Module 2 Flashcards
It is a system for providing health care
Healthcare Delivery System
Diagnosis, Treatment and Prevention of disease
and illness
Health Care
Health Care is influenced by:
- Socio-cultural factors
- Economic factors
- Health policies in place
Levels of Care
- Primary - Involves the community, primary healthcare facilities and community health workers
- Secondary – Health managed by District Health Hospital
- Tertiary – Referral to bigger hospitals
- ‐ Started by WHO
- ‐ Health centers are tasked to detect TB
- ‐ If confirmed, could be treated immediately
- ‐ Referred if MDR TB (multi-drug resistant)
TB-‐DOTS System (Tuberculosis–Directly Observed Treatment Shortcourse)
Philippine Health System
- DOH is the governing agency (est. in the 1990s)
and it provides:
- National policy direction
- National plan development
- Technical standards
- Health guidelines
Local Government Units (LGUs) were given autonomy in terms of financing and they can do what they want with the budget allocated to them
Decentralization
Robust financing system
- refers to “Total health expenditure by source”Sources of funding:
- ‐ National and local government
- ‐ Insurance
- ‐ Out-of-pocket (Most common!)
- ‐ Donors
Requirements of a Well-Functioning Health
System
- Robust financing system
- Well-trained and adequately paid workforce
- Reliable information
- Well-maintained health facilities
- refer to “Number of govt. health workers”
As of 2008, the Philippines have a total of:
- ‐ 2,838 Doctors
- ‐ 1,891 Dentists
- ‐ 4,576 Nurses
- ‐ 17,437 Midwives
Well-trained and adequately paid workforce
-‐ Sources: Computers, internet.. etc.
-‐ LGUs should provide these sources for the
Regional Health Units (RHUs)
Reliable information
- ‐ 40% are government hospitals
- ‐ 10% are DOH-managed
- ‐ 56% comes from Primary health facilities
Well-maintained health facilities
Health Facilities have 4 levels categorized according to the level of care
LEVEL 1 – PRIMARY care (emergency care and
treatment)
LEVEL 2 – PRIMARY care (the difference with level 1 is that it provides 24-hour care and is capable of minor surgery
and anesthesia)
LEVEL 3 – SECONDARY care (hospital with different
departments and has an ICU)
LEVEL 4 – TERTIARY care (hospital with departments and ICU and it is also a teaching/training hospital and has specialized/ subspecializedspecialized care)
-Started from the 1990s; target date: 2015
Millenium Development Goals
The 8 Millenium Development Goals
- Eradicate extreme poverty
- Achieve universal primary education
- Promote gender equality and empower women
- Reduce child mortality
- Improve maternal health
- Combat HIV/AIDS, Malaria and other diseases
- Ensure environmental sustainability
- Develop a global partnership for development
- ‐ Halve the population of people whose income is less than a dollar per day
- ‐ Achieve full and productive employment and decent work for all, including women and young people
- ‐ Halve the population of people suffering from hunger
Eradicate extreme poverty
-‐ All children will be able to complete a full course of
primary schooling by 2015
Achieve universal primary education
– eliminate gender disparity in primary and secondary education by 2005 and to all levels of education no later than 2015
Promote gender equality and empower women
-‐ Reduce by two-thirds (2/3), between 1990 and
2015, the “under-Five” mortality rate
Reduce child mortality
- ‐ Reduce by three-quarters (3/4), between 1990 and 2015, the maternal mortality ratio
- ‐ Achieve, by 2015, universal access to reproductive health
Improve maternal health
-‐ Have halted by 2015 and begun to reverse the
incidence of malaria and other major diseases
Combat HIV/AIDS, Malaria and other diseases
- ‐ Integrate the principles of sustainable development into country policies and programs to reverse the loss of environmental resources
- ‐ Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
- ‐ Halve, by 2015, the proportion of population without sustainable access to safe drinking water and improved sanitation
- ‐ By 2020, have achieved significant improvement in the lives of at least 100 million slum dwellers
Ensure environmental sustainability
-‐ Deal comprehensively with the debt problems of developing countries thru national and international measures in order to make debt sustainable in the long term
Develop a global partnership for development
(History)
– WHO Expert Committee on Professional and Technical Education and Medical Auxiliary Personnel met in Geneva. — Need to train Family doctors to serve as physicians of first contact with the patient, and that every medical student’s training should include exposure to family practice.
