 allac." 9CCC5 4a*riel" Hopson" Has.ins" O
Po1ell" 9CC;)5 childhood unintentional in:ury (#ass" +hristoDel" idome" #oyle"
Scheidt" Stan1ic." O /o*erts" 9CC8)5 and" use o bi"e helmuts (esson" Spence"
Hu" O Par.in" 20005 Par.in" Hu" Spence" 7ranz" Shortt" O esson" 9CC:)% &any
health programs have addressed substance abuse ,revention and treatment%
Programs have *een developed for children and adolescents (#iglan" Ary"
Smol.o1s.i" Duncan" #lac. 20005 A*ernathy" 9CC>)" minority ,o,ulations
(Plested" Smitham" $umper20hurman" Oetting" O 'd1ards" 9CCC)" and adult men
$$
Ta=&# 2/ A9Ri)@ Gr!?>)
+hildren and
adolescents
,mmigrants
&igrant farm 1or.ers
Older adults
People living in poverty
People 1ith disa*ilities
Prisoners
/acial?ethnic minorities
-ndocumented
immigrants
omen
and *omen ((isher" 4lasgo1" O 0er*org" 9CC0)% Programs also targeted speciEc
drugs including alcohol (4ies*recht O /an.in" 2000) and tobacco use ('d1ards
O &ac&illan" 9CC0)% Additionally" health promotion and protection programs
have focused on mental health issues (Dalgard" Sorensen" Sandanger" O #revi."
9CC;)" oral health (Pac." 9CCA5 4ift" Drury" )o1Hac.2/aymer" O Sel1itz" 9CC;)"
eye health (Sperandio" 9CCC)" and s"in care among adults and youths ($un.in"
20005 &iller" 4eller" ood" 6e1" O 7oh" 9CCC)%
A plethora of programs have *een developed for hypertension (7ong" 9CC@)"
cardiovascular disease (4yarfas" 9CC2)" dia*etes ('ngelgau et al%" 9CCA)"
seFually transmitted diseases and unintended pregnancies (van Dam O Holmes"
20005 Santelli" Di+lemente" &iller" O 7ir*y" 9CCC)" along 1ith eFercise promotion
(7ing" 9CCA)" maternal child health (&ora O )estel" 20005 Ste1art O )imrod"
9CC8)" nutrition (Arenas2&onreal" Paulo2&aya" O 6opez24onzalez" 9CCC5 -singer2
6eFJuereuF" 9CC>5 Stevens" 9CC>)" agricultural health (Schen.er" 9CC;)" tropical
health (6eontsini" 4il" 7endall" O +lar." 9CC8) and 1or.site health (4elfand"
Parzucho1s.i" /ivero2Perry" O ShernoD" 2000)%
5/3 HEALTH CONCERNSAISSUES
Health ineJuities among population groups continue to gro1 throughout the
PAHO /egion% Health professionals and communities must develop innovative
health promotion and health protection strategies that are culturally relevant to
at2ris. groups (see 0a*le 8 for eFamples) to enhance access and improve the
health status% Some strategies may include the creation of alternative health
care delivery models and the use of lay community outreach 1or.ers to *ridge
cultural issues (41yther" 9CCA)%
#.*.1 Primary Health Care
0raditional health care for older adults and
persons 1ith disa*ilities has focused on illness
diagnosis and management (S1enson" 9CC2)% As
individuals" 1omen especially" are living longer and
living *etter" the emphasis needs to shift to include
primary health care for elderly people (Paier O
#o1dish" 9CC:5 S1enson" 9CC2)% Although primary
health care includes health promotion and health
protection activities" older adults and persons 1ith
disa*ilities" unfortunately" are often not included in
health promotion programs (+allahan" 20005
/esnic." 20005 /immer" 9CCC)% &oreover" delivery of
primary health care to people 1ith disa*ilities is
often compromised due to the providerKs lac. of
.no1ledge concerning disa*ility issues and *arriers
to accessing health care services (6ennoF O 7err" 9CC@5 Perez" Oliver2<asJuez"
Andino" O <ega" 9CCC))% /esearchers also are Hust *eginning to eFplore the
conditions promoting optimum health among older persons and persons 1ith
disa*ilities%
$%
COMPONENTS OF CARE
Despite the evidence that health2promoting activities can maintain or
enhance health status" control or remove deleterious ris. factors" and prevent
chronic conditions" older adults and persons 1ith disa*ilities have only recently
*een included in health promotion activities% )onetheless" anecdotal evidence
and limited research suggests that older adults and persons 1ith disa*ilities are
interested and 1illing to participate in health promotion programs (Durham"
#eresford" Diehr" 4rem*o1s.i" Hecht" O Patric." 9CC9)% Ho1ever" /esnic. (9CCA)
found that older adults demonstrated a decrease in cancer screening *ehaviors"
aero*ic eFercise" and compliance 1ith a lo1 cholesterol diet% 0he most common
reasons identiEed *y participants for not having these tests 1ere advanced age"
not *eing instructed *y their primary health care provider" and no interest in
pursuing a*normal Endings% Participants stated that they had lived a suIcient
period of time" and 1ere no longer interested in disease prevention and
prolongation of life%
#.*.2 &ccess and -/uity
Access issues prevent people from receiving necessary screenings (e%g%"
cancer screenings) and health promotion and protection services (&asood"
9CC@)% 4lo*ally" girls and 1omen are still routinely denied access to education
and health care" including control over their reproductive activity" eJual pay"
and legal rights% ,n order to access services and learn ho1 to interface 1ith
these services" 1omen must *e given culturally appropriate health information
regarding the availa*ility of such services% &oreover" gynecological and
reproductive services" such as mammograms" health education for
seFual?reproductive .no1ledge" S0D counseling?treatment" and prenatal care for
1omen 1ith intellectual disa*ilities are often limited or not oDered (7opac" (ritz"
O Holt" 9CC;)%
0he consolidation of services in the Americas impinges on the resources that
1e have availa*le to provide care% 0his is especially pro*lematic for at2ris.
groups 1ho need more time in order to attain desired changes in health status
outcome% 0he lac. of time limits the a*ility to realize maFimal health goals%
hile health promotion services and health information is a critical
ingredient for health status" decision ma.ers must actively address access
*arriers such as the lac. of adeJuate preparation of health care providers" lac.
of health insurance coverage" transportation pro*lems" and geographic
unavaila*ility of health services% ,n addition" harsh social and economic
environments" communication *arriers" poverty" marginalization" a*use" and
lac. of support also may reduce access to health screenings and promotion
activities (&essias" Hall" O &eleis" 9CC;)%
Across the PAHO /egion" 1e are failing to involve those most in need of
health promotion% ,f e0uity in provision of health promotion is to *e achieved"
measures must *e ta.en on a local and national level to ensure that
underserved populations have access to services (Davis" &chirter" O 4ordon"
9CC;)%
$&
#.*.3 Priority &reas
PAHO (9CCC) delineates the follo1ing health concerns and issues as priority
areas to address in health promotion and protection activities throughout the life
cycle%
(amily health and population" 1hich attaches special importance to
promoting and assessing gro1th and development at diDerent ages5 this
includes programs for adolescent health" reproductive health" and health of the
elderly%
(ood and nutrition" 1ith special attention to malnutrition" the fortiEcation of
food 1ith micronutrients" *reast2feeding" supplementary feeding" nutritional
guidelines for the diDerent age groups" and food security%
Healthy lifestyles and mental health" particularly preventing the use of
to*acco" alcohol" and drugs5 domestic violence5 and child a*use" including social
communication in health" as 1ell as health education and community
participation" an area that involves initiatives to promote healthy schools"
healthy communities" and healthy environments%
$'
6/ METHODOLOGICAL AND MEASUREMENT ISSUES
As health promotion activities move from the individual level to the level of
organizations and communities" measurement criteria need to change%
0raditional Juantitative methods that are appropriate at the level of individual
*ehavior change reJuire adaptation and reEnement 1hen sociopolitical change
*ecomes the mechanism for health promotion (&c7inlay" 9CC85 &c7inlay" 9CC2)%
Health services researchers and health educators 1ho are challenged to ma.e
methodological changes as they move *eyond their initial training" eFperience"
and focus" often End it useful to use 1ell2designed and carefully conducted
Jualitative studies to complement Juantitative approaches% -sing techniJues
such as ethnographic intervie1s" participant o*servation" case studies" or focus
group activities can Ell gaps 1here Juantitative techniJues are su*2optimal or
even inappropriate% Additionally" Jualitative techniJues can also support
Juantitative methods% 0he utility of Jualitative techniJues in process evaluation
is no1 *eyond dispute% 0he role of Jualitative research in the evaluation of
health promotion through planned sociopolitical change is essential (&c7inlay"
9CC85 &c7inlay" 9CC2)%
6/0 PRIMARY HEALTH CARE MODEL
'mploying holistic approaches to evaluate health care programs and
services can ensure that .ey varia*les are measured ($an" 9CCA)% 0he use of
conventional forms of economic evaluation" 1here value (or *eneEt) is seen in
terms of either health conseJuences or individualsK utility" results in overloo.ing
a num*er of aspects of health2related programs% &oreover" use of economic
evaluation imposes limits on the capacity to inform pu*lic policy% ,n contrast" use
of a Primary Health +are model (see (igure 9) to measure health promotion and
health protection activities ac.no1ledges that change in the *roader socio2
political environment can *e a source of value% 0his is particularly relevant 1hen
evaluating indigenous health programs" 1here notions of Mcultural
appropriatenessN have strong inBuence over the e4ectiveness and acce,tability
of such programs% Additionally" community and population health depends on a
Jualitatively diDerent set of investigative methods" decision2ma.ing procedures"
and assignment of responsi*ility for action than those applied in the health care
systems (4reen" 9CC>)% #ecause no one evaluative approach is appropriate in all
situations" a Primary Health +are model allo1s for a *lending of methodologies
ranging from Jualitative to Juantitative and non2eFperimental to true
eFperimental%
-se of the Primary Health +are (PH+) model reJuires consideration of
several methodological and measurement issues% A fundamental tenet of the
PH+ model is the use of participatory methods throughout the educational"
practice" research process for the purpose of empo1erment and emancipation
(refer (igure 9)%
$(
6/1 TRANSFORMING ROLES
0he PH+ model creates a template for conducting participatory education"
practice" and research activities% Ho1ever" educators" clinicians" and researchers
must Erst consider 1ays of 1or.ing 1ith Msu*Hects?clients?patientsN to transform
the hierarchical relationship into a mutual partnership (+ampos" $aimovich"
+ampos" O #erger" 9CCA5 6ange O $aimovich" 9CC>)% SiF principles of
emancipatory research have *een outlined *y Stone O Priestley (9CC;)% 0he Erst
principle involves a shift from a positivist model that vie1s Mmedical pro*lemsN
as an individual pathology" to a model that incorporates the socio2political2
environmental interplay *et1een the individual and society (Stone O Priestley"
9CC;)% Secondly" 1e must surrender o*Hectivity G 1here the conteFt is one of
oppression% 0hird" 1e must *e ready to identify the relevance of the treatment
or research for the individual or the community% ,n other 1ords" 1hatKs in it for
themT (ourth" a principle that must *e considered is the reversal of social
relationships% /esearchers" educators" and practitioners are challenged to move
*eyond traditional approaches that treat people as Mpassive su*HectsN 1hich can
in turn eDectively disempo1er them (Stone O Priestley" 9CC;)% 0o produce
relevant research results 1ithin a PH+ frame1or." researchers must consider the
social conteFt of the research activity" social relations" and hierarchical
structures throughout the research process% 0his reJuires recognition of the
po1er structure 1ithin the researcher2researched relationship% (ifth" another
concern is the collectivizing rather than individualizing eFperiences of a
marginalized group% /esearchers and educators must move *eyond the
M.no1ing of individual realitiesN and locate personal eFperiences 1ithin a human
rights analysis% A siFth and Enal principle concerns the use of Jualitative and
Juantitative methodologies% ,n order to identify sociopolitical issues that aDect
health" investigators must employ *oth Jualitative and Juantitative
methodologies% [ualitative methods permit the personal narratives" 1hereas"
identiEcation of access *arriers may *e greatly enhanced *y Juantitative data%
ithin the PH+ frame1or." various methodologies may *e used
independently or simultaneously for the purpose of triangulating results or to
add richness to the data% (or" eFample" to eFamine access issues among rural"
older adults" focus groups may *e conducted along 1ith a Juantitative survey to
collect socio2demographic data (e%g%" health insurance coverage" age"
race?ethnicity" disa*ility status" sources of health care" perceived health status"
and geographical accessi*ility of health care provider)%
6/2 CRITERIA AREAS
7ey criteria areas 1ithin the PH+ model that need to *e accounted for *y
researchers" educators" and practitioners include several issues% (or eFample"
issues include aDorda*ility" accessi*ility" availa*ility" applica*ility" accepta*ility"
and eJuita*ility% ,n practice" 1hile each of the criteria can *e discussed as
discrete varia*les" they are all interrelated to each other%
,n revie1ing the literature concerning the core criteria areas in the PH+
model" several measurement issues emerge% One issue concerns the operational
and conceptual deEnitions of the criteria areas% As an eFample" various
$)
METHODOLOGICAL AND MEASUREMENT ISSUES
approaches have *een used to deEne varia*les aDecting access to health care
(Puentes2&ar.ides" 9CC2)% &oreover" varia*les aDecting access may *e highly
speciEc to each su*2population% (or eFample" some people may indicate that
a*ility to pay for services acts as a maHor determinant of access to health care"
1hereas others point to *ehavioral issues related to motivation" health see.ing
*ehavior or perception of illness as a deterrent to 1omen in the lo1
socioeconomic strata% (urthermore" others indicate that socio2cultural issues"
such as values" education" religion or demographic varia*les related to age"
inBuence access to health care% Other considerations aDecting access issues
concern geographical location (physical access)" perceived poor Juality of care
and eFperiences of discrimination and stigmatization" fear of legal?social
services" and punitive actions (Perry O 4esler" 20005 Oliva" /ien.s" O &cDermid"
9CCC)% 6astly" access issues may relate to the follo1ing3 eFamination ta*les that
are too high for transferring from a 1heelchair5 lac. of accessi*le rest rooms5
reading materials that are not visually accessi*le5 health education that is not
developmentally appropriate5 lac. of #raille signage in facility5 lac. of signage
regarding the accessi*le entrances5 or" programmatic *arriers" such as"
inBeFi*le appointments that fail to accommodate transportation diIculties or a
lac. of staD to assist in the eFamination room (&ar.s" 2000)%
As can *e seen *y the eFample a*ove" various deEnitions eFist concerning
access" 1hich in turn impacts other criteria areas" such as accepta*ility" cultural
sensitivity" eJuity" social participation" and accepta*ility% 0hus" researchers"
practitioners" and educators must incorporate Jualitative methods into their
practice" teaching" and research to ascertain a clear understanding of the issues
that may aDect access or any of the other criteria areas%
'valuation studies are generally limited to short2term follo12up studies in
the health promotion and health protection literature% (reJuently" monies are
targeted to1ard demonstration proHects" *ut the evaluation piece is often not
funded% +onseJuently" more evidence is needed to document the eDectiveness
of health promotion programs% 0his lac. of evidence poses several areas of
concern% (irst" ne1 models providing primary health care are often funded *y
foundations" and often em*race a mission oriented to1ard Maction proHectsN
versus Mevolving the science%N Additionally" 1or. environments present
additional competing values 1hen professionals have diIculty implementing a
particular model of care due to the values held *y the employing organization%
hile 1e need more evidence on one hand" this must *e *alanced 1ith the
values that 1e hold concerning social Hustice and eJuity% )onetheless" in spite of
the limited evidence2*ased data" 1e have enough evidence in the literature to
suggest that 1e must transform our vie1s of ho1 1e provide care% Health care"
Mthe health care *usinessN as 1e no1 .no1 it" must stop% e must *ring the
McareN *ac. into health care" and change the practice of treating patients?clients
as commodities for the health care industry%
#y em*racing a Primary Health +are (PH+) model" evaluations can *e
improved *y incorporating the social value aspect 1hen evaluating the
eDectiveness of a model of care% (or eFample" 1ithin a PH+ frame1or." *y
including the political dynamics of a community" health promotion programs
$*
have a greater potential to recognize that assisting people to empo1er their
communities is as important as assisting them to improve their health ('ng O
Par.er" 9CC>)% 0herefore the evaluation process 1ould use a participatory action
research approach to ensure that the methods 1ould not contradict or interfere
1ith the programKs empo1erment agenda% &oreover" a close and colla*orative
1or.ing relationship among evaluators and local service providers is an
essential component of the evaluation method% 7ey community informants and
program staD 1ould deEne and operationalize the areas for evaluation% 6astly"
the community 1ould then Mo1nN the data and decide ho1 *est to use the
information to address the issues that they 1ant to change or modify%
A PH+ model also incorporates the primary health care criteria areas (see
(igure 9) in the evaluation% ,ssues of access" eJuity" accepta*ility" availa*ility of
resources" and cultural values are central to all evaluation eDorts% Additionally"
evaluation methods include *oth Jualitative and Juantitative components to
assure accuracy of the Endings using criteria from the PH+ model (+otton"
#razier" Hall" 6indsay" &arsh" Polnay" O illiams" 2000)% 'vidence suggests that
using Jualitative evaluation methods (e%g%" focus groups" individual and family
intervie1s" intervie1s of community mem*ers" and intervie1s 1ith health care
providers) can demonstrate improvements in health and social need (6azen*att"
Orr" #radley" O &c hirter" 9CCC5 Phan" /osenthal" O Diamond" 9CCC)%
%+
7/ IMPLICATIONS, CHALLENGES, AND PERSPECTIVES
MHealth (or AllN remains an elusive vision in the PAHO /egion% e continue
to strive to1ard healthier communities *y reducing health disparities and
gaining universal access to health care services% Health professionals emphasize
multisectoral participation across disciplines" organizations" and community
mem*ers to create Mhealthy communities%N #ut" Juestions remainL1here are
the outcomesT &ore importantly" 1hy are health disparities a gro1ing rate for
marginalized groupsT
6eadership in deEning reJuisite action and securing necessary resources is
reJuired% 0his leadership must come from governments" health professionals"
and most importantly" the individual mem*ers of the community% Strong
national health programs must *e created and em*raced to achieve e0uity in
access to personal health care (&c#eath" 9CC9)% &ore relevant to the goal of
access and reduction of health disparities is e0uitable sharing in *asic health
determinants 1ithin communities (e%g%" nutritious food" primary education" safe
1ater" decent housing" secure employment" adeJuate income" and a non2violent
community)%
7/0 ALTERNATIVE APPROACHES TO CARE
,n general" there is a paucity of literature that captures the voice of the
people 1ithin their culture and communities% (uture eDorts need to incorporate
a Primary Health +are (PH+) model" 1hich em*races the values of participatory
action research and PH+ criteria% Primary care services are a crucial component
to achieving the goals of Mhealth for allN as 1e search for alternative 1ays of
providing services that are aDorda*le" accessi*le and appropriate% 0he services
provided *y a 4eneral Practitioner" 1hose role as the central health professional
or Mteam leaderN may satisfactorily provide Erst2contact medical services" is a
pro*lematic approach in terms of eJuity and access for people 1ho have lo1er
incomes% Studies that have eFamined nurse practitioners as the Erst contact in
primary care demonstrate that they can function competently and safely among
a similar clientele ()orth" 9CC9)% &ost important" clients report that nurse
practitioners are *oth satisfactory and accepta*le as health care providers%
Health care changes must also occur *eyond the routine provider re2
conEguration% 0he literature is overBo1ing 1ith evidence declaring a need to
revolutionize primary care services% ithin our use of a primary health care
frame1or." primary care services can no longer act as a repository for
dissemination of pharmaceuticals and diagnostic testing% 0oo often medications
are the Erst line of treatment among primary care providers and health
promotion and protection services ta.e a much lo1er priority ()orth" 9CC9)%
0ransitioning the primary care providerKs central focal point from medical
interventions to health promotion and educational activities" user2participation
and involvement in health services" along 1ith empo1erment and self2
responsi*ility in health are more li.ely to *e achieved% &oreover" eFpenses 1ill
decrease due to a reduction in use of pharmaceuticals and diagnostic tests% As
1e shift the main focus of primary care to health promotion and educative
%"
functions" 1e 1ill 1ant to consider providers that have training in the areas of
health promotion and health education%
#ecause health status is directly aDected *y environmental conditions and
*y personal health2related *ehaviors" as a comprehensive approach to health
care" primary care services need to educate individuals to adopt and maintain
personal *ehaviors that prevent disease and promote health (#ro1n" 9CC9)%
Primary care providers should discourage health2damaging personal *ehaviors
*y individuals and facilitate people engaging in health2promoting *ehaviors%
Primary care providers need to provide care 1ithin a physical and socio2
environmental conteFt 1here community action is a central tenet% Providing
primary care services 1ithin a PH+ frame1or. reJuires social and community
action to change environmental conditions as 1ell as eDorts to change
individual *ehavior% People are given the opportunity to acJuire s.ills to act on a
community level to eliminate health hazards from their environment and to
create a more health2promoting community%
+ommunity approaches are essential% #ecause most common health
pro*lems amena*le to prevention have strong environmental" cultural" lifestyle"
and *ehavioral components" people" communities" and 1hole countries can
ma.e choices a*out 1hether or not to consume alcohol and drive" smo.e
cigarettes" eFercise" or have their children immunized% (6uep.er" 9CC>)% hile all
of these *ehaviors involve personal choices" they also have eFternal
components% (or eFample" societal and cultural *arriers and enticements"
access" availa*ility" monetary and opportunity costs" la1s" and other
community21ide factors have a signiEcant impact on oneKs personal choices and
decision2ma.ing processes% Although some disease prevention issues respond to
traditional clinical or health care approaches" many do not% 0herefore" a
coordinated community approach is reJuired to support the health promotion
and protection eDorts" along 1ith activities to1ard developing an accessi*le and
healthy environment and an educated population%
A%2 .ARRIERS TO CHANGE
'Dorts at health promotion and health protection face numerous *arriers3
+ultural" physical and structural *arriers to access health care persist
(Ste1art" 9CC0)%
Severe Enancial constraints o1ing to the general economic situation
(0illinghast O 0chernHavs.ii" 9CC;)%
6ac. of acceptance of individual responsi*ility for health%
6ac. of role modeling *y the medical community%
6ac. of critical appraisal of *eneEts and cost2eDectiveness for health
promotion and disease prevention interventions%
6o1 priority for health care" and for prevention speciEcally%
(ailure to validate community voices or perspectives%
%#
IMPLICATIONS, CHALLENGES, AND PERSPECTIVES
7/2 PRIORITIES FOR THE NEW CENTURY
Priorities for the neFt decade include3
Providing epistemological" methodological" and historical?critical
interdisciplinary training for health care professionals so that they can
conceptualize their practice 1hich 1ill in turn enhance health care
services ()aHera O Perez" 9CCC" @>)%
'sta*lishing resiliency2*uilding interventions (#lum" 9CCA)%
'sta*lishing *roader multisectorial interdisciplinary teams (#lum" 9CCA)%
,ncorporating factors associated 1ith successful interventions" such as"
strengthening families5 strengthening educational involvement5
eFpanding economic opportunities5 and supporting youth development"
not Hust pro*lem reduction (#lum" 9CCA) and using life cycle" family cycle"
and gender approaches%
#uilding health promotion and health education as 1ell as +HKs into the
health care system to promote health for the population%
Adopting strategies that are consistent 1ith premises of the PH+ model
and health promotion3 9) education" 2) com,rehensive and ,ersonali2ed
care" 8) consumer ,artici,ation" and" >) environmental strate#ies
(Ste1art" 9CC0)%
,ncreasing the prevalence of health promotion and disease prevention
services in communities" so that distri*ution and availa*ility of the
services are eJuita*le and accessi*le to all community mem*ers (Olden
O +lement" 2000)%
Shifting from health outcomes as ends in themselves to Juality of life
concerns as deEned *y individuals and communities (4reen" 9CC>)%
Developing models of health care delivery that have a *alance *et1een
medical care and health care" *et1een pu*lic health and personal health
services" and *et1een curative and preventive care issues of cost(
access( and 0uality (right" 9CC8)%
Disseminating scientiEc and technical information on health promotion
and protection activities to the greatest num*er and variety of individuals
in the PAHO /egion 1ho are 1or.ing in health care services%
Providing training for health care providers to *ecome more actively
involved in decisions a*out the use of pu*lic resources in disease
prevention" health education and more rational and eJuita*le use of
advanced health care technology%
Providing training for health care providers to *ecome active advocates
for children and human rights issues%
(ostering international colla*oration" training and eFchange programs
involving agencies at all levels" local" national and regional%
%$
,mplementing community21ide or population approaches (6uep.er"
9CC>)%
Promoting evaluation of *oth inputs" processes" as 1ell as the short2 and
long2term outcomes of the health promotion strategies%
Documenting" analyzing" and disseminating information on the national
eFperiences in health promotion" noting the cost2eDectiveness of these
strategies compared to curative and reha*ilitation activities in health%
7/3 EDUCATIONAL ISSUES
hile community2*ased health promotion programs have *een implemented
over the past t1o decades" the shift in focus reJuires a reorientation of
professional training% Additionally" social structures in communities must *e
reorganized (4uldan" 9CC;)%
0.*.1. -ducational arriers.
