HEALTH EDUCATION AND PRIMARY HEALTH CARE

Item

Title
HEALTH EDUCATION AND PRIMARY HEALTH CARE
extracted text
In this issue

swasth hind
Magha-Phalguna
Saka 1914

•February 1993
Vol. XXXVII No. 2

OBJECTIVES

Swasth Hind (Healthy India) is a monthly journal
published by the Central Health Education
Bureau, Directorate General of Health Sendees,
Ministry of Health and Family Welfare, Govern­
ment of India, New Delhi. Some of its important
objectives and aims are to:
REPORT and interpret the policies, plans, pro­
grammes and achievements of the Union
Ministry of Health and Family Welfare.
ACT as a medium of exchange of information
on health activities of the Central and State

Health Organisations.
FOCUS attention on the major public health
problems in India and to report on the latest
trends in public health.

KEEP in touch with health and welfare workers
and agencies in India and abroad.
REPORT on important seminars, conferences,
discussions, etc. on health topics.

Health education and primary health care
Dr Gajanan D. Velhal
Education—health linkages: considerations for
integrated planning
B.B.L. Shanna
Private voluntary organizations and primary
health care
Dr B.K. Pattanaik
Health care delivery—need of comprehensive
health care
Dr Devi Sa ran Shanna
Dr S.B. Dabral
Nutrition training in community settings—NIN
experience
M. Mohan ram
V. Ramadasmurthy
Ideas for action—learning about your community
Educational intervention in management of
alcohol dependence
M. Ameer Hamza
Dr R. Parthasarathy
Messages on Anti-Leprosy Day—30th January
Traditional health practices for the care of
children
Dr Meh arban Singh

Page
29
32

37

40

42

45
46

47
50

Counselling for Psychosocial problems
Dr V.N. Rao
Dr R. Parthasarathy

52

Traditional healers and community health
Wilbur Hoff

54

Evaluation of dental health education approaches in
school children
Patina Lal, Dharmvir Jain and
Smt. Unnila Pant
W.H.O. Executive Board Session :
US S 1.8 Billion Budget for 1994-95 adopted
Diet and nutritional status of girl child
Book Review

59

61

64
3rd
cover

Articles on health topics are invited for publication in this
Journal.

Editorial and Business Offices
Central Health Education Bureau
Kolla Marg, New Delhi-110 002

State Health Directorates are requested to send in reports of
their activities for publication.

The contents of this Journal are freely reproducible.
The opinions expressed by the contributors are not necessarily
those of the Government of India.

SWASTH HIND, reserves the right to edit the articles sent
in for publication.

Edited by

M. L. Mehta
M. S. Dhillon

Cover Design

Madan Mohan

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HEALTH EDUCATION AND
PRIMARY HEALTH CARE
Dr Gajanan D. Velhal

Universalizing health education through mass spread of the relevant knowledge and
information by communication media and means has to become a high priority area of
action both by the government and the people themselves. Moreover, ways must be
found out to make health education sufficiently specific so that implementation of
educational activities can be monitored and their effectiveness evaluated. This
would enable decision-makers to judge, whether or not, their allocations to health
education were yielding adequate health benefits, says the author.

February 1993
1—16/DGHS/92

29

ealth education is defined as

H

a process that informs,
motivates and helps people to
adopt and maintain healthy prac­
tices and lifestyles, advocates
environmental changes that may
facilitate the achievement of this
goal and conducts professional
training and research to the same
end. Health education is con­
cerned with establishing or induc­
ing changes in the attitudes and
behaviour of individuals and
groups that promote healthier
living.
Primary health care has been
defined as essential health care
made universally accessible to
individuals and families in the
community by means acceptable to
them through their full participa­
tion and at a cost that the com­
munity and country can afford.
In fact if primary health care is to
be made accessible to all, the
inhabitants of every community
must learn to rely as far as possible
on their own resources. To achieve
such self reliance the people should
be involved in the planning,
implementation and evaluation of
health services based on primary
health care. In fact the Inter­
national Conference on Primary
Health Care organised jointly by
UNICEF and W.H.O. at Alma Ata,
U.S.S.R. in 1978 declared that peo­
ple have the right and duty to par­
ticipate individually and collec­
tively in the planning and imple­
mentation of their health care and
that education concerning prevail­
ing health problems and the
methods of preventing and con­
trolling them was the first of eight
essential elements in primary
health care.
Originally health education
developed along the lines of the
biomedical views of health and dis­
ease that were prevalent, at that
time, according to which social,
cultural and psychological factors
were thought to be of little or of no
importance. Relatively few efforts
were made to understand peoples
traditional health beliefs and prac­
tices. The assumption under
30

health education activities was that
people would enjoy belter health if
they would act in the manner
recommended by the health
workers. More often individuals
were the passive receivers of a ser­
vice. Hence the emphasis was on
the transmission of correct health
information to the general public.

The concept of primary health
care has drastically changed this
view. The modern concept is that
the role of health education is one
in which the health care providers
and the people both teach each
other and learn from each other,
changing their roles constan­
tly. The objective of health educa­
tion is to foster activities that
encourage people to be healthy, to
know how to stay healthy and to do
what they can individually and
collectively to maintain health and
to seek help when needed. Health
Education is a potent approach
that can influence people to the
extent that unfclt needs become felt
needs and felt needs become
demands. Far from merely seek­
ing the cooperation of com­
munities in carrying out plans
already made, health education
should aim at encouraging people
to be actively involved in the plan­
ning and maintenance of their
health care system and to act in
partnership with health care
providers.
Objectives of Health Education

The three major objectives of
health education are:
1. To make the people understand
the value of health not only as a
personal asset but also as a com­
munity asset and the individuals
own responsibility in maintain­
ing it I

2. To help people to develop
knowledge and skills to under­
take the activities which will
enable them to help themselves
in achieving* optimal healthand

