Journal of Nursing Education

An Integrative Review Illuminates Curricular Applications of Primary Health Care

Judith MacIntosh, MSc(A), RN; Dianne McCormack, MSc, RN

Abstract

ABSTRACT

The International Council of Nurses supported primary health care and advocated its acceptance by other intersectorial stakeholders. Nurse educators involved in curriculum development have respected this direction. To pursue the primary health care vision and influence the adoption of primary health care delivery systems, all principles of primary health care must be implemented simultaneously. An integrative review was conducted to ascertain the interpretation of primary health care held by nurse authors. A content analysis of the nursing literature revealed that 184 of the 254 articles retrieved (72%), applied primary health care in a manner that is consistent with the World Health Organization (WHO) definition. Through curricular applications of different interpretations of the primary health care principles, differences in the created learning environment are discussed.

The Declaration of Alma Ata, evolving from beliefs and values shared by 134 member nations present at the Assembly, delineated that primary health care was the accepted infrastructure to guide policies that direct health care delivery systems regardless of the context in the country (WHO, 1978). Even with this overwhelming endorsement, very few countries have made changes in policies and infrastructure for implementing the underlying values and beliefs ascribed in primary health care. Changes that have occurred have not been organized around the vision or the principles of primary health care. This delay has had, and will continue to have, a huge impact on nursing education, practice, and research. Nurses are interested in helping people attain, maintain, or regain health; primary health care has the potential to achieve health for all citizens of the world.

Abstract

ABSTRACT

The International Council of Nurses supported primary health care and advocated its acceptance by other intersectorial stakeholders. Nurse educators involved in curriculum development have respected this direction. To pursue the primary health care vision and influence the adoption of primary health care delivery systems, all principles of primary health care must be implemented simultaneously. An integrative review was conducted to ascertain the interpretation of primary health care held by nurse authors. A content analysis of the nursing literature revealed that 184 of the 254 articles retrieved (72%), applied primary health care in a manner that is consistent with the World Health Organization (WHO) definition. Through curricular applications of different interpretations of the primary health care principles, differences in the created learning environment are discussed.

The Declaration of Alma Ata, evolving from beliefs and values shared by 134 member nations present at the Assembly, delineated that primary health care was the accepted infrastructure to guide policies that direct health care delivery systems regardless of the context in the country (WHO, 1978). Even with this overwhelming endorsement, very few countries have made changes in policies and infrastructure for implementing the underlying values and beliefs ascribed in primary health care. Changes that have occurred have not been organized around the vision or the principles of primary health care. This delay has had, and will continue to have, a huge impact on nursing education, practice, and research. Nurses are interested in helping people attain, maintain, or regain health; primary health care has the potential to achieve health for all citizens of the world.

INTERPRETING PRIMARY HEALTH CARE POUCY

The International Council of Nurses (ICN) and member organizations embraced the concept and advocated that primary health care direct the health care delivery systems (ICN, 1988). Nurse educators have been examining and testing out strategies that integrate the primary health care concept in nursing curricula. The primary health care paradigm, or world view, encompasses a philosophy of care, a way of delivering health care, a strategy to achieve health for all, and a guide to direct health care reform (Aldaba-Lim, 1982; Chime, 1990; Choongo, 1990; Collado, 1992; Powell, 1986). The WHO defined primary health care as:

. . . essential health care based on practical scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost the community and the country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. . . (WHO, 1978, p. 3)

Defining Elements of Primary Health Care

The defining elements of primary health care, commonly known as the five principles, are derived from this definition. A primary health care delivery system is operationalized by these five principles while being responsive to the country's context: providing direction for health care reform. Primary health care encompasses the essential components of promotive, preventive, curative, supportive, and rehabilitative care. Health promotion and illness and injury prevention are emphasized in a primary health care delivery system but access to care for individuals, families, and communities is assured through each essential component of care (ICN, 1988). It is expected that acceptable and appropriate methods and technologies demonstrate effectiveness in addressing a known health challenge. Although the preferred method for testing outcomes is the scientific method, other acceptable ways of knowing include authority and tradition, inspiration and intuition, trial and error, and logical problem solving (Wilson, 1989). In a primary health care delivery system, full client participation is not only respected but also encouraged and supported. Through negotiating and networking, clients and health care providers form partnerships with people from other sectors so that essential health care needs are addressed.

