Community-Oriented Primary Care

The process of Community-Oriented Primary Care (COPC) started in South Africa in 1940 when Sidney and Emily Kark, two South African family physicians, went to live and work among a rural Zulu tribe in the province of Natal. Their goal was to build a health service delivery system for an impoverished community receiving little benefit from Western medicine (1). The system they developed provided primary care services while incorporating community involvement in epidemiological surveillance and maintenance of community health activities.

Over the years COPC has developed into a conceptual framework, (2) for primary health care services, and defined in 1983 by the Karks as "...a way of practicing medicine and nursing, or of providing primary care, which is focused on care of the individual who is well or sick, or at risk for illness or disease, while also focusing on promoting the health of the community as a whole or any of its subgroup..." (3). COPC has been also defined as " a continuous process by which primary health care is provided to a defined community on the basis of its assessed health needs by the planned integration of public health with primary care practice" (4).
 
A more recent definition describes COPC as "...the practice of primary care with population responsibility, oriented to the health improvement of a defined community served by the health service, with the progressive participation of the community and in coordination with all services involved with the health of the community or its determinants" (5).

COPC is particularly relevant for ISCOPES because it necessitates community involvement throughout the entire process. Moreover, it provides guidelines on how to develop effective community programs by clearly formulating, implementing, and evaluating the program. COPC is a model that covers elements of Quality Improvement and is specifically oriented to a defined total population and in that way constitutes public health at a local level. COPC is considered "a powerful concept whose ethos has endured…and whose science has been bolstered by exciting developments in health care..." (6).

The COPC model was identified by the Institute of Medicine in 1982 with four main steps: Define, Assess, Review, and Evaluate. The operational definition of COPC was later modified to add, "engaging and mobilizing the community" between the steps Define and Assess. In order to more practically apply COPC, however, faculty from the Hebrew University in Jerusalem and the George Washington University added a sixth step for Intervention.

The six sequential steps of COPC are as follows:

1) Definition of Community
The first stage of developing a new COPC practice is defining the community served by the practice. The community can be a geographically defined area, a health plan, a neighborhood, a school or a group of individuals registered to receive care at a certain clinic. In each of these settings, all members of the population (and not only the sick or the users) will be part of the COPC practice. Clarity in community definition is key to all of the subsequent stages in the COPC process.

2) Community Characterization
Characterizing the defined community is the next stage in the COPC process and is crucial in establishing a clear understanding of the geography and demography of the community and the health status of its population. The characterization should include information on the geography of the community; the demographic and social features of its population; health, social, and other services available to members of the community; and their health status. Additionally, opinion should be gathered about health issues in the community from individuals who live and work there. This should be done systematically by using methods, such as focus groups and key informants. This information will help the COPC team identify the main health problems and issues of the community. This stage is usually based on existing and available data.

3) Prioritization
Given the competing demands of different health problems and the restricted resources available at the primary care level in most health systems, the planning process must include a comparative assessment of the different health problems afflicting the community. An objective selection of a health condition or problem (or set of conditions/problems) then must be made, with the goal of initiating an intervention program. The participation of both community members and staff members from the COPC practice will assist the prioritization process and provide substantial commitment from individuals other than the COPC team. This prioritization process should include specific defined criteria (e.g.: effectiveness, feasibility, etc) that could make a comparative analysis between varied health problems possible and allow for an objective selection. Semi-quantitative techniques are available for performing this prioritization process.

4) Detailed Assessment of the Selected Health Problem
This stage involves the collection of additional data about the selected health condition and factors related to it. This step should provide the team with information about the distribution and the determinants of the selected condition in the specific population. It will be important to assess the past experience of the practice and the members of the community in regard to this health condition. Additionally, the COPC team will perform a literature search and general exploration on how this selected condition has been assessed elsewhere, as well as review relevant interventions.

5) Intervention
According to the results of the detailed assessment at the local level, the COPC team will select a single intervention from among the several candidate interventions that have proved effective in combating a specific problem. This process must keep practicality foremost at all times so that the intervention selected is feasible within the resources of the practice. The precise nature of the problem chosen for the intervention will, of course, determine the specifics of the intervention, such as its duration, location of the health care setting, and resources required. Intervention planning entails adapting a proposed, systematic intervention to the realities of the problem in the specific community and the realities of the COPC practice. This includes choosing the objectives of the intervention, allocating resources, promoting community involvement in the program, and planning the timeline for the intervention. The role of the community and clinical staff is very important in both planning and carrying out the intervention and should be given thoughtful consideration.

6) Evaluation
The nature of the evaluation of the COPC practice is, likewise, determined by the nature of the intervention. This step cannot be well performed as an afterthought. Evaluaton --together with on-going surveillance -- is an essential step in the COPC process to determine the utility of the intervention and to help in the process of considering future interventions. It is important to develop the evaluation plan in conjunction with the intervention itself. What will the data needs of the evaluation be before, during, and after the intervention? Who will collect them? Where will they be maintained? And who will analyze them? Decisions on these questions need to be made prior to initiating the intervention.

The evaluation of the COPC program produces new data generated by the health intervention. It constitutes a re-assessment of the situation that existed at the initiation of the COPC practice. Thus, the re-assessment produces the necessary feedback for the continuing process of COPC.

References
1. Gofin J. An invited article "on The Practice of Social Medicine" by Sidney L Kark and Emily Kark, Journal Social Medicine (www.socialmedicine.info) Vol 1(2) 2006: 107-115.
2. Kark, SL. (1981). The Practice of Community-Oriented Primary Health Care. New York: Appleton-Century-Crofts.
3. Kark SL, Kark E. An alternative strategy in community health care: community-oriented primary health care. Isr J Med Sci 1983;19:707-713
4. King Edward's Hospital Fund for London and the Department of Social Medicine of the Hebrew University-Hadassah School of Public Health and Community Medicine. Community-Oriented Primary Care: A Resource for Developers. King's Fund, London, 1994.
5. Foz G, Gofin J, Montaner I. Atencion Primaria Orientada a la Comunidad: Una vision actual, In: Martin Zurro A, Cano Perez JF (Eds), Atencion Primaria-conceptos, organizacion y practica clinica, Sixth Edition, Textbook of Primary Care, Elsevier, Madrid, 2008 (in Spanish).
6. Mullan, F, Epstein L Community-Oriented Primary Care: New Relevance in a Changing World. Am J Public Health 2002; 92(11): 1748-1755.