1962
(History)
– Millis Commission Report and Willard Report stated that there should be a specialty board, certification examination and diplomate status for physicians highly qualified in comprehensive care (total holistic care).
1966
(History)
WONCA (World Organization of National Colleges, Academies) was formally inaugurated. WONCA and Academic Associations of Family Physicians aka World Organization of Family Doctors.
1972
Objective of the World Organization of Family Doctors
To improve the quality of life of people of the world through fostering and maintaining high standards of care in family medicine.
(History)
WONCA arrived at a definition of Family Medicine.
1979
1961- Philippine Academy of General Practitioners was organized and ____ was the founding president
Dr. Ramon Angeles
1970- Recognition as a Specialty Society by ___
Philippine Medical Association (PMA)
1972- changed the name to ______
Philippine Academy of Family Physicians (PAFP)
Philippine Academy of Family Physicians (PAFP): Mission and Vision
Vision: Provide every Filipino family a physician, a family physician, to attain optimum family health
Mission: Optimum health and quality of life through family wellness programs
1974- First three year residency training program was established at ____
UP-PGH
1979- _____ was given and DOH recognition as a specialty
First Specialty Board qualifying examination
1986- Establishment of accredited three year residency training program at ____
UST- hospital
1990- Recognition of Family Medicine as a specialty by ___
Medicare
1997- Recognition by PMA as the mother specialty society in the field of ____
Family and Community Medicine
- Discipline of Medicine with distinct core of knowledge and characteristics of care, which refers to individuals, family and community, and functions within economic, cultural and social environments and resources.
- Family as a basic social unit
- Not only disease-oriented but health- oriented which emphasizes on the importance of disease prevention, health maintenance and curative medicine.
Family Medicine
Characteristics of Care of the Family Medicine are:
- Primary- first contact care
- Continuing- chronologically, geographically, interdisciplinary, and interpersonal
- Comprehensive
- Aspects of Care: Prevention, Curative, Rehabilitative
May it be at home, clinics, ambulatory, out-patient, and in the emergency room, there is always a family medicine doctor
Primary
chronologically: from womb to tomb
geographically: at home, clinic, hospitals
interdisciplinary: coordinate with other specialties in medicine and other non-health agencies
interpersonal: involvement of family in care and doctor-patient relationship (family is the greatest ally in the treatment
Continuing
deals not only the biological aspect of the disease but also the other factors resulting to the occurrence of the illness
Comprehensive
disease vs. illness
- disease: more of the pathophysiological/biological aspect or what happens in the person‟s body
- illness: includes subjective perception of the patient
Prevention: all levels of prevention with emphasis on health education
Curative: relief of symptoms, early diagnosis and treatment
Rehabilitative: assist the patient to go back into the society
Aspects of Care
Principles of Family Medicine
- The person, not the problem
- The patient’s context
- The preventive attitude
- The population at risk
- Community resources
- Integrating life
- Integrating work
- Subjective aspects of Medicine
- Resource management
- Family physicians are committed to the person rather than to a particular body of knowledge, group of diseases, or special technique.
- The commitment is open-ended in two reasons:
1. First, it is not limited by the type of health problem.
2. Second, the commitment has no defined end point. It is not terminated by cure of an illness, the end of a course of treatment, or the incurability of an illness.
- The commitment is open-ended in two reasons:
The person, not the problem
- The family physician seeks to understand the context of the illness.
- “To understand a thing rightly, we need to see it both out of its environment and in it, and to have acquaintance with the whole range of its variations” wrote William James.
- Why did the patient come?; Why did the patient come at this time?; What does the patient think is wrong?; How does the patient illness fit with his life situation and stage of development?
The patient’s context
- The family physician sees every contact with his patients as an opportunity for prevention or health education.
- What are this patient’s risk?; What can I do at this visit to promote his health or prevent disease?
The preventive attitude
- The family physician views his practice as a “population at risk”.