Challenges and Opportunities

There are challenges and opportunities in respecting the integrity of this approach to health care delivery. One challenge is highlighted when implementing the five principles simultaneously while one opportunity lies in implementing the principles in a way that supports the development of the country's resources. Because primary health care reflects the essential health care needs of citizens, it is expected that services addressing the determinants of health will differ between countries and even between regions within the same country. Subsequently, a nursing curriculum based on primary health care is reflective of the context of the community and the country in which it is offered, but connecting the principles of primary health care into an integrated whole is a challenge all nurse educators need to embrace.

Discussions with nurses revealed that the concept of primary health care and its principles were not consistently interpreted despite the clear articulation by the WHO. Differences in interpretation may have evolved from the use of the word primary in several concepts: namely, primary health care, primary care, and primary nursing. Although each of these concepts is distinct, the similarity of the language has created potential for confusion, resulting in interchange among very distinct concepts.

A review of the defining elements of these concepts demonstrates their differences. Primary care is initial care offered by physicians or nurses to address common medical conditions, illnesses, and injuries. Basically, primary care is illness oriented (Innes, 1987; Powell, 1986; Yapchiongco, 1984). In contrast, primary nursing is a strategy in which nurses are responsible for initial assessment and for providing comprehensive 24-hour nursing care to clients during hospitalization (Dier, 1986; Innes, 1987; Stacy, Down & Donaghue, 1986). Clearly, these concepts are different from each other and from the WHO definition of primary health care as previously described.

Another source of misconception may have originated from the proposed application that primary health care was inclusive of the first point of access to health services. However, the ICN has espoused that

. . . primary health care is not limited to primary prevention or treatment, to the initial contact, or to primary settings. The Alma Ata declaration explicitly provides for curative and rehabilitative services (secondary and tertiary levels of prevention or treatment). . . The treatment of prevailing health problems, not all of which can be done simply on an out-patient basis, suggests that primary health care extends into other settings beyond 'primary' settings (ICN, 1988, p. 1).

INTEGRATIVE REVIEW PROCESS

Varying interpretations of the primary health care concept were the impetus to carry out a modified integrative review of the published nursing literature. A search of one nursing data base- Cumulative Index of Nursing and Allied Health Literature on CD-ROM Information Retrieval System on Silver Platter- revealed that nurses have a demonstrated interest in the primary health care concept (Macintosh & McCormack, 1995). An examination of citations retrieved when searching the words primary health care indicated that nurse authors from Africa, Asia, Australia and New Zealand, North America, South America, and Europe have shared their experiences in testing out the primary health care concept in education (Anderson, 1987; Collins & Hammond, 1986; Davis & Deitrick, 1987; Edwards & Tompkins, 1988; Hernando, 1982; Jato, 1982; Mazibuko, 1989; Ngubeni & HUl, 1986; Reid, 1982; Yamba, 1990; Yu, 1992), in practice (BailonReyes, 1990; Ennever & Standard, 1983; Khanye & Ratsaka, 1989; Krebs, 1983; Mardiros, 1987; McConnell, Inderbitzin, & Pollard, 1992; Ndulo, 1990; Shaw, 1986; Tobin, 1987; Truscott, 1990; Wilson, 1991; Wuest & Stern, 1991), in research (Bjorn, 1986; Flynn, 1984; Lara, 1990; Onyejiaku, Hölzerner, Morrow, Olabode, & Rogers, 1990; Pacis, 1991), and in administration (Chamberlain & Beckingham, 1987; Choongo, 1990; Iu, 1987; Nisce, 1982; Rao, 1984).

