Until recently, the biological approach to health problems dominated the way health workers thought, to such an extent that the psychological and social dimensions were barely considered, either in the conceptual frameworks used to explain the cause, course and outcome of diseases, or in the development of techniques and the preparation of plans and programs for their prevention and treatment.
This one-dimensional approach to health and disease has evolved in recent years toward a less simple conception, one that places the phenomenon at the convergence of several axes of relative importance. Their presence is established more or less according to the nature of the three elements that make up the natural history of diseases: the etiological agent, the host and the environment.
Among these axes, the biological one has particular importance, since the vast majority of medical studies have advanced within its field. The psychological and social dimensions, although identified centuries ago, have only recently been considered at their proper value. Previously, they were merely mentioned in passing, as incidental factors that colored but did not determine the nature of diseases.
Because of the multiple relationships that exist between psychological and social aspects, and given their permanent coexistence, it is customary to group the facts covered by these two categories under the expression psychosocial factors.
Unlike biological factors, these factors generally lack concrete boundaries, do not always have a physical substrate and are difficult, and by no means exact, to quantify, given the rudimentary nature of the instruments used.
Another characteristic of psychosocial factors is their multiplicity. They ordinarily form a constellation of interacting elements that produce effects not only in relation to health, but also in different aspects of the individual’s and the family’s life, such as work, school activities, community life and general well-being.
Families affected by multiple problems, such as malnutrition, adolescent pregnancies, alcoholism, hypertension, poor housing, police problems, school dropout and others, illustrate this dynamic.
The WHO Division of Mental Health, in its desire to provide the primary health worker with a comprehensive view of the problems affecting families, has tested a simple classification. In it, the health disorders presented by members of the family group are recorded along a first axis; social problems, reduced to a few categories, are recorded from a second perspective; and psychological problems are identified in a third, also in a simple and brief manner.
This exercise attempts to test a recording method that gives the primary worker a more complete view of the problems affecting the population served. At the same time, it is expected that, in the long term, the new framework will succeed in modifying behaviors and attitudes which, in turn, will translate into a better understanding of the population served and an improvement in the quality of the services provided.
The psychological profile of individuals and groups, as well as their social dynamics, affects not only their condition as patients, but also determines their behavior as users of services. Circumstances such as personality traits, communication within the family, level of education and quality of housing, among others, will determine the acceptance or rejection of health measures, especially preventive ones, the use of public services, cooperation with health authorities and compliance with treatments. In other words, they determine the accessibility of services.
Maternal and Child Primary Care
There is no uniformity of criteria regarding the meaning of “primary healthcare” or “primary care.” Perhaps this occurs because, alongside that expression, the phrase “primary level of care” is often used, creating in the mind of those unfamiliar with this terminology the impression that primary care must necessarily be provided at a very simple level of complexity.
Added to this is the fact that, in most developing countries, primary care in rural areas and urban slums is indeed administered by primary health workers with minimal academic training and very limited availability of resources.
Primary healthcare is understood as the care provided at the user’s point of entry into the health services system. Depending on the amount of human and material resources available in a country and their geographic distribution, maternal and child primary care may be provided by a pediatrician or general physician, a registered nurse, a nursing assistant, or a person from the community who has received minimal health training and works under the supervision of a professional.
The place where this care is provided may be the home, a health post, a public or private clinic, a maternity facility or a general hospital. Whatever the degree of refinement of the providers and of the facilities in which they work, primary care must form part of an organized system, so that frontline workers have the technical and logistical support of the intermediate elements of the system, namely general and specialized hospitals, centers of excellence and universities.
On the other hand, the concept of primary care or assistance is not restricted to health. Alongside it converge primary assistance in education, housing and other aspects of common well-being.
Regardless of who provides the services or where they are delivered, psychosocial factors will always be present. Whatever the circumstances, the primary health worker must know them and possess the skills to detect and manage them for the benefit of the patient.
There are social factors such as poverty, malnutrition, corporal punishment and violent behaviors that are universally negative and whose effects on health and well-being are unfavorable. However, there are also other social support networks, certain practices of the extended family and self-help groups whose benefits are evident.
The following section will point out those aspects that may constitute risk factors for health, without forgetting that prevention and health promotion have their primary foundation in individual and collective behaviors that favor well-being.