3. To help people to understand the
nature and -purpose of health
services and facilities provided
for their benefit so that they may
be able to make the best use of
such services and facilities.
Health cannot be imposed, it has
to be attained and without the
fullest cooperation of an informed
and educated public willing to
become involved and self-reliant in
matters of health, this will be
impossible. Rather than health
services filtering down through a
number of layers to reach the
underserved, a movement starting
from the people has to be initiated
which reflects the will of indi­
viduals and communities to take a
full part in the affairs of their coun­
try and to share with the govern­
ment the responsibility for health
care and health promotion. Health
for all by the year 2000 A.D. is not
likely to be achieved by using the
available professional services
alone. Lay self care has an essen­
tial role to play in improving the
health status of the people and dec­
reasing health costs. In the
absence of health education com­
ponent being integrated properly,
the National and State health pro­
grammes will not be able to achieve
the objectives laid down and the
investment made will be nothing
but a drain on the state re­
sources.
The health of an individual, a
family, a community and a nation
depends on factors within the
purview of the individuals and
the community. Personal respon­
sibility covers a wide area in the
promotion of healthy life style.
Individually one can improve his/
her health by taking balanced food,
using safe drinking water and pro­
tecting it from contamination,
regular exercise, practising per­
sonal hygiene and keeping the
house and its surroundings and
place of work clean. Community
on its part can create facilities for
better upbringing of children and
youth; take steps to prevent and
control communicable diseases,
arrange for facilities for holding
SWASTH HIND

sports events and regular exercise,
encourage the use of locally avail­
able inexpensive nutritious foods,
change of social norms of smoking
and alcoholism and thus promote
healthy living. Community can
also organise health s’ervices and
can ensure full utilization of the
available health services.

The scope of health education is
widespread and there is enough
awareness about its importance at
all levels of administration and
policy making. It requires further
development mainly in the follow­
ing three areas:

1. Community participation.

2. Research.
3. Monitoring and evaluation.
Only by participating in building
their own future, can people grow,
hence peoples participation must
become a reality. In deciding the
nature of health care, attention
should be paid not only to peoples
health needs but also to the
possibility of utilising the peoples
ability and creative talent in the
processes of planning and im­
plementation. If people
are
treated with honesty and dignity
and are allowed to participate
actively at all its stages, they res­
pond with commitment. Par­
ticipation at community level
increases peoples sense of control
over issues that affect their lives.
Active community participation by
villagers has contributed a lot to the
success of comprehensive Rural
Health Project in Jamkhed,
Maharashtra.
Research in the production and
use of health education and train­
ing material and the impact of

FEBRUARY 1993

health education programmes have
received
very
little
atten­
tion. Health behaviour research
has been limited to KAP studies.
While K.A.P. studies convey what
people know and do, they rarely tell
why people do what they do.
Research will reveal why people
participate or do not participate in
health programmes, what are the
real factors responsible for
unhealthy practices and what can
bring about a change in the life­
styles of the people.
Ways must be found out of mak­
ing health education sufficiently
specific so that implementation of
educational activities can be moni­
tored and their effectiveness
evaluated. This will enable deci­
sion makers to judge, whether or
not their allocations to health
education are yielding adequate
health benefits.

3. Every educated person should
consider it as his duty to impart
the knpwledge to his less for­
tunate neighbours.

4. Schools and colleges dealing
with health education and
schools of social work should
conduct research into the
health behaviour and assess
the efficacy -of the various
ongoing programmes.
5. The students in the higher
secondary schools and colleges
should receive basic informa­
tion on health matters.
6. It is important that the
messages on health education
are clear and that there are no
inconsistencies or double
standards.

7. Primary health care should not
be looked upon as entirely poor
man’s health system.

If health education has to have
positive impact on overall health
status of the community and
nation, due consideration should
be given to the following things?

8. The political leadership must
be convinced that investment
in health is sound economics,
with popular appeal and
social imperative.

1. Ensure that health education
activities are based on the
peoples perception of their
health needs, priority being
given to goals that reflect both
the felt needs of the people and
the needs defined by health
professionals.

9. Hospital being a service institu­
tion deals directly with the
public and therefore health
education activities if carried
out by these institutions are
more effective to educate a
large population.

2. In strengthening lay resources,
attention should be paid-, to­
wards the three roles of women,
i.e., those of health protectors,
health consumers and agents
of social change.

Universalizing health education
through mass spread of the rele­
vant knowledge and information
by communication media and
means has to become a high
priority area of action both by the
government and the people
themselves.
A
31

EDUCATION—HEALTH LINKAGES :
Considerations for Integrated Planning
B. B. L. Sharma

Education is an important factor responsible for individual as well as family’s health. For
example, in India mothers are usually responsible for bringing up the children. So, the
level of literacy and education of mothers assumes more significance in determining the
health status of our children. This is more so where health care promotion is not
always institutionalised.
32

Swaste Hind

ccording to Alma-Ata dec­

A

laration Primary Health Care
is essential health care made
universally acceptable for Indi­
viduals and families in the com­
munity by means acceptable to
them through their, full participa­
tion and at a cost community can
afford. It forms an integral part
both of the community health sys­
tem of which it is the nucleus and
of the overall social and economic
development of the community.
Alma-Ata declaration further spelt
out the minimum essential com­
ponents of Primary Health Care.
These components are not merely
independent but are 'Linked Com­
ponents'. Since Primary Health
Care is an integrated development
approach to health; these com­
ponents have an ongoing interface
with education, health and deve­
lopment. These components are:

(i)

(ii)

Educating People
about
Health and Family Welfare
Matters.
Promotion of food supply
and proper nutrition.

(iii) Safe Drinking Water and
basic sanitation measures.

(iv) Maternal infant care and
family planning.
(v) Immunization.
(vi) Prevention and control of
locally endemic diseases.
(vii) Appropriate treatment of
common diseases and in­
juries.
(viii) Provision of essential drugs.