Delimiting Criteria

As directed by Rodgers & Knafl (1993), the integrative review process is guided by a broad research question that delimits the literature retrieved for examination. The research question directing this review was: what interpretation of primary health care is espoused by nurses in the published nursing literature? The explicit delimiting criteria were based upon five assumptions:

1. Articles containing the phrase primary health care in the title appropriately described and applied that concept.

2. Authors identified the central concept of an article in the title.

3. A search of one comprehensive electronic data base provided an acceptable sample of the literature.

4. A four-year period after the Alma Ata Assembly allowed adequate time for articles about primary health care to appear in the published literature.

5. A review of the literature that spanned a decade, 1982-1992, was a reliable indicator of the interpretation of primary health care held by nurses.

Inclusion Criteria

The inclusion criteria for this integrative review of the literature directed the retrieval of articles that had the words primary health care in the title; were written in the English language; were written by nurse authors; were published between 1982 and 1992; and were listed in the designated electronic data base. The electronic literature search is identified as one of the seven information locating methods discussed in the literature (Curlette & Cannella, 1985). Applying these inclusion criteria resulted in a data base of 254 articles.

Analysis of Articles Retrieved

A grid was developed to guide the content analysis of the articles retrieved. Both the definition of primary health care and its philosophical underpinnings were examined. The observed similarities and differences with the primary health care concept as defined by the WHO were noted and described. All five primary health care principles outlined in the WHO definition were delineated, and the authors' implicit and explicit meanings were discerned. Also examined were aspects of the nursing role as defined by the WHO: teacher or educator, direct care provider, researcher or evaluator, and supervisor or manager (WHO, 1986). Inter-rater reliability of this coding system was calculated at 96%.

FINDINGS

This examination reveals that 184 of the 254 articles retrieved, or 72%, apply primary health care in a manner that is consistent with the WHO definition. The remaining 70 articles, or 28%, reveal an inconsistency with the WHO- approximately 1 in every 4 articles examined. In this analysis, in the category of articles inconsistent with the WHO definition, the concept of primary health care was found to be interchanged with primary care, community health nursing, and selective primary health care.

Distinguishing Between Primary Health Care and Primary Care

In 46 of the 70 articles, or 65%, inconsistent with the WHO, the concept of primary health care is used interchangeably with the concept of primary care. Primary care

... is a medical care concept and is commonly thought of as front-line medicine. Essentially, it denotes first contact by physicians and their control of patient entry to insured services (Innes, 1987, p. 17).

Most of these authors refer to care delivered through medical practices. Some of the authors indicate that nurses have been employed to assist in providing patient services. Most of these authors discuss multidisciplinary health care teams restricted to doctors and nurses. In primary health care, intersectorial teams involving stakeholders from other sectors in society and clients are included.

Other authors of articles in this category suggest that nursing practice needs to be the gatekeeper to the health care delivery system. In primary health care, nurses may be one of the many access points, because other members of the health care team may be chosen by the client. In a primary health care practice, clients direct their own health care. However, the care described by these authors is not determined by clients. The health care provider is expert and there is no evidence of full community participation in the assessment, planning, and delivery of health care services.

The principles of universal accessibility, an intersectorial approach, and community participation are not evident within these articles. The implementation of the principle of socially acceptable, scientifically sound, and affordable delivery methods and technology is questionable in that client input is not considered. However, these articles describe all aspects of essential health care.

Distinguishing Between Primary Health Care and Community Health Nursing

A second concept that is used interchangeably with primary health care in this database is that of community health nursing. Of the 70 articles, 15, or 21%, view the existing practices of commiuiity health nurses as primary health care. Community health nursing is

... an art and a science that synthesizes knowledge from the public health sciences and professional nursing theories. Its goal is to promote and preserve the health of populations and is directed to communities, groups, families, and individuals across their lifespan, in a continuous rather than episodic process (The Canadian Public Health Association, 1990, p. 3).

Because these nurses work in a community setting and have been involved in health promotion and disease prevention, these authors assume that all principles of primary health care are guiding nursing practice.

However, the content of these articles excludes curative aspects of care, and most exclude full community participation in decision making regarding assessment, planning, and implementation of programs. The community health nurse is considered the expert in the health needs of community members, leaving clients with little, or no, input. The continued offering of government-approved programs without community input is evident. In other articles, interdisciplinary aspects of care and intersectorial involvement are missing.

