In the previous century we have seen an incredible paradigm shift of the understanding of

health and wellness by communities and health professionals. The evidence of this shift
can be seen when in 1948 the World Health Organisation updated it's definition of health
to a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity (WHO, 1948). Accordingly, this increasingly holistic approach to
health care began to encompass overall community knowledge, practices, and how it links
to the health of each individual. This has resulted in the development of the area known as
Primary Health Care (PHC). PHC came to the forefront of the world in the Declaration of
Alma-Ata by the World Health Organisation (WHO, 1978) where it was seen as a much
needed upheaval of current health perspectives in order to achieve better equality. PHC is
defined as essential health care based on practical, scientifically sound, and socially
acceptable methods and technology and made universally accessible (WHO, 1978). Talbot
and Verrinder (2005, p. 4) explain that the declaration, utilising PHC, was and is
essentially a call for social justice and that it is an on-going process that leads to
progressive improvements in the health of people. The declaration provides a number of
principles which encapsulate the overall philosophy of PHC and stresses the need for the
implementation of these principles by governments, health workers and community
leaders. By briefly dissecting and discussing these underlying principles and examining
case studies of PHC actions in the community, we can develop a thorough understanding
of the outcomes achievable and it's purpose and application in nursing.

Accessibility is one of the first major components of PHC and is ideally a stage where all
health services are universally accessible to individuals and families in the community
(AARN, 2003, p. 2). In order to achieve this outcome we must identify and work towards
eliminating disadvantages across community groups. Social disadvantages such as
unemployment and lack of education, geographical disadvantages such as difficult terrain
and distance from health services, and even simple factors such as race, age, gender and

language can all create inequality between community groups (McMurray, 2007, p. 33).
Abject poverty is often a major part of this issue of accessibility, and socio-economic aware
PHC community established initiatives can be used to greatly help people in such
communities. For example, as reported by Polan, Tesfagiorghis and Turan (2011), one such
initiative took place in remote and rural Northern Eritrea, where volunteers were trained
to give educational classes on safe motherhood. This initiative was undertaken due to a
high maternal mortality ratio and poor access to proper emergency facilities or staff in
cases of childbirth complication. The volunteers were educated on many aspects of
maternity, such as antenatal care, preparations for birth, malaria prevention and
awareness of complications or danger signs during pregnancy. In the evaluation carried
out a year later it was shown that this initiative was able to positively impact the
community, with the proportion of women giving birth in health care facilities rising from
3% to 47%, and the proportion of women who reportedly experienced a problem during
birth dropping from 34% to 13%. Given these facts we can see that a volunteer-driven costeffective PHC approach has worked well to give better self reliance and access to
knowledge in this rural and remote community. As nurses we must be aware of the
importance of educating and engaging with our patients, their families and anyone else
that we may be able to provide better access to health and wellness (Koch and Kralik,
2006, p. 95).

Appropriate use of technology is the second major principle of PHC, and with modern day
technologies, also ties in with accessibility. Technology is a broad term which encompasses
structure and delivery of health services, human resources, medical equipment,
pharmaceutical agents, or new interventions or techniques (AARN, 2003, p.3 ). The use of
electronic technologies can greatly increase the capacity and functionality of health care
systems, with the ability to be store, manage and share data, administrative functions and
health care management. The introduction of technology into a community based clinic

can have positive health outcomes for patients in that area as shown in a study presented
by Garrow (1990, as cited by Couzos and Murray, 2008, p. 121) based in a remote Western
Australian community in 1987. Here a computer management system was set up, based
around locally developed software known as Healthplanner. From this system much
information could be better organised and many functions automated, such as periodic
examinations, pathology results and possible risk factors. Patients who were over-due for a
follow-up were able to be targeted specifically, with less field visits required by clinical
workers. This resulted in a large gain in efficiency for the clinic and patients were able to
avoid feelings of intrusion from home visits. Due to this digitalising of information, as
nurses we must ensure that the use of technology and scientific advances are compatible
with the safety, dignity and rights of people (ICN, 2006, p. 3). Thus PHC nurses must be
knowledgeable about the technologies that are available so that they may utilise them
ethically and responsibly to give the best possible care.

Health promotion and education are two of the most important principles behind PHC,
which go beyond the sphere of normal health care. With proper use of this principle, many
health issues can be prevented rather than cured, which as stated by Couzos and Murray
(2008, p. 131) is a central premise of primary health care. Health promotion and
education is one of the most important ways to empower people to better control and
direct their health. In this way community groups can influence policy makers, and create
initiatives to help make positive public health policies. It also takes into consideration the
living and working environments of a community, and works towards taking care of these
environments so the inhabitants may have safer more enjoyable lives (Keleher,
Macdougall, Murphy, 2008, p. 18). In the realm of health education, health programmes
are formulated based on the need of the community. Through these initiatives, community
groups are educated on important topics such as health risks, disease prevention and
nutrition and sanitation. A study reported by Wolff, Young, Beck (2004, as cited by

Keleher et. al. 2008, p. 151) illustrates health promotion and education in Wisconsin, USA.
Here in disadvantaged communities where drug and alcohol abuse, mental health
problems and unchecked chronic illnesses are major problems, a programme called
Community Health Advocate (CHA) was begun. Community members were trained to
assist with other members with health and social issues and an academic partnership with
the Wisconsin University was developed. From this programme community members were
able to provide basic health care information and would refer to professional health
workers when necessary. As a result, community participation with health workers
increased, access to quality health care was improved and the community was shown
methods by which they can improve quality of life. From this example we can see the
empowerment and self-reliance that can be established as a result from PHC driven
initiatives within a community.

The last PHC principle to be discussed is community participation and the coordinated
intersecting collaborations required between all community members, management of
major sectors such as industrial, governmental, transport and health, the involved health
workers and the networks that must exist between all groups. All sectors must be united
with the shared goal of of achieving a healthy society, and to ensure proper levels of public
participation, health professionals must approach others as equitable partners not as
leaders. (McMurray, 2007. p. 42). In the context of PHC nursing, nurses are often working
within inter-professional teams in the community. The relationships of a PHC team in a
remote setting play a large role in the overall effectiveness of the teams efforts, with the
role of the nurse differing depending on the role of other members. This can be explained
as a move from traditionally based doctor-focused care towards team-focused care and is a
defined trend in PHC (Greenhalgh, 2007, p. 10). These inter-professional are understood
to be able to provide a higher level of holistic care due to their collaborative efforts (Birks,
Coyle, Francis, Henderson, Jones and Mills, 2010).

In conclusion, PHC is to be adaptable, sustainable, and based upon the current socioeconomic, cultural and political climate of the country. Main health and accessibility issues
are to be identified and addressed via relevant methods, technologies and services. Whole
and coordinated participation between communities, health, and industrial and
governmental sectors is essential in order to work towards achieving better health. Lastly
the health workers themselves, both professional and non-professional, must be able to
work together as a team, in order to give unbiased health care to those who require it most
and to empower communities with relevant skills and knowledge so that they may live
happier and healthier lives.

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