A REPORT IN THE METHODOLOGY HEALTH DELIVERY TRAINING PROGRAMME FOR COMMUNITY NURSES/HEALTH SUPERVISORS
Item
- Title
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A REPORT IN THE METHODOLOGY HEALTH DELIVERY TRAINING
PROGRAMME FOR COMMUNITY NURSES/HEALTH SUPERVISORS - extracted text
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*
PROJECT
KoTTZiyAM
KePoKT
Research in'm<= ^cthodoloo^
op health Deliver^:
TRAINS PRogAMme
COHNt/Nny
NvRscs/health
SuPgruiscRj
NARAYAN
> >
"fts
•=g
poR
t HT-lo
A Repost on
research in the
MTHODOLQQY OF HEALTH oelivery •
TRMNIN6 PROGRADE FOR CQmWTY NURSES/HEaLTH
SUPERVISORS,
IF
h Project
undertaken by
Dr* J<jcop Chundy - Prof* Emeritus, Govt* of Kerala
Dr« Roy Verghese* Dr* Rex Thornes* Dr. Cyril Hathai*
Dr. Mathew Jacob and Sr. Alice John.
Kottyam* August 1972 - December* 1976
COMMUNITY HEALTH CELL
’’anga’ore - 560 001
4
4
SPONSORED BY i
CSI Madhya Kerala Diocesan Medical Society*
SUPPORTED BY t
Family Planning Foundationt New Delhi*
REPORT COMPILED BY i
Dr* Ravi Narayan* MBBS* DTPH (London)* DIH (UK)*
Centre for Community Medicine*
All-India Institute of Medical Sciences*
New Delhi-1W 016
••Lot ua refliember that two thirds of the world9 a
people are under-privileged> underfed* underhealthy* under-educated and that many millions
live in squalor and suffering*
They have little
to be thankful for save hope that they will be
helped to escape from thia misery*
These
(problems) are symptoms of a new evolutionary
situation and these can only be successfully met
in the light and with aid of a new organisation
of thought and belief a new dominant pattern of
ideas * relevant to the new situation*”
Julian Huxley* 1961
CONTENTS
Page
PREFACE
1
CHAPTER I
INTRODUCTION
4
CHAPTER II
OBJECTIVES OF THE PROJECT
10
2.1
Problems in training of present
cadres of medical personnel
2.2,.3
Characteristics of new category
of workers
11
2.4
Overall objective of project
12
2.5
Specific Objectives
12
METHODOLOGY
15
3.1
Role definition of Community Nurse
15
3.2
Selection of trainees
16
3.3
Number of trainees
17
3.4
Selection of teaching staff
10
3.5
Orientation of staff
19
3.6
Training base and facilities
20
3.7
Field Practice Areas
20
3.8
Training programme
22
3.9
Curriculum Development
23
3.10
Special Courses
24
3.11
Examinations
25
3.12
Internship
26
3.13
Evaluation
27
CHAPTER III -
( >
10
4
CHAPTER IV -
PROCESS REPORT
20
4.1
The Curriculum
28
4.2
The Special Courses
29
4.3
The Course Programme
30
4.4
Programme Skills
33
4.5
Examinations
36
4.6
Internship
38
4.7
Development of Appropriate Technologies
43
RESULTS
46
5.1
Results
46
5.2
Suggested Model for Replication
48
5.3
Cost of Training Programme
50
EVALUATION
53
6.1
An Evaluation Report
53
6.2
Impact of the Project
59
6.3
Community Evaluation
62
HEALTH AWARENESS AND HEALTH SEIENCE
(a paper by Dr. Jacob Chandy)
64
REFERENCES
70
acknowledgement
72
CHAPTER V
CHAPTER VI -
CHAPTER VII -
appendices
A
Plan of Action for Community work
73
B
Family Records, Maternity & Infant Records
76
c
Question papers for Community Nurses
Programme
84
D
Certificate awarded to Community Nurses
98
3
RfiEEAa,
A Project entitled "Research in the Methodology
of Health Delivery" was supported by the Family Planning
Foundation of India from July 1972 to December 1976*
This
Project headed by Dr* Jacob Chandy (Padma Bhushant Professor
Emeritus> Government of Kerala and retired Principal of
Christian Medical College• Vellore) experimented with the
possibilities of developing a suitable cadre of community
health personnel ( referred to as ’community nurse’ in
this Project) by organising a community based training
programme using an integrated approach in Medical Teaching*
By its very nature such a Project cannot be expected to
be carried out in strictly controlled situations since the
course and the training programme evolve with the increasing
interaction between the project team* the trainees and the
community itself*
Hence a report on such a Project also
should attempt to highlight a developing and evolving process
rather than a statistical account of measured achievement*
During the period of this Project numerous reports were
written up from time to time by the team and by visiting
consultants and are available with the Family Planning
Foundation*
A need wue9 however• felt to consolidate all
these unpubliahed reports and reviews of the Project and
/ 5
present it && an overview of this interesting and creditable
endeavour*
I was requested by the Family Planning Foundation
to undertake this job*
I did it by reviewing all the avail
able reports and by visiting Kottayam and the Project environs
and interacting with Prof* Chandy* some membere of the Project
team especially Dr* Rex Thomas# many of the trainees and
members of the village communities covered by the Project*
I
also had an opportunity to meet some of the visiting consultants
from Kottayam Medical College# Trivandrum Medical College and
Christian Medical College# Vellore# who were associated with
this Project in various capacities*
The report therefore is
based on information gathered from various sources mainly
through personal interviews*
In a report produced by this
method there is bound to be certain discrepancies since it
is based on the views of many people and at some places the
reporters9 own views and experience also come into focus*
This is inescapable*
follows*
The report has been presented as
Chapter I outlines the broad developments on the
Indian scene in the field of medical man-power education
in the country*
Chapter II outlines the assumptions and
objectives of the Project team*
Chapter III outlines the
methodology used in the working of the Project*
Chapter IV
outlines some of the actual events in the form of a process
report*
Chapter V highlights some aspects of the cost of the
Project and evolves a model for replicating*
Chapter VI
outlines the implications for the future including the
suggestions of various evaluating teuiua and the responses
of the state health services in the Southern Area*
Chapter VII is a paper written by Professor Chandy summing
up hia own experience and making a plea for the development
of Health Science teaching in the country*
He is convinced
that the ideas enunciated in this article represent the
essence of the entire experience in this Project and though
an innovative training programme was organised* the main
observations made by the project team justify this plea for
increasing the health awareness of the community through
Health Science Teaching rather than only evolving more
innovative paramedical teaching curricula*
It is hoped
that this report of a very innovative project* will
stimulate both enquiry and further research into evolution
of relevant teaching curricula for doctors end other
para-medical personnel in the country as well as stimulate
serious consideration of this concept of Health Science
Teaching*
If it does so it would have served its primary
purposes*
Further details* clarifications and the
complete syllabus can be had from Professor Chandy or the
Family Planning Foundation of India*
Ravi Narayan
20th November* 1977
New Delhi-110 016
CHAPTER I
INTRODUCTION
In the last three decades since Independence^ India
has made considerable efforts in the development of a health
care delivery system which could ensure to all its citizens especially
the predominantly rural population the constitutional guarantee
of "public^ assistance in the case of unemployment* piftkneep
disablement* old age and any other cause of undeserved want**
With the Planning Commission established in 1950* the Government
luunchod a programme of economic and social development through
a series of five-yoar plans starting in 1951•
Health was
an important sector and the goal was *to provide scientific
medical aid to all who needed it and to promote public health
and preventive aspects of medicine**
With this goal in view
the main challenge to medical educationists* planners and health
administrators were
1* The organisation of training programmes for medical
and paramedical personnel which would develop in them
both competence and motivation to work in rural areas
whore th© majority of our people lived*
2» The rapid expansion of medical and paramedical manpower
resources to meet the increasing demands of the health
cure delivery system*
Thia ehalianga was evan greater considering the fact
that we had inherited a ayetorn of health care and radical
education which had developed along predominantly British
lines and in which the philosophy of care and education had
been focuased on high quality care of the individual patient*
Community orientation to medical teaching of doctors* nurses
and para*>ffledical workers was discussed and stressed at numerous
meetings* conferences and symposia*
Hany suggestions for
new programmes ware taken up and experimented with in numerous
training institutions*
However a wall established hospital*
based curative system can be very reoistant to change and
reorientation* and hence by the early 1960s* it was evident that
this *reorientation of medical education' was merely 'conference
rhetoric* rather than commitment to real change*
A predominantly
hospital based training with apologetic exposure to the community
remained the norm*
When John Bryant (1971) wrote that "in every comer
of the world the products of ouch systems have not only been
unwilling to work whore they are most needed • that is a familiar
story • but they had limited capability for working there* They
have not boon prepared to do what needed to be done* • he was
probably echoing the Indian experience till the mid-60's*
However* from the 1960's various innovative and
experimental
efforts began all over the country both in government health
training xnstitutionaf nedical and nursing colleges and various
voluntary health agencies to solve the problem of rural health
care*
It was becoming evident that a health care delivery
system dependent on highly qualified doctors and nurses would
not be feasible with the economic constraints that we had
and therefore we would have to evolve cadres of health workers
with graded skills coordinated together in an integrated
multi-tier system which would deliver comprehensive health
care to the community*
It would be outside the scope of this report to
discuss the various governmental and non-governmental efforts
in this very important task of developing teaching programmes
and training of various grades of health workers relevant to the
needs of our health services*
However Table I briefly summarises the Indian
rpspgnp^ to tbQ- delivery qT Health
health care system
i»Q* th^ four tier
and Table II indicates some of the
important institutions which ware primarily involved with
the development of the teaching curriculum and guidelines for
these category of staff*
■UPLL J.