These differences illustrate that essential health care, community participation, and an intersectorial approach are not respected. Because client participation has not been sought, both accessibility and strategies used to address health promotion and illness prevention may not be acceptable to clients even though health care providers perceive them to be appropriate. In these ways, the practice of community health nurses deviates from the principles of primary health care.

Distinguishing Between Primary Health Care and Selective Primary Health Care

Selective primary health care was described in 9 articíes, or 12%. Selective primary health care is philosophically consistent with the WHO definition of primary health care but selective in partially enacting the concept. Only one or two of the primary health care principles are operationalized to the exclusion of the others. The authors relate that this orientation is accepted because of the perceived difficulty in implementing primary health care within the economic constraints of the country and the expected time frames. Thus, selective primary health care is seen as a realistic way of providing the greatest improvement in health for the most people at the lowest cost.

However, selective primary health care differs from the WHO description in its implementation. The WHO directs that all principles be implemented simultaneously rather than selecting the most feasible of these principles (WHO, 1978).

APPLICATION OF FINDINGS

Learning Environment

Any nursing curriculum based on selective primary health care must not be interpreted as a curriculum guided by primary health care. The absence of any one of the primary health care principles results in the creation of a different learning environment. Even when all principles are implemented simultaneously, varying interpretations of any one principle can result in selective primary health care and can generate differences in the created learning environment. The implications of varying interpretations of primary health care principles are illustrated through two curricular applications. One application reflects the potential totality of each primary health care principle; a comprehensive view that is inclusive. The other application reveals a limited view of that principle; a narrow view that does not respect the philosophical intention of the principle.

Essential Health Care

Essential health care includes promotive, preventive, curative, rehabilitative, and supportive care ensuring that the essential health care needs of clients are addressed. The client may be an individual, a family, or a community.

In a comprehensive curriculum, students are educated to respond to essential health care needs identified by clients in any setting. Students in this curriculum develop competencies that enable them to respond to any promotive, preventive, curative, rehabilitative, and supportive health care need expressed by clients. Although it is recognized that the focus of nursing practice is health promotion and disease and injury prevention, nurses are educated to respond to any identified essential health care need at all levels of care; primary, secondary, and tertiary.

In a more limited interpretation, the focus of nursing education might be limited to health promotion and disease and injury prevention. This interpretation of essential health care excludes rehabilitative, supportive, and curative nursing care. The student develops competencies at the primary prevention level of care only. This curriculum does not direct educators to expose students to practice opportunities at the secondary and tertiary levels of care. Similarly, if the interpretation is limited to first contact, all institutionalized nursing is eliminated.

Universal Accessibility

Within primary health care, universal accessibility includes having health care "geographically, financially, culturally, and functionally within easy reach of the whole community" (WHO, 1978, p. 58). Clients must have reasonable access to the most appropriate health care provider. Communities need to define reasonable access and to seek health solutions by adopting a collaborative effort across community sectors. The health sector is not exclusively responsible for solving access issues within communities. As suggested earlier, nurses may be one of the many access points, but other members of the community may be chosen by the client.

In a comprehensive primary health care nursing curriculum, students are not only prepared to be gatekeepers in the health care delivery system but also to accept from, and to make referrals to, a diverse group of professionals. Nurse educators guide students so that competencies are developed through collaboration with stakeholders. Using this approach students learn to assess, prioritize and plan care, refer, share information, and facilitate decision making. All members of the health care team, including the client, bring knowledge and skills to the setting. Nurses are educated to collaborate and to respect the contributions of all team members. Access to care is facilitated through an egalitarian approach. Team members trust that choices made by clients reflect their understanding of the situation; however, team members also trust that if the provider selected requires consultation from another team member, that will occur. Turf protection is not an issue.