- Clinicians think normally in terms of single patients rather than population groups. Family physicians have to think in terms of both.
- It implies a commitment to maintain health whether or not they happen to be attending the office/ clinic.
The population at risk
– The family physician sees himself as part of a community-wide network of supportive and health care agencies.
Community resources
- Ideally, the family physician should share the same habitat as his patients.
- The Love Canal disaster in Niagara Falls provides a vivid illustration of what can happen when physicians are remote from the environment of their patients.
- E.g. Community immersions
Integrating life
- The family physician sees patients in their homes.
- Knowing the home gave us a tacit understanding of the context or ecology of illness
- The rise of the modern hospital removed much of this experience from the home. There were technical advantages and gains in efficiency, but the price was some impoverishment of the experience of family practice.
- Home Care
Integrating work
Benefits of Home Visits/ Home Care:
- It teach us how much background information can be obtained from patient and his family.
- It can show how many illness can be satisfactorily diagnosed and managed at home using very simple methods.
- It helps us in decision making with regards to hospital admission and help monitor recovery after discharge.
- The family physician attaches importance to the subjective aspects of medicine.
- Sensitivity to feelings and an insight into relationships
- Insight into relationships requires a knowledge of emotions, including our own emotions. Hence, family medicine should be a self-reflective practice.
Subjective aspects of Medicine
- The family physician is a manager of resources.
- As generalists and first-contact physicians, they have control of large resources and are able to control admission to hospital, use of investigations, prescription of treatment, and referral to specialists
Resource management
The Five- Star Physician
- Health Care Provider
- Researcher
- Educator
- Social Mobilizer
- Manager
- Considers the patient as an integral part of a family and the community
- Providing high standard clinical care
- Personalizes preventive care within a long-term, trusting relationship
Health Care Provider
- Chooses which technologies to apply ethically and cost- effectively
- Utilize evidence based medicine in the practice of profession, e.g. Clinical Practice Guidelines (CPG)
Researcher
- Promote healthy lifestyle by empathic explanation, thereby empowering individuals and group to enhance and protect their health.
- Health education is a process that bridges the gap between health and information.
- The ultimate goal of health education is the improvement of the nation’s health and the reduction of preventable illness, disability, and death.
- Clinical and community setting
Educator
- Pre- patient education directed at non- patients or pre-patients by educating about disease prevention and health promotion through pamphlets, magazine, media and other reading materials while in the waiting area.
- Patient education- informing the patient and significant other about their health problem and the need for them to participate in decision making and management of their illness.
Clinical Setting
Community Project (e.g. Mothers‟ Class, Lay Fora)
Community Setting
- Reconcile individual and community health requirements and initiate action on behalf of the community.
- Congruent in the core principle of Primary Health Care- People’s participation
- Catalyst role
Social Mobilizer
- Can work harmoniously with individuals and organizations, within and without the health care system, in order to meet his patients’ and communities’ needs.
- Knowledgeable in coordinating the timely referral of their patient, networking and linkages to different sectors of the government.
Manager
- Scientific model constructed to take into account the missing dimensions of the biomedical model.
- Enable the physician to extend the application of scientific methods to aspects of every day practice and patient care.
- Biomedical models of clinical medicine focus on pathophysiology and other biological approaches to disease, the biopsychosocial approach emphasize the importance of understanding human health and illness in their fullest contexts.
Bio-psychosocial Model
Systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery
Biopsychosocial approach
Bio-psychosocial Model systematically considers
BIOLOGICAL - Physiological/Anatomical, neurotransmitters, genetic factors, gender, age and ethnicity)
PSYCHOLOGICAL - Subjective perceptions, personality predisposition and their unique thought, feelings, and behaviors); what the patient understands about his/her disease (e.g. for a certain px, “acute” is synonymous to”fatal”)
SOCIAL FACTORS – Family, friends, societal expectations and available services, cultural background and environmen
Hierarchy of Natural Systems
Biosphere»Society-Nation»Culture-Subculture»
Community»Family»Two-Person»
Person(Experience and Behavior)»Nervous System»Organ/Organ System»
Tissues»Cells»Organelles»Molecules»
Atoms»Subatomic Particles
- Engel describes the commonsense observation that nature is a “hierarchically arranged continuum with its more complex, larger units superordinate on the less complex smaller units.“
- represents them schematically either as a vertical stack or as a nest of squares, with the simplest at the centre and the most complex on the outside.