CaRE
Ties
I
Community
•Doctor1
SYSTEM
( TIERS )
Existing cadres to be reoriented/
retrained/modified»
M.B.B.S. Graduate
p
II
Health Supervisors
Assistants
Hale/Female
Lady Health Visitor
Public Health Nurse
Sanitary Inspector
III
HuIti-purpose
Health Worker
Hale/Female
Auxiliary nurse midwife' Basic
Health Worker' Smallpox
Vaccinators* halaria Health
Workers* Trachoma*
Health Education Assistants etc*
n
It
IV
M
Community Health
Worker
Traditional birth attendant*
indigenous pructioners* school
teachers etc* Health volunteers*
. TABIE II
PIQNEERINfi PROJECTS / INSTITUTIONS
Category of Staff
Pionesxlng Projacta/Inatitation
Community Orientation
for Medical Under
graduates
Rural Health Research Project, Narangwal
Comprehensive Rural Health Services
Project, Ballabgarh, AlIMS*
Depts* of Preventive L Social Medicine
of Medical Colleges in India*
•Community* Doctor
Health Supervisors/
Assiatante
Gandhigram Institute of Rural Health
and Family Planning,
National Institute of Health Administration
and Education,
Comprehensive Rural Health Services Project
Ballabgarh, Al IMS*
Central and Regional Family Planning
Training Centres*
Multipurpose
Gandhigram Institute of Rural Health
and Family Planning
Comprehensive Rural Health Services Project,
Ballabgarh, AlIMS*
National Institute of Health Administration
and Education
Central and Regional Family Planning
Training Contres*
Health Worker
Community Level
Health Worker
Comprehensive Rural Health Project,
Jsnlchsd*
KASA model integrated Health 1 Nutrition
Project • KASA
Integrated Health Services Project, Miray
Voluntary Health Services Project, Madras
Nutrition Rehabilitation Contres,Madurai*
- 9 -
In the light of these dsvelopiaents Prof* Jacob Chandy’s
project entitled •Research in the Methodology of Health Delivery*
which is the subject matter of this rsport has added significance*
By using rather imaginative end unorthodox methodologies in the
training of a small group of girls now termed 1 Community Nurses•
the Kottayam project has shown that if training courses for health
workers have to be really relevant to the needs of the coumiunity
then major departures from traditional modes of thinking regarding
courses and training programmes and methods may be necessary*
Ths experiencss of this project team are particularly relevant
to the training of Tier I and II of our health cars system
staff ( refer Table I )•
CHAPTER
2.
2.1
II
Objectives of ths Proiact
A review of the Health Coro Delivery System in India
and the various training programmes for medical and
paramedical workers which have evolved over the last
few dscadss show certain characteristics in the pattern
of development and certain lacunae which must be taken
into account while planning future health policy.
Based on the insights gained by the director of this
project during the years of his involvement ip medical
education and health planning in thia country the
following five assumptions were made as the basis for
the development of this project.
1)
All the grades of health workers - Doctors* nuraes and
paramedical workers such as Lady Health Visitors*
Auxiliary Nurse Midwife* Basic Health Worker etc.
have been given their training in a hospital sotting
with emphasis on curative medicine*
2)
— G- /
The westernised system of medium which we have adopted
and which is taught to these health workers raise many
cross^cultrual conflicts and problems*
In addition the
workers are hardly trained to understand the sociological
and economic realities of the communities they serve*
3)
The para«medlcal workers get a sketchy training which
does not provide them with an adenuate academic base •
to make them acceptable as health advisors to the
community*
Most of the present grade of workers have not got the
4)
necessary knowledge or competence in the field of health
education which is and should get the main emphasis*
The Doctors who are expected to act as leaders of the
5)
health team are trained mainly to take care of the
sick and hence when asked to work ia the community
they find that they neither have the competence or the
inclinication for it*
■) (j.lr-l ’’
2.2
All these factors have resulted in a growing gap between
the health care delivery system and the community
especially the consumer in the village setting.
This
project was therefore planned to try and fill this gap
between the health system and the patient in his home
with a new cadre of adequately trained health personnel
with the right type of community orientation and
experience*
2.3
Based on the above assumptions* it was decided that the
new category of medical-workers should necessarily
have the following characteristics as a corrective
to the present system*
1)
Recipient of community based training
2)
Necessary understanding of the medical and
health problems of a community with specific
reference to the socio-cultural and economic
environment in which they occur*
3)
Adequate academic standing and technical competence
to be accepted by the community as health advisors*
4)
Competence in the principles and practice of
Health Education*
5)
Such a cadre would and should utilise the competence
^B^and knowledge of doctors and existing para-medicbl
workers in the field*
2.4
An Action-Research project was therefore undertaken by ue*
sponsored by the CSI Madhya Kerala
Medical Society
and supported by the Family Planning Foundation* New Delhi
with the following objectives in view.
QvAFfll], pbiBPtivw to produce a now eatwonry of
Health WoTkora (called Co">”unity Nufbo in thia
protect) bv wwolvino a community bgood treinino
programme* The Community
Aiiaaa between the Doctor end the Corowuni-ty ond
XaKO_n_ajte_Df_the comprohenalva haaltb naadg gf.
the community directly and through the super- .
2.S
SPAPifiP Qbiftctivw
To evolve through a community based
a)
training programme a >pammunitv Nurse1 who
should be able tot
1)
To collect* analyse and utilise important
demographical and statistical data of a
community required for planning health work*
2)
To organise and manage antenatal services
in the community*
3)
To undertake and/or supervise domiciliate
;
midwifery services in the communityi
4)
To organise and manage post-natal services
in the communityi
S)
To organise and manage under-fi^e services
in the communityi
6)
To organise and manage school health programmes
in the communityi
7)
To organise immunization services for the
community especially mothers and children|
8)
To organise• motivate and continuously
implement Family Planning services in the
communityi
9)
To organise and manage supplementary feeding
programme in the communityi
10)
To provide simple primary medical care for
the Communityi
11)
To identify and refer all problems that
reRuire further skilled attention|
12)
To provide health education and counselling
to the community to increase their health
awareness » utilization and participation in
the health care delivery system*
b)
To continously evaluate the effectiveness of
the training scheme in making the trainees both
competent to take care of the above health needs
and motivated towards being community
based personnel*
c)
To evaluate the effectiveness of such a
cadre >. in a community*
d)
To Identify and enumerate the factors which
will lead to the acceptance of such a cadre
by the community*
CHAPTER
III
H £ T H Q P Q UP fi Y
3.0
The project by its very nature had to be tentative
both in design and approach.
Based on the overall and
specific objectives laid down a mldefinition of the
^nmunitv Nurse* was attempted to act as a guideline
<
to evolving the course methodology*
3.1
Thfi
Oflfinitign
The »Community Nurse’ envisaged by the project team
would be expected to function in the following four
roles in any community in which she worked.
1)
Health Educator -
She should be able to
increase the health knowledge and improve the
attitude, practice, utilisation and participation
of the community in exieting health eervices by
inparting health education which would cover
the following aspects i Nutrition. Mother and
Child Care* Immunisations, Early detection of
disease and domiciliary management of minor
illneeses. Environmental Sanitation, Personal
Hygiene* Family Welfare.
c
2)
Fflmj.lv WaXfaye
I —
She should be able
to organise and manage ell pvomotive and preventive
services required to improve the welfare of the
family especially the women and children*
This
would include antenatal care* domiciliary midwifery*
postnatal care* underfire care* school health care*
family planning motivation* counselling*
3)
hgdical rtssiatqnt : • She should be able to
diagnose and treat the simple medical problems
of a community and be able to identify and
refer those who require a doctor's attention*
She should also be able to follow up patients
seen and treated by doctors*
4)
Health Supervisor i — She should be able to
involve other local health workers in the
field in all her activities end effectively
supervise them*
3.2
SELECTION GF TRAINEES t -
The following criteria was used in the selection of
trainees for this project t
1)
ull the trainees selected were fcu.ul.ca* This was
mainly because it was felt that the role definitive
emphasised the need to work mainly with women
and children and only female~workers should be
able to establish the necessary rapport and
contact with this group*
2)
The basic itiinimutn uualification for all t.>as
pra«>dearee with Dhvsica« chefiiistrv and biolociv
(same qualifications as required for medical
college admissions)*
This was insisted upon
since it was felt that the ‘Community Nurse*
should be able to acquire adequate technical
competence and professional skill to be able to
make independent decisions and thus be acceptable
to the community.
In addition* with a sound
academic base she would be able to undertake
her work confidently and without any complexes.
3)
The tr^ineep weyp dgawn from lowpg
proupp ^nd splsctpd io consultation with thP Ipcaj.
community leadership to ensure that they were
able to fit in with the local socio-cultural
environment•
4)
Motivation
criteria
aptitude wot® othgg^
for selection to ensure that the trainees
would accept their 9community role9 and responsibility*
3.3
NUKBCR OF TRAINEES*Based on the above criteria 9 (nine) girls were
selected out of about 52 (fifty two) applications.
The reasons for limiting the number of
were two-fold -
—trainees
1)
Since there was no guarantee that the course
would receive official recognition by the
Profeesional Councile in the country and there
wae a moral obligation to find auitable employment
for the students after the course it was decided to
get an undertaking from each of the tan mieeion
hoepitala run by the CSX Madhya Kerala Dioceaan
Society to abaorb one of the trained * Community
Nuraea' into their ataff and utiliae than to
run auitable community health programmea.