Several *arriers eFist in relation to the training of health care professionals%
0he follo1ing is a listing of some of the maHor issues that need to *e addressed%
Physicians are eFpected to provide an eFpanding array of clinical
preventive services and *e responsi*le for the health and 1ell2*eing of
entire populations and communities (Pomrehn" Davis" +hen" O #ar.er"
2000)% Although prevention principles are *eing taught in many conteFts"
most medical schools do not have adeJuate curriculum2trac.ing systems
that allo1 them to trac. the delivery of education and training in disease
prevention and health promotion%
&any countries in the PAHO /egion have an increased demand for nurses
(<illa" et al%" 9CCC)%
&ost countries in the /egion have a shortage of nursing personnel%
0.*.2 -ducational Needs
0he health care needs of people in the PAHO /egion are not met *y
physician specialists (O.asha" 9CC:)% 6i.e1ise" 1hile nursing education has
emphasized health education" along 1ith health promotion and protection
activities" this is *eginning to shift in some countries and institutions 1here
training is focusing more on diagnosis and medical treatment% 0hus" 1hile nurse
practitioners might impact on primary care *y enhancing peoplesK self2
responsi*ility for health through improving their competence and a1areness
(+ampos" 20005 +asas O 6opez" 2000)" current trends in training are minimizing
these s.ills%
7/4 SUMMARY
0he process of revie1ing models of care in the Americas is a 1orth1hile
endeavor for practitioners" researchers" and educators% hile 1e often vie1
models of care 1ithin a conteFt that is restricted to discrete areas of practice"
todayKs environment reJuires the use of models that are transparent" dynamic"
%%
IMPLICATIONS, CHALLENGES, AND PERSPECTIVES
and comprehensive in order to capture the compleFities of health% Additionally"
ongoing dialogue *et1een researchers" educators and practitioners must *e
fostered% e must identify 1ays to use the system to alleviate communication
*arriers to *ridge discussions across the PAHO /egion% 0he process of
generating" testing" and practicing ne1 ideas is an iterative process that
reJuires an active eFchange of ideas to move for1ard 1ith ne1 models of care%
0.5.1 Su""estions
Develop cooperative lin.s *et1een &'D6,)' and 6,6A+S" so the literature in
one data*ase can *e reached from the other%
Develop full teFt access to documents in the 6,6A+S to enhance its use and
promote inclusion of additional pu*lications in this data*ase%
,ncorporate a*stracts in 'nglish and Spanish for *oth the 6,6A+S and
&'D6,)' data*ases%
,ncorporate PH+ in the curricula for health professions students%
+reate a PH+ data*ase or virtual means 1here health 1or.ers" educators"
researchers" students" and politicians can share eFperiences%
-se a common language to discuss PH+ in the Americas /egion%
%&
8/ REFERENCES
1. Aaronson" /%H% (9CC9)% 4rassroots strategies for promoting maternal and
infant health% +omment in3 !irth( 11;2<( C82C%
2. A*ernathy" 0%$% (9CC>)% +ompliance for 7ids3 a community2*ased to*acco
prevention proHect% Canadian =ournal o Public Health. >evue Canadienne de
Sante Publi0ue( 15;2<( A22>%
3. Alderson" P% O 4oodey" +% (9CCA)% 0heories in health care and research3
0heories of consent% !ritish Medical =ournal( 31?;?1$1<( 98982:%
4. Anderson" D%" Harris" &%" O &c+os.er" H% (9CC@)% <iolence against 1omen3 an
education program for rural community health 1or.ers% 'ustralian =ournal o
>ural Health( 5;1<( 9@229%
5. Anonymous% (9CC@)% 4uidelines for school and community programs to
promote lifelong physical activity among young people% =ournal o School
Health( $?;$<( 20229C%
6. Anonymous% (9CC>)% ,ntegrated school health services% American Academy of
Pediatrics 0as. (orce on ,ntegrated school Health Services% Pediatrics( @+;3<(
>0022%
. Anonymous% (9CC9)% ,nBuence of religious leaders on smo.ing cessation in a
rural populationL0hailand% &&/ 2 Morbidity A Mortality %ee"ly >e,ort(
+2;1@<( 8;@2C%
!. Ansell" D%" 6acey" 6%" hitman" S%" +hen" '%" O Phillips +% (9CC>)% A nurse2
delivered intervention to reduce *arriers to *reast and cervical cancer
screening in +hicago inner city clinics% Public Health >e,orts( 1B@;1<( 90>299%
". Arenas2&onreal" 6%" Paulo2&aya" A%" O 6opez24onzalez H'% (9CCC)% Popular
education and child nutrition3 eFperience 1ith 1omen in a rural area of
&eFico% >evista de Saude Publica( 33;2<" 998229%
1#. Arm*ruster" +%" O 4ale" #%" O #rady" $% (9CCC)% 0hompson )% Perceived
o1nership in a community coalition% Public Health Nursin#( 1$;1<( 9@222%
11. Ash1ell" H%'%" O (reeman" P% (9CC:)% 0he clinical competency of community
health 1or.ers in the eastern highlands province of Papua )e1 4uinea%
Pa,ua Ne* Cuinea Medical =ournal( 31;3<" 9CA220@%
12. Attridge" +%" #udgen" +%" Hilton" A%" &cDavid" $%+%" &olzahn" A%" O Pur.is" &%'%
0he +omoF <alley )ursing +entre% Canadian Nurse( @3;2<( 8>2A%
13. #a.er" '%A%" #ouldin" )%" Durham" &%" 6o1ell" &%'%" 4onzalez" &%" $odaitis" )%"
+ruz" 6%)%" 0orres" ,%" 0orres" &%" O Adams" S%0% (9CC@)% 0he 6atino Health
Advocacy Program3 a colla*orative lay health advisor approach% Health
.ducation A !ehavior( 2+;+<( >C:2:0C%
14. #andeira" &% (9CC@)% D ostomi2ado e as circunstancias de ada,tacao da sua
vida no domicilio & Ehe ostomi2ed and the circumstances o ada,tation o
%'
REFERENCES
your lie in the home. -npu*lished &estre" -niversidade (ederal do +eara"
(ortaleza%
15. #ass" $%6%" +hristoDel" 7%7%" idome" &%" #oyle" %" Scheidt" P%" Stan1ic." /%" O
/o*erts 7% (9CC8)% +hildhood inHury prevention counseling in primary care
settings3 a critical revie1 of the literature% Pediatrics( @2;+<( :>>2:0%
16. #eauchesne" &%A%" O &eservey" P%&% (9CCC)% An interdisciplinary community2
*ased educational model% =ournal o Proessional Nursin#( 15;1<( 8A2>8%
1. #ental" 0% O Paran" '% (9CC0)% ,ncreasing pu*lic a1areness of the ris. of
cardiovascular disease using Phealth activistsP in a community health proHect
in ,srael3 a feasi*ility study% =ournal o Human Hy,ertension. +;+<( 8:;2;%
1!. #erger" 7%" +ampos" +%" +ampos" &%" $aimovich S% (9CCC)% 'voluciXn del
em*arazo y resultados perinatales de dos grupos de em*arazadas atendidas
*aHo diferentes modelos% >evista Chilena de Salud PFblica( 8(9)" 2C28:%
1". #er.ley2Patton" $%" (a1cett" S%#%" Paine2Andre1s" A%" O $ohns" 6% (9CC@)%
Developing capacities of youth as lay health advisors3 a case study 1ith high
school students% Health .ducation A !ehavior( 2+;+<( >A92C>%
2#. #erner" #%$% (9CC2)% Provision of health care in a frontier setting3 an Alas.an
perspective% =ournal o 'merican 'cademy o Nurse Practitioners( +;3<( AC2C>%
21. #iglan" A%" Ary" D%<%" Smol.o1s.i" 7%" Duncan" 0%" O #lac." +% (2000)% A
randomised controlled trial of a community intervention to prevent
adolescent to*acco use% Eobacco Control( @;1<( 2>282%
22. #illy" $%O%" 4rady" %/%" enzlo1" A%0%" #rener" )%D%" +ollins" $%6%" O 7ann" 6%
(2000)% +onteFtual inBuences on school provision of health services. =ournal
o 'dolescent Health. 2?;1<( 9222>%
23. #loc." #%" Sze.ely" 7%" O 'sco*ar" &% (9CC;)% DiIculties in evaluating
a*normal lead screening results in children% =ournal o 'merican !oard o
/amily Practitioners( @;$<( >:C2;9%
24. #lum" /%% (9CCA)% 0he 9CCA Her*ert 6% )eedleman A1ard 6ecture%
Adolescent health3 Priorities for the neFt millennium% Maternal A Child Health
=ournal( 2;3<( 9A92@%
25. #oo.er" <%7%" /o*inson" $%4%" 7ay" #%$%" )aHera" 6%4%" O Ste1art" 4% (9CC@)%
+hanges in empo1erment3 eDects of participation in a lay health promotion
program% Health .ducation and !ehavior( 2+;+<( >:22;>%
26. #orze.o1s.i" D%6%" O Poussaint" A%(% (2000)% +ommon themes from the
eFtremes3 using t1o methodologies to eFamine adolescentsP perceptions of
anti2violence pu*lic service announcements% =ournal o 'dolescent Health(
2$;3<( 9;>2@:%
2. #ossert" 0%" 6arranaga" O%" /uiz Peir" (% (2000)% Decentralization of health
systems in 6atin America% /ev Panam Salud Pu*ica" Pan 'merica =ournal o
Public Health( 1;1&2<" A>2C2%
%(
2!. #rindis" +% (9CC8)% Health policy reform and comprehensive school health
education3 the need for an eDective partnership% =ournal o School Health(
$3;1<( 882@%
2". #ro1n" '%/% (9CC9)% +ommunity action for health promotion3 a strategy to
empo1er individuals and communities% 8nternational =ournal o Health
Services. 21;3<( >>92:;%
3#. #ro1nstein" $%)%" +heal" )%" Ac.ermann" S%P%" #assford" 0%6%" O +ampos2Outcalt"
D% (9CC2)% #reast and cervical cancer screening in minority populations3 a
model for using lay health educators% =ournal o Cancer .ducation( ?;+<( 8292
;%
31. #rush" #%6%" O &c4ee" '%&% 0he 'Fpanded +are for Healthy Outcomes ('+HO)
ProHect3 addressing the spiritual care needs of homeless men in recovery%
Clinical .5cellence or Nurse Practitioners. 3;2<-99;222" 9CCC%
32. #ula" +%$%" Alessi" +%A%" Arono1" H%-%" =u*as" 7%" 4old" &%" )isen*aum" /%" #ec."
$%+% O /u*enstein" 6%Y% (9CC:)% +ommunity physiciansP cooperation 1ith a
program of in2home comprehensive geriatric assessment% =ournal o the
'merican Ceriatrics Society( +3;@<" 909;220%
33. #utterfoss" (%D%" 4oodman" /%&%" O andersman" A% (9CC;)% +ommunity
coalitions for prevention and health promotion3 factors predicting
satisfaction" participation" and planning% Health .ducation Guarterly( 23;1<(
;:2@C%
34. +airncross" S%" #raide" '%,%" O #ugri" S%Y% (9CC;)% +ommunity participation in
the eradication of guinea 1orm disease% 'cta Ero,.( $1;2<( 92928;%
35. +allahan" '%$%" #erta.is" 7%D%" Azari" /%" /o**ins" $%A%" Helms" 6%$%" O +hang"
D%% (2000)% 0he inBuence of patient age on primary care resident physician2
patient interaction% =ournal o the 'merican Ceriatrics Society( +1;1<( 802:%
36. +ampos" +% (2000)% 'nfermerZa para el autocuidado3 un desafZo del futuro 2
)ursing for self2care3 a challenge of the future% 3le#ando( 3(A)" 9A228%
3. +ampos +%" $aimovich" S%" O +ampos &%S%(9CCC)% 'Fperiencia de enfermerZa
en la atenciXn materno infantil %,n PAHO" .nermerHa en las 'mIricas(
,ublicaciJn cientH9ca 5?1( 2@-31.
3!. +ampos" +%" $aimovich" S%" +ampos" &S%" O #erger" 7% (9CCA) Sistema de
enfermerZa de apoyo educativo a la familia para la evaluaciXn del desarrollo
psicomotor en lactantes% /evista +hilena de Salud P\*lica 2(8 )" 9C929C@%
3". +arter" =%H% O $ones" P%% (9CC8)% 4eneral practitionersP *eliefs a*out their role
in the prevention and treatment of accidents involving children% #ritish
=ournal o Ceneral Practice( +3;3?$<( >;82:%
4#. +asas" )%" O 6Xpez" 6% (2000)% 'nfermerZa y el autocuidado ? )ursing and self2
care% 3le#ando" >(99)" >298%
41. +astro" (%4%" 'lder" $%" +oe" 7%" 0afoya2#arraza" H%&%" &oratto" S%" +amp*ell" )%"
O 0alavera" 4% (9CC:)% &o*ilizing churches for health promotion in latino
%)
REFERENCES
communities3 compa]eros en la salud% $ournal o the National Cancer
8nstitute. Mono#ra,hs( ;11<( 92@28:%
42. +hatters" 6%&%" 6evin" $%S%" O 'llison" +%4% (9CCA)% Pu*lic health and health
education in faith communities% Health .ducation A !ehavior( 25;$<( ;AC2CC%
43. +hen" &%S% $r% (9CCC)% ,nformal care and the empo1erment of minority
communities3 comparisons *et1een the -SA and the -7% 'thnicity A Health(
+;3<( 98C2:9" 9CCC%
44. +hristensen" P% #%" O 7arlJvist" S% (9CC0)% +ommunity health 1or.ers in a
peruvian slum area3 an evaluation of their impact on health *ehavior% #ulletin
o the Pan 'merican Health Dr#ani2ation( 2+;2<( 9A82C;%
45. +oo." +% (9CC@)% (aith2*ased health needs assessment3 implications for
empo1erment of the faith community% $ournal o Health Care or the Poor A
7nderserved( 1;3<( 80022%
46. +orrarino" $%'%" alsh" P%$%" #oyle" &%,%" O Anselmo" D%" (2000)% 0he cool .ids
coalition. 'merican =ournal o Maternal Child Nursin#( 25;1<( 902;%
4. +otton" ,%" #razier" $%" Hall" D%&%" 6indsay" 4%" &arsh" P%" Polnay" ,%" O illiams"
0%S% (2000)% School nursing3 costs and potential *eneEts% $ournal o 'dvanced
Nursin#( 31;5<( 90;82@9%
4!. +ourtney" /%" #allard" '%" (auver" S%" 4ariota" &%" O Holland" ,% (9CC;)%
Arlington school of nursing% the partnership model3 1or.ing 1ith individuals"
families" and communities to1ard a ne1 vision of health% Public Health
Nursin#( 13;3<( 9@@2A;%
4". +uEno Svitone" '%" 4arEeld" /%" <asconcelos" &%,%" O ArauHo +raveiro" <% (2000)
Primary health care lessons from the northeast of #razil3 the Agentes de
Saude Program% >ev Panam Salud Publica( ?;5<( 2C82802%
5#. Dalgard" O%S%" Sorensen" 0%" Sandanger" ,%" O #revi." $%,% (9CC;)% Psychiatric
interventions for prevention of mental disorders% A psychosocial perspective%
8nternational =ournal o Eechnolo#y 'ssessment in Health Care 12;+<( ;0>29@%
51. Davies" P% (9CC9)% Health promotion in general practice% 'ustralian /amily
Physician( 2B;1<( 282C%
52. Davis" #%S%" &chirter" &%(%" O 4ordon" D%S% (9CC;)% here needs and
demands diverge3 Health promotion in primary care% Public Health( 11B;2<(
C:2909%
53. Dellasega" +%" #ro1n" /%" O hite" A% (9CC:)% +holesterol2related health
*ehaviors in rural elderly persons% =ournal o Cerontolo#ical Nursin#. 21;5<( ;2
92%
54. Demar.2ahnefried" %" Ho*en" 7%P%" Hars" <%" $ennings" $%" &iller" &%%" O
&c+lelland" $%% (9CCC)% -tility of produce ratios to trac. fruit and vegeta*le
consumption in a rural community" church2*ased : A Day intervention
proHect% Nutrition A Cancer( 33;2<( 2982@%
55. DeSantis" 6% (9CC@)% #uilding healthy communities 1ith immigrants and
refugees% =ournal o Eranscultural Nursin#( @;1<( 20289%Dos Santos" P% (9CC@)%
%*
' enerma#en na comunidade- na historia do bairro Nossa Senhora das
Cracas( 8ta:ai( Santa Catarina & Nursin# in community- a story in history o
district Nossa Senhora das Cracas( 8ta:ai( Santa Catarina. -npu*lished
mestre" -niversidade (ederale de Santa +atarina" Santa +atarina%
56. Diaz <azJuez" +%A%" Alonso #ernardo" 6%&%" 4arcia &unoz" &%0%" del 'Hido
&ayo" $%" Sordo 'spina" &%A%" O Alonso" $%+% (9CC@)% 'valuation of activities and
eDectiveness of an asthmatic child program developed in primary care/
'tenciJn Primaria( 1@;+<( 9CC220;%
5. Dic." $%" O Schoeman" $%H% (9CC;)% 0u*erculosis in the community3 0he
perceptions of mem*ers of a tu*erculosis health team to1ards a voluntary
health 1or.er programme% Eubercle A 3un# Disease" ??;+<( 8A028%
5!. Dumas" 6% (9CC2)% Addicted 1omen% ProEles from the inner city% Nursin#
Clinics o North 'merica. 2?;+<( C0929:%
5". Dunham20aylor" $%" Olda.er" $%" De+apua" 0%" &anley" )%7%" Oprian" #%" O
restler $% (9CC8)% )urses cut health care costs% =ournal o Holistic Nursin#(
11;+<( 8CA2>99%
6#. Durham" &%6%" #eresford" S%" Diehr" P%" 4rem*o1s.i" D%" Hecht" $%A%" O Patric.
