|Education for Health (WHO, 1988, 274 p.)|
|Chapter 3: Planning for health education in primary health care|
Unless you understand clearly what factors are involved in a problem, you will not be able to control it. There are different causes that must be examined.
Why are there problems?
The most important word in this section is why. Information collected about the community or about individuals will show that some things are going well but that there are also many problems. Simply knowing that things are going well or badly is not enough for planning a programme.
It is important to know why a community project, for example, is succeeding or why people are healthy, so that you can learn from such information and promote similar successes in the future. In the same way, one must know why there are problems so that the most appropriate steps can be taken to find solutions.
Chapter I was written to help understand why problems occur, and why they don't. Read the four examples below. Look back to Chapter I and see if you can think of some possible explanations why some of the people in the examples have problems while others do not.
In one village 50 out of 100 mothers bring their children for monthly appointments at the c-hild welfare clinic. In another village, 85 out of 100 mothers attend. Why?
One man has come to the clinic complaining of roundworm twice in the past year. His neighbor has never had this problem. Why?
In October, there were very few people with a cough in one village. By March, there were three times as many people with a cough. Why?
In one village the people have built their own latrines, wells, and school. A nearby village has none of these things. Why?
Involving the community
It is not only the health or community worker who must understand why problems do or do not occur. The members of the community must also understand. Meetings and discussions with individuals, groups, or community representatives are useful for helping people look closely at the reasons for problems. In this way information gathered about the community can be shared and examined. When community members learn more about their problems, they will be better able to make good choices on action to solve them.
The role of behavior
Like beliefs, some kinds of behavior may promote health and some may lead to illness, while the effect of others may be neutral or at least unknown. We discussed this in Chapter 1.
When looking at health behavior, the first thing is to understand why people take certain actions that promote health. What resources, beliefs, values, and important people encourage healthy behavior or make it possible'! What activities can be planned to support and strengthen healthy practices?
Next comes consideration of unhealthy behavior. If people have shown that they want to improve the situation, at least three things could be done about unhealthy practices:
- Ignore the unhealthy behavior, and encourage instead an existing alternative way of behaving that is healthy.
- Slightly change the unhealthy behavior to remove some of its more dangerous aspects.
- Substitute completely new practices for the unhealthy ones.
An understanding of the situation is needed to help in deciding which of these actions would be the best. Since behavior is part of the way of life or culture of a community, the best step may be to encourage already existing healthy practices as an alternative to unhealthy ones. If no appropriate or acceptable alternatives exist, the next choice would be to find ways of slightly changing the harmful behavior. The most difficult line of action of the three is for people to try substituting completely new practices for old familiar ones.
Here is an example of how a good understanding of behavior can lead to appropriate action.
In one village the traditional midwives always used pieces of green glass to cut the umbilical cord of newborns. They believed that the glass had certain magic powers that protected the baby. Unfortunately, this village also had a high incidence of neonatal tetanus.
During a discussion, the midwives admitted that they were worried about tetanus, but did not know what to do. Were any other methods of cutting the cord used?
No others were used in that village, but one woman mentioned that in nearby villages some midwives used knives. An elderly midwife then reminded the group that she believed that metal held evil spirits that could harm a young baby. Thus a knife was not an acceptable alternative. At this point the health worker who was attending the discussion realized that substituting a new practice such as the use of clean razor blades would not work, because they were made of metal. Possibly the existing practice could be slightly changed? The sharp pieces of broken glass certainly could cut the cord almost as well as a razor blade. The problem was that a dirty piece of glass could cause tetanus. A simple change could be to put the glass, before use, in boiling water for at least ten minutes to kill the tetanus spores. This was acceptable to the midwives.
Using a clean, new razor blade to cut the umbilical cord of a newborn baby is a healthy practice which traditional midwives could adopt if local practices are not safe, it is often possible to modify traditional practices or find alternatives that would be equally safe and more in line with local beliefs and culture.
Who can solve problems?
Some problems can be solved by individual effort alone, while others require the assistance or cooperation of several people, or of the whole community. For example, a community may be experiencing the bad effects of poor environmental sanitation. The behavior of individuals and families contributes to the problem because waste and faeces are spread about everywhere. In solving the problem, the whole community may need to set up a waste collection system and to provide latrine facilities through cooperative action. Then it would be the responsibility of individuals and families to make hygienic use of these facilities. Here are other examples:
- An individual can take responsibility for personal hygiene.
- Good nutrition is usually the responsibility of the whole family.
- In order to rent a tractor, a group of farmers may have to share the cost.
- Guaranteeing a safe water supply is the responsibility of the community.
- The national government, through the ministry of health, is responsible for providing vaccines.
Sometimes the whole community may have to take action to solve a problem. This is the case when the problem is associated with unhealthy practices that are usual and accepted in the community.
What is the type of help needed?
Look at a disease like tuberculosis. Some people in the community may have recently fallen ill with the disease. They need treatment. They need to take their drugs regularly. They have lost weight, have become very weak, and may even have lost their jobs. They need rehabilitation to help them recover their health and jobs so that they may live a normal life again. Many are not sick, but they need to take preventive action to keep well. This includes not only immunization, but also health promotion measures such as adequate nutrition.
You can see that different kinds of behavior are needed depending on whether we want to prevent tuberculosis, treat the disease, or provide rehabilitation. This is true for most problems.
Try to understand the appropriate behavior at each stage of the problem. Plan education programmes to help people adopt the kind of behavior that will prevent them from becoming ill, cure them if they are sick, and help them lead normal lives if they are disabled.