2)
The aacond* though more important reason was the
need to limit the staff-student ratio and model
the community baaed training on the traditional
apprenticaehip training at the 'bed side*
the Gurukula eyetem so that the staff would be able to
help the trainees get the necessary insights and
experiences required for the success of such a
training programme.
Since financial considerations
of the project, made possible a team of only three
ox four doctor/nurees trainers • a group of 9-10
7
students was thought to be practicable^
3.4
SElECHtlN flf TCACHXN6 STAFF »
The project team coneieted of a Project Director and
Research Officer who were reaponaible for coordinating
all aspects oflhe project and directly in charge of
developing and implementing the teaching curriculum
and its ongoing evaluation.
However, for the purposes
of training the 'community nuree'e' a team consisting
of two young graduate doctors (M.B.B.S.) and a
Public Health Nurae (B.Sc») were ealected* The
tean was kept to a nlximum of three to maintain
a good staff student ratio of t|3»
The reasons
for selecting a team consisting of graduats doctors
and a Public Health Nurse was that it was felt that
i>
Every Primary Health Centre (PHC) should
become a training centre for such parawmsdieal
personnel in the future and moat of them would
have doctors and public health nurses to
participats in the training programme*
ii)
With the increaoing durations of posting of
interne from medical colleges in rural field
practice areas it was hoped that interne could
bo used to train such cadres*
This could be
as additional responsibility during thsir rural
postings*
3.5
RRTENTATIRN Qf STAFF i
To prepare the team f or their role aa teachers of the
proposed 'community nurses' a teaching workshop was
conducted by the Christian Medical College* Vellore
at the beginning of ths project*
In addition to the team of doctors and public
health nurse who were primarily responsible for all the
teaching* consultants and experts from various medical
colleges and mission hospitals wars associated from time
to time in the teaching programme*
3.6
TRAINING
ANQ fftCIUTIES I
The fore ms t principle in the planning and evolution of
th© teaching programme fbr the project was the attempt to
deinstitutionalise the training as far as possible* Keeping
this in view and also the factor of replicability of the
project it vias decided that from the very beginning inputs
into th© developing of the training base and teaching
facilities would be kept to a minimum and ths existing
resources and facilities available in the community
would be maximally utilised*
The training base therefore consisted of the CSI
hospital> Mundiapally a 60-bed mission hospital (general
and maternity beds# operation theatre» labour room*
X«ray and laboratory facilities) which served as the
• community nurses* school and provided residential
accommodation for the staff and trainees as well as
accommodation for class rooms• office and library*
The
hospital was ueed for bed-side teaching and for management
of referred patients from t he field practice area*
A
small library with important textbooks and journals and
necessary audio-visual ouc^ for teaching ware obtained
from th© project funds*
3.7
FIELD PRACTICE aREiL 1
The main innovative emphasis of this project was to make
th© training curriculum predominantly community• or field
based so that community side teaching would be carried out
and community involvement and participation in project
planning would be ensured*
For this purpose* three areas
which were geographically circumscribed and consisted of
people of lower socio-economic groups were selectod*
These areas were all part of the catchment area for
patients attending the CSI hospital hundiapally*
The
three areas were Elovanal* Thuruthumala* and Hundukotta*
Some of the important demographic data of these areas ore
shotm in Table-I*
TABLE - I
DEMOGRAPHIC CHARACTERISTICS OF FIELD PRACTICE AREAS
©
Elaranal
Thuruthamala
Hundukotta
Total
Total population
447
3S2
105S
1B54
Total number of
households
72
S3
F eaturs
Average family size 6.20
290
16'3
6.64
6.39
6.3
0 -Slyears
63
30
168
261
6 - IS years
109
84
251
444
15 ♦
275
238
636
1149
A very interesting and significant feature of these
populations were the overall literacy rate of Males - 97.5$
and Females - 94% (defined as reading and writing in
(nether tongue).
The participation of the people in
these areas was ensured by adequate interaction and
contact by the project leaders with the conwaunity leadership
Since the staff and students of the project would be
involved with daily field work programmes of family
care in the area a good rapport with the community by
discussions and meetings was ensured at the start of
the project*
3.8
The training programme of the project was based on the
following guidelines t
1)
Teaching was didactic • lecture discussions and
tutorials and practical • clinical* laboratory
and field work.
2)
Teaching was on all working days - Monday-Friday
and half-day on Saturday.
3)
There were four hours of class room teaching
(
(everyday Honday to Saturday) and four hours
of community work (Monday to Friday).
4)
For the purposes of field work the staff and
students were divided into three teams — each
team consisting of one stuff membar and three
students.
Each group was allotted an urea for
total family health care, and all the families in
the area were surveyed and regularly visited by
the team.
Definite guidelines for field work were
drawn up (ref. Appendix A) and specific records
were designed for the entire group of families
under the care of each team (ref* Appendix-B).
The field work wee so planned that in the initial
stages the field work was mostly observational
but as the seeestsrs progressed the students
were called upon to share growing responsibilities in tb
„ health care of the families*
These responsibilities
were commensurate with the degree of their acquired
professional competence both in community and
clinical medicine*
5)
The entire course was spread over a period of three
years • fire someeters followed by a period of
apprenticeship for 6 months*
3.9
PURRJPUUUH OEVEI-OPHENT t
After having defined the broad objectives of the project
and after attempting a 'role definition* of the community
nurse the actual curriculum was then developed*
The whole
methodology of development of this curriculum was itself
very innovative in that it wae not a once for all activity
but a regular activity that continued throughout the project
plan and was based on a series of staff seminars and
periodic meetings were each and every detail of the
syllabus/curriculum was drawn up following the under*
mentioned guidelines t
1)
The cuxrlculun was designed so as to equip the
community nurses with the knowledge and skills
required for their rolee in the community.
2)
The basic aim was to cover all the subjects
within ths six ssmsstsrs*
3)
In every subject unnecessary academic minutiae
were to bo avoided and stress laid on the practical
aspects of the matter covered.
4)
For each semester an outline of the course was
drawn up and the detailed syllabus worksd out*
5)
Throughout the course a very good Interaction was
maintained between staff, students and the community
and ths field oxperiencee were used as a feedback
to Modify or reorient the course and even make
mid~course changes.
The trainee was as much
involvsd as the trainer in designing and making
curricular changes.
6)
All the subjects wsrs taught by the same faculty
thus incorporating ths very important and relevant
factor of integrated medical teaching.
3.10
SPECIAL COURSES i
In addition to the teaching curriculum evolved by the team
of doctors and public health nurse certain special courses
were also arranged from time to time by visiting consultents
or by plonning short trips to various institutions in Kerala
and neighbouring States• As the training progressed the need
for gome of those courses to be organised by skilled
specialists in their respective fields was felt and
necessary arrangements made*
3.11
EVAlMTIBN PF TRAINEES i
At.u the end of each semester of teaching an examination
was held under the Chief Examinership of Prof* V* Benjamin
Professor of Community Medicine* CMC* Vellore and Dr*(Mrs*)
(■lolly Phillip, Professor of Preventive and Social Medicine*
Medical College* Kottayam*
The examinations were conducted
in the main subjects taught during each semester*
Ths
examinations consisted of written (theory)* practical
and viva-voce*
During the fifth and sixth semesters -
practical^ and viva-voce ware conducted in the community
itself*
In addition to these formal assessment. Sessions
there was a continuous but informal internal assessment
of each candidate by the project stuff during the regular
tutorials and field work sessions*
3.12
INTERNSHIP i
On completion of the final semester of teaching it was
felt that each of the successful candidates were to be
given a period of internship in a new area where the
independent work of the candidate would be observed
and assessed*
Each student nurse would be given two
hundred and fifty families to survey and organise and
manage a family health care programme. Their work would
be supported by neighbouring mission hospitals where all
patients referred by them would be investigated and treated*
3.13
EVAi-lMTTQN i
In addition to the formal evaluation of the traineea* the
project team invited many consultants and specialists from
medical cellogee* mioelon hoepitals and other health
institutions to observe the project in action and suggest
suitable changes and give their critical assessment*
The
project team alee played host to evaluation teams from
the Kerala Government* and other Interested institutions
and professional groups•
CHAPTER
4.0
IV
PROCESS REPORT t
Based on the methodology enunciated in Chapter HI
the project began in July* 1972 and was finally
completed in December* 1976*
In a project such
as thio the observations and results are more
experiential rather than statistical and consist of
the development of a course-curriculum and evaluation
of the efficiency of the trained individuals in the
field situation*
4.1
THE CURRICULUi-i t
The Course that was finally developed consistedoof the
following subjects (against each is shown the hours allotted
which include both theory cum practical sessions)*
A
detailed outline of the syllabus is given in AppendixAnatomy
Physiology
Biochemistry
Biostatistics
- 100
- 180
- 70
- 30
- 30
8
- 30
Psychology
Home Economics
Sociology
Fundamentals of
- 120
Nursing care
Principles of
60
Surgical Care
Personal Hygiene
Nutrition
- 12
- 35
- 20
- 30
- 20
- 20
- 200
Parasitology
Microbiology
Pathology
Clinical Pathology
Community Medicine
Principles of Medical
- 100
Care
Principles of
100
OBG Care
Principles of
Paediatric Care - 120
TOTAL HOURS • 1285
4.2
THE SPECIAL COURSF^i
The special courses arranged were nine in number and
are shown below t
No.
Subject
Teaching Centre
Hours
75
1.