D%6% (9CC9)% Participation of higher users in a randomized trial of &edicare
reim*ursement for preventive services% Cerontolo#ist( 31;5<( ;082;%
61. 'arp" $%A%" <iadro" +%,%" <incus" A%A%" Altpeter" &%" (laF" <%" &ayne" 6%" O 'ng" '%
(9CC@)% 6ay health advisors3 a strategy for getting the 1ord out a*out *reast
cancer% Health .ducation A !ehavior" 2+;+<( >822:9%
62. 'd1ards" )%+%" O &ac&illan 7% 0o*acco use and ethnicity3 the eFisting data
gap% Canadian =ournal o Public Health. >evue Canadienne de Sante Publi0ue(
11;1<( 822;%
63. 'hlers" $% O Palermo" 0% (9CCC)% +ommunity Partners for Healthy (arming3
involving communities in intervention planning" implementation" and
evaluation% 'merican =ournal o 8ndustrial Medicine" Su,,l 1390@2C%
64. 'isen" A% (9CC>)% Survey of neigh*orhood2*ased" comprehensive community
empo1erment initiatives% Health 'ducation [uarterly" 29(2)" 28:2:2%
65. 'ng" '%" O Par.er" '% (9CC>)% &easuring community competence in the
&ississippi Delta3 the interface *et1een program evaluation and
empo1erment% Health .ducation Guarterly( 21;2<( 9CC2220%
66. 'ngelgau" &%&%" )arayan" 7%&%" 4eiss" 6%S%" 0hompson" 0%$%" #ec.les" 4%6%"
6opez" 6%" Hart1ell" 0%" <isscher" %" O 6i*urd" 6% (9CCA)% A proHect to reduce
the *urden of dia*etes in the African2American +ommunity3 ProHect D,/'+0%
=ournal o the National Medical 'ssociation( @B;1B<( ;0:298%
6. 'ngel.es" P%'% (9CC2)% 'valuation of community health services utilization% A
case study from +olum*ia% Ero,ical A Ceo#ra,hical Medicine( ++;1-2<" :22@%
6!. (aul." D%" O &ancuso" (%&% (9CCA)% A colla*orative eDort for seF education in
rural school settings% Nursin# A Health Care Pers,ectives( 1@;$<( 2@928%
&+
REFERENCES
6". (ernandez" )%" 0ate" /%#%" #onet" &%" +anizares" &%" &as" P%" O =assi" A% (2000)%
Health2ris. perception in the inner city community of +entro Ha*ana" +u*a%
8nternational =ournal o Dccu,ational A .nvironmental Health( $;1<( 3+-+3%
#. (isher" '%#% $r%" Sussman" 6%7%" Arf.en" +%" Harrison" D%" &unro" $%" Sy.es" /%7%"
Sylvia" S% O Strun." /%+% (9CC>)% 0argeting high ris. groups% )eigh*orhood
organization for pediatric asthma management in the )eigh*orhood Asthma
+oalition% Chest( 1B$;+ Su,,l<( 2>AS22:CS%
1. (isher" 7%$%" 4lasgo1" /%'%" 0er*org" $%/% (9CC0)% or. site smo.ing cessation3
an analysis of long2term Juit rates from controlled studies% =ournal o
Dccu,ational Medicine( 32;5<( >2C28C%
2. (rame" P%S%" O erth" P%6% (9CC8)% Ho1 primary health care providers can
integrate cancer prevention into practice% Cancer( ?2;3 Su,,l<( 99822@%
3. (reimuth" <%" 6innan" H%%" O Potter" P% (2000)% +ommunicating the threat of
emerging infections to the pu*lic% 'merging ,nfectious Diseases" ;(>)" 88@2
>@%
4. 4a*riel" /%&%" Hopson" 0%" Has.ins" &%" O Po1ell" 7%'% (9CC;)% #uilding
relationships and resilience in the prevention of youth violence% 'merican
=ournal o Preventive Medicine( 12;5 Su,,l<( >A2::%
5. 4aDrey" '%A%" O #ergren" &%D% (9CCA)% School health services and managed
care3 a uniJue partnership for child health/ =ournal o School Nursin#( 1+;+<(
:292" 9>220%
6. 4arEeld" /% (9CC;)% +ommunity health promotion via local minority youth3 a
model for academic medical centers% 'merican =ournal o Public Health"
1$;1B<( 9>@:2@%
. 4elfand" D%'%" Parzucho1s.i" $%" /ivero2Perry" &%" O ShernoD" )% (2000)% or.2
site cancer screening3 a 6atino case study% Dncolo#y Nursin# /orum( 2?;+<(
;:C2;;%
!. 4ies*recht" )%" O /an.in" $% (2000)% Addiction /esearch (oundation Division"
+entre for Addiction O &ental Health" 0oronto% /educing alcohol pro*lems
through community action research proHects3 conteFts" strategies"
implications" and challenges% Substance 7se A Misuse 35;1-2<( 892:8%
". 4ift" H%+%" Drury" 0%(%" )o1Hac.2/aymer" /%'%" O Sel1itz" /%H% (9CC;)% 0he state
of the nationPs oral health3 mid2decade assessment of Healthy People 2000%
=ournal o Public Health Dentistry( 5$;2<( A>2C9%
!#. 4ill" +% (2009)% hat is the Msocial model of disa*ilityN and 1hy should you
careT 'lert( 12;2<( ;2C%
!1. 4ottlie*" )%H%" 7eogh" '%(%" $onas" $%/%" 4run*aum" $%A%" alters" S%/%" (ee" /%&%"
Saunders" /%P%" O #aldyga" % (9CCC)% Partnerships for comprehensive school
health3 colla*oration among colleges?universities" state2level organizations"
and local school districts% =ournal o School Health( $@;1<( 80@298%
!2. 4ottschal." $% (9CCC)% )ursing and sustaina*le development% Nursin# in the
'mericas. No. 5?1. Pan American Health Organization3 ashington" D%+%
&"
!3. 4oulart" (% (9CC@)% +enarios epidemiologicos e institucionais para os modelos
de attencao a saude ? 'pidemiological demographic and institutional models
of health care% S7S( 1(2)" 9@22;%
!4. 4racey" &% (9CCA)% 0he pediatricianPs role in the t1enty2Erst century% 'cta
Paediatrica =a,onica( +B;5<( 8C82C%
!5. 4reen" 6%% (9CC>)% /efocusing health care systems to address *oth
individual care and population health% Clinical A 8nvesti#ative Medicine -
Medecine Clini0ue et .5,erimentale( 1?;2<( 9882>9%
!6. 4reen" 6%%" O 7reuter" &%% (9CC9)% Health ,romotion ,lannin#- 'n
educational and environmental a,,roach (2nd ed%)% &ountain <ie1" +A3
&ayEeld Pu*lishing +ompany%
!. 4rey" &% 0he impact of the MPut Prevention into PracticeN initiative on
pediatric nurse practitioner practices% =ournal o Pediatric Health Care( 12;+<(
9@92:%
!!. 4rossman" D%+%" O /ivara" (%P% (9CC2)% ,nHury control in childhood% Pediatric
Clinics o North 'merica( 3@;3<( >@92A:%
!". 4uldan" 4%S% (9CC;)% O*stacles to community health promotion% Social
Science A Medicine( +3;5<( ;AC2C:%
"#. 4utierrez" 6%" O 4avilano" =% (2000)% Manual de ca,acitaciJn de ca,acitadores-
un documento diri#ido a ,ersonal de salud como a,oyo ,ara el traba:o
comunitario & Erainin# manual o trainers- document leadin# to health
,ersonal as su,,ort to community *or"% 6ima3 &inisterio de Salud%
"1. 4utierrez" 6% O Paredes" 4% (2000)% Manual ,ara ,romotores y ,romotoras de
salud & Health ,romoters manual% 6ima3 &inisterio de Salud%
"2. 41yther" &%'% (9CCA)% &igrant farm1or.er children3 health status" *arriers to
care" and nursing innovations in health care delivery% $ournal of Pediatric
Health +are"92(2)" ;02;%
"3. 4yarfas" ,% (9CC2)% +ardiovascular Diseases -nit" orld Health Organization"
4eneva% /evie1 of community intervention studies on cardiovascular ris.
factors% Clinical A .5,erimental Hy,ertension - Part '( Eheory A Practice(
1+;1-2<( 22828@%
"4. Hall" $%&%" Stevens" P%'%" O &eleis" A%,% (9CC>)% &arginalization3 A guiding
concept or valuing diversity in nursing .no1ledge development% 'dvances in
Nursin# Science 1$;+<" 282>9%
"5. Halperin" $%A%(9CCA)% Setting health standards for the 29st century% =ournal o
the 'merican Pharmaceutical 'ssociation. 31;$)" @;22;%
"6. Harper" 4%%" O +arver" 6%$% (9CCC)% MOut2of2the2mainstreamN youth as
partners in colla*orative research3 eFploring the *eneEts and challenges%
Health .ducation A !ehavior" 2$;2<( 2:02;:%
". Hart1ig" &%S%" O 6andis" #%$% (9CCC)% 0he Ar.ansas AH'+ model of community2
oriented primary care% Holistic Nursin# Practice( 13;+<( 2A28@%
&#
REFERENCES
"!. Hausman" A%$%" O /uze." S%#% (9CC:)% ,mplementation of comprehensive
school health education in elementary schools3 focus on teacher concerns%
=ournal o School Health( $5;3<( A92;%
"". Heller" 0% O &ar.s" #%A% (*oo. chapter in press)% Health Promotion and omen
1ith ,ntellectual Disa*ilities%
1##. Hill" &%)% O #ec.er" D%&% (9CC:)% /oles of nurses and health 1or.ers in
cardiovascular health promotion% 'merican =ournal o the Medical Sciences(
31B( Su,,l 1" S9282;%
1#1. Hollinger2Smith" 6% (9CCA)% Partners in colla*oration3 0he Homan SJuare
ProHect% =ournal o Proessional Nursin#( 1+;$<( 8>>2C%
1#2. ,m" 'un2O. O &eleis" Afaf ,*rahim% (9CCC)% Situation2speciEc theories3
Philosophical roots" properties" and approach% 'dvances in Nursin# Science(
22;2<" 9922>%
1#3. $ac.son" '%$%" O Par.s" +%P% (9CC@)% /ecruitment and training issues from
selected lay health advisor programs among African Americans3 a 202year
perspective% Health .ducation A !ehavior( 2+;+<( >9A289%
1#4. $an" S% (9CCA)% A holistic approach to the economic evaluation of health
programs using institutionalist methodology% Social Science A Medicine.
+?;1B<( 9:;:2@2%
1#5. $eDery" /%%" (orster" $%6%" (rench" S%A%" 7elder" S%H%" 6ando" H%A%"
&c4overn" P%4%" O $aco*s" D%/% $r% (9CC8)% 0he Healthy or.er ProHect3 a 1or.2
site intervention for 1eight control and smo.ing cessation% American $ournal
of Pu*lic Health" A8(8)" 8C:2>09%
1#6. $ohnson" Y%" Ho1ell" (%" O &olloy" #% (9CC8)% +ommunity mothersP
programme3 randomised controlled trial of non2professional intervention in
parenting% #&$" 80;(;AC0)" 9>>C2:2%
1#. $un.in" $% (2000)% Promoting healthy s.in in various settings% )ursing
+linics of )orth America" 8:(2)" 88C2>A%
1#!. 7ang" /% (9CC:)% #uilding community capacity for health promotion3 a
challenge for pu*lic health nurses% Pu*lic Health )ursing" 92(:)" 8922A%
1#". 7eating" S%#% (9CC:)% Health promotion and disease prevention in home
care% 4eriatric )ursing" 9;(>)" 9A>2;%
11#. 7han" A%A%" O #hard1aH" S%&% (9CC>)% Access to health care% A conceptual
frame1or. and its relevance to health care planning% 'valuation and the
Health Professions" 9@(9)" ;02@;%
111. 7ing" A%+% (9CCA)% Ho1 to promote physical activity in a community3
research eFperiences from the -S highlighting diDerent community
approaches% Patient 'ducation O +ounseling" 88(9 Suppl)" S8292%
112. 7lein" $%D%" O +oF" '%&% (9CC:)% School2*ased health clinics in the mid2
9CC0s% +urrent Opinion in Pediatrics" @(>)" 8:82C%
&$
113. 7ohler" +%6%" Dolce" $%$%" &anzella" #%A%" Higgins" D%" #roo.s" +%&%" /ichards"
$%&% $r%" O #ailey" %+% (9CC8)% -se of focus group methodology to develop an
asthma self2management program useful for community2*ased medical
practices% Health 'ducation [uarterly" 20(8)" >292C%
114. 7ong" #%% (9CC@)%+ommunity2*ased hypertension control programs that
1or.% $ournal of Health +are for the Poor O -nderserved" A(>)" >0C29:%
115. 7opac" +%A%" (ritz" $%" O Holt" /% (9CC;)% Availa*ility and accessi*ility of
gynecological and reproductive services for 1omen 1ith developmental
disa*ilities% American )et1or. of +ommunity Options and /esources
(A)+O/)%
116. 7ozlo1s.i" 6%A%" O Yotti" &%'% (9CC>)% ,nBuencing community leaders
to1ard the promotion of prenatal care at the community level" Public Health
Nursin#( 11;5<( 8>82:9%
11. 7reitzman" $%" O &c7night" $% (9CC8)% !uildin# communities rom the inside
out- ' ,ath to*ard 9ndin# and mobili2in# a communityKs assets. +hicago3
A+0A pu*lications%
11!. 7rieger" $%%" Song" 6%" 0a.aro" 0%7%" O Stout" $% (2000)% Asthma and the
home environment of lo12income ur*an children3 preliminary Endings from
the Seattle27ing +ounty healthy homes proHect% =ournal o 7rban Health(
??;1<( :02;@%
11". 7uss" 0%" ProulF24irouard" 6%" 6ovitt" S%" 7atz" +%#%" O 7ennelly P% (9CC@)% A
pu*lic health nursing model" Pu*lic Health )ursing" 9>(2)" A92C9%
12#. 6a*onte" /% (9CCC)% &utual accounta*ility in partnerships3 health agencies
and community groups% Promotion et 'ducation" ;(9)" 82A" 8;%
121. 6ange" 6%" Aguilo" A%" O #arros" +% (9CC>)% Health promoters3 invisi*le
providers of care% ,n /% iHeyaratne" $%" 7itts" P%" Arsenault" 6% ('d%)" 4ender"
health" and Sustaina*le Development3 A 6atin American perspective (pp%
9C>29CA)% Otta1a3 ,nternational Development /esearch +enter%
122. 6ange" ,% O $aimovich" S% (9CC@)% Selfcare nursing as a contri*ution to
Juality improvement in health3 A 6atin American eFperience% ,n &% +% $% O H%
4race ('ds%)" +urrent ,ssues in )ursing( (pp% 88:28>2)3 &os*y.
123. 6ange" ,% O $aimovich" S% (9CC>)% Selfcare as a concept to guide Juality
nursing practice in 6atin American countries ,n &% +% $% O H% 4race ('ds%)"
+urrent ,ssues in )ursing( (pp% 8:028:;)3 &os*y.
124. 6a/osa" $%H% (9CC>)% OIce of /esearch on omenPs Health% )ational
,nstitutes of Health and the 1omenPs health agenda% Annals of the )e1 =or.