Systems Theory
Subdivided the vertical stack into two stacks (Systems Theory)
1st (organismic hierarchy): person is the highest level
– starts with sub-atomic particles and ends with the individual person
2nd(social hierarchy): person is the lowest unit
– Starts with the person and finishes with the biosphere.
Principles of Systems theory
- Each level in the system is relatively autonomous. Thus a cell can be studies just as a cell.
- Each level depends on the level below. Thus a cell is composed of nuclei, mitochondria and all sorts of other organelles.
- Each level is a component of a higher system. Thus cells organise together to become tissues, and organs etc.
What is the family?
- Traditional:
- Group of 2 or more persons related by: Marriage; Adoption; Emotional ties
- Residing in a single household
Functions of families
- Physical maintenance and care of family members.
- Addition of new members.
- Socialization of children for adult roles.
- Social control of members.
- Maintenance of family morale.
- Production and consumption of goods and services.
Categories of Families
- Nuclear families
- Extended families
- Joint families
- Blended families
- Adoptive family
- Foster family
–Consists of the parents, and their dependent
children (if any).
– Only one family
Nuclear families
- Multigenerational
- The nuclear family, plus the in laws /nephews and nieces/cousins, etc., living in the same household
- Either unilaterally (from either the mother or the father’s side) or bilaterally (from both the mother and father’s side) extended
Extended families
– Similar to communal families – in a single house or compound, multiple families reside; the
parents take care of the other children, and the
children treat the other parents his/her own.
– Parents have authority to discipline the other
children.
– Common in rural areas in South East Asia
Joint families
- Remarried man and woman living together in a single household with their children from their previous marriages.
- Father, mother, children, child out of wedlock.
- Common in the US
Blended families
– Couples unable to have a child and decided to adopt (Permanent)
Adoptive family
- temporary
- is still classified as a family: a.) the family takes care of you; b.) you live in one household, and c.) you abide to their rule
Foster family
Attributes of a well-functioning family
- Role distinctions are clear.
- High degree of individuality.
- Rules are clear and reasonable.
- With good communication.
- Clear sense of authority.
- Able to express emotions.
- Able to resolve conflicts.
- There is sharing of tasks or chores.
- Uniqueness is accepted.
- With high esteem, both for self and family.
Impact of the family on illness
- Family»role models
- Decision making
- - Health seeking behavior
- - Therapeutic allies
Family Assessment Tools
- Family genogram
- Family APGAR
- SCREEM
- Family Lifeline
- To record family history through the lives of each member.
- Quick and useful contact to evaluate patient’s health risk.
- Family tree: Inheritance patterns; Family illnesses; Family members; Family structures; Emotional processes
Family Genogram
Parts of a Genogram
- Names and ages of all family members.
- Dates of significant life events.
- 3 or more generations
- Illnesses
- Indication of which family members live together in the same household
- Names of two families with the address of the index family
- The informants
- Date the genogram was generated
– Measures family functioning
– Patient’s perception and level of satisfaction on the
current state of his/her family
– Summarizes the history of a Family’s experiences
Family APGAR
Component of APGAR
ADAPTATION: Capability of the family to utilize and share inherent resources
PARTNERSHIP: Sharing of decision making; measures the satisfaction attained in solving problems by communicating
GROWTH: Emotional and physical growth; Measures the satisfaction of the available freedom to change
AFFECTION: How emotions are shared between members; Measures satisfaction with emotional interaction
RESOLVE: How time, space, money are shared; Measures the satisfaction with the commitment made by other members of the family
Family APGAR scoring and Interpretation of score
Scoring:
2 - Almost Always
1 - Some of the time
0 - Hardly ever
Total:
8-10 - Highly Functional
4-7 - Moderately dysfunctional
0-3 - Severely dysfunctional
- Summarizes the history of a family
- Family’s experiences
- Chronological
Family LIFELINE
- Represents family resources
- Helps identify and assess their resources
- Social, Cultural, Religious, Economic, Educational, Medical
SCREEM S – social C – cultural R – religious E – economic E – educational M – medical
Meaning of SREEM and Pathology 1
SOCIAL – social interaction is evident among family members
Pathology: The family is socially isolated from extra familial groups
CULTURAL – Cultural pride or satisfaction can be identified
Pathology: The family has feelings of cultural-ethnic inferiority or shame.