MCH 1 Family Planning
CHAI Team* Bangalore
2.
National T.B. Control
N.T.I
3.
National Filaria Control Filaria Control Unit,
Uuilon
i
National Leprosy
Control
Leprosy Sanatorium*
Nooranad
Leprosy Hospital*
Trivandrum
Leprosy Hospital
Oddanchatram
5.
6.
8.
9»
25
Bangalore
5
3
8
25
14
Deptt. of Community
Health, CMC* Vellore
15
Public Health
Administration *
National and
International
Agencies* Hsalth
legislation
Departmant of Social
1 Pravantlva Medicine
Medical Collage*
Kottayam
B
Supervisory
responsibilities
in Community Health
Practica
College of Nursing*
Trivandrum
10
Hospital Nursing
Care
Fellowship Hospital
Oddanchatram*
CSX Hospitals*
Pallo is. Kanakari
First Aid
Rod Cross Socisty,
Kottayam
Health Education
1200
16
1379
4.3
TH£ COURSE PROGRAhHE t
The entire •Community Nurses* course was divided into
five semestere followed by a period of internship* The
outline of the work done in each semester is as
follows t
1)
let Semester
Sobiffcts Covered t
Sociology* Psychology* Biostatistics*
Personal Hygiene* Anatomy I* Physiology I* Biochemistry*
field Work t
Staff members contacted village leaders*
did baseline surveys* gave health education talks and
provided free consultation services and treatment of
minor ailments to the people*
Courses s
2)
Nil
I Ind
Sub loots covered > Nutrition* Community Medicine*
Microbiology* Anatomy II* Physiology II* Fundamentals
of Nursing*
During the field work students were allowed
to make independent visits and report their findings
and work*
Immunization
Clinics held and different
types of motivation methods were tried out* School
health programme started in a neighbourhood school*
Nil
IIIrd Semester
Subfeet3 cpvirid » Community Medicine* Pathology*
Bacteriology* Parasitology* Clinical Pathology*
Fundamentals of Nursing.
fiflld Worki
A new area wae selected for community
health work and students asked to do baeeline survey
themeelvee and analyse data collected*
Preventive*
promotive and curative services through home visite
to previous areas were continued*
'
■______________________________ _____________________________________________________
Field Work ;
areas*
Target couple eurveys done in all
Family planning motivation begun in all
areae along with all other servicee which were
continued* School Health Programme started in
second echool*
Saislal yialti 1
yflodus •) Medical College & Hospital* Department
of Preventive and Social Medicine* Department of
Rehabilitation* Anatomy Museum* Hietopathology laboratory
Microbiology Laboratory* Forenaic Laboratory* Mortuary*
Labour Room* Prematura Nursery* Malnutrition Ward*
Blood Bank* Cobalt Therapy Unit*
b)
Government Analysts Laboratory* Water works* School
for Montally Retarded Control Dairy* Hindustan Latoa
Factory* Poor Home*
c)
Bangalore t Course on TB Control at Nutritional
Tubsrculoois Institute*
d)
Course ia Maternal and Child Health and Family
Planning by CMAI Team*
O
i
4)
IVth Sammatar
SuhlOBf covered i
Communicable diseases. Pharmacology
and Therapeutics* Medicine* Surgery* Obstetrics and
Gynecology* Pediatrics* Domiciliary Nursing Care*
Home Economics*
fiaAd Woih i Independent field work in field practice
area encouraged* Participation in group teaching
sessions in all areas ensured*
continued*
School Health Programme
Participation in antenatal care services
and in immunisation clinics* BCG immunization done in
all areas*
Special Vlaite/Cou;
a)
Course in Health Education by Department of Health
Education* CMC. Vellore*
b) Kottevew Medical College • Posting in Department
of Preventive and Social Medicine end Primary Health
Centres and sub-contras to study smallpox* vaccination*
malaria blood surveys* working of SET centres* well
disinfection and other practical public health
procedures*
S)
Vth Semastar
SuhUFto Rpvered t Medicine* Surgery* Obatetrics and
Gynecology, Pediatrics and Community Medicine*
field Work l Independent decision making and asoeasment
encouraged in field practice area and all services
continued*
Saosldl
ZtewaM
a) JdtiJBQ. • National Filaria Control Programme.
b) Trivandrum - Leprosy Hospital* Collegs of Nursing
for course in supervisory responsibilities in
Community Health Practice*
e) Orionchitram • Leprosy Hospital* Fellowship Hospital
for training in hospital nursing cars*
d) KottaviB - Rod Cross Soclsty's First Aid Course*
Uncial Aawionmant Conductsd-.t
20 • 25 normal dollvaries.
4.4
PROGRAMME SKILLS .
Throughout ths training programme special emphasis was
mads to ensure that the trainees wars mads proficient in
certain medical end community health skills*
It was thus
ensured that they had the following definits measurable
skills*
a) Prawfltiv anri Preventive
1) Capacity to organise Community Health Survey with a
view to find out community characteristics and the
morbidity pattern determined by socio-cultural
variants*
ii) Competence to organise under five clinics antenatal
clinics and school health programmes*
lii) Skill to screen patients and treat common ailments
Including minor disorders of pregnancy* vitamins
deficiency states* parasitic infections* such as
hookworm* round worm and so on*
iv) Skill to provide pronatal9 intranatal and postnatal
care in the homes* (Each student conducted 20*25
deliveries in hospital and domiciliary settings)*
v) Competence to identify local leadership towards
involving them in health care planning and delivery*
vi) Skill in health education techniques at individual
and group level on problems related to nutrition^
environmental sanitation immunisation and family
planning*
vii) Skill to organise immunization programmes and
administer smallpox* BCG* DPT* Tetanus Toxoid*
TAB* Cholera and oral Polio vaccines*
b)
Curative Skills
i) Skill to diagnose minor ailments and treat them
e*g* Respiratory Tract Infections* Diarrhoea*
Conjunctivitis* ear infections and common skin
infections*
ii) Competence to diagnose the following conditions
with the aid of history* clinical observations and
laboratory investigations e*g* urinary tract infections
specific vaginitis* helminthiasis* tuberculosis*
leprosy* eruptive fevers such as measles* chickenpox
end typhoid fever*
iii) Skill to identify acOte and emergency conditions
which need immediate referral e*g* acute abdomen*
respiratory distress* heart failure* severe dehydration
and shock* abnormal conditions associatod with
prognancy and labour e»g» ante-partum* haemorrhage*
moderate to severe pre-eclamptic toxaemia* cord prolapse
prolonged and obstructed labour*
iv) Skill to follow up chronic cases such us hyperionsiont
_
cardiac failure*t diabetes, mllitUB and tuberculon>
v) Awareness of side-effects of routinely used drugs
such aa sulfonamides, penicillin, streptomycin.
tetracycline* salicylates, antihelminthic drugs*
anti tubercular drugs etc*
vi) Skill to use following diagnostic tools - Sthethescope,
snailens vision chart, oral and nasal specula*
c)
jjp la 1 q x 1 x uy y N y y 3 i n q Care »
Special skills to administer domiciliary nursing care
in the following t
i) Sick children e*g* measles, scebies, gastroenteritis
ii) Neonatal Care
iii) Puerpenal care
iv) Chronically ill and bed-ridden patients* e.g* post-stroke,
They were also skilled in the following procedures i) Tube feeding
ii) Enema
iii) IV fluid therapy
iv) Injectione
v) Vaginal douche
d)
Piaflfioaltip Skill a t
All the trained candidates were given necessary
V
'iIa
training to carry out the following investigationa t
Blood • Hemoglobin* total and differential WBC count*ESR
Urine - Albumin* auger* (idtones* microscopic
©
ill) Stool • Datoction of ova* cyata* blood
lv) Sputum - for AFB
4.5
EXAMINATIONS »
