International Journal of Integrated Care, 2 November 2005 - ISSN 1568-4156
Editorial
Prevention and cure should be integrated

Mostly, this Journal publishes papers on integration of health and social services. Or on the relation between primary health care and hospital care. However, a high degree of integration is also desirable between preventive services and treating doctors and nurses. In this editorial, four examples of this type of integration are demonstrated and discussed. This is done to stimulate treating professionals and preventive workers to cooperate and to inspire readers to submit papers about this form of integration. The cases mentioned originate from study visits of the editor in chief.

1. Caroline is a general practitioner in a poor, old neighbourhood of the British town Sheffield. Many of her patients live in houses with leakages and broken windows. Most families live with four or more members in small three roomed apartments, built in the post war period. Caroline and her colleagues at the health centre where she works, invite a medical student to describe the pathology they see. What they already knew by experience, is now shown in epidemiological data: the prevalence of the use of valium and benzodiazepine is significantly higher than elsewhere in Sheffield. The health centre representative in the regular platform of professionals and municipal authorities introduces the data during several meetings. Ten years later, the neighbourhood is renovated. The use of pharmaceutical drugs decreased, although the stress grew because of different ethnic groups living close to each other. This item is now high on the agenda of the mentioned platform.

In this example, medical treatment is linked with a community intervention, that is the notification of the local democracy to improve the housing of the population. The last intervention is embedded in regular encounters of a platform of health workers and municipal authorities.

2. Midwife Jeanette works in a suburb of Wellington, the capital of New Zealand. She sees the pregnant women during their pregnancy and a couple of weeks after child birth in the local day clinic. With a special grant from the government she can spend a lot of health education time with women belonging to the Maori, the original inhabitants of New Zealand. This minority group has lower educational, financial and health standards than the ‘Europeans’ in New Zealand.

In this case, Mother and Child Care is linked to health education for a special group in the population. The initiative comes from the government, which provided a special financial regulation.

3. In the American town of Seattle, a program exists with the name Cops and Doc's. Policemen, who meet a high incidence of violence in high schools, invite doctors and nurses of the Emergency and Incident Departments of local hospitals to give lectures about what happens after an acute hospital admission. They also give instructions to the students about first-aid and lifesaving interventions. The programs diminished the prevalence of violence in the schools and the acute admissions of students.

In this example, a community intervention by policemen is linked to health education. Here, the initiative comes from outside the health services. The local E and I departments understand that they have a broader mission than treating individual patients. The health professional saw the health education as an enrichment of the regular tasks. The contacts between police officials and health professionals were structured in a project organisation.

4. Jacqueline works as a general practitioner in the Dutch town of Utrecht. She noticed in her practice and in statistical overviews that many young children in her group practice were overweight. Mostly the parents are also obese and have a low income and a low education. They cannot pay for the more expensive, healthy food and don't understand the importance of it. They are also the wrong role models for their children, drinking too much beer and eating too much fat. Together with the municipal health education services she makes a distinction between her overweight younger and older patients in three groups: green, yellow and red. This is an analogy with the traffic lights. Green patients are open for health education and are referred to courses about cheap and healthy food. Yellow patients are willing to take care of their own weight and other health aspects. However, this costs a lot of persuading time. The red patients don't want to change their life habits and always urge for medical treatment and pharmaceutical drugs if they have complaints due to being overweight. Jacqueline and her colleagues do not provide preventive services to them, because these are useless. Jacqueline is proud about her results in weight reduction in the green and yellow patients. She feels pity and sometimes guilty about the red patients.

In this example, medical treatment and health education are closely related. The access to the preventive services is in the hands of the general practitioner. The approach is family oriented: children and parents get their health education simultaneously. The contacts between the different health professionals are structured in a network organisation.

What have these four examples got as common features? Five common characteristics can be distinguished.

  1. The mentioned health professionals have a broader focus than only working for individual patients with one specific complaint. They aggregate individual cases (Sheffield, Seattle, Utrecht) and made them broader than a one issue case (Wellington).

  2. They all used statistical data and epidemiological techniques to aggregate and to describe the social and health problem.

  3. The items of cooperation between preventive and curative workers were related to lifestyles: housing, violence reduction, illiteracy and food consumption.

  4. The initiatives came from both sides: from the preventive side (Seattle, Wellington) as well as from the cure side (Sheffield, Utrecht).

  5. The organisational structures followed the characteristics of the initiative: structures followed strategy. A regular linkage between preventive and curative workers was available in Sheffield and Wellington. Housing and illiteracy are continuous items on the agenda of preventive and curative working and ask for standing committees and structures. A project organisation was developed in Seattle: that is enough for a concrete item like violence reduction in schools. A network organisation was developed in Utrecht: obesity is an item for many preventive and curative workers.

These were four good practices on three continents with five common characteristics. The Editorial Board of the Journal is convinced that more good practices, everywhere in the world with more common features exist. That's why we invite IJIC readers to submit papers with descriptions and evaluations of programs and projects, which integrate prevention and cure. In the long run the mission of the International Journal of Integrated Care is to contribute in a scientific way to the integration of prevention, treatment, long term care and social care. We already received many papers on integration of cure, long-term care and social care. We will continue with them. However, do not hesitate to submit papers with a focus on the link between prevention and cure.

Guus Schrijvers

Editor in Chief