In a limited interpretation, students are educated to be gatekeepers. As gatekeepers to the health care system, nurses do not need to know how to receive and respond to referrals. A gatekeeper is burdened with being a decision-maker and an expert while the client is expected to comply; to be a passive recipient of health care services. This approach to care creates a social distance that ultimately decreases accessibility. Students develop competencies in independently assessing, prioritizing and planning care, referring, decision-making, guarding and controlling information, and implementing solutions for clients. In this curriculum, students are educated to develop a plan of care for the client. Compliance becomes an issue to be considered.

Socially Acceptable, Scientifically Sound and Affordable Delivery Methods and Technology

This principle recognizes that methods, techniques, and equipment must be scientifically sound, be in keeping with the accepted cultural values of the community, be affordable, and be able to address adequately a known health care challenge (Macintosh & McCormack, 1994). This principle implies that nursing practice is grounded in research, including measuring the effectiveness of nursing interventions.

In the comprehensive primary health care curriculum, students develop competencies to think critically, to analyze nursing interventions, and to provide appropriate, culturally sensitive, nursing care. Empirical indicators that have been tested for cost-utility in addressing known health challenges constitute the nursing care provided (Vail, 1995). Where empirical indicators have not been tested, this critical way of looking at the world directs students to identify research questions in practice and to market these research questions to, or partner with, nurse researchers so that the gaps are examined scientifically. To ascertain whether methods and technologies address known health care challenges, nurses take initiative to examine client outcomes. Evaluation processes become central within the curriculum. The process of critical thinking begins with cognition and moves into action.

In a more limited interpretation, students might be educated to accept all technological advances without consideration for cost, effectiveness, and acceptability to the client. There is a high risk of this interpretation in a society that values technical over human development. Students in this curriculum develop competencies that reflect the new technologies and methods accepted. These students do not need to develop competencies in critical thinking.

Full Community Participation

Full community participation attends to client values, interests, and concerns. Clients actively participate in assessing, planning, implementing, and evaluating health care from both a personal and a systems perspective. Students apply this principle when working with individuals, families, or communities.

Community parameters may include linguistic, geographic or cultural determinants but the community itself must be an equal partner involved in identifying those common values, interests and concerns. . . A sense of community ownership fosters full participation in decision making (Macintosh & McCormack, 1994, p. 11).

In a comprehensive primary health care curriculum, students develop competencies in building relationships with clients, in engaging and negotiating with clients as equal partners, and in group dynamics. In partnering with clients, students respect client competencies, client decisions, client-initiated strategies to improve health, and client criteria for evaluating care. Students learn to create safe environments that enable clients to take risks in sharing their knowledge and skills. In turn, students learn to take risks in offering for critique nurse-initiated strategies based on their knowledge and skills.

Students are accountable to clients. Sometimes clients are willing partners; other times clients may not wish to participate actively in certain aspects of care. Students learn to recognize these cues and to explore with clients issues related to timing, safe environment, or information. Students are taught to respect clients who may not choose to, or who are unable to, be active participants in care.

In a more limited interpretation of this principle, students develop competencies in accepting client input into decision making, in acknowledging client suggestions in nurse-initiated strategies, and in developing evaluation criteria to which clients may respond. Clients become token partners by giving the perception that client input is sought and used while reinforcing their passive participation. In this curriculum, students trust that their expert knowledge and skills lead to appropriate decisions for clients. Because clients are passive participants and are not encouraged to challenge decisions, care is not consistently acceptable to clients. Therefore, students learn strategies that address noncompliance but do not need to engage in risk-taking behavior that supports the critique of nursing interventions.

Intersectorial Approach

Within an intersectorial approach professionals from the various sectors in society work interdependently with community members to promote the health of the community (WHO, 1978). Intersectorial collaboration involves people from all sectors including health professionals, economists, politicians, housing experts, social workers, traditional healers, and others. Team members influence the health of the community through actively participating in assessing, planning, implementing, and evaluating health care (Macintosh & McCormack, 1994).

In a comprehensive primary health care curriculum, students develop competencies in negotiating, networking, and working effectively as a group. Nurse educators create learning environments that provide students with opportunities to practice being a group. Students develop competencies to act on their observations within groups, to critique group dynamics, and to develop partnerships with people from other sectors and with clients. These partnerships generate appropriate and acceptable care. Adherence or compliance is not an issue when partners plan care.