RELIGION – offers satisfying spiritual experiences
Pathology: Dogma and rituals are so rigid that they limit the family’s problem solving capacity
Meaning of SREEM and Pathology 2
ECONOMIC – ability to meet the economic demands of normal life events and illness.
Pathology: Financial problems make it difficult for the family to meet monetary demands of crisis or illness
EDUCATION – education of the family is adequate to allow members to solve and comprehend most of the problems
Pathology: Limit the ability of the family members to comprehend the problem or recommend the solution
MEDICAL – Medical care is available through channels that are easily established.
Pathology: Inaccessible and under utilized
– “A group of two or more persons related by birth, marriage, adoption, or emotional ties residing together in a single household..” (Burgess and Locke)
– It is primary social unit consisting of parents and children
Family
Six Essential Functions of Family
- Physical maintenance and care
- Procreation or adoption
- Socialization of children for adult roles
- Social control of members
- Maintenance of morale and motivation
- Production and consumption of goods and services
Effects of Family on Health
- Effects on Illness Behavior
- Effects on patients with long term illness
- Family and social networks promote health
- Dysfunctional families and poor parenting
- Learning of health-related behavior
- Family changes can affect health
- Stoic? Self-medicate? Seek alternative medicine? Effects on medical adherence?
- e.g. religion & health (faith healing, Jehovah’s Witness)
Effects on Illness Behavior:
– Quality of care provided by family members (female relatives as care providers for kids, husbands, in-laws and elderly parents)
Effects on patients with long term illness
– Socially isolated have poorer mental health; recover slower from sickness
Family and social networks promote health
- Child abuse – neglect, physical abuse, verbal abuse, sexual abuse
- Overindulgence
- Domestic violence
- Alcoholism and substance-abuse in the family
- Gambling problems
Dysfunctional families and poor parenting
“Troubled family that has a negative effect on the physical or psychological well-being of its individual family members”
The Dysfunctional Family
– e.g. quality of diet and health (including obesity), smoking and passive smoking, alcohol (religion & alcohol consumption), risk-taking behavior, values and behavior (including sexual behavior)
Learning of health-related behavior
– “Stressful life events” such as marital breakdown and divorce, death of spouse etc. increase risk of sickness for other family members
– Large families: can affect health of kids in a negative manner
Family changes can affect health
Effect of Sickness on the Family
- Effect of chronic disease or death
- Stress from taking care of sick family member
- Stigmatizing diseases such as HIV/AIDS
- Role changes: if the wife gets sick or dies, the husband has to adjust (or vice-versa)
- Economic pressures: family member stops work to care for the sick, patient is unable to work, medical bills become high
Effect of chronic disease or death
– e.g. Alzheimer’s disease, serious mental illness, relative who is bed-ridden or incontinent
Stress from taking care of sick family member
– e.g. hostility from neighbours, abandonment by own family
Stigmatizing diseases such as HIV/AIDS
Important Points 1
– The family defines for itself what good health means and consequently, what lifestyle to pursue
– Health habits and practices both good and bad, are taught and observed from one generation to the next
Important Points 2
– Whatever illness may beset a family member, particularly if it is potentially serious, complicated or life-threatening, will affect the entire family in varying degrees.
– Family is seen a system, wherein one part necessarily affects the another.