Semester Examinations ware held at the and of each samester
by a group of oMtarnal aMaminsre under Dr« V. Benjamin*
Profeaeor of Community* Medicine* CMC* Vellore and included
Dr* Molly Phillip* Professor of Preventive and Social Medicine*
Kottayam Medical College and other staff of CMC Vellore from
time to time. The distribution of the subjects for examinations
by samaatere were aa follows t
Sociology
Psychology
Biostatiatics
Personal Hygisa
Anatomy I
Physiology I
Biochemistry
Theory and Viva voce
IInd Sowsatog
Anatomy II
Physiology II
Nutrition
Fundamentals of
Nursing
Theory and Viva voce
Hird Semester
Comiuunity Medicine
Maternal and Child Health
and Family Planning
Pathology* Bacteriology*
Parasitology* Clinical
Pathology
Theory* Viva Voce* Praotickl
IV Samestar
Health Education
Theory* Viva Voce
Medicine
Surgery
Obstetrics &. Gynecology
Pediatrics
Nursing
Family Cara Presentations
Theory* Viva Voce* Ward Caees
All the theory papers were set up by the external examiners
baeed on an outline of the portione covered in each semester
provided by the teaching faculty*
The quoations were not
theoretical but oriented towards practical situations
(Refer.j Appendix O*
A review comnittee appointed by the
Government of Kerala consisting of the Deputy Director
Hwalt.h Services* Government of Kerala* Professor of Preventive
and Social Medicine* Trivandrum Medical College* and Principal
of the College of Nursing* Trivandrum participated in the
final examinatione•
all tho candidates except one eowolated tha aKaminaticmg
sat isf actori.lv •
All the candidates who were successful
were given the certificates shown in Appendix * D and
ware then given a period of internship#
4.6
INTERNSHIP l
Following the final examinations the eight successful
candidates were divided into two batches of four each
and were posted in two areas Kanakari and Pallotn where
each student was given independent responsibility for the
total health care of 250 families#
The teaching staff
of the project were posted at the mission hospitals
in Pallom and Kanakari and they supervised the work and
supported the ’community nurses’ by treating the patients
referred by them to the mission hospitals#
During
thia periodf the’community nurses’ did regular house
visiting and took cere of minor illnesses* motivated
for family planning gave health education* conducted
antenatal postnatal under five and immunization clinics*
undertook domiciliary midwifery#
They were also
responsible for nutritional programme3 for the children*
distribution of free milk and cereals and also giving
nutritions education#
They maintained family records
for each family under their care and analysed the data
themselves and used the information for the planning
of their work#
... I
DcLFtC>C.PiQPHiC
CHPROcrERloTCS
i>F
V / <-
CHARACTERISTIC
KANAKARI
PrtLLON
No* of Fdiuiliea
1000
1025
Single Families
763
807
Joint Families
237
218
Total
6115
6449
6.1
6.2
Mala
2940
3074
Female
3175
3375
Under-5
605
641
Literacy
95%
93%
^Population
Average Family Si^e
Employment
igiL-u
fcrU v / Rc? H
t F/i--
CkiPR P^rf5P)^TiC&
ir4 TFFfi-J^OH iP
/i.LL-p) 6 Z-
KANAKARI
PALLOM
955
906
b) Donation from Govt*
45
119
Eloctrifiod
23
32
1 TOOK.
328
297
2 rooms
592
475
3 rooms
80
253
Protected
187
486
Unhygienic
813
539
Fair
370
223
Poor (without)
630
802
CHARACTERISTIC
a) Own
No* of Roping
Sanitation
TrtBLE
XU.
immunization status and family planning acceptance
//'4
/N
CHARACTERISTIC
IP
Vi L.L l-l&£
KANAKASI
PALLOM
Gif I
Status (■>»’
Smallpom
298
313
BCG
84
94
DPT
218
236
92
96
Couples
805
825
Eligible Couples
610
613
Tubectomy
43
93
Vasectomy
25
128
IUCD
3
IB
Other woasures
93
122
3 doses
Polio
fff^llYul..^nlnMau^Gfi,gatia.9.£a
NB I
Kanakari has a large Roman Catholic Population
and hence the lower acceptance rates*
Table I and Table II show the demographic and environmental
characteristics of the two areas selected for the internship*
I
It is evident from the tables that the main characteristics
of these areas are high literacy rates* average family si^e
of 6«7» increased percentage of nuclear families living
in their own houses* poor environmental sanitation • all
of which are characteristic of rural areas of Kerala*
Table III * Shows the immunisation status and family
welfare acceptance • these being taken as two indicators
of health awareness in the area which inspite of a high
literacy rate is not as much aa expected*
After a period of six months the major thrust of their
work was directed towards teaching of health and related
subjects in the class rooms of local schools in the area*
Their responsibilities here were
i)
to teach good health habits to children* starting
from Kindergarten to high school*
ii)
to teach health as a science subject to grade 8*9 and 10*
iii)
to take care of the health problems of the student body*
iv)
to visit the homes of the children with even minor health
problems and to create awareness of the same in their
families*
In both the community and the school situations discussion
with village leaders end teachers* increasing community
participation motivating community to accept and get
involved in these programmes » all this was done by the
trainees themselves*
Since the internship was divided into two phases - the project
team got an opportunity to assess the impact of these trainees
on the health of the community in their two defined roles*
Phase I of internship was spent mainly as Comtnunity Nurses
where regular house visiting* organising MCH clinics treatment
of minor illness and health education at individual and
community level was mainly done*
Phase»II • of internship was spent mainly health educating
children at school level and providing a good school health
service and using it as a contact point with the community•
A comparison of the impact of these workero by the two approaches
was made possible and it was obvious that the participation and
creation of awareness in the community was much higher by the
second approach*
To <iuote one example in one of the communities
there had been a ninety per cent hook-work infestation*
The
trainees had been trying to get the people to accept better
sanitary conditions like building latrines, avoiding defecating
in the neighbourhood and providing footwear.
poor*
The response was
However during the second phase when the children ware
educated regarding the problem of hook-worm in their school
and the families were approached through their children more productive participation cane from the sama community*
4.7
geyelopment of Appropriate Tqchnolpav |
A very interesting outcome of this dose interaction
between the trainees, the teachers and the community was the
adaptation of some of the available local materials in medical
and nursing procedures*
This innovative approach is a
necessary lesson in the training of health workers especially
in the developing world where financial constraints are a
reality*
All workers must be taught to improvise and adapt
not only their skills but also develop newer and more
appropriate technologies in their work*
Only two eNumpies
will be given from the many developed by the team to illustrate
this aspect of the work*
1•
gf dry pediclp of Afecgnut leaf known as*Paula*
Ml 'iHUMia I
A good si^ed pedicle measures about two feet x
foot
This can be easily folded into any shape and fixed in that
shape by suturing with fibre*
The Paala was used by the
team for various purposes t
i)
As a basi^ to collect urine and feces of patients
who are bed»ridden*
ii)
As a baby tray to receive the new born baby*
The
baby can also be given a bath in the Paula*
iii)
As a receptacle for the placenta during domiciliary
delivery*
Since the •pedicle* is freely available it can be
used as a disposable receptacle*
If necessary* it can also be
washed and dried in the sun and used again.locally the Paala
in these areas has been used by the people for storing curd
or for drawing water from wells*
2*
LBavBH of ppppsr or plantan yged as aubatitutsa
fBi YMBUnfl 9UHW , »
Burna ara not an uncommon emergency in rural areas
flinco open stoves are still the norm*
In the hospital sat up
we usually use vaseline guaxe dressings to prevent the dressings
sticking to the wound surface*
Vaseline is not so easily
available and therefore the project team improvised a
dressing using cleaned• smooth leaves of pepper or plantain
painted with gingelly oil and wanned over a flame#
The
leaves were then applied to the burnt area and served the
same purpose*
Antibiotlea and immunisation against tetanus
toxoid were given routinely*
£ih£I£fi v
ft—£.,.S u
S.1
L
T
5
To suwiariao* the Kottayen Project has achieved the
following results t
1«
It set out to produce a now category of health
workers (called Connunity Nurse) who would act
as liaison between the Doctor and the Community
and take care of the comprehensive health needs
of the community directly and whenever neceasary
through supervision of oMisting para medical
workers*
2.
It sslscted nine female students with minimum
predegree qualification* and from lower socio
economic groups*
With a small staff-student ratio of 1|3 it evolved
a community baaed training programme wherein the
cowunity substituted for the teaching hospital*
4«
The students were instructed by the same team of
preceptors in all the subjects basic sciences*
clinical medicine and community medicine*
This
team consisted primarily of two HBB5 Doctors and
a B»Sc» Nurse*
5.
After defining the role of thia new cadre of worker
which included Health Educator* Family Welfare Workers*
Medical Assistant and Health Supervisor* it evolved
a curriculum by close interaction of preceptor and
trainees and udeHuate feed back from field work
experience*
6«
The students were examined at various stages by the
same team of examiners (again integrated approach )
The Final Examinations were attended by the visiting
Evaluation Team from the Kerala Government*
All the
candidates except one was found adequately prepared
with the knowledge skills and attitudes required for
their laid down roles in community health programmes*
7*
The eight students were given a year of internship
which was divided into two phases * the first one in
which they primarily worked as community Nurses and
the second phase in which they primarily worked as
Health Education in schools*
6*
The eight students ware then absorbed by the Mission
hospitals of the CSI Madhya Kerala Diocesan medical
Society where they are to date involved with the
organization of community health programmes in the
catchment areas of these Mission hospitals*
Because
of the comprehensive nature of their training nearly
all of them work part time ae Hospital nurses as
well*
5«2
SUGGESTED hODEL FOR REPLICATION i
Based on the experience of the project team the tentative
model evolved by the project team which could be used by
others interested in replicating the idea is as follows t
Define Role of Worker needed
in local situation
Baaed on the Role Definition
evolve a basic curriculum content
Select trainers and training
base from existing resources
available in the local areut
community and the existing
health infrastructure and
regional training institutions
Select trainees from existing
pool of pre-degree students
(sex> number* economic status*
motivation * aptitude etc* being
locally defined)* Wherever possible
get community participation in
selection of trainees
I
Organise a training programme
which hwa the community ua a
teaching hoapital and didactic
teaching and field work and
field iKtaita are doaely inte-
grated*
Uee the same preceptor
for all atages of training*
Duration of Course will vary
depending on course content*
Degree of Interaction between
preceptors and trainees should
allow for adequate feedback from
field work experiences to allow
for mid»course changes in
curriculum*
Evaluate the trainees with a
suitably constituted examination
panel consisting of consultants
familiar with ths role definition
of the grade of worker and the
course curriculum
Plan a suitable period of internship
to assess the efficiency of the worker
in ths actual field situation especially
where independent and unsupervised
decision making has to be undertaken
The Final Product of such a
programme will be a varying
combination of the four roles
i)
Health Educator
ii) Family Welfare Worker
iii)ftsdical Assistant
iv) Health Supervisor
This will depend on the manpower
needs and defined roles adopted
by the State or District Health
Service
V
Idontify/creute suitable job
opportunities where the products
of such training programmes could
be utilised and maximum utiliidtion of her knowledge skills and
attitudes could be made under the
supervision of a Hedical Officer
5.3
COST OF THE TRAINING PRQGRA^hC |
At this stage the cost of the training programme as
visualised by the above mentioned model should be
considered*
Table I shows the estimated expenditure
of the Kottuyam Project*
However• it is important
to remember that being the first of its kind such
a project has a research input in addition to the
TABLE I
PSntWTEO COST OF KOTTAYAM PROJECT
&•
TRAINING PERIOD
PER ANNUM
FOR 3 YEARS
1.
