Commentary: in search of innovative approaches to international health.

The community health program of the Aga Khan University in Pakistan is reviewed from the perspective of historic and present-day developments in primary health care based in and focused on the community. The approach commonly referred to as community-oriented primary health care involves the complementary functions of clinical practice and epidemiology in partnership with the community. Encouragement and support by governments and other organizations for teaching and research in this field would ensure more adequate preparation of future practitioners and health scientists for community-oriented primary health care and would lead to improved health. Continuity of support for community health programs is important.

An alternative strategy in community health care: community-oriented primary health care.

The need for alternative strategies in providing personal health services in the community is discussed in relation to Israel, which has a widespread network of community-based curative clinics and preventive family health centers. Community-oriented primary health care (C-OPHC) is the major alternative strategy, which has been developed and evaluated by the Hadassah Teaching and Research Health Center in Kiryat Hayovel, a neighborhood of Jerusalem. The case for adapting this C-OPHC approach throughout the country is presented in a review of existing primary health care services.

PIP: Community-oriented primary health care (COPHC), which coordinates individual clinical care and community medicine, requires a change in both orientation and skills. Although Israel has a network of over 2000 community-based curative clinics and preventive family health centers, they are not necessarily community-oriented facilities. The increasing age of Israel's population and the prevalence of chronic diseases in younger age groups indicate a need for integration of health and personal social services in the community. This strategy has been implemented at the Jerusalem Kiryat Hayovel Teaching and Research Health Center. 1 of its programs aimed to reduce the gap in intelligence and development quotients between infants of poorly educated mothers and those with more educated mothers. All children in the community served by the health center's maternal and child health service were involved. Other interventions at this center have focused on family formation and reproduction, infant and child health, control of cardiovascular diseases, and surveillance of acute infectious illness. Among the important features of COPHC are the following: 1) definition of the population; 2) defined community health programs; 3) use of epidemiologic and clinical skills as complementary functions; 4) accessibility; 5) involvement of the community in the promotion of its health; 6) coordination of activities, including the integration of different types of health care, specialties, services, and instritutions; and 7) a comprehensive approach to health care. In countries such as Israel, the community medicine orientation can be integrated into existing primary care practice. The Israel experience demonstrates several encouraging trends. 1st, the scope of preventive maternal and child health centers has been widened to family health centers, which now include care of the aged, chronically ill, and mentally ill. 2nd, community programs focused on the prevention and control of risk factors for cardiovascular diseases have been implemented. 3rd, the need for an appropriately trained staff has been recognized. All 4 medical schools in Israel have facilties for students to participate in community-based primary care. Research and controlled trials on the development of community health care and its effectiveness and suitability in the different communities of the country are needed.

Prevalence of selected health characteristics of women and comparisons with men. A community health survey in Jerusalem.

The health status of women was studied as part of a community health survey in Kiryat Hayovel, a neighborhood in western Jerusalem. Most women (66%) reported that they felt well; clinical appraisals indicated a need for treatment in 34%. Hypertension was found in 14% and coronary heart disease in 4%. Other common disorders included varicose veins (31%), overweight (25%), hemorrhoids (20%), hypercholesterolemia (15%), gallbladder disease (8%), and diabetes (4%). Prevalence of symptoms of emotional ill-health ranged from 6 to 40%. A quarter reported serious current problems, 10% were dissatisfied with their present life situation, 8% had concentration camp experience and 27% were current cigarette smokers. Prevalence of most disorders rose in successive age groups. Comparisons with the men in this community indicated a higher prevalence among females of self-appraised ill-health, high symptom and emotional ill-health scores and complaints about a number of physical conditions. This way reflect how women in this community respond to illness and their life situation. With some exceptions, age trends and sex differences were similar to those found in population studies in the USA.

Community diagnosis of physical growth of infants based on monitoring in a routine preventive service.