– When the illness impacts the family, the family also impacts the illness
- Understand the health and illness responses of patients and their families
- Delineates various developmental stages in the status of the families and describes the manner in which a family is functioning
- Can be related to clinical events and to health maintenance of the family
Learning the Family Life Cycle
- Occurs as one family member moves through different stages over a period of time
- Mastery of new skills
- Molds the identity of an individual
Adaptation
- A set of predictable steps or patterns and developmental tasks families undergo within a given time frame
- Emotional, psychosocial, physical changes
- Normal process of family development
Family Life Cycle
– Each stage is associated with a certain developmental task in order to proceed to the next stage
– Analyze and predict how illness will affect family psychodynamics and give appropriate psychosocial support
Family Life Cycle
– A time period in the life of a family that has a unique structure
Family Stage
– The shift from one family stage to another
Transition
Two Levels of Orders of Magnitude of Change
First order changes
Second order changes
- Involve increments of MASTERY AND ADAPTATION
- “NEED TO DO” something new
- No change in main structure of family
- No change in identity and self-image
- Additions to existing state of self and family
- Tasks that must be accomplished by the family and members working within a stage
First order changes
- Involve TRANSFORMATION of an INDIVIDUALS STATUS and MEANING
- “NEED TO BE” something new
- Change in very basic attributes of the family system
- Change in roles and identity of family members
- Occurs between stages
Second Order Changes
- Most widely used model
- Emotional Process of transition
- Changes in Family Status required to Proceed Developmentally
Six Stage Cycle
Six Stage Cycle
STAGE I -- Unattached Young Adult STAGE II -- Newly Married Couple STAGE III -- Family with Young Children STAGE IV -- Family with Adolescents STAGE V -- Launching Family STAGE VI -- Family in Later Years
STAGE I – Unattached Young Adult
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
– Accepting financial and emotional responsibility for oneself
CHANGES IN FAMILY STATUS REQUIRED TO PROCEED DEVELOPMENTALLY
(2nd order changes)
– Differentiation of self in relation to the family of origin
– Development of intimate peer relationships
– Establishment of self in relation to work and financial independence
Issues in Stage I
Address the ff:
- Proper nutrition
- Physical fitness
- Safe sex practice
STAGE II – Newly Married Couple
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
Commitment to the new system
SECOND ORDER CHANGES:
Formation of the marital system
Realignment of relationships with extended families and friends to include the spouse
Issues in Stage II
Clinical concerns include:
- Pregnancy
- Childbirth
- Infertility
Emotional/social:
– Problems relating to in-laws, demands of new role
STAGE III – Family with Young Children
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
Accepting new members into the system
SECOND ORDER CHANGES
- Adjusting the marital system to make space for children
- Joining un child-rearing and financial and household tasks
- Realignment of relationships with extended family to include parenting and grandparenting roles
Issues in Stage III
- Main medical problem revolves around childhood illness
- Immunization
- Preventive health
STAGE IV – Family with Adolescents
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
– Increasing flexibility of family boundaries to include children’s independence and grandparents’ frailties
CHANGES IN FAMILY STATUS REQUIRED TO PROCEED DEVELOPMENTALLY
(2nd order changes)
– Shifting of parent-child relationships to permit adolescents to move in and out of system
– Focus on midlife marital and career issues
Issues in Stage IV
- Clinical encounters may deal with stress brought about by gender identity and sexual orientation
- Peer pressure may also lead to problems such as drug dependence and smoking
STAGE V – Launching Family
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
Accepting multitude of exits from and entries into the system
(2nd order changes)
- Beginning shift toward joint caring for the older generation
- Renegotioation of marital system as a dyad
- Development of adult-adult relationships between grown up offspring and their parents
- Realignment of relationships to include in-laws and grandchildren
- Dealing with disabilities and death of grandparents
Issues in Stage V
- Hypertension
- Heart disease
- Arthritis
- Osteoporosis
- Menopause
- Weight problems
- Depression
STAGE VI – Family in Later Years
EMOTIONAL PROCESS OF TRANSITION: KEY PRINCIPLES
Accepting the shifting of generational roles
SECOND ORDER CHANGES
- Maintaining own and/or couple functioning and interests in the face of physiological decline; exploration of new familial and social roles
- Support for a more central role of middle generation
- Making room in the system for the wisdom and experience of the elderly and supporting the older generation
- Dealing with the loss of spouse, siblings and peers; preparation for one’s own death
- Life review and integration
Issues in Stage VI
- Degenerative conditions and debility
- - Depression
