Hills Marcia, Mullett Jennifer, Carroll Simon
School of Nursing, Centre for Community Health Promotion Research, Faculty of Human & Social Development, University of Victoria, Canada.
Rev Panam Salud Publica. 2007 Feb-Mar;21(2-3):125-35. doi: 10.1590/s1020-49892007000200007.
Health care systems throughout the world are in the process of restructuring and reforming their health service delivery systems, reorienting themselves to a primary health care (PHC) model that uses multidisciplinary practice (MDP) teams to provide a range of coordinated, integrated services. This study explores the challenges of putting the MDP approach into practice in one community in a city in Canada.
The data we analyzed were derived from a community-based participatory action research (CBPAR) project, conducted in 2004, that was used to enhance collaborative MDP in a PHC center serving a residential and small-business community of 11,000 within a medium-sized city of approximately 300,000 people in Canada. CBPAR is a planned, systematic approach to issues relevant to the community of interest, requires community involvement, has a problem-solving focus, is directed at societal change, and makes a lasting contribution to the community. We drew from one aspect of this complex, multiyear project aimed at transforming the rhetoric advocating PHC reform into actual sustainable practices. The community studied was diverse with respect to age, socioeconomics, and lifestyle. Its interdisciplinary team serves approximately 3,000 patients annually, 30% of whom are 65 years or older. This PHC center's multidisciplinary, integrated approach to care makes it a member of a very distinct minority within the larger primary care system in Canada.
Analysis of practice in PHC revealed entrenched and unconscious ideas of the limitations and boundaries of practice. In the rhetoric of PHC, MDP was lauded by many. In practice, however, collaborative, multidisciplinary team approaches to care were difficult to achieve.
The successful implementation of an MDP approach to PHC requires moving away from physician-driven care. This can only be achieved once there is a change in the underlying structures, values, power relations, and roles defined by the health care system and the community at large, where physicians are traditionally ranked above other care providers. The CBPAR methodology allows community members and the health-related professionals who serve them to take ownership of the research and to critically reflect on iterative cycles of evaluation. This provides an opportunity for practitioners to implement relevant changes based on internally generated analyses.
世界各地的医疗保健系统正在对其卫生服务提供系统进行重组和改革，将自身重新定位为一种初级卫生保健（PHC）模式，该模式使用多学科实践（MDP）团队来提供一系列协调、综合的服务。本研究探讨了在加拿大一个城市的社区中实施MDP方法所面临的挑战。
我们分析的数据来自于2004年开展的一个基于社区的参与式行动研究（CBPAR）项目，该项目用于加强一个初级卫生保健中心的协作式MDP，该中心服务于加拿大一个约有30万人口的中型城市中一个有11000人的居民和小企业社区。CBPAR是一种针对与感兴趣社区相关问题的有计划、系统的方法，需要社区参与，以解决问题为重点，旨在实现社会变革，并为社区做出持久贡献。我们借鉴了这个复杂的多年项目的一个方面，该项目旨在将倡导初级卫生保健改革的言辞转化为实际的可持续实践。所研究的社区在年龄、社会经济和生活方式方面具有多样性。其跨学科团队每年为大约3000名患者提供服务，其中30%的患者年龄在65岁及以上。这个初级卫生保健中心的多学科、综合护理方法使其成为加拿大更大的初级保健系统中非常独特的少数成员之一。
对初级卫生保健实践的分析揭示了对实践的局限性和边界存在根深蒂固且无意识的观念。在初级卫生保健的言辞中，MDP受到许多人的赞扬。然而，在实践中，协作式、多学科的团队护理方法很难实现。
成功实施初级卫生保健的MDP方法需要摆脱以医生为主导的护理模式。只有当医疗保健系统和整个社区所定义的基础结构、价值观、权力关系和角色发生变化时，这一点才能实现，在传统上医生的地位高于其他护理提供者。CBPAR方法允许社区成员和为他们服务的健康相关专业人员对研究拥有自主权，并对迭代的评估周期进行批判性反思。这为从业者提供了一个基于内部生成的分析来实施相关变革的机会。