This paper attempts to present
(hat the dual goals of India’s health
policy (1983) which encompasses
Health for All (HFA) and Popula­
tion Stabilization (Net Reproduc­
tion Rate of Unity)—by 2000 AD,
have intimate links with education
and—its development. The health
policy goals in the statement (1983)
are levels of health and Family
Welfare status. But these sugges­
ted achievements 'pre-suppose' the
creation of educational conditions
for desired moderation of mortality

February 1993

and fertility. These 'implicit pre­
suppositions' with respect to educa­

tion are the ones which could help
achieving these HFA goals.
Broad Conceptual Frame

In the light of this backdrop of
primary health care, it is further
reflected here that the nature of
both of these two sub-sectors of
social sector /.e Education and
Health is also responsible pri­
marily to create ‘Merit Goods and
Merit Services’ in the sense of
social economics. So, not only
this commonality of conceptual
welfare-frame is noticed between
education and health; but these are
inter-linked and inter-locked situa­
tions which may be used for effec­
tive integrated planning. Besides,
Health Care and Care for Educa­
tion being Merit and Public Goods;
both sectors and services emanat­
ing from these sectors may be seen
governed by ‘Externalities’, Exter­
nal Benefits or External Losses and
Costs on Promotion and Non­
promotion of these possibilities.

Again, the premises between
Health and education, particularly
with reference to achieving Health
for All and also education for all
stem from the same roots of

Accessibility, Availability, Affor­
dability, Acceptability, Accountability
(in terms of creating conditions for
equity and efficiency).
Operation Base

Support mechanism for both—
Health Care and Care for educa­
tion for all and its sustainability
depends on community participa­
tion and inter-sectoral, coor­
dination. This has been vividly
reflected in case of HFA
commitments.
Education—Health Linkages

We know education is an impor­
tant factor responsible for indi­
vidual as well as family’s health.
For example, in India, mothers are
usually responsible for bringing up
the children. So, the level of
literacy and education of mothers

assumes more significance in
determining the health- status of
our children. This is more so
where health care promotion is not
always ‘institutionalised ’.
World Bank study of Kerala
(1981) has shown that the high level
of literacy and education among
the females in Kerala is the ‘one
single’ factor which has significan­
tly contributed to the improve­
ments of health status of infants
and children. Lot of studies and
statistics can be quoted to show the
association, and differentials for
high infant mortality, non-utilisfttion of health care, extent of low
birth babies, ‘non-coverage of
immunisation’ etc. with the edu­
cational status of females in
India.
Not only literacy and education
gives the chance and access to
information and services but also it
has inherent strength supported by

'knowledge for decision making'
towards conditions of Health Pro­
motion. Education—Health lin­
kages bring out a simple fact in this
context for integrated planning is
that ‘An educated mother can
ensure the optimal utilisation’ of
available resources for nutrition as
also for better hygiene and health
of the family. Educated mother
can better utilise the available
health and medical services and
bring accountability into them by
demanding what she knows is her
right. (Antia, 1992 Science Pop­
ulation Development: The Inevit­
able Plus).
Moninag (1981 Economic Politi­
cal Weekly) of course has tried to
see literacy and education as fac­
tors which determine political
awareness and this in turn gives the
indicative right to demand and use
health and other welfare faci­
lities. This itself is a function of
awareness created by education. To
indicate this Education—Health
Linkage; the examples given by
studies are from rural Kerala and
rural West Bengal. Possibility of
mobilisation for integrated plan­
ning at present is not only an issue

33

of economic development but also
an agenda for social issues in
health and education. Literature
in India and other developing
countries have brought out that
among households (for any given
income level), families were better
fed where the Mother’s education
was higher. These differentials are
known also for child survival.

In'this context, the basic conten­
tion emerges from the available
personal
and
professional
experiences that health needs (par­
ticularly of women, children and
olh6r under-privileged groups in
terms of illiteracy and uneducated)
will hardly be met if health pro­
gramming continues to focus
narrowly on health sector alone
and ignoring the education health
promotion linkages. All the eight
components of Primary Health
Care Approach (as listed above)
can be pushed through the lever of
education and literacy promotion.
However, the Primary Health Care
Components or some of its Sub­
components can be supported
more directly are:

Of many programmes, this coun­
try wide programme of child
development is known for its ‘holis­
tic approach* to improve health
and educational .environment of
child. It has twin goals (i) to
encourage school enrolment via
early pre-school stimulation pro­
gramme for children 3-6 years old
(ii) to improve the health and nut­
rition status of children 0-6 years
via supplementary feeding to selec­
ted beneficiaries. But, it also
brings mother's in picture and
attempts to promote • mother's
education via ‘health and nutrition
education exposures'. A broad
package of six integrated services
are delivered through ICDS which
could be further strengthened as
an area for Integrated Planning:
— health checkup
— immunisation

— referral services
— supplementary nutrition
— non-formal education
— nutrition and health education
to mothers.

— Educating People about the
Health and Family Welfare
Matters.

Accessibility for Health Care Ser­
vices
and
Educational
Facilities

— Promotion of proper- nutri­
tion.

Physical accessibility to health
services and also towards educa­
tional facilities have been enhanc­
ing over the period of time.
However, there remain gaps for
these ‘social inputs’ among some
states, districts, rural-urban areas,
terrains, within socio-economic
strata organized vs. unorganized
groups, etc. These accessibility gaps
are there not just in terms of
general basic (elementary) services
and facilities but also for type, fre­
quency, qualitative aspects, etc.
Besides these, observed ‘locational
biases’ are also there.

— Basic sanitation measures.

— Maternal, infant care
Family Planning.

and

— Immunisation.
Integrated Child Development Ser­
vices : An Example

Of many programmes and ser­
vices, example may be given for
one programme where linkage bet­
ween Health Care Services and
Educational efforts may be seen
subtly forged*.
34

World Bank Paper (August 1990
WPS 491) on ‘How Well do India’s

Social Service Programme serve
the poor’, have culled out data from
fourth All India Educational Sur­
vey and other studies in Health
Care to bring out the strange con­
tentions in this paper. The acces­
sibility situation about health is
found more striking in terms of
rural-urban differences—for an
access to health facilities. There
are nearly 87 per cent of hospital
beds in urban $reas of the country
but the majority of population lives
in rural areas. Also there are
studies to show that the population
served by a Primary Health Centre
varied between 10 to 17 per cent of
what it was expected to serve
because of its unsuitable location
(Bose etc. 1983). Again, in terms
of accessibility, health services are
also not found readily accessible
for tribals; although there is special
‘tribal sub-plans’. Studies are
there to show—Gare (1983) found
that one hospital and 167 sub­
centres were covering a population
of 2.8 million in three districts of
Maharashtra. That was
one
fourth of the infrastructure re­
quired. Another study of a tribal
district in Madhya Pradesh showed
that a Sub-Centre served about
7000 population, covering an aver­
age of 76 sq. kms. against the norm
of 3000 population (AFC 1980).
Even for nutrition there are some
studies to show (Hargopal G. et al
1985) that poor people have been
denied, at times, the access to nutri­
tion programme by local leaders.
These may be small studies in
number, micro in nature but speak
for the gaps to be filled out through
systematic integrated planning.
Another work entitled ‘School
Education in India: The Regional
Dimensions’ (Moonis Raza, Aijazuddin Ahmad and Sheel C. Nuna,
1990, NIEPA) has brought out both
applied as well as methodological
issues with respect to accessibility,
availability, quantity, quality,