Academy of Sciences" @8;" 9C;220>%
125. 6azen*att" A%" Orr" $%" #radley" &%" O &chirter" 6% (9CCC)% 0he role of
nursing partnership interventions in improving the health of disadvantaged
1omen% =ournal o 'dvanced Nursin#" 3B;$<( 92A02A%
&%
REFERENCES
126. 6ennoF" )%4%" O 7err" &%P% (9CC@)% Primary health care and people 1ith an
intellectual disa*ility3 the evidence *ase% $ournal of ,ntellectual Disa*ility
/esearch" >9 (Pt :)" 8;:2@2%
12. 6eontsini" '%" 4il" '%" 7endall" +%" O +lar." 4%4% (9CC8)% 'Dect of a
community2*ased Aedes aegypti control programme on mosJuito larval
production sites in 'l Progreso" Honduras% 0ransactions of the /oyal Society of
0ropical &edicine O Hygiene% A@(8)32;@2@9" 9CC8%
12!. 6evine" D%&%" #ec.er" D%&%" #one" 6%/%" Stillman" (%A%" 0uggle" &%#% 2nd"
Prentice" &%" +arter" $%" O (ilippeli" $% (9CC2)% A partnership 1ith minority
populations3 a community model of eDectiveness research% 'thnicity O
Disease" 2(8)% 2C;280:%
12". 6opez" ,% (9CCC)% Agentes comunitarios del sector salud3 perEl y proceso
de capacitaciXn en +olom*ia ? +ommunity health 1or.ers3 proEle and
training process in +olom*ia% ashington" D+3 PAHO%
13#. 6othrop" A% (9CCC)% 6a satisfacciXn de los usuarios de atenciXn primaria de
salud en dos modelos de gestiXn aplicados por la ++SS? 0he satisfaction of
the users in primary health care in t1o models of attention applied in the
++SS% >evista MIdica de Costa >ica CentroamIrica( $$(:>@)" ;C2@:%
131. 6ough" &%A% (9CCC)% An academic2community partnership3 a model of
service and education% =ournal o Community Health Nursin#( 1$;3<( 98@2>C%
132. 6ove" &%#%" 4ardner" 7%" O 6egion" <%(9CC@)% +ommunity health 1or.ers3
1ho they are and 1hat they do% Health 'ducation O #ehavior" 2>(>)" :90222%
133. 6uep.er" /%<% (9CC>)% +ommunity trials% Preventive Medicine( 23;5<( ;022:%
134. &ac.ie" $%% O Oic.le P% (9CC:)% School2*ased health promotion3 the
physician as advocate% CM'=( 15$;@<( 98092:%
135. &alo" D%" +ote" S%" 4iguere" <%" O OP/eilly" 6% (9CCA)% 0he &c4ill model and
local community service centers% A fetching com*ination% 8n9rmiere du
Guebec( $;2<( 2A28:%
136. &arion" 6% )% (9CCA) Primary +are% ,n $% (itzpatric. ('d)% 'ncyclopedia of
)ursing /esearch% )e1 =or.3 Springer" >::2>:@%
13. &ar.s" #%A% (2000)% .5,eriences o Peo,le *ith Disabilities in .vanston(
8llinois% &onograph% Sycamore" ,63 #arna*y" ,nc%
13!. &c#eath" %H% (9CC9)% Health for all3 a pu*lic health vision% 'merican
=ournal o Public Health( 11;12<( 9:;02:%
13". &c+lo1ry" S%4%" 4alehouse" P%" Hartnagle" %" 7aufman" H%" $ust" #%" &oed"
/%" O Patterson2Dehn" +% (9CC;)% A comprehensive school2*ased clinic3
-niversity and community partnership% =ournal o the Society o Pediatric
Nurses( 1;1<( 9C22;%
14#. &c'lmurry" #%$% (9CCC)% ,ntroduction to primary health care in ur*an
communities% ,n #%$% &c'lmurry" +% 0ys.a" /% S% Par.er ('ds%) Primary Health
+are in -r*an +ommunities% $ones and #artlett Pu*lishers" #oston%
&&
141. &c'lmurry" #%$% O #rum*augh27eeney" 4% (9CCA)% Primary Health +are% ,n $%
(itzpatric. ('d%) 'ncyclopedia of )ursing /esearch% )e1 =or.3 Springer" >:@2
>:A%
142. &c'lmurry" #%$%" S1ider" S%&%" 4rimes" &%$" Dan" A%$%" ,rvin" =%S%" O 6ourenco"
S%<% (9CA@)% Health advocacy for young" lo12income" inner2city 1omen%
'dvances in Nursin# Sciences" C(>)" ;22@:%
143. &c'lmurry" #%$%" S1ider" S%&" O )orr" 7% (9CC9)% A community2 *ased
primary health care program for integration of research" practice" and
education% N3N Publication( 15-23@1( @@2C0%
144. &c'lmurry" #%$%" 0ys.a" +%O Par.er" /%S% (9CCC) Primary Health +are in
-r*an +ommunities% $ones and #artlett Pu*lisher" #oston%
145. &c7inlay" $%#% (9CC8)% 0he promotion of health through planned
sociopolitical change3 challenges for research and policy% Social Science A
Medicine. 3$;2<( 90C29@%
146. &c7night" $% (9CC:)% 0he +areless society3 +ommunities and its
counterfeits% )e1 =or.3 #asic #oo.s%
14. &c7inlay" $%#% (9CC2)% Health promotion through healthy pu*lic policy3 the
contri*ution of complementary research methods% Canadian =ournal o Public
Health. >evue Canadienne de Sante Publi0ue( 13 Su,,l 1( S992C%
14!. &endoza" (%S%" O (uentes2AUic." '% (9CCC)% 6atino childrenPs health and
the family2community health promotion model% %estern =ournal o Medicine(
1?B;2<( A:2C2%
14". &essias" D%7%" Hall" $%&%" O &eleis" A%,% (9CC;)% <oices of impoverished
#razilian 1omen3 health implications of roles and resources% %omen A
Health( 2+;1<( 9220%
15#. &iller" D%/%" 4eller" A%+%" ood" &%+%" 6e1" /%A%" O 7oh" H%7% (9CCC)% 0he
(almouth Safe S.in ProHect3 evaluation of a community program to promote
sun protection in youth% Health .ducation A !ehavior( 2$;3<( 8;C2A>%
151. &ora" $%O% O )estel" P%S% (2000)% ,mproving prenatal nutrition in developing
countries3 strategies" prospects" and challenges. 'merican =ournal o Clinical
Nutrition( ?1;5 Su,,l<( 98:8S2;8S%
152. &ullen" P%D%" 'vans" D%" (orster" $%" 4ottlie*" )%H%" 7reuter" &%" &oon" /%"
OP/our.e" 0%" O Strecher" <%$% (9CC:)% Settings as an important dimension in
health education?promotion policy" programs" and research% Health .ducation
Guarterly( 22;3<( 82C2>:%
153. )^Hera" /%&% O P_rez" &%&%y +%S% (9CCC)% 6a interdisciplina" un proceso vital
para el desarrollo de la enfermerZa% )ursing in the Americas% )o% :@9%
OrganizaciXn Panamericana de la Salud3 ashington" D%+%
154. )avarro" A%&%" Senn" 7%6%" 7aplan" /%&%" &c)icholas" 6%" +ampo" &%+%" O
/oppe" #% (9CC:)% Por 6a <ida intervention model for cancer prevention in
6atinas% =ournal o the National Cancer 8nstitute( Mono#ra,hs( ;11<( 98@2>:%
&'
REFERENCES
155. )avarro" A%&%" Senn" 7%6%" &c)icholas" 6%$%" 7aplan" /%&%" /oppe" #%"
O+ampo" &%+% (9CCA)% Por 6a <ida model intervention enhances use of cancer
screening tests among
156. )ay" /% (9CC@)% 0he ;0 and #etter Program3 a primary health care program
for the aged% Contem,orary Nurse( $;1<( A29>%
15. )igenda" 4%" 6oc.ett" 6%" &anca" &%" O /odriguez" #% (9CC@)% &odelos
complementarios de atenciXn3 un componente eFcluido en la reforma de los
sistemas de salud ? +omplementary health care models3 a neglected
component in the health care systems reform% >evista Medica de Chile(
125(99)" 98CC29>0>%
15!. )orth" )% (9CC9)% Primary care services% ,n search of alternative 1ays of
providing services that are aDorda*le" accessi*le and appropriate% A revie1
of recent literature% Nursin# Pra5is in Ne* Lealand( $;3<( 992A%
15". Oc.ene" ,%S%" He*ert" $%/%" Oc.ene" $%7%" &erriam" P%A%" Hurley" 0%4%" O
Saperia" 4%&% (9CC;)% 'Dect of training and a structured oIce practice on
physician2delivered nutrition counseling3 the orcester2Area 0rial for
+ounseling in Hyperlipidemia (A0+H)% 'merican =ournal o Preventive
Medicine( 12;+<( 2:22A%
16#. OeFmann" &%$%" 0homas" $%+%" 0aylor" 7%#%" OP)eil" P%&%" 4arvey" %0%"
6ac.land" D%0%" O 'gan" #%&% (2000)% Short2term impact of a church2*ased
approach to lifestyle change on cardiovascular ris. in African Americans%
.thnicity A Disease( 1B;1<( 9@228%
161. O.asha" A% (9CC:)% Settings for learning3 the community *eyond% Medical
.ducation( 2@ Su,,l 1" 9922:%
162. O.1uma*ua" $%O%" &artin" #%" +layton2Davis" $%" O Pearson" +%&% (9CC@)%
Stro.e #elt initiative3 the 0ennessee eFperience% =ournal o Health Care or
the Poor A 7nderserved( 1;3<( 2C22C%
163. Olden" P%+%" O +lement" D%4% (2000)% 0he prevalence of hospital health
promotion and disease prevention services3 good ne1s" *ad ne1s" and policy
implications% Milban" Guarterly. ?1;1<( 99:2>;" iii2iv%
164. Oliva" 4%" /ien.s" $%" O &cDermid" &% (9CCC)% hat high2ris. 1omen are
telling us a*out access to primary and reproductive health care and H,<
prevention services% '8DS .ducation A Prevention( 11;$<( :9822>%
165. Oliver &% (9CCA)% 0heories in health care and research3 0heories of
disa*ility in health practice and research% !M=( 31?( 9>>;2C%
166. Olvera" /%" /odriguez" S%" Perez" 6%" 'i*enschutz" +%" O <illal*a" $% (2000)%
Salud comunitaria en los Altos de +hiapas" &_Fico ? +ommunity health at the
Altos of +hiapas" &eFico% >ev. 8nst. Nac. .nermedades >es,iratorias( 13(9)"
2A289%
16. Pac." A%/% (9CCA)% Dental services and needs in developing countries%
8nternational Dental =ournal( +1;3 Su,,l 1<( 28C2>@%
&(
16!. Paier" 4%S%" O #o1dish" $%/% (9CC:)% Primary care for healthy aging%
'dvanced Practice Nursin# Guarterly( 1;3<( ;:2@8%
16". Pan American Health Organization% (2000)% 0o*acco in the Americas%
.,idemiolo#ical !ulletin( 21;+<(
http3??111%paho%org?'nglish?HPP?HP&?0OH?1ntd2factsheet9%htm%
1#. Pan American Health Organization% (9CCC)% Pan American Sanitary #ureau%
Strategic and Programmatic Orientations" 9CCCG2002% Document ` 2C9%
/etrieved from the orld ide e* at
http3??111%paho%org?english?spoCCaeng%htm`health:%
11. Pan American Health Organization% (9CCA)% Health in the Americas%
<olume 9% ashington" D%+%
12. Pan American Sanitary #ureau" Pan American Health Organization
Strategic and Programmatic Orientations" 9CCCG2002%
13. Pan American Health Organization% Health situation in the Americas3 #asic
indicators 9CC:29CCA% /etrieved from the orld ide e* at
http3??111%paho%org?'nglish?SHA? *sindcvr%htm%
14. Pan American Health Organization% (2000)% 0o*acco in the Americas%
'pidemiological #ulletin" 29(>)" -/6
http3??111%paho%org?'nglish?HPP?HP&?0OH?1ntd2factsheet9%htm%
15. Par.er" '%A%" Schulz" A%$%" ,srael" #%A% O Hollis" /% (9CCA)% DetroitPs 'ast Side
<illage Health or.er Partnership3 community2*ased lay health advisor
intervention in an ur*an area% Health .ducation A !ehavior( 25;1<( 2>2>:%
16. Par.in" P%+%" Hu" b%" Spence" 6%$%" 7ranz" 7%'%" Shortt" 6%4%" O esson" D%'%
(9CC:)% 'valuation of a su*sidy program to increase *icycle helmet use *y
children of lo12income families% Pediatrics( @$;2 Pt 1<( 2A82@%
1. Parrish" /%S%" O Allred" /%H% (9CC:)% 0heories and trends in occupational
health nursing3 prevention and social change% ''DHN =ournal( +3;1B<( :9>2
29%
1!. Parsons, &%6% (9CCC)% Health promoting organizations3 a systems model for
advanced practice% Holistic Nursin# Practice( 13;+<(A02C%
1". Perez" '%" Oliver2<asJuez" &%" Andino" /%" O <ega" /% (9CCC)% +ondiciones de
salud y limitaciones funcionales en la po*laciXn de edad% Puerto >ico Health
Scienti9c =ournal( 11(>)" 8@@28A;%
1!#. Perry" #" O 4esler" % (2000)% Physical access to primary health care in
Andean #olivia% Social Science and Medicine( 5B;@<( 99@@2AA%
1!1. Peru" &% d% S% d% (9CC;)% Promotores de salud en acciJn & Health ,romoters
in action% 6ima" Peru3 &inisterio de Salud del Peru%
1!2. Peters" /%&% (9CCA)% 0he negative eDect of the clinical model of chealthc3
implications for health care policy% =ournal o Health Care /inance( 25;1<( @A2
C2%
&)
REFERENCES
1!3. Pham" 0%&%" /osenthal" &%P%" O Diamond" $%$% (9CCC)% Hypertension"
cardiovascular disease" and health care dilemmas in the Philadelphia
<ietnamese community% /amily Medicine( 31;@<( ;>@2:9%
1!4. Pomrehn" P%/%" Davis" &%<%" +hen" D%%" O #ar.er" % (2000)% Prevention for
the 29st century3 Setting the conteFt through undergraduate medical
education% 'cademic Medicine( ?5;? Su,,l<( S:298" 2000
1!5. Puentes2&ar.ides" +% (9CC2)% omen and access to health care% Social
Science and Medicine( 35;+<( ;9C22;%
1!6. /eger" #%" ootan" &%4%" O #ooth2#utterEeld" S% (2000)% A comparison of
diDerent approaches to promote community21ide dietary change/ 'merican
=ournal o Preventive Medicine( 11;+<( 2@92:%
1!. /esnic." #% (2000)% Health promotion practices of the older adult/ Public
Health Nursin#( 1?;3<( 9;02A%
1!!. /esnic." #% (9CCA)% Health promotion practices of the old2old% $ournal of
the American Academy of )urse Practitioners" 90(>)" 9>@2:8%
1!". /immer" $%H% (9CCC)% Health promotion for people 1ith disa*ilities3 the
emerging paradigm shift from disa*ility prevention to prevention of
secondary conditions% Physical Ehera,y( ?@;5<( >C:2:02%
1"#. /o*inson" S%A%" O 6arsen" D%'% (9CC0)% 0he relative inBuence of the
community and the health system on 1or. performance3 a case study of
community health 1or.ers in +olom*ia% Social Science A Medicine( 3B;1B<(
90>92A%
1"1. /odney" &%" +lasen" +%" 4oldman" 4%" &ar.ert" /%" O Deane" D% (9CCA)%
0hree evaluation methods of a community health advocate program% =ournal
o Community Health" 28(:)" 8@92A9%
1"2. /ouzier" P%A% (9CC:)% 0he primary care physician as a sports medicine and
eFercise advocate and activist% Primary Care6 Clinics in DMce Practice( 22;+<(
@A:2A0>%
1"3. /ue*ush" 0%7%" Yeissig" /%" 7oplan" $%P%" 7lein" /%'%" O 4odoy" H%A% (9CC>)%
+ommunity participation in malaria surveillance and treatment% ,,,% An
evaluation of modiEcations in the <olunteer +olla*orator )et1or. of
4uatemala% 'merican =ournal o Ero,ical Medicine A Hy#iene( 5B;1<( A:2CA%
1"4. Sanders" '%+% 2
nd
% (9CC@)% )e1 insights and interventions3 churches
uniting to reach the African American community 1ith health information%
$ournal of Health +are for the Poor O -nderserved" A(8)" 8@82;%
1"5. Santelli" $%S%" Di+lemente" /%$%" &iller" 7%S%" O 7ir*y" D% (9CCC)% SeFually
transmitted diseases" unintended pregnancy" and adolescent health
promotion% 'dolescent Medicine( 1B;1<( A@290A" vi%
1"6. Schen.er" &%#% (9CC;)% Preventive medicine and health promotion are
overdue in the agricultural 1or.place% =ournal o Public Health Policy( 1?;3<(
2@:280:%
&*
1". Schorr" 6% (9CC@)% Common ,ur,ose- stren#thenin# amilies and
Nei#hborhoods to rebuilt 'merica% )e1 =or.3 Anchor #oo.s%
1"!. Schulz" A%$%" ,srael" #%A%" #ec.er" A%#%" O Hollis" /%&% (9CC@)% M,tPs a 2>2hour
thing %%% a living2for2each2other conceptN3 identity" net1or.s" and community
in an ur*an village health 1or.er proHect% Health .ducation and !ehavior(
2+;+<( >;:2A0%
1"". Selden" +%/% O iederhorn" )% (9CC8)% +ommunity2#ased Health +are
&odels3 $anuary 9CA@ through August 9CC8% -%S% Department of Health and
Human Services" Pu*lic Health Service" )ational ,nstitutes of Health% -/63
http3??111%nlm%nih%gov?pu*s?c*m? c*models%html%
2##. Seravalle" 6%" O #oo." &% (9CC;)% ,ntroducao a discussao so*re o ensino de
practicas alternativas em saude?An introduction to discussing the teaching of
alternative practices in health% Saude em Debate (:9)" A22 AA%
2#1. Shortell" S%&%" 4illies" /%/%" O Devers" 7%$% (9CC:)% /einventing the
American hospital% Milban" Guarterly( ?3;2<( 9892;0%
2#2. Shuler" P%A%" O Hue*scher" /% (9CCA)% +larifying nurse practitionersP uniJue
contri*utions3 application of the Shuler )urse Practitioner Practice &odel%
$ournal of the American Academy of )urse Practitioners" 90(99)" >C92C%
2#3. Silva" $%" O 4omes" A% (9CCA)% &odelos tecnoasssistenciais em saude3 o
de*ate no campo da Saude +olectiva ? Health care models3 the discussion in
the Eeld of community health% Sao Paulo3 Hucitec%
2#4. Simpson" &%/%" O 7ing" &%4% (9CCC)% M4od *rought all these churches
togetherN3 issues in developing religion2health partnerships in an
Appalachian community% Pu*lic Health )ursing" 9;(9)" >92C%
2#5. So*sy" D% (2000)% (aces of violence against 1omen 1ith developmental
disa*ilities% ,mpact" 98(8)" 228" 2:
2#6. Solla" $%" &edina" &%" O Dantas" &% (9CC;)% O PA+S in #ahia3 avaliacao do
tra*alho dos agentes comunitarios de saude ? 0he PA+S in #ahia3 evaluation
of the 1or. of community healthPs agents% Saude em Debate(:9)" >29:%
2#. Solorzano &oguel" $%$%" O Alvarez +uevas" &%'%" (9CC9)% +are of tu*erculosis
patients at the community level in the state of +hiapas" &eFico% #oletin de la
OEcina Sanitaria Panamericana" 999(:)" >822A%
2#!. Sperandio" A%&% (9CCC)% 'ye health promotion and early visual pro*lem
detection in the pu*lic health services% /evista de Saude Pu*lica" 88(:)" :982
20%
2#". Steven" &%+% (9CC0)% Strategies to inBuence nutrition *ehaviour% )utrition
O Health" ;(>)" 9AC220>%
21#. Ste1art" &%$% (9CC0)% Access to health care for economically
disadvantaged +anadians3 a model% +anadian $ournal of Pu*lic Health% /evue
+anadienne de Sante Pu*liJue" A9(;)" >:02:%
'+
REFERENCES
211. Ste1art" P%$%" O )imrod" +% (9CC8)% 0he need for a community21ide
approach to promote healthy *a*ies and prevent lo1 *irth 1eight% +anadian
&edical Association $ournal" 9>C(8)" 2A92:%
212. Stoc.ins" #%" O PantoHa" &% (9CC@)% (acultad de &edicina de la -niversidad
de la (rontera ? 0he -niversidad de la (rontera School of &edicina% >evista
MIdica de Chile( 125(@)" A9A2A22%
213. Sto.ols" D%" Pelletier" 7%/%" O (ielding" $%'% (9CC;)% 0he ecology of 1or. and
health3 /esearch and policy directions for the promotion of employee health%
Health .ducation Guarterly( 23;2<( 98@2:A%
214. Stone" '%" O Priestley" &% (9CC;)% Parasites" pa1ns and partners3 disa*ility
research and the role of non2disa*led researchers% #ritish $ournal of
Sociology" >@(>)" ;CC2@9;%
215. Strau*" H%" +ross" $%" +urtis" S%" ,verson" S%" $aco*smeyer" &%" Anderson" +%"
Sorenson" &% (9CCA% Proactive nursing3 the evolution of a tas. force to help
1omen 1ith postpartum depression% American $ournal of &aternal +hild
)ursing" 28(:)" 2;22:%
216. StreHa" D%A%" O /a*.in" S%% (9CCC)% Section of 'ndocrinology of 4reater
6os Angeles% (actors associated 1ith implementation of preventive care
measures in patients 1ith dia*etes mellitus% Archives of ,nternal &edicine"
9:C(8)" 2C>2802%
21. S1enson" &%&% (9CC2)% Primary health care of elderly 1omen% $ournal of
the American Academy of )urse Practitioners" >(>)" 9>82@%
21!. 0arlov" A%/% (9CCC)% Pu*lic policy frame1or.s for improving population
health% Annals of the )e1 =or. Academy of Sciences" AC;" 2A92C8%
21". 0aylor" S%&%" 'lliott" S%" O /iley #% (9CCA)% Heart health promotion3
predisposition" capacity and implementation in Ontario Pu*lic Health -nits"
9CC>2C;% +anadian $ournal of Pu*lic Health% /evue +anadienne de Sante
Pu*liJue" AC(;)" >902>
22#. 0essaro" ,% (9CC@)% 0he natural helping role of nurses in promoting healthy
*ehaviors in communities% 'dvanced Practice Nursin# Guarterly( 2;+<( @82A%
221. 0homas" S%#%" [uinn" S%+%" #illingsley" A%" O +ald1ell" +% (9CC>)% 0he
characteristics of northern *lac. churches 1ith community health outreach
programs% 'merican =ournal o Public Health( 1+;+<( :@:2C%
222. 0illinghast" S%$%" O 0chernHavs.ii" <%'% (9CC;)% #uilding health promotion into
health care reform in /ussia% =ournal o Public Health Medicine( 11;+<( >@82@%
223. 0omas Sancho" A%" 7ennedy" 6%" O +olomer /evuelta" +% (9CCA)%
<olunteerism and the reorientation of health services% 'tenciJn Primaria(
22;?<( >:02;%
224. -singer26esJuereuF" $% (9CC>)% +ommunity2*ased nutrition education%
=ournal o Nutrition( 12+;@ Su,,l<( 9A20S29A22S%
'"
225. <alois" /%(%" O Hoyle" 0%#% (2000)% (ormative evaluation results from the
&ariner ProHect3 a coordinated school health pilot program% =ournal o School
Health( ?B;3<( C:2908%
226. <an Dam" +%$%" O Holmes" 7%7% (2000)% S0D prevention3 eDectively reaching
the core and a *ridge population 1ith a four2component intervention%
Se5ually Eransmitted Diseases( 2?;1<( C299%
22. <an 6oon A% (9CCA)% 0he development of faith community nursing
programs as a response to changing Australian health policy% Health
.ducation A !ehavior( 25;$<( @C02C%
22!. <el^sJuez" /% (9CC8)% Ca,acitando sin letras. Manual de ca,acitaciJn ,ara
instructores de ,lani9caciJn amiliar( en Nreas rurales & Erainin# *ithout
letters. Manual o trainnin# or amily ,lanin# instructors( in rural areas.