Teaching Staff Salaries
31,200
93,600
2*
Other staff salaries
(Peon, Watchmen etc*)
4,200
12,600
3,
Travel
5,000
19,000
Equipoent Material and Books
for Library
6,800
20,400
5,
Contingent exponsee including
stationery and printing
T,800
23,400
6»
Contingent expenses on
visiting consultants etc*
5,000
15,000
T.
Scholarships for students
( 9 students )
25,000
75,000
TOTAL t
85,000
2,55,000
Wl
B.
INTERNSHIP PERIOB ( 6 nonths period )
1,
Staff salaries
7,800
2,
Interns Stipends
19,200
3»
Petrol/Oil
6,000
Incidental exponsee including
otationery etc*
6,000
Drugs etc*
12,000
TOTAL I
GRAND TOTAL t 3,06,000
51,000
cost of the training inputs*
The former being the
cost of planningt evaluating and recording all aspects
of the training programme with the view to evolving a
strategy for replication*
However* once this is done
then the cost of the replicative model will only be
the cost of the teachers salaries plus ancillary
staff salaries plus travelling grant for field work
and field visits plus contingent expenditure for
stationery specialist visits* examinations etc*
plus cost of teaching aids* library books plus cost
of drugs* vaccines and basic equipment for eompre*
hensive home-based healthcare*
A major part of
these costs will also be mainly capital and not
recurring*
In addition if an adequate inventory
is made of available training manpower and material
resources in the health infrastructure and training
institutions of the area even the recurring costs
can be markedly reduced*
CHAPTER VI
CVAUUATIQN
Th® evaluation of such a project in quantitative at
qualitative tecuie is a very difficult proposition because
the application of any pre-planned evaluation criteria to
a continous evolving and developing process such as the
training programme in the Kottayaa project would neither ba
justifiable nor be successful in giving us the real
achievements, failures and implications of such a project,
A good training programme should bs sensitive to the socal
environment of the community which it seeks to serve, and
constantly adapt itself to the changing requirements. Msasuring
this sensitivity or adaptability to local needs is also a
difficult task.
Moreover, in any attempt to evaluate this
project one must not loose sight of the fact that the whole idea
and experiment developed in the state of Kerala whore the
socio-cultural and political milieu ie quite different from the
rest of India,
In an area of high literacy rate the people
are more aware of their rights,
In addition, with a more
equitable distribution of wealth and a more planned distribution
of health infrastructure the people will demand not only
better quality of service but also better quality of health
wock»s«
Professor Chandy’s project is thus an attempted
answer to such a need.
6.1
AN EVALUATION I
In a comprehensive evaluation report written on this
project Professor George Joseph* Head of Centre for Community
Medicine* All India Institute of Medical Sciences has commented
that "This project aims at filling up the gap that ie felt to
exist between the home and the hospital with a new cadre of
adequately trained health personnel with the right type of
coautunity experience so as to achieve the effective integration
of the four»fold dimensions of health right at the hub of the
field of action (which perforce the family has to be)*.
b
Commonting on the conceptual model of this project he further
states that *The project is an attempt to establish the feasibility
of an intermediate level health worker who will have greater
independence and initiative and therefore must have better
professional training than their counterparts todqy.
Such a
cadre of health peraonnsl however is not developed as an
•alternative1 to ths sxistent cadre of Basic doctora/eommunity
physicians but to complement and supplement them. It must
hero bo stated that so far we have not identified ths ideal
type of health functionary who can be expected to deliver
the goods in a comprehensive health care delivery system in the
rural setting.
The emphasis on better training for this now
category ia well pieced in the context of the continued and
continuing disparity* between the standards of health services
in the
urban and rural settings. As these personnel are
meant to function in harmony with the home settings in the
rural mlieu this can effect a breakthrough of the accessibility
barrier of nodarn nodicine*
Fiore so because either consciously
or imperceptibly they have to indulge in health education in the
given context# they are expected to possess the required expertise
to deliver comprehensive health care upto a level beyond which
they function in consultation with the physicians at the rural
hospital or the health centre (existing network)*
integration therefore ie postulated*
A close function
The point behind emphaeising
the techniques of community organization in the training programme
for these personnel is to enable them to make use of the existing
potential including the indigenous health manpower (dai# village
physician etc) on a better scientific baeie*
The envisaged shift in orientation may perhaps be explained
thus instead of having the health establishments representative
in th© community in the present set up it is desirable to have
the community1s representative that the community nurse is want
to be in the health establishment**
Commenting on the methodological
aspects of the programme# Professor Jospph mentions that
i) "the making of the community the sole field for training
is both innovative and corrective**
ii) "the initiation of trainees into a community survey and
its continued and committed follow up offers a venue for
training in community medicine in the traditional sense
and clinical medicine in an unorthodox way**
iii) "The constant prasenca of the pseceptoss with the
trainees in the family setting made the training both
natural and realistic and the project proved that clinicbl
instructions regarding the normal and deviations
therefrom can be adequately imparted in the home
setting**
iv) "It desires mention that the Project Director had a
weekly session with the team (teacher and trainees)
when the work done in each week was rsviewed and
evaluated*
Suggeetions that could thus bs given •
as guidelines for training thereafter helped to make
any mid course corrections that was necessary*
It is
significant that svaryons concerned participated in
this process*
v) »Since the objective of the project was to evolve a
group of health personnelwith a minimum of inputs
preserving at the came time an optimum standard of
training, institutions based instruction was reduced
to the minimum and the training facilitiea that were
readily acceesible were maximally used and to greater
advantage*
Another aspect of the same idea was the
greater utilisation of the facilities available in the
community for organising training and community service
programmes (e*g* school, panchayat building, churches etc*)
All these helped to minimise programme inputs*
Finally commenting on the overall relevant and replicability
of this project he states
"The replicability of any projeect can only be inadequately
discussed in isolation from the feasibility of its laid down
objective*
Ideally* considerations of replicability should
not be allowed to obscure ths relevance of the objective*
Even
so* the project under evaluation appears wholssome* in this
context due to the minimal requirements of inputs which is a
direct result of its conceptual reorientation*
It appears
therefore highly desirable that instead of the traditional and
expensive institution bases* this project has accepted the
community setting on the whole as its venue for training*
The
organisational structure is simple enough* the preceptorial
role resting with two doctors and a Public Health Nurse* in the
present instance*
The emphasis on a better quality of training that is aimedcat
augurs well in the context of our old mistake of diluting rural
health services*
This changed emphasis is evident right from
the outset* from the fact that the minimum elegibility qualifi
cation is pre—degree* and can therefore presuppose a fair
grounding in basic sciences*
This has facilitated their
improved image and acceptance in the community where they can
command respect*
In a community like the one in which the
trainees were posted which io considerable enlightened (base—line
survey conducted by the trainees has revealed an overall
literacy rate ranging between 93% and 95%) it is unfair to
send a poorly trained rod diffident community health worker*
Even in communities with a less impressive literacy rate* there
is no excuse for sending a semiliterate* illtrained* ill-equipped
health worker to represent the promise of modern medicine to rurll
folk*
It should be emphasised that the trainees as far as poesibls
should be drawn from the respective communities so as to emphasise
The
the local singularities in the delivery of health care*
possible apprehension about the possibility of attracting local
talents of sone standing (such as possessing basic educational
qualification) into such a training programme will be misplaced
not only because of the promise that the present programme holds
out but also because of the every-growing problem of the educated
unemployed in the country*
A concrete product of the project was the gradual evolution
of a core curriculum which for purposes of national adaptation
may be critically checked up against the profeasional skills
aimed at* in the light of the overall health policy of the country.
This in itself can have far reaching consequences*
Once this
is achieved* eny health organisation withthe requisite training
manpower and effective links with the community (futuristic
role of any hospital including the teaching hospitals) can be
expected to undertake the responsibility of training.
The
Department of Community Medicine in various Medical Coliegee
in collaboration with the other clinical and preclinical
departments and ths existing nursing collages/schools can take
up this challenge.