Swasth Hind

Linkages between health care services and educational efforts must strive to bring mothers in
limelight and attempt to promote mothers’ education through health and nutrition
education exposures.

equity inter-connectivity
and
utility. Such crystilized work is
grossly unavailable as yet for
Health Care Sector. Besides, the
fourth All India Educational Sur­
vey showed that nearly one fifth of
all inhabitants including 16.4 per
cent of inhabitants with a popula­
tion of less than 300 do not have
even a primary school. Forty per
cent of primary schools have no
permanent buildings, 39.7 per cent
have no blackboards and 49.5 per
cent have no drinking water
facilities. Thirty five per cent of
schools have only a single teacher
to teach 3-4 different classes. The
economic base of a region exerts a
strong influence on the spread of
education (Moonis Raza and
Aggarwal 1983).

February 1993

Broad Conclusion

Since early 1980’s Government is
reflecting its meaningful awareness
and taking new initiatives: whether
it is in terms of National Health
Policy (1983), National Policy on
Education (NPE) 1986, Revised
Family Welfare Strategy (1986)
which has strengthened the mother
and child health and earlier Inte­
grated Child Development Services
(1975) which deliver a package of
basic health, nutrition and pre­
school education services to child­
ren under six and to pregnant and
lactating women. However, inter­
sectoral effort for ‘Integrated and
Composite Planning* has not been
operationalised seriously and
meaningfully—within the frame­
work of Education and Health
Linkages.

Before, it is concluded it has to
be emphasised that not only there
is need to integrate both Health
and Education Sectors and its ser­
vices; but also required is the
integration of social sector sendees
with ‘poverty alleviation program­
me*. As such, vocational educa­
tion, adult-health, particularly
Reproductive Health, and adult
nutrition need to be included and
stressed with primary education,
child health and child nutrition.

Recently 90 districts in the coun­
try have been identified by the
Government of India for taking up
special efforts to promote family
welfare and health performan­
ce. These districts have been
identified on the basis of their
backwardness in terms of literacy,

35

infant mortality, sex ratio, etc. A
beginning for 'decentralised inte­
grated planning' may be made keep
ing in view the strong linkages
between education and Family
Welfare and health care in these
identified districts. For this pur­
pose the efforts may have to be
taken at Block Level and further at
village level planning for health
and family welfare. At the village
level also the care has to be taken
for all the'social groups? at the grass
root levels and to be tagged with
socio-economic processes having
direct and indirect linkages with
education and health.
This integrated planning is not to
be a static one and a one time
attempt; but it has to be a ‘flexible’
and ‘ongoing one’. The ‘entry
points’ may not always be the
same. Sometimes, it may be edu­
cation creating demand generation
for health care services and their
utilisation. At times, it may be
‘health promotion’ creating de­
mand generation for higher school

enrolment, etc. Besides, the 'de­
mand generation planning efforts';
the 'supply creation planning efforts'
have to take due account of the lin­
kages between education and
health. Lastly, this will\also re­
quire new administrative sructures
which would be more ‘responsible’
to these areas of commonality of
social transformation. Involve­
ment of NGOs and people has
been advocated afresh, and more
vigorously in various deliberations
in developmental forums. Lastly,
in the light of observations made by
Dr Amartya Sen and others, the
role of market economies or role of
‘market forces’ for promotion of
social sector may be taken with lit­
tle caution. It is a matter of con­
cern whether Social Sector is
'market friendly' when we know
Education and Health; both are
Merit and Public Goods. This is
also a point while deliberating for
Integrating Planning beyond pub­
lic sector interventions.

NOTES AND REFERENCES
World Bank (1989) India : Poverty, Employ­
ment and Social Services, A World
Bank Country Study, Washington,

DC, USA. pp. 163-165.
Murthy, Nirmala et. al. (1990): ‘How Well Do
India’s Social Service Programmes
Serve the Poor*, —Working Papers
Public Sector Management and Private

Sector Development. WPS, 491, World
Bank, pp. 21-30.
Wishwakarma, R.K. (1991): Health Status
of Under Privileged—Vol. I & n. Cen­
tre for Urban Studies, Indian Insti­
tute of Public Administration, New

Delhi
Sharma, B. B. L.and Talwar, P. P. (1991) :
Health for All and Population Stabi­
lization in India, Journal of Rural

Development, Vol. 10 (6) November
1991, pp. 779-794.

Gowarikar Vasant (Edt.) (1992) : Science
Population and Development : An
Exploration of Inter Connectivity and
Action Possibilities in India, Unmesh
Communications, pp. 27-42.

A

PRINCIPLE FOR ALL PEOPLE TO HAVE PEACE
All people have to make use of their peaceful condition to work for their collective
welfare and in turn to maintain Peace.