4uatemala3 AP/O(A&%
22". <illa" 0%+%" Assis" &%&%" &ishima" S%&%" Pereira" &%$%" de Almeida" &%+%"
Palha" P%(% O Pinto" ,%+% (9CCC)% )ursing and the health system in #razil% ,mage
2 the $ournal of )ursing Scholarship" 89(>)" 8CC2>09%
23#. al.er" P%H%" #a.er" $%$%" O +hiverton P% (9CCA)% +osts of interdisciplinary
practice in a school2*ased health center% Dutcomes Mana#ement or Nursin#
Practice( 2;1<( 8@2>>%
231. allac." 6% (9CCC)% 0he +alifornia <iolence Prevention ,nitiative3 advancing
policy to *an Saturday night specials% Health .ducation A !ehavior( 2$;$<(
A>92:A%
232. alsh" $%&% O &cPhee" S%$% (9CC2)% A systems model of clinical preventive
care3 an analysis of factors inBuencing patient and physician% Health
.ducation Guarterly( 1@;2<( 9:@2@:%
233. assel" &%6% (9CC:)% Occupational health nursing and the advent of
managed care3 meeting the challenges of the current health care
environment% ''DHN =ournal( +3;1<( 282A%
234. eis" D%" &atheus" /%" O Schan." &%$% (9CC@)% Health care delivery in faith
communities3 the parish nurse model% Public Health Nursin#( 1+;$<( 8;A2@2%
235. erner" D% (9CC>)% Dnde nao medico & %here do not have a ,hysicians
( 9: ed%)% Sao Paulo" #razil3 Paulus%
236. esson" D%" Spence" 6%" Hu" b%" O Par.in" P% (2000)% 0rends in *icycling2
related head inHuries in children after implementation of a community2*ased
*i.e helmet campaign% =ournal o Pediatric Sur#ery( 35;5<( ;AA2C%
23. illis" '% (2000)% School2*ased?school2lin.ed health centers eFpanding
points of access% %M=. @@;1<( >>2@%
23!. ilson20homas" 6% (9CC:)% Applying critical social theory in nursing
education to *ridge the gap *et1een theory" research and practice% =ournal
o 'dvanced Nursin#( 21;3<" :;A2:@:%
'#
REFERENCES
23". HO% ($anuary 2>" 2000)% M0o1ards a strategic agenda for the HO
SecretariatN Statement *y the DirectorL4eneral to the 'Fecutive #oard at its
90:
th
session%
24#. HO% (9C@A)% Declaration of Alma2Ata3 ,nternational +onference on
Primary Health +are" Alma2Ata" -SS/" ;292 Septem*er 9C@A% /etrieved on
the orld ide e* at http3??111%1ho%d.?policy?almaata%htm%
241. orld Health Organization (HO) and the orld Organization of (amily
Doctors (O)+A)% Ma"in# Medical Practice and .ducation More >elevant to
Peo,leOs Needs- the Contribution o the /amily Doctor% (rom the Hoint HO2
O)+A +onference in Ontario" +anada" ;2A )ovem*er" 9CC>%
242. orld Health Organization% (9CAA)% Health ,romotion or *or"in#
,o,ulations- >e,ort o a %HD .5,ert Committee (4eneva3 0echnical /eport
Series @;:)%
243. right" /%A% (9CC8)% +ommunity2Oriented Primary +are3 0he +ornerstone
of Health +are /eform% ='M'( 2$@;1@<( 2:>>22:>@%
'$
ANNEXES
ANNEX A: THE AMERICAS 9 37 COUNTRIES AND TERRITORIES
)orth America3 #ermuda" +anada and the -nited States of America
6atin America3 the Andean /egion" #razil" +entral America" the 6atin
+ari**ean" &eFico and the Southern +one%
+entral America3 #elize" +osta /ica" 'l Salvador" 4uatemala" Honduras"
)icaragua and Panama%
6atin +ari**ean3 +u*a" Dominican /epu*lic" Haiti and Puerto /ico%
Andean /egion3 #olivia" +olom*ia" 'cuador" Peru and <enezuela%
Southern +one3 Argentina" +hile" Paraguay and -ruguay%
)on26atin +ari**ean3 Anguilla" Antigua and #ar*uda" Aru*a" #ahamas"
#ar*ados" +ayman ,slands" 0ur.s and +aicos ,slands" <irgin ,slands (-7) "
<irgin ,slands (-SA)" Dominica" (rench 4uyana" 4renada" 4uadaloupe"
4uyana" $amaica" &artiniJue" &onserrat" )etherland Antilles" Saint 7itts and
)evis" Santa 6ucia" San <incent O the 4renadines" Surinam" 0rinidad and
0o*ago%
"
ANNEX .: PAHO STRATEGIC AND PROGRAM ORIENTATIONS, 08889
1::1
According to PAHOKs (9CCC) Strategic and Programmatic Orientations" 9CCCG
2002" a ne1 culture of health promotion and protection must *e Hointly created
1ith the countries% As health *ecomes a social value" individuals and
communities" as 1ell as pu*lic" non2governmental" and private institutions 1ill
*e trained to assume responsi*ilities for preserving and continually improving
their health and 1ell*eing% Additionally" PAHO (9CCC) recommends that
technical cooperation *e provided to address the follo1ing3
Ac.no1ledge the role of health promotion as a tool for empo1erment5
Promote the formulation of policies" plans" programs" standards" and tools for
health promotion5
Support cooperative and operations research through the net1or. of HO
designated +olla*orating +enters in the /egions of the Americas5
Design and strengthen methodologies and models for the evaluation of
health promotion programs and interventions5
Develop environmental initiatives or healthy spaces in schools and
municipalities5
+onsolidate net1or.s of mayors" pu*lic health oIcials" and school health
associations5
Develop intersect oral 1or. strategies5
&o*ilize technical" scientiEc" political" and Enancial resources in support of
health promotion5
Develop technical" political" and social support net1or.s at all levels"
including strategic alliances *et1een the Pan American Health Organization
and *oth the international community and the relevant organizations in the
countries5 and"
Promote the use of social communication in health" especially through the
mass media%
#
ANNEX C: PRIMARY HEALTH CARE IN .RA;IL
THE SANITARY REFORM IN .RA;IL
,n #razil" the sanitary reform process started in the mid 9C@0s% After the
political opening and in a period 1hen the transition to democracy had
advanced" the M#razilian Sanitary &ovementN started to Ell important positions
in institutional health apparatuses in federal" state and municipal levels% 0he
reforming proHect 1as supported *y *road criticism of the prevalent model"
*ased on the gro1th of the private sector at the eFpense of the pu*lic sector
(the former *eing Enanced *y the latter)" 1hich led to the *an.ruptcy"
deterioration" ineIciency and crisis in the pu*lic health system% 0he Sanitary
/eform ProHect 1as *ased on a conception of enlarged health care" 1hich 1as
related to general life conditions" such as housing" sanitation" diet" 1or.
conditions" education and leisure% ,n this sense" health care is deEned as a
citizenPs right and" conseJuently" a StatePs o*ligation" that is" health care
reaches *eyond the treatment of diseases and is also eFtended to prevention
and to the improvement of life conditions that generate illness% 0hus" the
proposed health care policies 1ere3 the creation of a -niEed Health +are
System" S-S" 1ith the remar.a*le predominance of the pu*lic sector" the
systemPs decentralization and the hierarchization of the health care units" the
populationPs participation and control in the reorganization of services and"
Enally" the sectorPs Enancial readaptation%
,n 9CAA" the universal right to health care and the creation of a
decentralized" accessi*le and democratic -niEed Health +are System 1ere
included in the #razilian +onstitution% Since then" and more actively in the
9CC0s" many eDorts have *een made throughout the country in order to
conform to the ne1 health care system%
Methodolo"y
0he revie1ed literature dated 9CC0 to 2009% ,t 1as in Portuguese and 1as
o*tained from the 6,6A+S data*ase% 0he search strategy used the follo1ing .ey
1ords3 model b health b clinical% One hundred and eighty2seven articles 1ere
o*tained" of 1hich :0 1ere disconsidered due to the follo1ing reasons3
repetitions" a*sence of a*stracts" a*stracts in Spanish" and no reference to the
health care model eFisting in #razil% ,n this 1ay" the sample consists in 98@
a*stracts and through their repeated reading" there 1as an attempt to ans1er
the follo1ing Juestions3
hat health care models and levels of health care service provision are
availa*le to the populationT
9% hat are the types of health care service provisionT
2% ho are the health providersT
8% here are the services locatedT
$
>% hat are the health programsT
:% hat are the main interests and health care2related Juestions found in
literatureT
;% hat are the challenges and implications associated 1ith health care
models in #razilT
@% Ho1 can such models *e used *y professionals and researchersT
1esults
Health care models and provision levels% Discussions in literature (chart 9)
focus on themes related to the countryPs sanitary reform as an alternative
political proHect to the privatization2inclined care model 1hich" along its course"
has follo1ed a decentralization strategy that esta*lishes the creation of regional
health care centers and integral health care actions (2" 9:" 22" 2>" ;:" @2" @@"
A@" AA" C8" C;" C@" 90:" 92>)%
A lot of criticism of the process of change in the care model is made 1hen it
is o*served that the individual and curative medical model is maintained" since
the principles on 1hich the ne1 proposal is *ased have not *een concretized in
practice (A" 92" C@" CC" 99C)%
0ypes of health care services provision% 8n addition to medical care in
accordance *ith the various s,ecialties o4ered to the ,o,ulation( the ty,es o
health care services ,rovision are as ollo*s- ;chart 2<-
)ursing care to pregnant 1omen" school2age children" in intensive care units"
*reastfeeding" family planning" dia*etic patients" the elderly" 1or.ers" in
emergencies" etc% (;" 20" 8@" 8A" >8" ::" ;2" ;@" C0" 90;" 90C" 990)
-ser em*racement as a care strategy in health care services" (2C)%
Psychological care *y psychologists (in hospitals" pu*lic health services)
(2C" C2)%
+are to adolescents (>;)
Dental care (>C" A2" C9" 989)
Health education (especially for street *oys and girls) (9C)
Oral Health (98)
2 Hospital emergency care (2;)
2 )on2alophatic practices (929)
%
ANNE$ C: PRIMARY HEALTH CARE IN BRA%IL
C'ar 0
The various models and levels of services References
,ndividual and curative medical model
The health care system in the city of -anaus has been characterized as essential, clinical, individual and curative since
the occupation of the Amazon .orest ())
.amily Health Program (#)
The principles of the /nified Health 0are 1ystem (1/1) have not been concretized in the clinical practice ("#)
2ecentralization and administrative reform are fundamental elements for the characterization of the ne care model3 The
/nified Health 0are 1ystem (1/1) (#%, (#, *(),
2ecentralized information system to accelerate outpatient care ((()
4egionalization model ()))
The effective implementation of 1/1 must not be restricted to measures of a 5udicial, administrative or institutional
nature (**)
Proposal for the characterization of the health care services netor6 (""*)
The area7s general characterization and sanitary profile in order to propose the implementation of the ne care model ($)
Presentation of instruments and of a legal basis for the municipalization of 1/1 ("&)
2escription8discussion on the care model (##, '&, )(, "+&, "#%)
Points out the importance of the health surveillance process and the fulfillment of the population7s care needs in order to
legitimize the change in the care model (*')
The analysis beteen concepts and practices from past decades ith the organization of the /nified Health 0are 1ystem
forecasts improvements in health care (*$)
Organization process of municipal8state conferences as a preparation phase for the 9ational Health 0onference ("#%)
4eport on the or6shops on health policies ("$&)
0oncept of :municipalization;districtalization: in the light of the te!ts by the Pan;American Health Organization based
on the strategy for the development of local health care systems ("$%)
The sanitary reform proposed through a care model centered on :organized provision: enables the recovery of the
epidemiological focus for the control of health problems and imposes a constant updating of technical and scientific
advancements ()')
Proposes the use of the ris6 focus in the planning and programming of health care actions (*&)
#, $, ), "#, "&,
##, #%, '&, (#,
((, )', )(, )),
*$, *&, *', *(,
**, "+&, ""*,
"#$, "#%, "$%,
"$&
&
C'ar 1
Types of service provision References
9ursing care to pregnant omen ('")
9ursing care to school;age children ($))
9ursing care in ,ntensive 0are /nits (#+, '()
9ursing care during breastfeeding (*+)
9ursing based on the medical model
9on;allopathic practices ("#")
/ser embracement as a care strategy favors accessibility to health services (%()
0linical psychological care in public health care services (#*)
2ental care (%*, )#, *", "$")
Health education for street boys and girls ("*)
9ursing care to diabetic patients in the public and private netor6s; self;care promotion (%$)
Oral health3 re<uires more global actions in order to overcome the idea that it is a lu!ury article hich is restricted to
private institutions ("$)
9ursing model3 application of 4oy7s Theory (&&)
9ursing care model for the elderly centered on =ing7s -odel ("+*)
9ursing care in the perspective of >iliana .elcher 2aniel, the attempt to systematize care to pregnant omen ('#)
Proposes the use of the ris6 focus in the planning and programming of health care actions (*&)
9ursing care model in ,0/ aiming at care humanization and at the participation of the involved actors in the hole
process of caring ('()
0linical and hospital psychology service (*#)
9ursing care in or6er7s health ($()
Hospital emergency services (#')
9ursing care in the perspective of 2orothy ?ohnson (#+)
9ursing care in emergencies3 the construction of a theoretical mar6 ("+')
A small number of assisted adolescents is observed and their care is directed to curative and individual assistance (%')
There is a disagreement beteen the theoretical assumptions concerning the ne care model and hat actually ta6es
place in everyday practice, since in the concrete aspects of health care services, nursing actions are subordinate to the
biomedical model, hich is centered on the client7s complaints, thus privileging medical and clinical actions, reinforcing
emergency care and not detecting significant changes ith regard to the integrality of health care actions (*+)
0onstruction of a theoretical model to help in the systematization of nursing actions in health education for family
"$, "*, #+, #',
#*, $(, $), $*,
%$, %', %(, %*,
&&, '", '#, '(,
)#, )), *+, *",
*#, *&, **, "+',
"+*, ""+, "#",
"$"
'
planning programs (""+)
(
Health care providers / /egarding the types of health care providers" various
1or.s analyzed the role of diDerent health care agents" such as3 doctors" nurses
(20" 8A" 8C" >8" ::" ;9" ;2" ;@" @0" 90C" 990)" dentists (989)" psychologists (C2)
and community agents%
+oncerning community agents" the articles point out the need for a more
active" and conscious participation as 1ell as a critical vie1 of their 1or. in their
education% Some studies sho1 that there is a disagreement *et1een the
theoretical assumptions concerning the S-S (-niEed Health +are System) care
model and that 1hich is eDectively found in the everyday care delivered to the
population% 0hey reveal that" in the concretion" of health care services" nursing
actions are su*ordinate to the *iomedical model" 1hich focuses on the clientPs
complaints" thus privileging clinical medical actions and not detecting signiEcant
changes concerning the integrality of health care actions (C0)%
/esearchers have claimed that nurses may have someho1 come to
understand ho1 to deal 1ith clients (especially 1omen)5 ho1ever" the
determinations 1hich are present in their everyday practice have prevented
more concrete actions to1ards the transformation of such practice% (+hart 8)%
6ocation of health care services% ,n addition to hospitals" health care
provision ta.es place in the follo1ing locations3 elementary and high schools"
1or.places" health units" outpatient units" at home" companies and associations%
(+hart >)%
C'ar 2
Care components related to care models
A -Types of providers References
2entist ("$")
Au!iliary personnel in the oral health programs (*")
9urse (#+, $), $*, %$, &&, '", '#, '(, (+, "+*, ""+)
Psychologist (*#)
0ommunity agents
#+, $), $*, %$, &&,
'", '#, '(, (+, *",
*#, "+*, ""+, "$"
C'ar 3
Care Components:
Location of services References
1chools (@lementary and High schools) ("*) (*")
Aor6place (/rban 0leaning 2epartment) ("#+)
Health 0enters ($&)
Outpatient units8 hospitals 8 home (nursing care to the elderly) ("+*)
Hospital8 psychological care (*#)
Outpatient and home care to pregnant omen ('")
0ompanies ($()
Hospital (more comple! care) ('))
Associations (&#)
hospital8 ,ntensive 0are /nit8 nursing care (#+, '()
"*, #+, $&, $(, &#
'", '( '), *", *#,
"+*, "#+
)
Health care programs% Chart 5 ,resents the *or"s that identiy the health
care ,ro#rams o4ered as ollo*s- /amily Health Pro#ram( /amily Plannin#( Dral
Health and Dental Care( Mental Health.
