ENTRAR            

CONSENSUS

International Symposium on Community Nursing Research
Granada (Spain), Escuela Andaluza de Salud Pública, 2007 October 4-5

Response
Democratising health care

Maribel Blázquez Rodríguez
RN, BS Anthr. Escuela Nacional de Sanidad. Instituto de Salud Carlos III. Madrid, Spain

Index de Enfermería [Index Enferm] 2010; 19(2-3): 136-137

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    In my view, out of all the ideas presented by Prof. Glittenberg, we should focus on some of the elements pertaining to the concept of "competence", which I shall address below.

1. Start by understanding the population. Knowledge is acquired through two channels, rather than only by studying the social and demographic characteristics of the population or available healthcare data. These two sources are as follows:
    a) Working within the community. An intensive, ongoing, on-site presence enables us to confirm whether the data and information acquired through previous studies are genuine and up-to-date. This approach also allows us to ascertain the resources available to people -what I shall call contextualising the population's healthcare status- as well as to bring to light their healthcare cultures, any possible or potential health risks or problems, self-care and protective factors, while gaining the community's trust.
    b) Involvement of the community itself, to ensure:
    -That people are fully integrated, on an equal footing.
    -That the expected outcomes meet their needs and demands.
    -Confer authority on those persons who have essential know-how and the ability to make and implement healthy decisions in their lives.
    -Exercise the right to health protection.
    Although this premise is pivotal when working with unknown groups or communities -as has been the case with immigrants- this is an increasingly important factor when dealing with autochthonous population groups given their greater diversity. Hence, we could raise the question: Which variables or features underpin changes in healthcare needs and problems?

2. Each person, social group and community has its own healthcare culture. Each human group has its own definitions for the concept of health and disease, as well as different representations to illustrate the meaning of being ill. Each group attaches a given significance to certain diseases, and has different views on the value of health in the life of an individual. Each has a therapeutic context establishing which practices and/or care and healing habits are most appropriate, and how these should be organised in a healthcare system, with a specific relationship between healthcare professionals and users. Some authors refer to this as healthcare culture, an issue that is highly influential, complex and difficult to address.
    Culture is not homogenous, and each and every one of us has his or her own culture. As a result, cultural expressions provide no explanation on their own. Instead, they need to be correlated and cross-linked with other variables such as sex, gender, age, social status, employment situation, ethnic background, religion, etc. that can account for a given culture By doing so, we will be able to clarify shared and specific, inter- and intra-group needs and issues.
    All social spheres -including health- are influenced by culture. In nursing, issues such as the holistic or bio-psycho-social intervention model, interdisciplinary training, and community health., have all been included in undergraduate training programmes. However, in terms of healthcare delivery, even at primary care level -where it is increasingly evident that the reasons for consultation are more related to social issues- there are still examples of existing deficits, such as healthcare assistance to immigrants, women who are dissatisfied with services?

3. Start by defining "Community Health". As suggested by Dr. Glittenberg through the cases presented, social problems can be solved by delivering health. We all know that improving health has an impact on eradicating poverty, for instance. This illustrates that there are very close links between the health and social spheres and that the social status of individuals has a decisive impact on their level of health. We therefore need to come up with a broader definition of the term "health", where the emphasis is not on the biological over and above psychological or social features, but instead a definition which sees all these areas acting jointly. So, among various social groups -immigrants, women...- we are seeing a "bodily discourse of social unrest". The body somatises and manifests -through organic dysfunction- any frustrations and conflicts whose origin is not biological. So, when faced with an individual's signs and symptoms, we should not only analyse any biological processes present, but also social, political, and economic issues. In other words, we should correlate what the patient feels with his or her personal circumstances.

4. Re-visit our role as healthcare professionals. This will lead us to review the direction in which we want nursing care to go - whether towards addressing health and disease, or going beyond, fully aware of the role we play as drivers of the population's health and social welfare. In order to do so, we need a community health approach that is both interdisciplinary and multi-sectoral in nature, as described in the Alma Ata and Health Promotion Conferences, which constitute our supporting regulatory framework.
    We should make the transition from assistance to attention, aware that we deliver a service to the community. We make our know-how available to the community we serve, so that eventually it is the community and its individuals who manage their own health according to their own visions, health, and lives their own health according to their own view of their health and lives. This entails working from the standpoint of diversity, respect and equality. It also means that, in many cases, our role should not be merely technical or decisive, but instead we should work with the people, building consensus and focusing on healthcare education.
    So, we must be aware that what we do and say depends on the situation at hand and that we are not always aware of everything we do. We have to seize opportunities, such as this Conference, to review the positions underpinning any action on the part of both the population and ourselves. We should also reflect on the complexity of social relationships, acknowledge possibilities for change and the limitations that we all face when taking action. This also points to other issues such as removing the healthcare focus from certain areas of life, strengthening health education and making health more democratic.