They must bear the principle that peace

results from the harmony of mind, body and environment and operation of an effective
system for maintaining conditions of peace by eliminating antagonistic forces such as
tension, war, pollution, pain and conflicting discrimination, etc.
—M. B. S. CHAR

36

Swasth Hind

PRIVATE VOLUNTARY
ORGANISATIONS AND
PRIMARY HEALTH CARE
Dr B. K. Pattanaik

Improving the health of all citizens is an endeavour in which, every section of the
society must feel involved. Medical personnel are the leaders of this campaign, but
ultimately, it is the people’s cooperation which counts. At this juncture, role of
voluntary organisations in the promotion of primary health care in rural areas cannot
be overemphasised. They are important resource to adopt innovative approaches
and provide services to support sustainability and effective implementation of the
health and family welfare programmes.
HE Alma-Ata Declaration of
provide Primary Health Care rele­
vant to the actual needs of the com­
1978 identified Primary Health
T
munity in the rural areas, health
Care (PHC) as the key instrument

to attain the twin goals of Health
For All (HFA) and Net Reproduc­
tion Rate (NRR-1) unity by 2000
A.D. India being a signatory of
the historic declaration reiterated
in its. National Health Policy
(1989), her commitment to attain
Health For All by the year 2000.
But ironically, the SLOGAN OF
HEALTH FOR ALL by the year
2000 remains as distant a dream as
ever though this century draws to a
close. Similarly, the goal of
achieving Net Reproduction Rate
equal to one by the year 2000 also
looks incredible as the Eighth Five
Year Plan document envisages that
it would not be attainable even
before 2011-2016 A.D.
Primary Health Care Approach
seeks to provide universal com­
prehensive health care services
relevant to the actual needs and
priorities of the communities at a
cost which people can afford. To

February 1993
2—16/DGHS/92

infrastructure, i.e. Sub-centres, Pri­
mary Health Centres, Community
Health Centres, etc. are being
established and rural health ser­
vices are replenished through these
centres. Notwithstanding, a collossal improvement in health infra­
structure since independence, the
quality of life of the rural masses
has not been adequately amelio­
rated. It is rather appropriate to
emphasise that improving the
health of all citizens is an endea­
vour in which every section of the
community must feel involved.
Medical personnel are the leaders
of this campaign, but ultimately, it
is the people’s cooperation which
counts. At this juncture, the role
of voluntary organisations in the
promotion of Primary Health Care
in rural areas cannot be over­
emphasised. The Seventh Five
Year Plan has rightly highlighted

the involvement of Non-Govemmental Organisation (NGO) alongwith community participation in
health and family planning pro­
grammes on priority.
There are over 30,000 private
voluntary organisation (PVOs) in
India of different sizes and orien­
tation. Some of the previous
studies depict that activities of
PVOs are primarily related to
income generation and in some
cases feeding supplements for
children, thus, include health and
family welfare within its pre­
mises. Therefore, mobilising the
active participation of PVOs in
health and family welfare pro­
gramme will yield
salutary
benefit for the successful imple­
mentation of the programme in
rural areas.
Need and Utility of PVOs

The pertinence of PVOs has been
greatly acknowledged by the
Government for the successful
launching of the health and family
37

planning programme in the rural
areas. Sometimes, governmental
personnel are viewed with suspi­
cion
by
the
rural
com­
munity. They even do not have
the necessary rapport between
them
and
the 'Community.
Moreover, the Government cannot
face the challenge of carrying out
the community centered social
development
programmes. At
(his juncture, PVOs are important
resource to adopt innovative
approaches and provide services to
support sustainability and effective
implementation of the health and
family welfare programme. PVOs
with trained workers and volun­
teers can better communicate with
(he people by ensuring full public
participation for providing sustain­
able benefits to the people than are
possible in government set-ups.
Considering its importance, the
India Population Project VII run­
ning in the States of Bihar, Gujarat,
Punjab, Haryana and Jammu and
Kashmir has emphasised the need
of PVOs for increasing demand of
MCH and family planning services
in these States. The project envi­
sages that the priority would be
given particularly to those PVOs
with strengths in community in­
volvement and participation, those
which provide services or efforts
(hat would stimulate greater deve­
lopment of activities to involve
women in the delivery of services as
well as their demand for services,
and those PVOs which meet the
needs of the poorest groups in both
urban and rural settings.

The PVOs work as a link bet­
ween the people and the govern­
ment. They motivate, persuade
and popularise programmes and
projects by bringing about atti­
tudinal changes and involving peo­
ple in the community projects.
They encourage people to consider
their responsibilities in relation to
their development Once com­
38

munity interest has been mobi­
lized, it is quickly crystallised into a
formal mechanism capable of tak­
ing action. The active participa­
tion of the people ensures greater
chances of success and cost-effect­
iveness than the total dependence
on the government when people
tend to become passive. The
PVOs work to make the govern­
ment supported programmes more
responsive to the needs of the peo­
ple and also make it aware of the
felt needs of the community and
their inter se priority with con­
siderations oi resources and local
constraints.
It is true that government has
larger pool of skilled persons, more
intelligent and better informed, but
they are bound by rules, regulation
and set procedures which some­
times restrict their decision making
process. On the contrary, PVOs
have greater flexibility in respect of
taking quick decision on price,
location shift, chosing right alter­
natives and so on. They have
greater scope to choose areas of
work and taking spot decision.
Their methods of mobilisation,
evaluation, monitoring, leadership
and supervision are far more effec­
tive than those of official agen­
cies. Communication,
motiva­
tion, awareness, implementation
and follow up action in the case of
PVOs are faster than that of the
official agenciefi. Therefore, the
rich experience of the PVOs should
be exploited and utilised for
achieving greater effectiveness in
the delivery of primary health care
in rural areas. It is needed to
establish rapport and strengthen
the small PVOs which are doing
good work to achieve result in a
time-bound manner.
Activities of PVOs

The Eighth Five Year Plan of the
Government of India has empha­
sised on the involvement of volun­

tary agencies in various develop­
ment programmes, particularly in
planning and implementation of
programmes of rural develop­
ment As population control and
health and family welfare are
important areas of rural develop­
ment the involvement of voluntary
organisations in these activities are
very important Some of the
activities, the private voluntary
organisations are- needed to carry
out for the health and family
welfare programmes are:

1. To conduct awareness-build­
ing camps for motivating com­
munity participation linked
with the health and family
welfare programme such as by
organising (a) Dental hygiene
camps, (b) eye camps, (c)
diagnostic camps, (d) blood
donation camps, (e) TB and
cancer detection camps, (f)
MCH services, (g) FP services
particularly
sterilisation
camps and (h) Sanitation
Camps; motivating people for
immunisation of infant and
pregnant women; imparting
health education and popula­
tion education in the com­
munity; helping the health
personnel in controlling epidemic/communicable
dis­
eases.