0he (amily Health Program" as a strategy that ma.es the change in the care
model via*le" has *een a focus of controversy for if such model is not shaped
1ithin a large political structure" it 1ill present limitations in its practice and in
the stratiEcation of ,ts clientele (2" 9@" 20" 80" 992)
0he community programs descri*ed in the analyzed literature are those
targeted at indigenous populations (92C)" mentally ill patients and dental care
(A2)%
Among the other programs for the populationPs health care" those aiming at
adolescentsP health (>;" 90>)" oral health (98" A2" 989)" mental health (@" 9@"
998)" school2age childrenPs health (8A) and pre2natal care (;9" ;2) are
distinguished%
&aHor health2related issues and interests% 0he maHor health2related issues
and interests focused on in the analyzed literature" according to +hart ;" are as
follo1s3
access to ris. groups (children" pre2school2 and school2age children)
(CA" 989)
adolescents" especially street *oys and girls (9C)
mental health ? psychiatry (@" C" 99" ;;" 998)
oral health (98)
systematization of )ursing assistance to speciEc groups (2;" 8@" 8A"
;9)%
construction of theoretical models for nursing systematization (20" 89)
alternative practices (929)%
*
C'ar 4
Types of programs References
.amily Health Program (P1.) ( #, "(, $+, "$()
.amily Planning (""+)
Oral Health ("$, *")
2ental Health associated to popular participation ()#)
-ental Health (""$)
#, "$, "(, $+,
)#, *", ""+,
""$, "$(
A- The family References
.amily 2octor Program3 Ahen it is not shaped ithin a large political structure, it presents limitations in its practice and
clientele (""#)
.amily Health Program3 is in danger of becoming isolated by 6eeping its autonomy and not communicating ith the
system ($+)
.amily Health Program3 in spite of consisting in a ne proposal for a care model, it has not been able to change the logic
of the assistance centered on the clinical model. ,ts ay of delivering health care does not incorporate the principles of the
1anitary and Psychiatric 4eform (#+)
The team7s influence on social netor6s is still very modest and the action dynamics is passive and individual ("()
Approaches based on listening, embracement and ties are rarely used, e!cept for health community agents, ho sho
greater continence and concern about people such as those ith mental disorders ("()
The .amily Health Program as a strategy that ill ma6e the change of the 0are -odel in the 1/1 conte!t has been
<uestioned once it can both serve to simplifying tendencies and to the encouragement of changes in order to generate more
effective results in the /nified Health 1ystem ; 1/1 (#)
#, "(, $+ ""#
- Community References
.amily Health Program -odel (mentally ill person)
Health care to the indigenous populations ("#*)
Association develops a structure of community participation (&#)
Aor6 ith street boys and girls and the /niversity ("*)
Popular participation through associations and incorporating dental care ()#)
,n the community participation model, the community is the essential component in the decisions concerning the health
sector and the or6 model in communication by means of multidisciplinary teams (&')
"*, &#, &', )#,
"#*
C- Health care program References
Adolescents7 Health (%', "+%)
Oral Health Preventive Program at 0harity ,nstitutions ("$")
(, "$, "(, $),
%', '", '#, )#,
)$, "+%,
"+
Oral Health ("$)
2ental 0are ()#)
-ental Health Program ((, "(, ""$)
1chool;Age 0hildren Health Program ($))
Pre;natal Program ('", '#)
2isabled People7s Health Program ()$)
@lderly People ith 0hronic 2iseases ("+*)
"+*,""$, "$"
C'ar 5
!nterest and health-related issues References
Alternative practices ("#")
Access to ris6 groups ; pre; school; and school;age children ("$")
2einstitutionalization of psychiatric care ('')
Adolescents (street boys and girls aged "" to "% years) se!uality, drugs, hygiene ("*)
2iabetic people (%$+
Accessibility of children aged & to * years (school;age children7s health) (*))
Problems in the implementation of mental health care policies in the basic netor6 (*)
Access of ris6 groups3 psychiatric patients ("")
The population7s greater access to oral health ("$)
To design a model for the use of the multi;colored media by the 1tate and medical companies in order to enlarge
aareness of the sanitary reform (*%)
The transformation of the care model as an attempt to find a ne logic in the relations in the field of psychiatry ith users
is an important alternative for the improvement of the situation of mental health care (()
@laboration of a theoretical mar6 in order to help in the systematization of nursing care in ,ntensive 0are /nits (#+)
1ystematization of nursing care to school;age children so as to facilitate the planning of nursing actions ($))
0onstruction of a theoretical model for the systematization of nursing care to pregnant omen ('")
0haracterizes the nursing personnel performing in the or6ers7 health field ($()
0haracterize the profile of the demand for hospital emergency services in order to ad5ust to the ne care model (#')
1egregation and pre5udice to psychiatric patients (""$)
,nclusion of disabled people in the health care system ()$)
9ursing or6 in the process of construction of the care model ($")
@" C"
99" 98" 9C"
20" 2;" 89"
8@" >A" >8"
;9" ;;" A8"
C>" CA"
998" 929"
989
""
S-S" as a Primary Health +are strategy" determines the use of other
practices such as the non2allopathic% /esearch (929) aiming at understanding
the culture involving non2allopathic practices in the pu*lic services of #elo
Horizonte?&inas 4erais reveals that non2allopathic professionals eFperience
dilemmas and conBicts during the rites leading from the 1estern medical
practice to their engagement in non2allopathic medicine% 0he data sho1 that the
)on2Allopathic Practice Program has not yet *een esta*lished as a policy in the
eFtent of that cityPs &unicipal Health Secretariat" thus revealing the need for a
more eDective integration of such practices in the pu*lic services in order to
demythicize preHudice and ma.e such practices respected%
+hallenges and implication associated 1ith the health care model% 0he
literature presents a series of diIculties in the implementation of the Primary
Health +are &odel through the -niEed Health +are System 2 S-S2 proposed *y
the #razilian government (+hart @)%
0herefore" studies point out that the construction of S-S has *rought
challenges in the change of the care model" 1hich must *e *ased on the
principle of integrality" that is" a ne1 vie1 of individual and collective health is
reJuired in order to revert the clinical hospital model (2:" >2" >A" :C" @A" 900"
92;" 92A)%
/egarding the challenges" the need for collective adherence to the ne1
model and the professionalsP motivation to change is emphasized (:)%
'nsuring the populationPs access to services" particularly that of ris. groups
such as children" mentally ill people and adolescents" has *een a great
challenge (2A" ;A" A>)%
,n the same 1ay" the emphasis on potential preventive" collective and
educational health promotion actions needs to *e implemented actions (>;)%
0he practice of decentralization of health care services as 1ell as *rea.ing
the dichotomy *et1een the curative b the preventive approaches are long
processes to *e concretized (99>" 99;" 99@)%
Authors have pointed out that the change in the care model 1ill not *e
concretized if it is dislocated from the development of health care professionals"
since such JualiEcation must *e associated 1ith the *asic principles of the
countryPs current health care system%
"#
C'ar 6
"$
Challenges and implications associated "ith care models References
A ne ay of thin6ing and acting in health care resists to governmental changes hen there is the collective adherence and
persistence by technicians (&)
The /niversity7s responsibility to overcome inefficiency and lo <uality in health care services ("$$)
,mprove nurses7 education for the application of the .amily Health Program model ("+)
Public Health schools must define their teaching, research and technical cooperation programs based on the epidemiological and
epistemological conte!ts of the health care services conte!ts (#")
The implications concerning 5ustice, education and care in the nursing professional practice ($')
-edical education is inade<uate for the model (#$)
2ecentralizations is not synonymous to municipalization (""()
,nfluence from actors (physician) in the conformation of the care system3 based on professional autonomy, corporative interests
and conflicts present in micro;institutional environments ((')
@stablishment of directives for medical education according to the sanitary reforms (', ""&)
@nsure various forms of access (#))
9eed to revert the present care model so as to emphasize preventive, collective and educational activities ith greater effectiveness
potential for the health promotion of adolescents (%')
The care model has shon limits in the offer of care services to children (aged #) days to & years old) in more comple! levels ('))
The teaching of mental health nursing is still directed to a predominantly hospital;centered care model ith emphasis on
pharmacotherapy ("#$)
Over time, /niversity hospitals have produced and reproduced a hospital;centered technical care model aimed at the clinical
treatment of individual patients ("+")
Health planning and local programming (Pau de >ima 8 1alvador) have been partly incorporated, but have not been used as a
means of or6 for most managers, hich has shaped a partial implementation of health surveillance ("$')
/nderstanding interdisciplinary in the vie of positivism, hich is predominant in the present mental health care system and
precedes that hich is based on dialectic materialism ith the purpose to change mental health care through the participative
action of all those involved in it (health care or6ers and the population) (""%)
The implementation and development of primary care services have faced various deadloc6s resulting from the difficulty in
changing political principles, represented by those concepts in or6 operation techni<ues ($&).
The construction of 1/1 has shon the need to re;direct health care practice and the formation of human resources including
community agents ()")
Balue health care or6ers ($#)
0hange disease profiles, brea6 the dichotomy beteen curative and preventive actions (""')
@ducation of physicians is based on a specialized profile and on limited 6noledge on the current health care system ($%)
The characteristics of a ne care model re<uires the training and formation of human resources to be associated ith the model7s
%, &, ', "+,
#", #$, #&, #(,
#), $#, $$, $%,
$&, $', %+, %",
%#, %&, %',
%), &(, &*, '%,
'), (+, ($, ('
(), )", )%, .
"++, "+" ,
"+$, ""%, ""&,
""', ""(, "#$,
"#', "#(, "#),
"$+, "$#, "$$,
"$'
"%
Challenges and implications associated "ith care models References
A ne ay of thin6ing and acting in health care resists to governmental changes hen there is the collective adherence and
persistence by technicians (&)
The /niversity7s responsibility to overcome inefficiency and lo <uality in health care services ("$$)
,mprove nurses7 education for the application of the .amily Health Program model ("+)
Public Health schools must define their teaching, research and technical cooperation programs based on the epidemiological and
epistemological conte!ts of the health care services conte!ts (#")
The implications concerning 5ustice, education and care in the nursing professional practice ($')
-edical education is inade<uate for the model (#$)
2ecentralizations is not synonymous to municipalization (""()
,nfluence from actors (physician) in the conformation of the care system3 based on professional autonomy, corporative interests
and conflicts present in micro;institutional environments ((')
@stablishment of directives for medical education according to the sanitary reforms (', ""&)
@nsure various forms of access (#))
9eed to revert the present care model so as to emphasize preventive, collective and educational activities ith greater effectiveness
potential for the health promotion of adolescents (%')
The care model has shon limits in the offer of care services to children (aged #) days to & years old) in more comple! levels ('))
The teaching of mental health nursing is still directed to a predominantly hospital;centered care model ith emphasis on
pharmacotherapy ("#$)
Over time, /niversity hospitals have produced and reproduced a hospital;centered technical care model aimed at the clinical
treatment of individual patients ("+")
Health planning and local programming (Pau de >ima 8 1alvador) have been partly incorporated, but have not been used as a
means of or6 for most managers, hich has shaped a partial implementation of health surveillance ("$')
/nderstanding interdisciplinary in the vie of positivism, hich is predominant in the present mental health care system and
precedes that hich is based on dialectic materialism ith the purpose to change mental health care through the participative
action of all those involved in it (health care or6ers and the population) (""%)
The implementation and development of primary care services have faced various deadloc6s resulting from the difficulty in
changing political principles, represented by those concepts in or6 operation techni<ues ($&).
The construction of 1/1 has shon the need to re;direct health care practice and the formation of human resources including
community agents ()")
Balue health care or6ers ($#)
0hange disease profiles, brea6 the dichotomy beteen curative and preventive actions (""')
@ducation of physicians is based on a specialized profile and on limited 6noledge on the current health care system ($%)
The characteristics of a ne care model re<uires the training and formation of human resources to be associated ith the model7s
%, &, ', "+,
#", #$, #&, #(,
#), $#, $$, $%,
$&, $', %+, %",
%#, %&, %',
%), &(, &*, '%,
'), (+, ($, ('
(), )", )%, .
"++, "+" ,
"+$, ""%, ""&,
""', ""(, "#$,
"#', "#(, "#),
"$+, "$#, "$$,
"$'
"&
Other1ise" in addition to the sectorPs ineIciency" the ris. of its reversion
*ecomes imminent (88)%
On the 1ay to the construction of the -niEed Health +are System" the need
for re2orientation of health care practices as 1ell as of the education of human
resources has *een pointed out (A9)%
Studies reveal the urgent need to adapt professionalsP education 2 doctors"
nurses 2 as 1ell as the training of community agents" etc%
&ost of the #razilian medical schools do not use health units as a practice
Eeld for their students5 therefore such students remain in specialized hospital
institutions" the structure of 1hich is directed to the resolution of more compleF
pro*lems%
Hence" the result is the inadeJuacy of the current clinical training model if it
is assumed that the maHor Juality of a doctor should *e the capacity to resolve
health pro*lems 1ithin an enlarged perspective of the clinical practice in 1hich
it is eFpected that .no1ledge and practice should contemplate *iological"
su*Hective and social aspects (;" 88" 8>" @;" @C" 99:" 99;)%
,n the same 1ay" nursing teaching is also criticized" since in many Eelds"
namely &ental Health" teaching is directed to a predominantly hospital2centered
clinical model 1ith emphasis on pharmacotherapy (@0" 909" 99>" 928)%
0he utilization of the model *y professionals" educators and researchers%
Ehe literature sho*s that in clinical ,ractice( the Primary Health Care model
enables-
greater autonomy in administrative and Enancial management (:0"
:A)
reduction in social ineJuities (92:)
the development of care model for the defense of life (@>" @:)
the consideration of particularities of groups?cultures?organizations
1ith speciEc sanitary proEles (92:" 92C" 98@)%
the incorporation of traditional practices (;8)
the use of decrees and norms (9;)
participative management (@:)
0he faculty2clinical practice integration is an important strategy in the
development of human resources in health care and" at the same time" for the
implementation of the ne1 care model% <arious studies have sho1n that the
faculty2clinical practice integration contri*utes to the transformation of health
care practices and implementation of S-S (9>" AC" 982)%
,n the same 1ay" the ne1 model presents a ne1 mar.et for health care
professionals (particularly for doctors) and conseJuently reJuires a ne1
education model (@C)%
"'
0o researchers" it is an eFcellent opportunity to ma.e an analysis of the
process of transformation of the health sector in #razil according to a historical
perspective%
"(
REFERENCES
9% A*reu A[" (eliF #4" Dias D#" +hiaratto (ilho D" 4oto 'H" Paris (S"
=amamoto &" 4as.uma &H" 7imura &(" Yanutti &" &artins /#" Oliveira
/4" AleiFo <+" Paraschi +" +a*reira &AS" <annuchi &0O" Sugmiyama
6+=" 0omazzi Y(% De,oimentos sobre a construPQo coletiva e
,artici,ativa de um novo modelo ,ara a saFde & Statements about the
collective and ,artici,ative construction o a ne* health care model.
Divulg% sa\de de*ate 9CC: set5 (99)3;;2@%
2% Aguiar" DS% ' saFde da amHlia no Sistema Rnico de SaFde- um novo
,aradi#maS & /amily health in the 7ni9ed Health Care System- a ne*
,aradi#mS ddissertatione% /io de $aneiro (/$)3 'scola )acional de Sa\de
P\*lica5 9CCA%
8% Alagoas% Secretaria de Sa\de5 Sergipe% Secretaria de Sa\de5
+ompanhia Hidroel_trica do Sfo (rancisco5 Piranhas% Prefeitura
&unicipal5 Olho DPAgua do +asado% Prefeitura &unicipal5 +anind_ do
Sfo (rancisco% Prefeitura &unicipal5 Pogo /edondo% Prefeitura
&unicipal% +onsXrcio ,ntermunicipal de Sa\de de bingo - C8S'T-
Distrito SanitNrio do Tin#o & Tin#oKs 8ntermunici,al Health Consortium
- C8S'T- Tin#o Sanitary District. +H'S(9CC9 a*r 2:8 p%
>% Al*uJuerJue +P% Munici,ali2aPQo e crise de cultura institucional- o
caso do Centro PrevidenciNrio de NiterJi 1@@B&1@@2 & Munici,ali2ation
and the institutional culture crisis- the case o NiterJiKs Social Security
Center 1@@B&1@@2 ddissertatione% /io de $aneiro (/$)3 'scola )acional
de Sa\de P\*lica59CC>
:% AleFandre 6#SP" Salum &$6% ' mudanPa( a resistUncia e a ,ersistUncia
dos tIcnicos do N.P8 de um e5-distrito de saFde do municH,io de SQo
Paulo & Chan#e( resistance and ,erseverance o N.P8Ks technicians in a
health district o SQo Paulo +ity% Sa\de Soc 9CCA ago%2 dez5 @(2)3A82
999%
;% Almeida &$% .ducaPQo mIdica e saFde- limites e ,ossibilidades das
,ro,ostas de mudanPa & Medical education and health care- limits and
,ossibilities o chan#in# ,ro,osals. d0hesise% Sfo Paulo (SP)3
-niversidade de Sfo Paulo% (aculdade de Sa\de P\*lica%
Departamento de Pr^tica de Sa\de P\*lica5 9CC@%
@% Alves DS)" Seidl '&(" Schechtman A" Silva /+% 'lemento para uma
an^lise da assisthncia em sa\de mental no #rasil ? (acts for the
analysis of mental health care in #razil% $ *ras% psiJuiatr9CC2 set5
>9(A)3>282;
A% Alves '0#/" +yrino $+#% Caracteri2aPQo do sistema de saFde do
municH,io de Manaus & Characteri2ation o the health care system in
the city o Manaus. ,n3 /oHas ," #asilia 6" 0oledo 6&% 'spago e doenga3
")
um olhar so*re o Amazonas ? Space and illness3 a vie1 of Amazonas%
/io de $aneiro (/$)3 (,O+/-Y5 9CCA% p%,,%98%92>%
C% Amaral &A% 'tenPQo V saFde mental na rede bNsica- estudo sobre a
e9cNcia do modelo assistencial & Mental health care in the basic health
net*or"- a study on the eMcacy o the care model. /ev% sa\de p\*lica
9CC@ Hun5 89(8)32AA2C:
90% Andrade +S% 's enermeiras e#ressas da 7.SC e sua atenPQo nos
serviPos de saFde de 8tabuna & Nurses *ho #raduated rom 7.SC and
their ,erormance in 8tabunaKs health care services. ddissertatione
Salvador (#A)3 -niversidade (ederal da #ahia% (aculdade de 'ducagfo5
9CC@%
99% Andrade &S% Democrati2aPQo no hos,ital ,si0uiNtrico- um estudo
da ColWnia =uliano Moreira nos anos oitenta& Democrati2ation in
,ychiatric hos,itals- a study o =uliano Moreira Colony in the 1@1Bs.
ddissertatione% /io de $aneiro (/$)3 -niversidade do 'stado do /io de
$aneiro% ,nstituto de &edicina Social5 9CC2%
92% #ar*ieri A/% ' assistUncia V saFde em Cam,o Crande atravIs do
S7S- a construPQo de uma ,olHtica &Health care in Cam,o Crande
throu#h S7S- the construction o ,olicies. Divulg% sa\de de*ate 9CC@
Hun5 (9A)39@22:%
98% #ar*osa S)% Cidadania( saFde bucal e o S7S & Citi2enshi,( oral
health and S7S Sa\de em de*ate 9CC8 Hun5(8C)3@029%
9>% #arros S" Silva A6A" 6op_rgolo A+D" Pitta A&(% Eentativas inovadoras
na ,rNtica de ensino e assistUncia na Nrea de saFde mental - 8 &
8nnovative attem,ts in the teachin# ,ractice and clinical care in the
9eld o mental health. /ev% 'sc% 'nfermagem -SP 9CCC Hun5 88(2)39C22
C%
9:% #or*a </% Munici,ali2aPQo da saFde- roteiro bNsico e ,lano diretor &
Health care munici,ali2ation- a basic #uide and a directory ,lan. Sfo
Paulo5 +'DAS5 9CC8% 22Ap%
9;% #rasil% &inist_rio da Sa\de% Portarias da Secretaria )acional de
Assisthncia i Sa\de3 &inist_rio da Sa\de 9AC?C9dD%O%-% 99?92?C9e e
22>?C9 dD%O%-% 80?09?C2e ? Decrees of the )ational Health +are
Secretariat3 Department of Health 9AC?C9(D%O%-% 92?99?C9) e
22>(D%O%-% 09?80?C2)% 8n- ConerUncia Nacional de SaFde Mental. '
reestruturaPQo da atenPQo em saFde mental no !rasil & National
Conerence on Mental Health. Ehe re-structuri2ation o mental health
care in !ra2il. !rasHlia ;D/<- !rasil. &inist_rio da Sa\de" 9CC2% p%;02;;%
9@% #rhda" &Y% D cuidado ao ,ortador de transtorno ,sH0uico na
atenPQo bNsica de saFde & Ehe care to ,eo,le *ith ,sychic disturbance
in the basic health care net*or" ddissertatione% /ecife (P')3 (undagfo
Os1aldo +ruz% +entro de PesJuisas Aggeu &agalhfes5 2009%
"*
9A% #rito '&S% ' DP'S( um ator ,olHtico- anNlise do modelo tecno-
assistencial ,ro,osto ,elo documento XormulaciJn de ,oliticas de
saludX( DP'S( 1@?5 & DP'S( a ,olitical actor- analysis o the technical
and clinical model ,ro,osed by the document XormulaciJn de
,oliticas de saludX( DP'S( 1@?5% ddissertatione% /io de $aneiro (/$)3
-niversidade do 'stado do /io de $aneiro% ,nstituto de &edicina Social5
9CC2%
9C% #rum YP" Pereira &A% .ducaPQo em saFde enocando hi#iene(
se5ualidade e dro#adiPQo :unto aos meninos de rua na ai5a etNria de
11 a 1+ anos & Health education ocusin# on hy#iene( se5uality and
dru# addiction or street children a#ed 11 to 1+ years. /ev% *ras%
enfermagem 9CC; Hul%2set5 >C(8)38882>2%
20% #u* &#+% Eeoria de Dorothy =ohnson e a classi9caPQo dia#nJstica
da N'ND' em tera,ia intensiva- im,licaPYes ,ara a enerma#em &
Dorothy =ohnsonKs theory and the N'ND' dia#nostic classi9cation in
intensive care- im,lications or nursin#. ddissertatione% (lorianXpolis
(S+) -niversidade (ederal de Santa +atarina3 9CC2%
29% #uss P&% PromoPQo e educaPQo em saFde no Zmbito da .scola de
Coverno em SaFde da .scola Nacional de SaFde PFblica & Health
,romotion and health education at the School o Covernance in
Health( National School o Public Health( #razil%+ad% sa\de p\*lica
9CCC59:(supl%2)39@@2A:%
22% +ampos 4S% >eorma da reorma( re,ensando a saFde & >eorm o
the reorm- re-thin"in# about health care. Sfo Paulo5 Hucitec5 9CC2%
28% +ampos 4S% .ducaPQo mIdica( hos,itais universitNrios e o
Sistema Rnico de SaFde & Medical education( university hos,itals( and
the 7ni9ed Health Care System in !ra2il. +ad% sa\de p\*lica 9CCC
Han%2mar59:(9)39A@2C8%
2>% +arvalho 4+&% D momento atual do S7S- a ousadia de cum,rir e
a2er cum,rir a lei & Ehe ,resent status o S7S- the coura#e to obey
the la* and ma"e it obeyed. Sa\de soc 9CC85 2(9)3C22>"%
2:% +astro +4$% ' im,lantaPQo do Sistema Rnico de SaFde [S7S\ no
!rasil e o modelo de atenPQo V saFde- uma 0uestQo de decisQo(
com,romisso e iniciativa & 8m,lementation o the 7ni9ed Health Care
System [S7S\ in !ra2il and the health care model- a 0uestion o
decision( commitment and iniciative% s%l5 s%n5 s%d% 9: p%
2;% +astro +4$% D estudo da demanda do serviPo de ,ronto
atendimento de um hos,ital como subsHdio ao modelo assistencial do
Sistema Nacional de SaFde & ' study on the demand at an emer#ency
hos,ital service as a subsidy to the clinical care model o the National
Health System. [dissertation\. SQo Paulo ;SP<- (aculdade de Sa\de
P\*lica Departamento de Pr^tica de Sa\de P\*lica? -SP" 9CC9
2@% +ear^% Secretaria da Sa\de5 (ortaleza% Secretaria &unicipal da
Sa\de% >eorientaPQo da assistUncia V saFde na #rande /ortale2a-
#+
,ro:eto ,rJ-saFde & >e-orientation o health care in the #reater
/ortale2a6 the Pro-Health Pro:ect. 9CC0 nov%5 9;0 p
2A% +ecilio 6+O% Modelos tecno-assistenciais em saFde- da ,irZmide ao
cHrculo( uma ,ossibilidade a ser e5,lorada & Eechnical and clinical
health care models- rom the ,yramid to the circle( a ,ossibility to be
e5,lored. +ad% sa\de p\*lica 9CC@ Hul%2set5 98(8)3>;C2@A%
2C% +haves 'S% 'tuaPQo do ,sicJlo#o clHnico em serviPo de saFde
,ublica & Ehe ,erormance o clinical ,sycholo#ists in ,ublic health
services. Divulg% sa\de de*ate 9CC: set5 (99)390A298%
80% +ohen &&% D modelo assistencial no S7S - NiterJi- con]ito e
,actuaPQo ,olHtica no ,rocesso de inte#raPQo do ,ro#rama mIdico de
amHlia& Ehe clinical model in S7S - NiterJi- con]ict and the ,olitical
,act in the ,rocess o inte#ration o the /amily Doctor Pro#ram.