Students learn to work in intersectorial teams; that is, working interdependently to achieve a common purpose. In an advanced nursing practice situation, students learn to work using a nonsectorial approach; that is, individuals from all sectors work together as an integrated whole toward a common purpose, moving beyond collaboration.

In a more limited interpretation, students develop competencies in recognizing group dynamics, roles of group members, functions of groups, and how to observe and to evaluate the behavior of group members. In this curriculum, practice opportunities do not challenge students beyond acting as individuals within a group. Students learn to work in multidisciplinary, multiprofessional, and multisectorial teams; that is, students learn competencies to work independently within the team to achieve a common purpose.

IMPLICATIONS

For purposes of illustration, each primary health care principle has been discussed separately. It is recognized that primary health care is an integrated whole and all principles of primary health care are implemented simultaneously. However, curricula guided by primary health care create learning experiences that differ from those experiences created when the philosophical intention of principles is not respected. The comprehensive curricular application respects the WHO definition of primary health care in its totality while the limited application restricts nursing education, and subsequently nursing practice.

The two diverse curricular applications shape the scope of nursing practice differently; beginning with defining essential health care needs, to describing reasonable access, to analyzing acceptable and appropriate methods and technologies, to describing processes of involving clients in care, to moving beyond multidisciplinary to intersectorial partnerships. The two curricular applications illustrate that diversity in values and beliefs influence the enactment of primary health care.

The role of nursing within society is influenced by the interpretation of foundational curriculum concepts. Primary health care is one example of a foundational concept. It is essential that educators developing nursing curricula based on primary health care clarify the meaning of each of the principles and understand the inherent implications of these interpretations; remembering that the whole, the primary health care concept, is equal to, but greater than, the sum of its parts.

Nurse educators need to speak a common language and to share their understanding of primary health care so that students develop confidence in recognizing and in articulating the concept. This conceptualization and articulation is essential because all nurses need to monitor the implementation of primary health care so that selective primary health care does not go unnoticed. Hirschfeld (1992) identified that nursing's

. . . first challenge is that education, practice, and management must be developed jointly. Education must prepare for better practice, and practice must make sound and relevant education possible. This must be guided and made possible through competent management, which encompasses the education and practice fields (p. 2).

Health care delivery systems guided by primary health care require changes in interactions between providers and consumers of health care. Nurses and other providers move from the dominant positions of expert to egalitarian positions of active participants. Consumers move from merely complying with proposed treatments to active participants. Passive participation is no longer an acceptable position for consumers of primary health care. Both consumers and providers form partnerships that enable consumers to reach their health care goals.

All stakeholders need to become aware of their particular responsibilities, and be enabled to act on these responsibilities within the partnership. Health must become an item on the agenda of all sectors in society. Communication pathways that link sectors and enable the development of intersectorial partnerships are needed. During this time of health care reform primary health care needs to be considered and tested.

This integrative review of the primary health care literature reflects the published work of nurses during a ten year period. Nurses have continued to publish their understanding of, and experiences with, primary health care indicating that primary health care continues to be relevant (Astedt-Kurki & Koponen, 1994; Bac, 1993; Barnes, Eribes, Juarbe, Nelson, Proctor, Sawyer, Shaul, & Meléis, 1995; Beddome, Clarke, & Whyte, 1993; Bray & Edwards, 1994; Brumwell, 1994; Burdette, 1993; Cook, 1993; Downe-Wamboldt, 1994; Dykeman & Ervin, 1993; Hall, 1993; Kerr, 1993; Macintosh & McCormack, 1994; Meagher-Stewart, 1994; Methen, 1993; Ntoane, 1993; Parent & Arsenault, 1994; Poulton & West, 1993; Quillian, 1993; St. John, 1993).

Implementation of primary health care 20 years after Alma Ata remains sporadic and confusing. Yet the primary health care paradigm respects the values and beliefs of diverse societies; providing an opportunity for global partnerships that lead to achieving health for all.

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