2. To visit individual families,
organise group meetings and
conduct shows and exhi­
bitions on primary health care
and family planning themes.
Also to encourage school
teachers for immunisation of
school children and conduct
essay, debate, painting and
drawing competitions primary
health care themes.
3. To undertake their activities
within a flexible time frame
which allows the community,
the time to understand, accept

SWASTH HIND

or even reject, make modi­
fications and mould the com­
munity to give positive res­
ponse towards their pro­
gramme.

4. Develop appropriate Informa­
tion, Education and Com­
munication (IEC) support
through visual aids such as
posters, models flip charts,
flash cards, slides, etc., which
arc particularly appropriate
and appealing to women,
children, and the community
as a whole, using local
languages. In this regard
they should conduct Com­
munication Need Assessment
(CNA) studies and develop
appropriate communication
materials and methods suit­
able to particular com­
munity.
5. To monitor their programme
in order to assess the intensity
and frequency of inter-action
between field level motivators
and the community, the level
of usage of facilities, the extent
of adoption of MCH and
family planning services pro­
vided and to check the quality
of these facilities.

6. To conduct some evaluative
studies in order to assess the
impact of their efforts.
7. To maintain co-ordination in
their activities and also keep­
ing linkages with different sec­
tors in operation for rural
development besides health
sector as well as with panchayat institutions, youth
clubs and Mahila Mandate.
Dominant Issues

I. The effective functioning of
PVOs are based on certain guiding
principles, these are:
(i) The personnel of PVOs must
be involved in the basic

FEBRUARY 1993

aspects of programme for­
mulation, decision making,
implementation, monitoring
and evaluation.
(ii) The volunteers of PVOs
should be drawn from
divergent fields, ie., social
sciences, medical, nursing,
etc., both male and female so
that they can effectively deal
with the different issues of
primary health care and
family planning.
(iii) Every effort must be jnade to
minimise the dependence of
the activity conducted by
PVOs either, on material or
on human terms from out­
side, otherwise group auto­
nomy of PVOs will be
lost;
(iv) They must see that the pro­
gramme or activity taken up
by them must be able to sus­
tain in the context of locally
available resources;
(v) Should always think of what
technologically is the next
step for the group;
(vi) They should see that the
activities being taken up by
them are effective, if not effi­
cient for the time being.
The programmes are eff­
ective :
(a) When participants de­
velop skills that they
can utilise these in
future programmes;

(b) When learning spreads
from person to person
in the community;
(c) When they are respon­
sive to needs expressed
by the community;
and

(d) When they are designed
to reach a large number
of community mem­
bers.

(vii) Finally,
the
volunteers
should be guided by the
principle and should con­
vince the community that a
developmental or preventive
approach is more efficient
than a remedial approach.
Pre-rcquisitcs
PVOs

of

Volunteers

in

While considering the role of
volunteers in terms of pedagogy of
empowering them there are num­
ber of areas that merit atten­
tion:
(i) Criteria for 'selection : Selec­
tion of volunteers is crucial
for effective functioning of a
PVO. They should possess
humility, commitment, sen­
sitivity and self-confidence
for working in the rural
areas.

(ii) Skill: The volunteers should
possess adequate ability to
communicate both verbally
and non-verbally and also to
analyse and diagnose the
context of his work to the
rural people.
(iii) Training: In order to develop
the above characteristics and
skills with the volunteers,
pertinence of training cannot
be overemphasised. Many
experiences suggest that
agents are best prepared for
work by learning through
experience, formal institu­
tional training in primary
health care and family plan­
ning concepts and methods
and in extension techniques,
including
inter-personal
communication and the use
of audio-visual aids will go a
long way in better equipping
the volunteers for their
work.
(Contd. on page 63)

39

HEALTH CARE DELIVERY
—Need of Comprehensive Health Care
Dr Devi Saran Sharma
Dr S. B. Dabral
tremendous advancements in the field of
medicine, medicare and health, health status
DESPITE

of most of the communities in India is far from being
satisfactory. The socio-economic and demographic
profile is not taking very favourable trend
At the
present population growth rate, the population of
India is expected to cross 1000 million mark by the

40

end of the year 2000. The literacy rate is 36 per
cent More than 50 per cent of the population is
below poverty line. According to Centre Calling
Reports, 60 per cent of the hospital beds in India are
occupied by the sufferers of infective and parasitic
disorders. Measles, polio, viral hepatitis and
Japanese encephalitis are viral diseases. Malaria,
SWASTH HIND

TB, Leprosy and blindness still remain major public
health problems as great barriers to ‘Health for
AH’. Malnutrition is very severe among women and
children of lower socio-economic group. Iron
deficiency xerophthalmia and endemic goitre are our
important nutritional problems. The main reasons
of all these problems are social in nature namely,
poverty and ignorance. Non-communicable dis­
eases like heart-disease, cancer and Hypertension are
the problems of affluent groups. Occupational dis­
eases
are
increasing
with
rapid
indus­
trialization. Health hazards due to environmental
pollution, alcoholism, smoking, drugs, accidents,
AIDS, etc. are increasing particularly in urban
areas.
If the efforts so far made are critically
examined, Sharma (1988) opined that “they have
purely been curative; and social, preventive and
rehabilitative approaches have totally been
neglected”.
Present health situation in India proposes that
a major magnitude of the problem can be contained
if our health delivery system is totally reoriented to
provide comprehensive health care to the masses.
Comprehensive health care

Comprehensive health care combines preven­
tive, promotive, curative and rehabilitative care to
all. The elements of comprehensive health care
are:
Prevention
Prevention is better than cure is a well known
dictum for one and all. Immunization for example
can change the incidence and prevalence of many
vaccine preventable diseases. The provision of safe
water supply can avert waterborne diseases. The
care of pregnant mothers can help to reduce the
maternal and infant mortality and morbidity.
Similarly the use of specific nutrients, protection
against occupational hazards, accidents and environ­
mental delepidation and pollution can prevent much
of the physical human sufferings. Modification in
human health behaviour through health and general
education, motivation for cleanliness and adoption of
healthy practices only can check the disease
process effectively.