ddissertatione% /io de $aneiro (/$)3 'scola )acional de Sa\de P\*lica5
2009
89% +or*ishley A+&% D trabalho de enerma#em no ,rocesso de
construPQo de um modelo assistencial em saFde coletiva & Nursin#
*or" in the ,rocess o construction o a collective health care model.
d0hesise% /io de $aneiro(/$)3 'scola de 'nfermagem Anna )ery5 9CCA%
82% +orneta <7" &aia ++A" +osta 4A% ' reor#ani2aPQo dos serviPos de
saFde no sistema Fnico de saFde e a ormaPQo de recursos humanos &
Ehe re-or#ani2ation o health services *ithin the 7ni9ed Health Care
System and the develo,ment o human resources. Sa\de em De*ate
9CC; Hun5 (:9)3>>2C%
88% +osta )eto &&" Amaral +&" $aniJues &A+% 'l#umas ,ro,ostas ,ara
a elaboraPQo de uma ,olHtica de desenvolvimento de recursos
humanos em saFde ,ara o Distrito /ederal & Some ,ro,osals or the
elaboration o a ,olicy in order to develo, human resources in health
care at the /ederal District. /ev% sa\de Dist% (ed 9CC: Hul%2set5 ;(8)3:2
92%
8>% +osta )eto &&" 6opes +#" Peganha 6&(% 7m estudo sobre o
conhecimento dos ormandos de 1@@5 da 7niversidade de !rasHlia
sobre o Sistema Rnico de SaFde & ' study on the "no*led#e o
medical students *ho #raduated rom the 7niversity o !rasHlia in
1@@5 concernin# the 7ni9ed Health Care System ;S7S<. /ev% sa\de
Dist% (ed 9CC; out%2dez5 @(>)3:228%
8:% +yrino APP% Dr#ani2aPQo tecnolJ#ica do trabalho na reorma das
,rNticas e dos serviPos de saFde- estudo de um serviPo de atenPQo
,rimNria V saFde - 2v & Eechnolo#ical or#ani2ation o *or" in the
reorm o ,ractices and o health care services- the study o a ,rimary
health care service 2 2v% ddissertatione% Sfo Paulo (SP)5 -niversidade de
Sfo Paulo% (aculdade de &edicina% Departamento de &edicina
Preventiva5 9CC8%
#"
8;% Damaso /" Silva A6A+" -ziel AP" &oreira &+)% ' :ustiPa cuidadosa-
introduPQo V anNlise institucional de ensino de enerma#em & Careul
:ustice- an introduction to the institutional analysis o nursin#
teachin#. /ev% enfermagem -'/$ 9CC> maio5 2(9)38292%
8@% Douglas $6% +ontri*uigfo para a caracterizagfo da enfermagem Jue
atua na assisthncia i sa\de do tra*alhador na Am_rica 6atina ?
+onti*ution to the characterization of nurses 1ho perform in 1or.ersP
health care in 6atin America% ddissertatione%Sfo Paulo (SP)% (aculdade
de Sa\de P\*lica% Departamento de Sa\de Am*iental?-SP5 9CC9
8A% Duarte 6/% Consulta de enerma#em em saFde do escolar- ,ro,osta
e avaliaPQo de um modelo o,eracional & Nursin# consultation in
school-a#e childrenKs health- ,ro,osal and evaluation o an
o,erational model. /ev% paul% enfermagem 9CC2 maio2ago599(2)3A:2
C9%
8C% 'gry '=" (onseca /&4S DimensQo ,eda#J#ica da inte#raPQo
docente assistencial como estratI#ia de intervenPQo no saber&a2er
em saFde coletiva & Ehe ,eda#o#ical dimension o the aculty-clinical
care inte#ration as a strate#y o intervention in
"no*led#e&,erormance in collective health. Sa\de em de*ate 9CC>
mar (>2)39;222%
>0% 'scrivao $unior A% ProduPQo e uso das inormaPês de saFde na
Secretaria Munici,al da SaFde de SQo Paulo- uma 0uestQo estratI#ica
,ara a construPQo do S7S & Production and use o health care
inormation in the Munici,al Health Secretariat- a strate#ic 0uestion
or the construction o S7S( +ongresso #rasileiro de 'pidemiologia5
9CC0% set 82;5 Sfo Paulo" Sfo Paulo 9CC0%p 20%
>9% (aria )&b% Silos- uma visQo da linha de rente do sistema & 3ocal
health systems- a vie* on the systemKs ront line. 8n- ConerUncia
Nacional de SaFde. Cadernos da nona- descentrali2ando e
democrati2ando o conhecimento. #rasZlia" 4rupo de 0ra*alho 0_cnico
da +omissfo Organizadora" 9CC2% p%C@2A%
>2% (ernandes /<" 6is*oa (ilha <O" /ego /+% D,eracionali2aPQo da
vi#ilZncia V saFde no Distrito SanitNrio de Pau da
3ima&D,erationali2ation o health surveillance in the Sanitary District
o Pau da 3ima" #A" #razil% Salvador5 9CC>% 98 p%
>8% (ernandes 6% 'ssistUncia de enerma#em ao diabItico :ovem
embasada no autocuidado & Nursin# care to youn# diabetic ,atients
based on sel-care. ddissertatione% $ofo Pessoa (PA)3 -niversidade
(ederal da ParaZ*a5 9CC:%
>>% (euer1er.er 6+&" &arsiglia /% .stratI#ias ,ara mudanPas na
ormaPQo de >Hs com base nas e5,eriUncias 8D'&7N8 & Strate#ies or
chan#es in human resources develo,ment based on 8D'&7N8
e5,eriences. Divulg% sa\de de*ate 9CC; Hul5 (92)32>2A%
##
>:% (ormigli <+" Heloniza O4" &olesini $j" (ernandes /<% Dr#ani2aPQo da
atenPQo V saFde em Distritos SanitNrios na !ahia & Health care
or#ani2ation in !ahiaKs Health Districts. /ev% *aiana enfermagem 9CC2
out5 :(9)3:220 3
>;% (ormigli <6A" +osta &+O" Porto 6A% 'valiaPQo de um serviPo de
atenPQo inte#ral V saFde do adolescente & .valuation o an inte#ral
health care service or adolescents% +ad% sa\de p\*lica 2000 Hul%2
set59;(8)3A892>9%
>@% (ranco 0#" #ueno S" &erhy ''% D acolhimento e os ,rocessos de
trabalho em saFde- o caso de !etim( Minas Cerais( !rasil & 7ser
embracement and the *or" ,rocesses in health care- tre case o
!etim( Minas Cerais( !ra2il. +ad% sa\de p\*lica 9CCC a*r%2
Hun59:(2)38>:2:8%
>A% 4eraldes P+% Co-#estQo- um modelo de administraPQo de serviPos
,Fblicos de saFde. ' e5,eriUncia da re#ionali2aPQo e hierar0ui2aPQo
da assistUncia ,si0uiNtrica no municH,io do >io de =aneiro & Co-
mana#ement- a model or ,ublic health care services administration.
'n e5,erience o re#ionali2ation and hierarchi2ation o ,sychiatric
care in the city o >io de =aneiro. ddissertatione% /io de $aneiro (/$)3
-niversidade do 'stado do /io de $aneiro% ,nstituto de &edicina Social5
9CC0%
>C% 4evaerd S% Plane:amento em odontolo#ia- ,ers,ectivas ,ara os
sistemas locais & Dentistry ,lannin#- ,ers,ectives or local systems.
Divulg% sa\de de*ate 9CC9 out5 (;)39@2A%
:0% 4utierrez P/% ' munici,ali2aPQo e a e5,erimentaPQo de modelos
assistenciais em 3ondrina- os dilemas e as descontinuidades do
,rocesso & Munici,ali2ation and e5,erimentation o care models in
3ondrina- the dilemmas and the discontinuities o the ,rocess.
d0hesise% /io de $aneiro (/$)3 'scola )acional de Sa\de P\*lica5 9CCC%
:9% Hospital -niversit^rio do )orte do Paran^% 'nte-,ro:eto de
im,lantaPQo do distrito sanitNrio-escola da 2ona norte de 3ondrina &
Pre-,ro:ect or the im,lementation o the sanitary district-school in
northern 3ondrina. 9CAA out p >8%
:2% ,*a]ez )% Sistema local de saFde de Cotia- estudo de caso & CotiaKs
local health care systems- a case re,ort .[thesis\. Sfo Paulo (SP)3
(aculdade de Sa\de P\*lica% Departamento de Pr^tica de Sa\de
P\*lica -niversidade de Sfo Paulo5 9CC0%
:8% ,t^lia% coordenagfo de ProHeto de Sa\de no #rasil5 associagfo
,taliana para a Solidariedade entre os Povos% >elatJrio de intercZmbio
entre tIcnicos da Secretaria Munici,al da SaFde- Distrito SanitNrio
Cam,o 3im,o 2 Sfo Paulo e t_cnicos do Distrito Sanit^rio Pau da 6ima 2
Salvador 2 #ahia ? ,taly% +oordination of the Health ProHect in #razil5
,talian Association for Solidarity Among People% >e,ort on the
e5chan#e o technicians rom the Munici,al Health Secretaria- Cam,o
#$
3im,o Sanitary District - Sfo Paulo and technicians from Pau de 6ima
Sanitary District 2 Salvador 2 #ahia% nov% 9CC0" 9@p%
:>% ,to A&=% .stratI#ias de reorma da educaPQo dos ,ro9ssionais de
saFde na 7.3 & Strate#ies to reorm health ,roessionalsK education at
7.3. Divulg% sa\de de*ate 9CC> ago5 (C)3::2A%
::% ,vo &6" #achlon &&% ',licabilidade do modelo de >oy- uma revisQo
da literatura de 1@1B a 1@@1 & Ehe a,,licability o >oyKs model- a
literature revie* rom 1@1B to 1@@1. /ev% gauch% enfermagem 9CC8
Han%5 9>(9)3922A%
:;% ,zJuierdo $% ' comunidade como com,onente essencial dos Pro:etos
7N8 & Ehe community as an essential com,onent o the 7N8 Pro:ect ,n3
7isil" &arcos5 +haves" &^rio. Pro#rama 7N8- uma nova iniciativa na
educaPQo dos ,ro9ssionais da saFde & Ehe 7N8 Pro#ram- a ne*
initiative in the education o health care ,roessionals. #arueri"
(undagfo %7% 7ellogg" 9CC>% p%:92;9%
:@% $unJueira 6AP CerUncia dos serviPos de saFde & Mana#ement o
health care services. 8n- ConerUncia Nacional de SaFde. Cadernos da
nona- descentrali2ando e democrati2ando o conhecimento. #rasZlia"
4rupo de 0ra*alho 0_cnico da +omissfo Organizadora" 9CC2% p%A:2C%
:A% $unJueira 6AP% CerUncia dos serviPos de saFde & Health services
mana#ement. +ad% sa\de p\*lica 9CC0 Hul%2set5 ;(8)32>@2:C%
:C% $unJueira 6AP" coord5 'duardo &#P" So*oll &6&S" ,noHosa /&"
$ardanovs.i k" Ara\Ho 6+&)% Modelo de atenPQo V saFde do .stado de
SQo Paulo & Ehe health care model in SQo Paulo State% ,n3 $unJueira 6P"
coord5 'duardo &#P" So*oll &6&" ,noHosa / &" $ardanovs.i k" Ara\Ho
6+& )% Pro#rama decenal ,ara a Nrea social em SQo Paulo- #estQo
,Fblica no setor saFde6 um ,lano estratI#ico. (undagfo do
Desenvolvimento Administrativo" out% 9CC2% p%90>298%
;0% 7opf A% ' reormulaPQo do setor saFde no municH,io de 8:uH ;>S<(
no ,erHodo de 1@13 a 1@1@. >eormulation o the health care sector in
the city o 8:ui ;>S< rom 1@13 to 1@1@. ddissertatione% ,HuZ (/4) 'scola
)acional de Sa\de P\*lica5 9CC9%
;9% 7untze 0D% ' assistUncia de enerma#em ,lane:ada V mulher
#estante- undamentada nos estudos de 3iliana /elcher Daniel &
Planned nursin# care o ,re#nant *omen- based on 3iliana /elcher
DanielKs studies. ddissertatione% (lorianXpolis (S+)3 -niversidade
(ederal de Santa +atarina 9CC9%
;2% 7untze 0D ' assistUncia de enerma#em ,lane:ada V mulher
#estante( undamentada nos estudos de 3iliana /elcher Daniel &
Planned nursin# care o ,re#nant *omen based on 3iliana /elcher
DanielKs studies. ddissertatione% (lorianXpolis (S+)3 -niversidade
(ederal de Santa +atarina %+entro de +ihncias da Sa\de5 9CC9
#%
;8% 7urcgant P" +astilho <" 6eite &&$% Ca,acitaPQo do ,ro9ssional de
saFde no Zmbito da ormaPQo e da educaPQo continuada&
Develo,ment o health care ,roessionals in the e5tent o
develo,ment and contiuin# education. /ev% 'sc% 'nfermagem -SP
9CC> dez5 2A(8)32:92;%
;>% 6eflvre (% ContribuiPQo ,ara o entendimento de uma Nrea nebulosa
do S7S & Contribution to understandin# an obscure area o S7S.
;:% 6evcovitz '% ' ca,acidade o,erativa da rede assistencial do S7S-
recu,eraPQo e ade0uaPQo &D,erative ca,acity o S7S health care
net*or"- recovery and ad:ustment. /io de $aneiro5 -'/$?,&S5 9CC8% 2@
p%
;;% 6ougon &% Ds caminhos da mudanPa- alienados( alienistas e
desinstitucionali2aPQo da assistUncia ,si0uiNtrica ,Fblica & Erends o
chan#e- the alienated( the alienatin# and deinstitutionali2ation o
,ublic ,sychiatric care. ddissertatione% /io de $aneiro (/$)3 -niversidade
(ederal do /io de $aneiro% &useu )acional5 9CA@%
;@% &artins $$" (aria '&% ' ;re< or#ani2aPQo do trabalho da enerma#em
em 7E8 atravIs de uma nova ,ro,osta assistencial & ;>e< or#ani2in#
nursin# *or" at the 8C7 by means o a ne* care ,ro,osal. 0eFto O
conteFto enfermagem 2000 maio2ago5 C(2)38AA2>09%
;A% &edeiros 7/" &endes A+4% Modelo assistencial e atenPQo hos,italar
em menores de 5 anos- o caso do municH,iode Camara#ibe - P. & Ehe
care model and hos,ital care o ,atients under under 5 years old- the
case o Camara#ibe District 2 P'% /ev% ,&,P 9CCC Hul%2dez5 98(2)39202@%
;C% &ellin AS% As representagmes sociais dos proEssionais de sa\de
so*re as Enalidades e pr^ticas do +entro de Sa\de ,ntegragfo ? Health
care professionalsP social representations of the purposes and
practices of the ,ntegration Health +enter% d0hesise% +ampinas (SP)3
-niversidade de Sfo Paulo% (aculdade de Sa\de P\*lica%
Departamento de Sa\de &aterno2,nfantil5 9CCA%
@0% &elo +% 'nfermagem3 teoria e pr^tica para construir Jual sistema de
sa\deT ? )ursing3 theory and practice to *uild 1hat health systemT
/ev% *aiana enfermagem 9CC2 out%5% :(9)3292C%
@9% &endes '<% ' descentrali2aPQo como ,rocesso social &
Decentrali2ation as a social ,rocess. ,n3 7alil &'b" org% Sa\de mental e
cidadania no conteFto dos sistemas locais de sa\de" Anais% Sfo
Paulo(SP)3 H-+,0'+" 9CC2% p%;:2@>%
@2% &endes '<% Ds modelos de descentrali2aPQo do sistema de saFde
no !rasil & Descentrali2ation models in the !ra2ilian health care
system. Divulg% sa\de de*ate 9CC9 Hun5 (>)3;:2@"%
@8% &endes '<%D consenso do discurso e o dissenso da ,rNtica social-
notas sobre a munici,ali2acao da saFde no !rasil & Ehe consensus o
discourse and dissensus o social ,ractice6 notes on the
#&
munici,ali2ation o health care in !ra2il. ,n3 +onferencia &unicipal de
Sa\de de Sfo Paulo" 9CC9% maio9@5 Sfo Paulo" Sfo Paulo 9CC9% p 99%
@>% &erhy k'" +ecZlio 6+O" )ogueira /+% Por um modelo tecno-
assistencial da ,olHtica de saFde em deesa da vida- contribuiPQo ,ara
as conerUncias de saFde & /or a technical and clinical health ,olicy
model in deence o lie- contribution to health conerences. ,n3
+onferhncia )acional de Sa\de% +adernos da nona3 descentralizando e
democratizando o conhecimento% #rasZlia" 4rupo de 0ra*alho 0_cnico
da +omissfo Organizadora" 9CC2% p%C92;%
@:% &erhy k'% .m busca da 0ualidade dos serviPos de saFde- os
serviPos de ,orta aberta ,ara a saFde e o modelo tecno-assistencial
em deesa da vida & Searchin# or 0uality in health care services-
services *ith o,en doors to health and the technical and clinical
model in deence o lie. ,n3 +ecilio 6+O% ,nventando a mudanga na
sa\de% Sfo Paulo (SP)3H-+,0'+59CC>% p%99@2;0%
@;% &onnerat 46 MIdicos-atores sociais e as mudanPas atuais no setor
saFde- a e5,eriUncia do municH,io de NiterJi & Social doctor-actors and
the current chan#es in the health care sector- the e5,erience o
NiterJi. ddissertatione% /io de $aneiro (/$)3 'scola )acional de Sa\de
P\*lica5 9CC;%
@@% &oreira &6% _rea de inormaPQo & 8normation area. Divulg% sa\de
de*ate 9CC> ago5 (C)3C928%
@A% &oura )eto (D&% !ases ,ara uma reorma ,si0uiNtrica & !asis or a
,sychiatric reorm. ,n3 Anon% Sa\de mental e cidadania% Sfo Paulo"
&andacaru" 9CA@% p%:@2;:%
@C% )ascimento 6'% ' retomada de um ,rocesso de desenvolvimento
curricular & Ehe re-start o a curricular develo,ment ,rocess. /ev% m_d%
&inas 4erais 9CC2 Han%2mar5 2(9)3:92@%
A0% )eto &D" Soares S&S% Pro:eto de coo,eraPQo tIcnica ,ara
distritali2aPQo dos serviPos de saFde & Eechnical coo,eration or the
districtali2ation o health care services. 9CC0 nov%
A9% )unes" +A% ' ormaPQo em saFde coletiva e as ,raticas de saFde
em ,ro#ramas comunitNrios & .ducation in collective health and health
,ractices in community ,ro#rams. ddissertatione% Salvador (#A)3
-niversidade (ederal da #ahia% ,nstituto de Sa\de +oletiva5 9CCC%
A2% Oliveira &($" Al*uJuerJue A$% Partici,aPQo ,o,ular e ,rNtica
odontolJ#ica em serviPo ,Fblico de saFde- uma e5,eriUncia & Po,ular
,artici,ation and dental ,ractice in a ,ublic health service- an
e5,erience. Sa\de em de*ate 9CC2 dez%5 (8@)3>028%
A8% Oliver (+% ' atenPQo V saFde da ,essoa ,ortadora de de9ciUncia no
sistema de saFde do MunicH,io de SQo Paulo- uma 0uestQo de
cidadania & Health care to handica,,ed ,eo,le in the health care
system in the munici,ality o SQo Paulo- a 0uestion o citi2enshi,%
#'
ddissertatione% Sfo Paulo (SP)3 (aculdade de Sa\de P\*lica%
Departamento de Pr^tica de Sa\de P\*lica?-SP59CC0%
A>% OPS?O&S% Distritali2aPQo- construindo um novo modelo
assistencial & Districtali2ation- Constructin# a ne* care model.
