Health Service Applications Community-Oriented Primary Care: A Process for School Health Intervention Stephen Barnett, Virginia Niebuhr, Constance Baldwin, Harold Levine

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rior to the 194Os, when infectious diseases posed the most serious threat to child health, the medical community focused primarily on physical wellbeing of children through immunization protection and improving early treatment of disease. Today, social and behavioral problems, compounded by economic scarcity, threaten the survival, development, and future productivity of youth. The battleground for the new “infections” lies in the community, particularly the schools. Teamwork between the health and education communities is essential to solve the complex problems that jeopardize the next generation of workers and leaders. An array of programs have been developed to reduce school failure or dropout by addressing problems in isolation, such as teen pregnancy, substance abuse, learning disabilities, or behavior/violence problems. Unfortunately, categorical programs address only parts of the problem, and their outcomes often have been poorly documented because of the public demand for quick remedies. As a result, these programs consume the time and energy of school staff without producing convincing results. Professionals need to address the complex problems of children and youth with comprehensive, preventive solutions using procedures appropriate and proven successful in the school environment. I One such approach, the Community-Oriented Primary Care (COPC) process,* provides a way to focus and coordinate the energy and resources of primary care practitioners, school districts, and community agencies. COPC combines the methods and experience of community medicine, health planning, applied general systems theory, descriptive epidemiology, and primary care.*” Though other school intervention processes have been described ,6.’ few have the power of COPC to focus on specific measurable outcomes for a target population.

THE COPC PROCESS COPC is a five-step problem-solving process that focuses on measurable outcomes.* The methodology Stephen Barnett, MD, Associate Professor; Virginia Niebuhr. PhD. Assistant Prof w o r ; Constance Baldwin, PhD. Assistant Professor; and Harold Levine, MPA. Professor, Depl. of Pediatrics, C-19. The University of Texas Medical Branch, Galveston. TX 77550. This article was submitted November 22, 1991, and revised and accepted for publication April 20. 1992.

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described and expanded by Nutting is designed to help a school or community assess the status of its environment and use some classical tools to determine where to go, how to get there, and later, whether a positive change has occurred (Figure 1). Step 1 - Community Involvement. Elements of the target community, both providers and consumers, need to participate in any interaction that affects community outcomes. The goal is to organize a representative group as inclusive as possible, but which can reach consensus and make a commitment to the team’s goals. Defining a consensus is a timeconsuming but necessary challenge. Consensus can be powerful, especially if the community has “squeaky wheels” impeding the process. Community involvement, the most crucial step, provides the energy, effort, and connections to make the subsequent steps successful. Step 2 - Definition and Quantification of the Target Population. Defining the boundaries of the target population is crucial. In descriptive epidemiology, this step is the definition of the denominator population. The target population may be all eighth grade students, a particular junior high school, a school district, or all school districts in a county. Step 3 - Definition of Problems in the Target Population. The COPC group must select and quantify problems using measurable indicators that are valid and reliable. The measures need to describe accurately the extent and severity of the problem. In descriptive epidemiology, this step is equivalent to defining the numerator, such as the sub-population that exemplifies the defined problem. With numerators and denominators identified, incidence rates can be established for defined time limits, making it possible to compare problems in one community with other communities, establish changes in incidence rates over time, and identify and prioritize problems. Step 4 - Identification of Interventions or Program Mod@kations. Program modification requires identifying interventions proven efficacious in other settings based on outcome data. Schools no longer can afford to adopt methodologies not documented to improve outcomes. Step 5 - Evaluation of Results from the Intervention. Prevalence or incidence of outcomes can be reviewed before and after program modification, and can be compared to similar measures elsewhere. Sim-

ilarly, changing the status of risk factors contributing to incidence or prevalence rates can be useful. Evaluation indicates whether the intervention has made a difference or whether to readjust the approach. Commitment to evaluation requires a substantial allocation of resources and energy. CASE STUDY A school district in Galveston County, Texas, has the larger share of multi-ethnic poverty. The population’s problems are chronic and inter-generational, and they have worsened with the economic recession and burnout of local service providers. While the school district has worked vigorously to address the segments of the district with high dropout and poor performance - the latest district manual for at-risk programs is at least an inch thick - affluent segments of the community, particularly the business community, have criticized the district for its failure to reverse the social deterioration. Among the many problems evident in the youth population, the local public health officer has identified teen pregnancy as the community’s most urgent problem. In Texas, 35% of school drop-out and its accompanying socioeconomic problems are attributed to teen pregnancy and parenthood.9 To address the growing crisis, the administration and district school board formed the Texas Community Collaboration Institute for Children and Youth with the assistance of The Danforth Foundation. As Step 1 of the COPC process, the group developed a broad-based, community team involving the business community, judicial system, community representatives of low-income families, health care, and social service providers. The group’s task was to inventory the community’s resources, identify key Figure 1 Five Steps of Community-Orlented Primary Care (COPC) Steps

Application in Care Study

1 .Community participation (Consensus)

a. Form a community collaborative (school, public health, social service. private sector, and lmal health science center) b.Survey students about needs, current sources of care, and types of needed care

Z.Define population (Denominator)

a. Define district’s school-aged children as target population

3.ldentify problem (Numerator)

a. Define problem as young women having children before 18th birthday b.ldenlify risk factors resulting in school-aged parenthood by survey

4.Monitor program (intervention)

a. Select school-based primary care as intervention with documented efficacy to reduce school-aged parenthood b.Establlsh joint venture of school district with private and public health and social service providers c. Identify and begin to eliminate student user barriers