Promotion
Adequate nutrition and provision of basic
sanitation, personal hygiene, health education,
marriage counselling, sex education, periodical
health check-up, regulation of lifestyle, improvement
in the standard of living and population control are

February 1993

Harty diagnosis and treatment are important
io make the cure easier and economical.

some essential measures for promoting health of the
common man.
Cure
Cure is the felt need which a patient requires in
illness situation. Early diagnosis and treatment are
important to make the cure easier and
economical. For this purpose the health services are
required to be easily and conveniently approachable
to needy persons. In the contemporary context there
is an urgent need that curative care reaches the needy
in tribal and rural areas, to the people of lower strata
to the weak and ailing children and women, taking
into consideration the existing socio-economic, geo­
political and psycho-cultural realities of most
developing societies.

Rehabilitation
Rehabilitation is an integral part of medical
care. W.H.O. (T.R.S. 1969, 81) define it as “the com­
bined and coordinated use of medical, social,
educational and vocational measures for training or
retraining the individual to the highest possible level
of functional ability”, and “at enabling the disabled
and handicapped to achieve social integration”.
Rehabilitation requires multidisciplinary team
approach through physicians, various therapists, psy­
chologists, social workers and experts in
vocational guidance.

(Contd. on page 44)
41

NUTRITION TRAINING IN
COMMUNITY SETTINGS
—NIN Experience
M. Mohanram
V. Ramadasmurthy

The National Institute of Nutrition (NIN), Hyderabad, has introduced the element of
community based learning in its international nutrition training programmes for
health professionals. Assessment of the quality and applicability of the learning
experience including field placement in work situation was made and it has proved
the applicability and utility of community based education approach in the basic and
inservice training of health professionals in the Indian situation.

MPORTANCE of
need-based
education of health pro­
Ifessionals
to meet national goals is
now recognised all over the
world. India and other develop­
ing countries have chosen primary
health care as the tool for delivery
of health services. Primary health
care approach implies a reorienta­
tion of health services so that
secondary and tertiary care rein­
force the health care at primary
level and an even distribution of
health resources is facilitated with
accent on support to primary
care.
In a country like India, majority
of the population lives in villages
and preventive, promotive and
curative health care should be
made
accessible
to
these
people. The health team headed
by the medical officer, supported
by paramedical health pro­
fessionals and other grassroot level
workers, has to provide these ser­
vices. It is imperative that the
basic education as well as in­
service training of all the members
of this team should be such that

42

they are fully equipped for their
respective job responsibilities.

In most educational institutions,
including those preparing the
health professionals in the country,
the commonest method adopted is
a teacher-centred, subject-based
approach. In this approach, it is
assumed
that the learners’
experience in learning is of lesser
value than that of the teacher. If
the learning is problem-based and
student centred, the learner will
acquire skills in using that
knowledge. Miller (Joum. Med.
Edn., 37, 185-191, 1962) has obser­
ved that even before they graduate,
medical students forget most of the
traditionally learnt subjects taught
during first year, since only
knowledge used is better re­
membered.

Our studies (Mohapatra, et al.,
World Health Forum, 9, 612-614,
1988) on PHC Medical Officers
brought to light several short­
comings in their understanding
and functioning in the area of
primary health care, particularly

regarding nutrition. Gaps in
knowledge were apparent with res­
pect to growth monitoring, nutrient
contents of various foods, nutrient
requirements of certain important
physiological groups like children,
women during pregnancy and lac­
tation, their own involvement in
national nutrition intervention
programmes. Very few of them
were aware of their responsibility
for referral services, an important
component of primary health
care.
Rationale
for
Community
Based Education (CBE)

Achieving educational relevance
to community needs is particularly
essential in the case of health pro­
fessionals. Their education has to
be not only.community oriented,
but should be aslo community
based. Several
international
organizations such as WHO (WHO
Tech. Rep. 746, 1987) have re­
cognised the merits of CBE. CBE
consists of learning activities which
use the community extensively as a

Swasth Hind

learning environment The learn­
ing activity takes place pre­
dominantly in community health
service settings. The curriculum
has to reflect a judicious blend of
activities covering a range of health
services at different levels.
CBE
Approach
Training

in

‘Nutrition

The national Institute of Nutri­
tion (NIN), Hyderabad, has
introduced the element of com­
munity based learning in its inter­
national nutrition training pro­
grammes
for
health
pro­
fessionals. Participants of the
NIN Postgraduate Nutrition Cour­
ses arc either medical college
teachers in specified disciplines or
health professionals holding res­
ponsible positions as' State Nutri­
tion Officer or connected with
health care delivery. Middle level
paramedical personnel from pri­
mary health care sector such as
trainers and supervisors—health
Supervisors, Health Extension
Educators—are also trained under
one training programme.

The methodology of the
Institute’s training courses has
recently been modified. Par­
ticipants visit and stay in a rural
set-up-PHC-area—about 100 kms.
from the Institute for a field based
training for two weeks. The PHC
base selected has a permanent
infrastructure for training, estab­
lished by Osmania Medical
College,
Hyderabad. Spacious
classrooms and hostel facilities
with boarding are provided. Par­
ticipants camp in this place along
with training faculty from the dis­
ciplines of community nutrition,
sociology, anthropology, statistics
and dietetics along with supporting
staff. Equipment
and
other
necessities for diet and anthro­
pometric surveys are made avail­
able along with audio-visual tools
for teaching.
The three major spheres of
activities in which the participants
engage themselves at the field
camp are: Community diagnosis,

February 1993

assessment of the nature and extent
of the community health and nutri­
tion problems and management
strategies for prevention and con­
trol of the identified problems.
Student-Centred Learning Process

In this entire exercise, the didac­
tic approach is totally dispensed
with. Since a student-centred
learning is envisaged, only in­
troductory briefings to problems
and programmes are provided by
the faculty who operate as faci­
litators. Opportunities for inter­
action between concerned expert
faculty and the participants are
provided during short presen­
tations in the evening and discus­
sion sessions on the day’s work,
gaps and shortcomings £re held.
As for development of skills and
allied aspects comprising psy­
chomotor domain of learning, the
method of choice, viz., task
approach
is
followed. After
demonstration of a technique such
as diet or nutrition survey, par­
ticipants are given the assignment
involving that task, under faculty
supervision. The observed defects
and deficiencies are rectified and
discussed. The task is repeated till
the participant gets familiar with it
and performs satisfactorily. Apart
from the experience at the field
base, participants have the oppor­
tunity to visit the teaching hospitals
in Hyderabad where NIN has OutPatient and In-Patient facilities for
cases of malnutrition. In the
course of these visits, supported by
bedside clinics, participants get
first hand experience at tertiary
level in different aspects relating to
health and nutrition.
Integrated Approach