In this context, the kind of training programme
envisaged can be doubly beneficial in enhancing the medical
training programmes say of Interns and Postgraduates with
direct experience in the community as a badly needed category
of health worker is being moulded**
6.2
IHPACT Qf THE PROJECT >
A very good method of evaluating a project could also be
by studying the impact that a certain project has on existing
training programmes* This impact could be by the diffusion of
the ideas and experience gathered in the project and disseminated
through discussions and reports of the project*
In this particular
context the Kottayam Project has been particularly successful in
a) making an impact on the B»Sc* Nursing training in
Kerala| and
b) leading,the introduction of a Q«Sc* Health Science course
in Osmania University*
(a)
A Report of the Committee appointed by the Kerala
Gov Bxn Kian t to evaluate the training programme for community nurses
at Kottayam observes "That the standard shown by the candidates
at the examination was quite satisfactory and they were found
to possess a good background of community health work .•••••••
Based on the observations of the performance of the trainees in
the V Semester Examination and from the information that could be
gathered by scrutiny of the curriculum and by interrogation
of the teachers and organisers of the programme and the trainees®,
the Committee felt that the training programme had been conducted
well with a group of dedicated teachers who have been successful
in motivating the trainees for community health work.” They
further observed that the objectives of the course as contemplated
are to prepare a new category of Health Supervisory Staff to
render comprehensive health care in the community, to plan and
to supervisa ths care given by the peripheral health workers and
to assist them in their pereonal and professional development so
that they may make their maximum contribution to society as
individuals* citizens and health workers*
The products of thio
course can render better service to the community than the present
Public Health Nurses as they are better equipped to function
independently to a certain extent*"
After a few further observations
on lhe needa of increasing the training in effective supervieion
of ANMs and health visitors and adding some hours on theory
and practice of supervision* administration personnel management
and educational psychology and counselling as well increasing
institutional experience in the clinical subjects the review
committee made this rather significant observation* "The present
4 year B.Sc* Nursing may be suitably modified to prepare health
supervisors of this category*
The first year of the present
B»Sc* may be allotted for Basic Sciences and fundamentals of
health care*
At the end of the first year the students may be
given an option******* of either a course leading to degree in
community Health Sciences or to a degree in Hospital Nursing
work*
The community oriented training (as in this project) for
the degree in Community Health Sciences can
prepare personnel
of the right typo -to replace the present category of Public
Health Nurses in due course" <>
(b) B.Sc* Health Science Course at Osmania Univsrai.t.V—1
At the Convocation of the Osmania University in
March 1976, Sri P* Jagan Mohan Reddy, Vice Chancellor mentioned
in hie report the institution of the new Degree couree on Health
Sciences and observed "This Degree course on Health Sciences
will be administered by the Faculty of Medicine and will be of
great interest to the youth of today because it is job-oriented
in its very conception*
The key word of this naw course is
•Awareness’ - to make our student body aware and through
them make the whole population aware of the scientific and
technological knowledge and practice of positive health*****
One of the objectives of this scheme is the integration of
family planning with health and nutritive facilities working
in the context of modern society*
This new course is aimed
at creating a new cadre of personnel who would be adequately
trained in the scientific knowledge of health*
It will be
community oriented* These graduates will* therefore* fulfil
a vital need by becoming the teachers of the impressionable
minds of school children and bringing about health awareness
among people of all ages**
He later went on to add that the
whole inspiration and guidance for such a course came from the
expexisnee of the Kottayam Project directed by Professor
Jacob Chandy*
(c)
The Tamilnadu State Health Services while considering
plans for development of thsir Health Assistance Course* has it
is reliably learnt studied the experiences of this project and
takes the course syllabus into consideration and suitably modified
it to meet their local needs*
Thus it would not at all be an exaggeration to
suggest that this project has already had a very important and
pioneering role to play in the development and modification of
training programmes in the Southern regions of the country*
6«3
CQhHUNZTY EVALUATION t
After considering the evaluation reports of ram of the
consultants and the impact that this project has had on various
existing and new training programmes in the south I would like
to end this chapter on Evaluation by quoting from an interview
I had with a group of mothers living in Hundiapally village
one of the areas where the Community Nurses worked*
It must
be remembered that in the final analysis the evaluation or
success of any cadre of health worker will depend on what
the community thinks of him/her and perceives as his/her role*
This is the ultimate and real evaluation*
When asked of what the
community thought of the nurses who had bean working there and
why?
The answers (translated from Malayalam) put together were
"Th© Community Worses were of great help to we mothers in the
area because they gave medicines during our children's illnesses
and advised us on how to bring up our children in a health way *»
with cleanliness and good food*
In the hospitals we visit^the
doctor gives a prescription and the nurse some medicines but
neither seem interested in listening to our problems or worries*
The main difference with these nurses was that they were
sympathetic to our problems and had time to explain why the
problem had arisen and what all should be done to tackle it*
This interest in spending tim with us to discuss our worries
was mott ifreasauring*
When the nurses were here.sores had
nearly disappeared and now it sores have become even worse
than before*
When they were here there was a motivation to
follow their advice*
Now we are not getting the health talks
and—the continoue advice from them* Wetherefore follow sometmie
follow their advice*
Now we are not getting the health
talks and the continoue advice from them*
follow sometimes*
We* therefore*
We forget mostly**
1
CHAPTER
VII
health awareness ano health
Health education and consequent experience
of scientific knowledge as on instrument in
ths dynamics of development in the developing
countries*
.
The creation of awareness is the sine«qua«»non of
development of man and hia environment* and aa such assumes
uniMue importance in the context of a developing economy.
Development can only occur if the individual can become
aware of hie own needs and can take responsibility to meet
those needs.
A scientific understanding of hie physical*
sociological and intellectual life and needs* and a means
of realising them without institutionalising them* is essential
to enable man to delight in the joy of living.
All education*
ideally* should lead to the individual accepting responsibility
for himself rather than seeking for service agencies to protect
and preserve him.
Consequently* Health Education and the
experiences gained from this scientific knowledge* can create
the health awareness which will lead to development.
Health
educationt to become meaningful* has to ba associated with
health care.
Throughout the world* in the developed aa well as
in ths developing countries* we have been seeing the futility
of a quantitative proliferation of health care facilitieo
aimed at enriching healthful living.
Well-hieaning and colossal
investment in this direction, without adequate efforts to create
4,
M
health awareness among the people* had been just like hoping
to entertain a blind nan with a really superior mirror*
It
has taksn years of trial end error to realize that the provision
of hsalth care facilities alone does not assure their utilization
by the community*
The signal importance of the creation of health awareness
being recognised* it reamins to be considered how best this can
be achieved*
Surely people cannot bo ordered overnight into
awareness* Considering the human drama involved in this process*
it is necessary to identify effective breakthrough points in ths
life of the individual* for the infusion of enlightenment into
the human mind*
I am convinced* and I am sure you will agree*
that they receptive minds of children at school are precisely
at such a point in development*
I don’t have to emphasize that habits are developed very
early in life and underfives are* therefore, the most vulnerable
group*
IncMcation of healthy habits has to start as early
as possible*
Ths vital role of health education in health care efforts
is* conceptually* but now axiomatic*
Yet in all developing
countries it is waiting for a systematic attempt at dissemination*
with the school child as the focal point*
Only programmed and
formally imparted health knowledge and education* with a hard
core of the scientific exposition of "Health Sciences"* as
against half-hearted and episodic attempts at health propaganda
It is the coming generationt with
can save the situation*
the scientific understanding of the necessity and urgency
of fa»dly limitation^ who will be able to nullify the
ill effects of population growth*
Hence there is an urgent
need to introduce the teaching of "Health Science"t us a
separate subject* at the secondary level of schooling in all
the developing countries*
It becomee clear that there
should be a steady progression from health habits learned
early in life to the scientific awareness created through
formal education* which is the dynamics in development
for the attainment and maintenance of health*
It is necessary here to distinguish "Health Sciences"
from "Medical Sciences"* in their present pattern*
Health
Science is a discipline that seeks scientific and
technological compilation of facts regarding positive
health aspects of man and his environment - in its totality
and the systematic dissemination of this vital knowledge
in the community* which will facilitate the enjoyment of
healthful living*
It is necessary to emphasise this
distinction because of the fact that "Medical Sciences"*
in general* have been assuming and asserting their major
thrust and orientation towards sickness and curative efforts
rather than positive health and promotive efforts for better
»
B
k
k
t
k
i
<
4
r
living*
The essential ingredients of "Health Sciences"*
as they are envisaged to be taught at school level* may be
outlined us follows t
Population Dynamicst Family Life and
Sex Education* including need for family sire limitationt
Home Economic# Dietary needs and Practices! Normal Pregnancy
and Doliveryj Child Developments Child Rearingi Personal
Hygiene and Habits> Preventive Health Caret including
ImmuniMtion# Environmental Health# including common occupational
health hazards# socio-cultural# as well as psychological and
motivational factors influencing health and disease*
Unless
it is realised that "Health Science" is an important scientific
discipline needing in-depth comprehensive knowledge# it may not
be possible to have its full influence on health policy and
socio-cultural and economic goals# with their resultant impacts
on the dynamics of development*
It is# therefore# unrealistic
to assume that any teacher# with only a short orientation course#
or anyone from the existing health man-power could be invited
to carry out this onerous responsibility at the secondary school
level*
Personnel who could be expected to satisfy the
requirements of this commitment are* to my knowledge# not
available*
This highlights the need for a full-fledged degree
course comprehending the various facets of "Health Sciences"
envisaged*
This discipline of "Health Sciences" will include
sufficient competence for the following t
1)
Developing positive health habits from the lowest
classes onwards*
z)
Teaching "Health Sciences" in the senior classes*
3)
Organizing and maintaining school health care programmes
for the entire student and stuff population of the
school*
4)
Establishing contacts with the cowinunity as a
natural expansion of the school health programiref
through the parents of the students*
5)
Creating awareness in anclenlisting the participation
of the school teaching staff for the total care of
the students*
I was able to convince the authorities of the Osmania
University at Hyderabad• including its enlightened Vice-Chancellort
of the need for introducing a 3 year degree course in "Health
Sciences" for this very purpose*
The courscf which has also
found favour with the Government of Andhra Pradesh* has since
then been instituted*
The easy modus operand!* at least for the time being*
is to incorporate the course into the medical colleges* making
the departments of Social and Preventive Hedicine responsible
for organising it as a part of their faculty commitments* The
junior faculty* as well as interne* can be given training
responsibilities in the field work*
This programme must be
essentially community bused and community oriented*
It ie
important to note that these arrangements help to minimise
additional financial inputs into the training programme*
Also*
there need not be much difficulty in starting this programme
in any Arts and/or Sciences College with sufficient financial
input*
(>
The deeirability of introducing Health Sciences
as a separate subject at the school level and the framework
of the degree course in Health Sciences have emerged from an
action research project in the "Methodology of Health Care*
that was organised in Kerala State* India* through the C»S»I*
Madhya Kerala Medical Society* and funded in part by the
Family Planning Foundation of India
I am convinced that we in India should strive toward
instituting a degree courao in *Health Sciences* in all our
medical or allied colleges* so that wo will have teachers to
teach "Health Sciencee* as a subjact in all of our high
schools*
Ae thsse teachers also look aftsr the school health
programme and extend health education to the community*
there will be transformation of school children into torch
bearers of enlightened health awareness* which in turn will
bring about positive dimensions of health into the way of
life of ths people in our country* i)
r 'i
- 70 •
REFER E N C £ 5
1.