!Monitor program (Evaluation)

a. Establish computerized database to monitor changes in risky behaviors associated with schwlaged parenthood and pregnancy outcomes b. Follow school-aged pregnancy and repeat pregnancy outcomes documented by local health district.

problems, and initiate solutions. Teen pregnancy and repeat pregnancy became a priority for the collaborative group. The collaborative group and the community’s health service providers agreed to address this problem and defined the “at risk” population as school-aged children in the school district catchment area (Step 2). School-age pregnancy was defined as any woman having her first baby before age 18 (Step 3). Incidence rates were calculated at 50% above the national average for school-age pregnancy; repeat pregnancy was 100% in excess of the national average. To expand the COPC process to the student body (Step l), the school district surveyed students using a questionnaire developed by the Support Center for School-Based Clinics.’O The survey assessed risk behaviors, particularly those associated with sexuality (Step 3) and student use of health services. Local option questions provided an opportunity to learn about desiredheeded services (Step 4). Because school-based clinics have been associated with reducing school-aged pregnancy,” the collaborative members supported and worked together to implement such an approach (Step 4). A joint partnership venture was launched which included a previously existing Teen Health Center managed by private practitioners, the health district, the school district, the Department of Human Services, and the school consultant from the local health science center. Partners contributed space, personnel, time, and obtained grants to underwrite start-up costs for the new school-based primary care center. In addition, the joint venture project established a computerized data system that will create a database to follow health status indicators, morbidity, and risk behaviors for the schools’ junior high and high school populations. The database, with outcome data from the local health district, will be used to track progress of the intervention, especially reductions in school-age pregnancy and associated behaviors (Step 5). The collaborative’s commitment to address results of the evaluation is essential; it lays the foundation for using outcomes of preventive interventions as benchmarks for progress, and dedicates the group to continuing to accept, reject, or modify the interventions as necessary.

CONCLUSION What then are the benefits of COPC to schools and school health practitioners? Despite the time and cost of initiating the process, COPC offers several compelling benefits. By building a community-based group of students, parents, faculty, administrators, and community leaders working in concert, COPC provides a consensus group that can support new innovations. This support is essential to initiate the comprehensive, resource-intensive solutions needed to address the complex problems of today’s youth.’ Small but vocal obstructionist groups will not have the persuasive data from Steps 2 and 3 of COPC, and thus are likely to be constrained in their ability to force limited solutions on the school and community. In the COPC process, only those who make a com-

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mitment to the goals earn the right to craft the intervention. Another advantage of COPC is that a school’s commitment to the process of measuring identified problems and outcomes, based on program interventions and changes, will provide concrete indicators of the success of its work. Few experiences are more professionally satisfying or rewarding than seeing measurable improvements in a population of children. Hard data are invaluable in generating support for budgetary expansions. It is much easier to obtain funding when problems that need to be addressed are expressed in precise quantitative terms. It also is much easier for a school district or other private or governmental entities to budget for efforts which documented effectiveness, To school health personnel and their colleagues who seek to address the complex health issues in schools, the five COPC steps can be implemented with the following considerations: Step 1. Adopt an egalitarian approach to school health that involves all who have a commitment to the team’s goals. Step 2. Appreciate and understand the usefulness and power of clearly defining populations to obtain comparable incidence/prevalence rates. Step 3. Agree to identify and address problems based on the extent of incidence/prevalence within the school district. Step 4. Select interventions previously tested and proven, but tailored to the local environment before

launching a new, untested intervention. Step 5 . Become knowledgeable about the strengths and weaknesses of program monitoring/evaluation, w especially the use of outcome measures. References 1. Shorr L. Within Our Reach: Breaking the cycle of disad-

vantage. New York, NY: Anchor Press; 1988. 2. Kark SL. Community Oriented Primary Health Care. New York, NY: Appleton-Century-Crofts; 1981. 3. Boufford JI, Shonubi PA. Community Oriented Primary Care: Trainingfor urban practice. New York, NY: Praeger; 1986. 4. Nutting PA. Connor EM. Community oriented primary care: An examination of the US experience. Am J Public Health. 1986;76(3):279-281. 5. Reed FM. The school-age community: Addressing a predefined population. In Nutting PA, ed. Community Oriented Primary Care: From principle to practice. Washington, DC: US Dept of Health and Human Services, Health Resources and Service Administration publication HRSA-PE 86-1;1987. 6. Howell K. Establishing and Maintaining School Health Advisory Councils. Greensboro, NC: University of North Carolina School Health Training Center; 1991. 7. Killip D. Integrated school and community programs. J Sch Health. l987;57(10):437-444. 8. Nutting PA. Community oriented primary care: An integrated model for practice, research, and evaluation. Am J Prev Med. 1986;2(3):140-147. 9. T am Teen Fact Sheet. Austin. Texas: Texas Dept of Human Services, School-Age Pregnancy Clearinghouse; 1990. 10. Kirby D. An Assessment of Six School-Based Clinics: Services, impact. and potential. Washington, DC: Center for Population Options; 1989. 11. US Congress, Office of Technology Assessment. Healthy Children: Investing in the future. Washington, DC: US Government Printing Office; 1986.

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Community-oriented primary care: a process for school health intervention.

Health Service Applications Community-Oriented Primary Care: A Process for School Health Intervention Stephen Barnett, Virginia Niebuhr, Constance Bal...
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