The physical growth pattern of infants aged from one month to two years was studied in a lower middle class community in Jerusalem. Weight and length were measured at one month and at three, six, 12, and 24 months. In each age and sex group there were at least 200 children. At one month and 24 months the percentage of children below the 10th percentile for weight and also for length was higher than expected, although severely impaired linear growth was observed in only 0.5% of males and 1.3% of females at 24 months. The percentage of overweight infants was highest at three months (6.2% of males and 5.2% females). In the light of these findings, we discuss the feasibility of accurate monitoring of physical growth in maternal and child health clinics; the possibility of an association between maternal stature and the high percentage of children below the 10th percentile for length; and the association between food intake and growth pattern.

A community health study in Jerusalem. Design and response.

A longitudinal community health study was commenced in a neighborhood of western Jerusalem in 1969. Its main aims were the investigation of etiologic factors in selected common diseases and disabilities, the development and testing of epidemiologic tools for use in community diagnosis, the provision of a factual basis for decisions concerning community health care for the population studied, and the use of the findings in an evaluation of the effectiveness of community health care. In the first round, 90% of residents 25 or more years old were interviewed and 81% were examined. Among children under 15 years of age, the corresponding rates were 94 and 83%. Response was low among persons in the age range 15 to 24 years, especially males. People who were concerned about their health were readier to be examined. Response was not related to region of birth, education or other variables. The possible bias introduced by nonresponse appeared to be small except in the age group 15 to 24 years.

Prevalence of selected health characteristics of men. A community health survey in Jerusalem.

The health status of males aged 15 or more years was studied as part of a community health survey in a neighborhood of western Jerusalem. Most subjects (75%) reported that they felt well; clinical appraisals revealed a need for treatment in 33%. Hypertension was found in 14% and coronary heart disease in 6%. Other common disorders included hemorrhoids (16%), varicose veins (11%), overweight (18%), hypercholesterolemia (13%), inguinal hernia (13%), symptoms of prostatic hypertrophy (10%) and diabetes (5%). The prevalence of specific symptoms of emotional ill health ranged from 6 to 23%. A quarter reported serious current problems; 10% were dissatisfied with their present life situation; and 10% had concentration camp experience. Half were current cigarette smokers. The prevalence of most disorders rose in successive age groups. Mean diastolic blood pressure, serum cholesterol, relative weight and the prevalence of cigarette smoking were lower in the oldest age groups. With some exceptions, the age trends were similar to those found in other populations.

Variation in the sex ratio in cardiovascular mortality.

The favorable mortality rate of adult women compared with that of men is well known in western countries. The sex difference varies in different population groups. In Israel there is a low male:female ratio, as compared with Greece, Holland, and England and Wales. This is due to the relatively high female mortality rates in Israel. Within Israel, the Jewish population of North African origin has a relatively low male:female ratio. In this group, the marked increase in mortality due to ischemic heart disease has occurred in both women and men, in contrast to various western countries in which the male:female ratio increased during the 20th century with the rise in the death rate from ischemic heart disease, especially in middle-aged men. Social disequilibrium, especially family disorganization with its selective stressful effects on women, is suggested as an hypothesis on which to base further study in communities with a low male:female ratio associated with high mortality rates in women.

The control of hypertension, atherosclerotic diseases, and diabetes in a family practice.

A community-orientated programme for the control of hypertension, atherosclerotic disease, and diabetes has been developed in a family practice in a neighbourhood of Jerusalem. Intervention is directed mainly towards the control of risk factors associated with these diseases.The programme has specific objectives for diet, smoking, obesity, blood pressure, serum cholesterol, glucose intolerance, and diabetes mellitus, and the identification and treatment of patients with cardiovascular diseases. The survey seeks to identify the nature and extent of problems, intervention by medicinal and educational means, and continuing surveillance and evaluation.The programme aims to test and demonstrate the feasibility of carrying out multifactorial community health care within the framework of a family practice, thereby developing a joint practice of primary health care and community medicine.