BRYANTt J« (1969) Health ..^nd .th0....Pe.va.lcming WqxX4»
Cornell University Press, Ithaca and London*
2.
PaTEL* B*P. (1970) Roorientation of ftedigaX EdUO^tion
for CpoMuynjty Health Scrviqoo» Ministry of
Healthf Family Planning, Works, Housing and
Urban Developuient, Government of India, New Delhi*
3*
NARaYAN, RAVI (1973) T rends- In jwdi cal Educat ion In Xndi a»
DTPH Dissertation, London University (unpublished)*
4*
GOVT* OF INDIA (1975) Health Services and Modlgal.■CdMC.^tlo.n,
Report of the group on Medical Education and Support
Manpower, Ministry of Health and Family Planning,
New Delhi*
5*
GOVT* OF INDIA, Ministry of Health and Family Planning(1973)
Rgpprt pf th^ Commit
on iuultipurpose vorkers under
Health and Family Planning Programme, Departwent of
Family Planning*
6*
ICMR (1976) Alternative approaches to Health Care, Indian
Council of Medical Research, New Delhi (circulated
publication)•
7.
CH ANDY, JACOB (1976), Report on the.-H.oaparch. in the
Methodology of Health Delivery, Preliminary report
submitted to Family Planning Foundation*
- 71 -
8*
CHANDY' JACOB (1976)® Kempyandym an. Health Sgienggst
(Unpublished document)*
9.
JOSEPH, GEORGE (1975), an Overview of the Project tiUsd
in the i<ethodoXoQV of Health Qeliyerve”
submitted to Family Planning Foundation*
10.
GOVT. OF KERALa (1976), Report of the Cpiamittoe apopintgd
tq Evaluate the training gf Female Health Supervisors
organised fry Prof* Jacob Chandy in. .K<LlAdMrta
(unpublished, internal circulation document).
11.
REDDY9 JAGANHOHAN P*e (1976) Convocation Report pyee^nted
by Vice^Chancellqrt Osmania UniveypitV' Hyderabad•
12.
THOMAS, REX (1977) Personal Communications on Project
especially present work of trained nurses and
evolution of appropriate locally adapted
methodologies in health cure.
I
ACKNBWUEPfiEHENT
I would liko to thank the Family Planning Foundation
of India and aapeeially Prof. J.C. Kavoori for giving no
thia opportunity and faeilitiaa to study thia Project and
compile a report on it.
I would like to thank Professor Jacob Chandy for his
hospitality and stimulating discussions on the Project and
its evolution.
Thanks are also due to Dr. Rex Thomas and
many of the sisters trained in this Project who helped me
in collecting the details required for the report.
Dr.
Molly Phillip (Professor PSH •» Kottayam Medical College)*
Dr. Madharan Kutty (Professor PSH, Trivandrum Medical
Collage) and Dr. V. Benjamin (Professor PSH* Christian
Medical College* Vellore) were also kind enough to discuss
the Project with me and I would also take this opportunity
to thank them.
Most of all I would like to thank Profeesor George
Josepbh(Head* Centre for Community Medicine* All India
Institute of Medical Sciences) for all the assistance and
encouragement in planning the report and the patience in
discussing moat of the manuscript.
Lastly thanks are due
to Hr. Kulkami and Mr. R. Sharma* of AllMS for the excellent
job done in typing the report and the appendices respectively.
APPENDIX - ft
THE PLAN OF ACTION FOR COMMUNITY WORK
Selection of Area:
In selecting the area for community work, priority was given to
an area with a low economic background and where health facilities
were meagre.
Contacting the leaders: and arranging a meeting with them.
The objectives of the work and the modus operand! were explained
to them and their co-operation solicited. Suitable places and buildings
to conduct Under Fives’ Clinics and Anternatal Clinics were selected
with their help.
Baseline Survey and Mapping of the Area,
Analysis of the Baseline Statistics,
- Socioeconomic Status
- Main sources of income
- Literacy status
- Source of water supply
- Sanitation
- Housing conditions.
- Kitchen garden, crops etc.
- Poultry, cattle etc.
- Utilization of health services
- Types of medical care available
- Demographic data:
.Total population
.Sex distribution
.children - Pre school § Infants
Target couples § Eligible couples
Family Planning Acceptors.
- Morbidity Characteristics:
Common morbidity conditions
Usual modes of treatment
Knowledge, Attitude and Practice on
Water Supply
Sanitation
Nutrition
Immunization
Family Planning
Common Communicable Diseases
Mortality:
No. of deaths in five years preceding the work: Age, Sex, Cause.
Deaths during the plan period. Age, Sex, Cause.
n
Regular and follow-up visits:
The students are expected to keep a dally diary in which they
note in advance the houses to be visited and the type of visit
(regular or follow-up). They present their plan for the day and the
concerned staff member gives necessary instructions.
Records are maintained on:
Morbidity Statistics
Maternity Services
- Growth and development
- Nutrition
- Immunization
- Morbidity Conditions.
Infants.
Under Fives
- Age and sex distribution
-No. of pregnancies
- Type of Antenatal Care
(home or clinic)
- Health talks given
- Family Planning motivation
- Mode of delivery
- Postnatal follow-up
including nutriton education.
Immunization
Nutrition
Morbidity conditions
School Health
Types of Service given:
Health education - Individual and group
Free consultation service : Early diagnosis and
management of minor ailments.
Follow up of Chronic Cases
Tuberculosis - Case finling, treatment, health education,
midwifery services and follow up
Underfives* Clinics - Health Education
Assessment of growth and development
Immunization
Nutrition Programme
School Health Programme -
General check-ups
Treatment of minor ailments
- Health Education
Improvement of Socioeconomic Status:
Motivation for kitchen Garden and Poultry
Improvement of Sanitary Facilities:
Health Education
Exploring possibilities for subsidizing
Sanitory latrines andprotected water.
1
Family Planning - Motivation and Referral - Follow up
Nutrition -
Education
Exploration of possibilities for nutritional
supplementation including tapping of the
locally available resources.
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7 - b, DEA55IS (Since H o tine of inception of tee f;52kdly in 19... -)■
of tiie Relateansiilp with Sex Date of Ago of Cause of deate Ifodil
deceased.
head of aousoiiold
bUrte doatii Prtoary Secondary csa
ar any ot'.;er,
(note s. no.)
8, SKmoraCllTi (Dew a neat cletch m page 4.)
Detatehod
1. Tyj>e e>£ building# Attateod
i*
neat* cc®splete
2. Sulld-dn ai*oa:
Etetei;od/Silod/CooK?ete/Ot£wD (Specify)
3. Roofs
4. Walls4 TMte^WDrich/ntetered/Woocl/cm^rs(specify)
5* Floors Mud/l kid with dwg plos-ter/Cmait/OtSieira
6» Kitol'on: functiouing/Rot fwotimlEAZ^TO3®'1® stevo, etc./Bloct=
7. mnislng waters
Kwt<Msi>3d^J^xrot4x;ted/a'oteste'l/U^.^tectod Tube xroll/Sanlc/PJlvc
Fetally well
CcMnunlty W1X
llpad/Otl.crs
3. Draanegeos
9. Itubbish!
10. .Latj.'inos
Abstt^^saWKlto.^ gar&aa/-J&al^go pit,
□u<>i^Ca^^stiiig/IisciT^rctl0n/Scatterod/L£ttrir.e
Strface/Opm pit/Pig La-fa’inu/Closod pit/Closed pils
c Water /nd t®
Barecl m® Eoeri hole septic tanSs Urbcn
(no V’,S, £W(© W.S. Slab)
flix.h out
awsijrwney/toy ©tear (specify)
11. Came
Zxu^Utaajy/Smiitary
Distance £raa house
l
12, Rani; vege-taaiant
Alwnt/Prosesit/P^W
13. t'iosf.juit® br-osdin^
14, DlcOo,$lGal cawi.
15. Fly broedins pl&coss
^^mt/Abseut
Actual
Presmt/Abscst
Potential
Cuts
Sheep Gouto
Ifosquite® Flies
Otliere (specify)
1X4
Presont/Abs^it
Actual
Cws
Present/Absent
Potential
»
■» 4 ■»
9.
FEWJCIAL EirORIimCKI:
Ha.
iWfc'Oy family tocaae from
Itatbly family ®q?mdits
fors
1. Solorios and w t/ugos
i. lOOd
2. Land and ^icultuml
2. (XLathas
products
4« Dusinoi-o
3* Sduoatitm
4. Medical csare
3 amt os’/and oortgagc
5* Liw3toalz
u. Ta.;.
6. Ot2ier items (Specify)
7, Debt® - intarost
3. DtiildinBa
Hepayamt
8. Any others (Specify)
Total
Total
i
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