(ortaleza (+') Prefeitura &unicipal5 9CC8% 2> p% ProHeto OPS?O&S%
Sa\de meio am*iente e luta contra a Po*reza%
A:% Padilha /[% Pro:eto 7N8-MarHlia & 7N8-MarHlia Pro:ect. Divulg% sa\de
de*ate 9CC> ago5 (C)3@82C%
A;% Paim $S ' reorma sanitNria e os modelos assistenciais- a
e,idemiolo#ia na or#ani2aPQo dos serviPos de saFde & Ehe sanitary
reorm and care models- e,idemiolo#y in the or#ani2ation o health
care services. ,n3 6ima e +osta" &((" Sousa" /P% [ualidade de vida3
compromisso histXrico da epidemiologia% Anais do ,, +ongresso
#rasileiro de 'pidemiologia% #elo Horizonte" +OOP&'D?Associagfo
#rasileira de Sa\de +oletiva" 9CC>% p%9AC2CA%
A@% Paim $S% ' reorma sanitNria e os modelos assistenciais & Ehe
sanitary reorm and care models. ,n3 -niversidade (ederal da #ahia%
(aculdade de &edicina% Departamento de &edicina Preventiva% Sa\de
coletiva3 teFtos did^ticos% Salvador" +entro 'ditorial e Did^tico da
-(#A" 9CC>% p%;92A9%
AA% Paim $S% ' reor#ani2aPQo das ,rNticas de saFde em distritos
sanitNrios & Ehe reor#ani2ation o health ,ractices in sanitary districts.
,n3 &endes" 'ughnio <ilaga" org% Distrito sanit^rio3 o processo social de
mudanga das pr^ticas sanit^rias do Sistema nnico de Sa\de% Sfo
Paulo" H-+,0'+" 9CC8% p%9A@2220"
AC% Paim $S% .stratI#ias ,ara inte#raPQo multidisci,linar e
multi,ro9ssional na ,rNtica de saFde- o Zmbito da #raduaPQo &
Strate#ies or multi,roessional and multidisci,linary inte#ration in
health ,ractice- the e5tent o under#raduate ,ro#rams. /ev% *aiana
enfermagem 9CC8 out5 ;(2)38@2>@%
C0% Pereira &$#" Assis &&A" /eis &+4% D modelo assistencial de saFde e
o atendimento de enerma#em ,restado V mulher com vistas ao
aleitamento materno ;'M< & Ehe clinical health model and nursin# care
or *omen aimin# at breasteedin#. /ev% *ras% enfermagem 9CCC Hul%2
set5 :2(8)3>2828;%
C9% Peres &AA% ' saFde bucal em um sistema local de saFde- estudo de
caso municH,io de 8,atin#a( MC( !rasil 1@1@-1@@+ & Dral health in a
local health care system- a case study in the city o 8,atin#a( MC(
!ra2il 1@1@-1@@+. ddissertatione% Sfo Paulo (SP)3 -niversidade de Sfo
Paulo% (aculdade de Sa\de P\*lica% Departamento de Pr^tica de Sa\de
P\*lica5 9CC:%
C2% PeruDo D+" SantPAnna &4&% Percursos e ,ercalPos do trabalho do
,sicJlo#o em hos,ital #eral & Courses and dra*bac"s o a
#(
,sycholo#istKs *or" in a #eneral hos,ital. &omento O perspectiv%
sa\de 9CAC Han%2dez5 8(9?2)3;928
C8% Pinto +6 7m modelo em discussQo & ' model in discussion. Divulg%
sa\de de*ate9CC> ago5 (C)3A029"%
C>% Pitta A&/" &eira /% ComunicaPQo social em saFde e modelo
assistencial- do discurso mIdico he#emWnico ao discurso da
inte#ralidade6 uma introduPQo V discussQo de modelos & Social
comunication in health care and the care model- rom the he#emonic
medical discourse to the discourse o inte#rality6 an introduction to
discussion on models. Sa\de em De*ate 9CC9 Hun5 (82)3A>2C2%
C:% Porto 6A" &oura /&(" &ascarenhas 'S% .no0ue e,idemiolJ#ico na
,ro#ramaPQo das aPês de saFde & Ehe e,idemiolo#ical ocus on the
,ro#rammin# o health care actions. /ev% *aiana enfermagem 9CC8
out%5 ;(2)3>A2@@%
C;% /aggio A% SaFde como dimensQo da ,rN5is urbana & Health as an
urban ,ra5is dimension. Sa\de em de*ate 9CC2 Hul%5 (8:)3>82:% ,
C@% /aggio A% SaFde I mudanPa & Health is chan#e. Divulg% sa\de
de*ate9CC2 maio5 (A)3::2A%
CA% /i*eiro 0/0&% 'cessibilidade dos serviPos de saFde- subsHdios ,ara
o atendimento V ,o,ulaPQo de 5 a @ anos - Centro de SaFde .scola
Ceraldo de Paula Sou2a - SQo Paulo( SP & 'ccess to health services-
subsidies or the care to the ,o,ulation a#ed 5 to @ years old6 Ceraldo
Paula Sou2a 7niversity Health Center( SQo Paulo( SP( !ra2il.
ddissertatione% Sfo Paulo (SP)5 -niversidade de Sfo Paulo% (aculdade
de Sa\de P\*lica% Departamento de Sa\de &aterno2,nfantil5 9CC@%
CC% /io de $aneiro ('stado)% Secretaria de Sa\de% 0Ztulo3 Pro,osta bNsica
,ara o ,lano diretor do Sistema Rnico de SaFde no >io de =aneiro
&!asic ,ro,osal or the directory ,lan o the 7ni9ed Health Care
System in >io de =aneiro. /io de $aneiro5 +entro de ,nformagfo de
Sa\de5 9CC0% 9>9 p%
900% /odrigues )eto '" (ortes PA+" 0eiFeira +" &agaHe1.i (/6" #arone <%
O controle social no S-S e sua relagfo com o processo de
descentralizagfo5 mesa redonda ? Social control in the -niEed Health
+are System and its relations 1ith the descentralization process5
round ta*le% ,n3 )eder +AP" +ontrole social no S-S3 a pr^tica e os
desaEos% Sfo Paulo(SP)3 ,nstituto de Sa\de5 9CC:% p%902:%
909% /odrigues /D% Hos,ital universitNrio no !rasil contem,orZneo-
dilemas e ,ers,ectivas ante o ,rocesso de consolidaPQo do S7S &
7niversity hos,itals in contem,orary !ra2il6 dilemmas and
,ers,ectives in ace o the ,rocess or consolidation o S7S. d0hesise%
/io de $aneiro (/$) -niversidade do 'stado do /io de $aneiro% ,nstituto
de &edicina Social59CCC%
#)
902% /osa A/% D com,onente acadUmico dos Pro:etos 7N8 & Ehe
academic com,onent in 7N8 Pro:ects. ,n3 7isil &" +haves" &% Programa
-),3 uma nova iniciativa na educagfo dos proEssionais da sa\de%
#arueri" (undagfo %7% 7ellogg" 9CC>% p%2:28;%
908% /osa &64% 'ssistUncia e ,rNtica mIdica em Du0ue de Ca5ias- 1@1B-
1@1? & Medical care and ,ractice in Du0ue de Ca5ias% ddissertatione%/io
de $aneiro (/$)3 'scola )acional de Sa\de P\*lica5 9CC0%
90>% /uzany &H" Peres '&% Pro:eto Maisa 88- modelo de atenPQo inte#ral
V saFde do adolescente da 7.>= ,or uma e0ui,e multidisci,linar &
Maisa 88 Pro:ect- 7.>=Ks 8nte#ral Health Care model or adolescents by
a multidisci,linary team. /ev% *ras% 'nfermagem% 9CC25 a*r%2 set%
>:(2?8)39::2A%
90:% Salvador% Secretaria &unicipal de Sa\de% Plano munici,al de saFde-
Salvador -!a & Munici,al health ,lan- Salvador 2 #a% 9CC0% p 209%
90;% Santos A% ' hemotera,ia e a 0ualidade total- um modelo de sistema
,adroni2ado ,ara o controle da 0ualidade do san#ue & Hemothera,y
and total 0uality- a model o a standardi2ed system or blood 0uality
control. ddissertatione% (lorianXpolis (S+)3 -niversidade (ederal de
Santa +atarina5 9CC@%
90@% Santos A+" +osta H#&% 7ma nova iniciativa no Sistema de SaFde do
Distrito /ederal & ' ne* iniciative in the health care system o the
/ederal District. Divulg% sa\de de*ate 9CC> ago5 (C)3882;%
90A% Santos A/% ' rede laboratorial de saFde ,Fblica e o S7S & Ehe ,ublic
health laboratory net*or" and the 7ni9ed Health Care System. ,nf%
epidemiol% S-S 9CC@ a*r%2Hun5 ;(2)3@29>%
90C% Santos S&A% PrNtica assistencial de enerma#em ,ara idosos
crWnicos undamentada no marco conceitual de ìn# & Nursin# care
,rovided to elderly ,ersons su4erin# rom chronic diseases based on
the theoretical rame*or" by ìn#. ddissertatione% (lorianXpolis (S+)3
-niversidade (ederal de Santa +atarina59CC0%
990% Santos &'P% .ducaPQo em saFde- a construPQo de um ,rocesso
sistemati2ado no ,ro#rama de ,lane:amento amiliar( do municH,io de
8ta:aH-SC & Health education- the construction o a systemati2ed
,rocess in the amily ,lannin# ,ro#ram in the city o 8ta:ai( SC( !ra2il.
ddissertatione% ,taHaZ (S+)3 -niversidade (ederal de Santa +atarina5
9CCA%
999% Schrai*er 6#5 Dalmaso AS5 6ima A&&" Sala A" +astanheira '/6"
Ayres $/+&" )emes &,#" 0eiFeira //% Pro#ramaPQo em saFde ho:e &
Health ,ro#rammin# today. Sfo Paulo (SP)3 Hucitec5 9CC8%
992% Senna &+&% Munici,ali2aPQo e controle social- o ,ro#rama mIdico
de amHlia em NiterJi ;1@@2-1@@+< & Munici,ali2ation and social
control- the amily doctor ,ro#ram in Niteroi ;1@@2-1@@+<.
#*
ddissertatione% /io de $aneiro (/$)3 'scola )acional de Sa\de P\*lica5
9CC:%
998% Shira.a1a ,% Preconceito( se#re#aPQo e distFrbio ,si0uiNtrico &
Pre:udice( se#re#ation and ,sychiatric disorder. #ol% psiJuiatr5 22?283:2
A" Han 9CAC dez% 9CC0%
99>% Silva A6A" (onseca /&4S% >e,ensando o trabalho em saFde
mental- a 0uestQo da interdisci,linaridade &>e-thin"in# about the *or"
in mental health- the 0uestion o interdisci,linarity. /ev% *ras%
enfermagem 9CC: Hul%2set5 >A(8)32922@%
99:% Silva 6&<% .ducaPQo mIdica e a or#ani2aPQo dos serviPos de
saFde & Medical education and the or#ani2ation o health care
services. 8n- 7niversidade /ederal da !ahia. /aculdade de Medicina.
De,artamento de Medicina Preventiva. Sa\de coletiva3 teFtos
did^ticos% Salvador" +entro 'ditorial e Did^tico da -(#A" 9CC>% p%C82
90>%
99;% Silva S(% ' construPQo do S7S a ,artir do municH,io- eta,as ,ara a
munici,ali2aPQo ,lena da saFde & Ehe construction o the 7ni9ed
Health Care System rom the munici,ality6 ,hases or the com,lete
munici,ali2ation o health care services. Sfo Paulo5 H-+,0'+5 9CC;%
99@% Silva S(" 0omazi Y(0% Distritali2aPQo em saFde 3ondrina- um ,ro:eto
em construPQo & Health care districtali2ation in 3ondrina- a ,ro:ect
under construction. Divulg% sa\de de*ate 9CC> ago5 (C)3;:2@0%
99A% Silva (<" 6i*eralino ()" #ar*osa )#% 7niversidade( serviPos e
comunidade- diNlo#os no 7N8-Natal & 7niversity( services and the
community- a dialo#ue in the 7N8-Natal Pro:ect. Divulg% sa\de de*ate
9CC; Hul5 (92)390;2992%
99C% Silva A$&" Silveira D&," #atista (6/" #raga $&" +arvalho 6+)"
(onseca
920% Silveira D0% Consulta-aPQo- educaPQo e re]e5Qo nas intervenPês de
enerma#em no ,rocesso trabalho-saFde-adoecimento & Consultation-
action- education and re]ection on nursin# interventions in the *or"-
health-illness ,rocess. ddissertatione% Porto Alegre (/S)3 -niversidade
(ederal de Santa +atarina5 9CC@%
929% Soares S&% PrNticas tera,Uuticas nQo-alo,Nticas no serviPo ,Fblico
de saFde- caminhos e descaminhos- estudo de caso etno#rN9co
reali2ado na Secretaria Munici,al de SaFde de !elo Hori2onte & Non-
allo,athic thera,eutic ,ractices in ,ublic healthcare services-
ethno#ra,hic case re,ort develo,ed at !elo Hori2onte Munici,al
Health Secretariat. d0sesise% Sfo Paulo (SP)3 -niversidade de Sfo Paulo%
(aculdade de Sa\de P\*lica% Departamento de Pr^tica de Sa\de
P\*lica5 2000%
922% Souza /4% 'utonomia( identidade e interesses do ,ro9ssional da
saFde- uma re]e5Qo sobre o modelo assistencial & Ehe health
$+
,roessionalKs autonomy( identity and interests- a re]ection on the
care model. ddissertatione% /io de $aneiro (/$)3 'scola )acional de
Sa\de P\*lica 9CC>%
928% Stefanelli &+" /olim &A" 0eiFeira &#" #arros S" (u.uda ,&7" (orcella
H0" Arantes '+% 8nte#raPQo dos conceitos de saFde mental nos cursos
de #raduaPQo em enerma#em &8nte#ration o mental health conce,ts
in nursin# under#raduate ,ro#rams. /ev% paul% enfermagem 9CC; Han%2
dez5 9:(9?8)3:92;:%
92>% 0eiFeira +(% ConerUncias munici,ais de saFde- construindo o S7S
na !ahia & Munici,al health conerences- constructin# S7S in !ahia.
Sa\de em De*ate 9CC; set5 (:2)3:02@%
92:% 0eiFeira +(% .,idemiolo#ia e ,lane:amento em saFde- contribuiPQo
ao estudo da ,rNtica e,idemiolo#ica no !rasil 1@@B-1@@5 & Health
,lannin# and e,idemiolo#y- contribution to the study on the
e,idemiolo#y ,ractice in !ra2il- 1@@B-1@@5. d0hesise% Salvador (#A)5
-niversidade (ederal da #ahia% ,nstituto de Sa\de +oletiva5 9CC;%
92;% 0eiFeira +(% Munici,ali2aPQo da saFde- os caminhos do labirinto &
Health care munici,ali2ation- the labyrinth ,assa#es. 9CC9 Hul% p 98
92@% 0eiFeira &46+" Paim $S% Ds ,ro#ramas es,eciais e o novo modelo
assistencial & S,ecial ,ro#rams and the ne* care model. +ad% sa\de
p\*lica 9CC0 Hul%2 set5 ;(8)32;>2@@%
92A% 0eiFeira +(" &elo +" 4omes ,(" <ilas*oas A6 ' construPQo de uma
nova ,rNtica sanitNria no conte5to de im,lementaPQo do S7S-
elementos ,ara a im,lementaPQo de instrumentos #erenciais em
S83DS & Ehe construction o a ne* sanitary ,ractice in the conte5t o
im,lementation o S7S- elements or the im,lementation o
mana#ement tools in S83DS. Salvador5 9CC:% >; p% ProHeto +'/4AS"
(,t^lia)5 -niversidade de #arcelona5 ,nstituto de Sa\de +oletiva (#a)5
-niversidade de Sfo Paulo5 (aculdade de Sa\de Pu*lica% ProHeto S,6OS3
PesJuisa e ,mplementagfo de ,nstrumentos 4erenciais%
92C% 0elarolli $\nior /" +arvalho (% 'l#umas consideraPês sobre a
assistUncia V saFde das ,o,ulaPês indH#enas & Some considerations
on the health care o indi#enous ,o,ulations. Sa\de em de*ate9CC>
mar (>2)3>C2:8%
980% 0esser +D% ' clHnica( a e,idemiolo#ia e os outros saberes em saFde-
,ensando os modelos assistenciais & Ehe clinic( e,idemiolo#y and
other ty,es o "no*led#e in health care- re]ectin# on care models.
Sa\de em De*ate5 (>:)38A2>2" dez% 9CC>%
989% 0omita )'" Oliveira A#'" Paniguel +P&A" 7iata.e 6=" 4onzaga 6HS"
&onteiro PA" (reitas S&Y% Pro:eto ,aiva- modelo inte#rado de
assistUncia em saFde bucal & Paiva Pro:ect- an inte#rated model
ororal health care. /ev% (ac% odontol% #auru 9CC> a*r5 2(2)3:92A%
$"
982% -niversidade (ederal da #ahia 2 -(#A" #ahia% Secretaria de
Sa\de5 %Salvador" Secretaria &unicipal de Sa\de% Organizagmes
+omunit^rias do Distrito Sanit^rio #arra /io <ermelho (#A)% Pro:eto
7N8- Distrito SanitNrio !arra - >io )ermelho6 relatJrio ano 8&7N8 Pro:ect-
!arra Sanitary District - >io )ermelho6 re,ort o year 8% Salvador5
9CC:% @C p%
988% <ecina )eto 4" 0erra <% ' universidade e a ormaPQo de recursos
humanos na #estQo da saFde&7niversities and the develo,ment o
human resources or health care mana#ement. /ev% adm% p\*lica
9CCA mar%2a*r5 82(2)39A:2C>%
98>% <eloso #4% Distrito sanitNrio e territJrio- construindo a
descentrali2aPQo no municH,io de !elo Hori2onte&MC&Sanitary district
and territory- constructin# decentrali2ation in the City o !elo
Hori2onte&MC. ddissertatione% /io de $aneiro (/$)3 'scola )acional de
Sa\de P\*lica5 9CC:%
98:% <ilas*oas A6% OEcina de tra*alho conHuntura atual e polZticas de
sa\de3 relatXrio Enal?%or"sho, on the current situation and health
care ,olicies- 9nal re,ort. Salvador5 9CC@% A p%
98;% <ilas*oas A6[% )i#ilZncia V saFde e distritali2aPQo- a e5,eriUncia de
Pau da 3ima & Health surveillance and districtali2ation- the e5,erience
o Pau da 3ima. ddissertatione% Salvador (#A)3 -niversidade (ederal da
#ahia% ,nstituto de Sa\de +oletiva5 9CCA%
98@% anderley )eto $" &^rcia A% 'la#oas muda ,er9l do ,ro9ssional da
saFde ade0uando-o V sua realidade & 'la#oas State chan#es the
,ro9le o health care ,roessionals to ada,t it to reality% Divulg% Sa\de
De*ate 9CC@ mar5 (9@)3C292%
$#

Primary Healthcare

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Primary Healthcare

Hochgeladen von

Copyright:

Verfügbare Formate

PRIMARY HEALTH CARE IN THE AMERICAS:

CONCEPTUAL FRAMEWORK, EXPERIENCES,

Das könnte Ihnen auch gefallen