The fact that solution of nutri­
tion and health problems lies not in
the health sector alone, but several
allied areas in non-health sector as
well,
is widely recognised.
Towards this end, participants are
encouraged to collect data on
various aspects, influencing the
health and nutrition status of the

community. They visit in groups
sets of villages in the study
area. Using standardised proformae developed by the Institute,
information is collected on de­
mography,
agriculture,
food
availability, distribution, educa­
tional, credit and communication
facilities, health statistics, health
programmes, developmental, eco­
nomic and social welfare projects,
for community diagnosis. These
data enable them to better com­
prehend the existing situation and
diagnose the reasons for the same,
as well as to interpret results of the
surveys that they would be con­
ducting, and to suggest ameliora­
tive measures in respect of that
community.

Participants undertake the sur­
veys in selected village households
and develop necessary skills for
conducting diet and nutrition sur­
veys independently, standardising
the techniques. They also gain
experience in conducting insti­
tutional surveys in addition to
assessing nutritional status of
individuals in households. Later
in the day, they process the survey
data and compute diet and nutrient
intake.
Management Strategies

Choosing
an
appropriate
management strategy requires the
collation of basic data pertaining to
the community and the results of
the diet and nutrition sur­
veys. Together, they would serve
as a backdrop against which one
has to devise suitable solutions
keeping in view the available
infrastructure and ongoing pro­
grammes. It calls for crucial deci­
sion making which equips the
participants for future work in their
own home settings.

In this phase, participants form
into two or three groups. Pooling
the data gathered on different
aspects, they work on various com­
ponents. Under the guidance of
the faculty, they draw up a com­
prehensive , plan, the merits and
43

demerits of which are dis­
cussed. After a critical review by
the faculty and fellow participants,
a report on the entire field
experience is drawn up at the end
of the placement period. The
utility of such problem-based
learning has been established at
centres like McMaster University
and Michigan State University.
Feedback on
placement

utility

of

field

A full fledged mechanism of par­
ticipant feedback is built into the
N1N
training
program­
mes. Opinions of the participants
on all important aspects such as
course structure, content, organisa­
tion, utility and suggestions for
improvement are obtained. Rele­
vant information on specific
chunks of the course syllabus, par­
ticularly, their opinion on field
placement arrangement and its
utility, is obtained-in the feedback.
Special instruments are developed
for this purpose and administered
during different stages of the course
and thereafter, i.e., entry, exit and as
follow-up after the participants
rejoin their positions subsequent to
the training. Care is taken to
ensure that the responses of the
participants are objective and
reflect their own considered opi-

nion on various aspects, without
operation of extraneous factors like
influence of faculty etc. Assess­
ment of the quality and* appli­
cability of the learning experience
including field placement in their
work situation was made. For this
purpose, 0-4 point rating scale was
employed to measure the level of
confidence to perform specific
activities covered in the training
courses.

Responses regarding field place­
ment experiences received from 64
participants in the Institute’s train­
ing courses were analysed. It was
seen that 65-90% of respondents
were confident of undertaking
specified
activities. Capability
with regard to management of
ongoing community nutrition pro­
grammes raked highest with 91% of
them giving rank-4 (highest). Com­
ing next were the aspects ‘iden­
tification of nutritional problems’
(84%) and ‘conducting diet and nut­
rition surveys’ (76%). The com­
munity based orientation sessions
have been endorsed as useful by
the participants in respect of cogni­
tive domain of learning and in the
development of psychomotor skills
regarding nutritional assessment
This experience of NIN proves
the applicability and utility of com-

(Contd. from page 41)
There are four basic areas of concern in
rehabilitation :
1. Medical Rehabilitation i.e., restoration of bio­
physical function^
2. Vocational Rehabilitation i.e„ restoration of the
capacity of an individual to earn a
livelihood,
3. Social Rehabilitation i.e., restoration of family
and social relationships and the capacity to
react to social roles,
4. Psychological Rehabilitation i.e., restoration of
personal dignity and confidence.
Some examples of rehabilitation are : establish­
ing schools for the blind, provision of aids for the
crippled, reconstruction surgery in leprosy and graded
exercise in neurological disorders like polio, change of
occupation for a more suitable living and modification
of lifestyle in general in the cases of tuberculosis, car­
diac patients and others.

44

munity based education approach
in the basic and inservice training
of health professionals in the
Indian situation. During his sub­
sequent observation study as part
of a comprehensive impact assess­
ment of the training courses, one of
the authors (MMR) noted that
many of the erstwhile participants
were undertaking community sur­
veys utilising skills obtained during
the training. This confirms the
effectiveness of the training
methodology adopted.
It should however, be mentioned
that there are some constraints and
problems in the implementation of
community-based
education.
Firstly,
it
needs
multisec­
toral coordination for planning the
field based study. The conven­
tional system of education does not
lend itself to such innovations and
suitable modifications have to be
made. There are also bound to be
logistic difficulties such as travel,
transport and infrastructure faci­
lities for stay etc. Community
based study is faculty-intensive and
calls for appropriate faculty resour­
ces representing various dis­
ciplines. Nevertheless, the rich
dividends it is expected to yield jus­
tify the additional effort and inputs
demanded by community based
learning.
A

The following points may be made as grounds
for implementing comprehensive health care:
1. Medical education and training should be
reoriented rather socially reoriented to imple­
ment comprehensive health care.
2. The services should be planned and organized
through multidisciplinary team approach in
order to meet psycho-social as well as bio­
physical needs of the patients.
3. A shift from individual patient to mass based,
hospital based to community based strategy is a
must to provide comprehensive health care
in India.
REFERENCES

Sharma, Devi Saran; Health, Hospital and Community, Aadhar
Publication, 1988, Agra.
2. Technical Report Series No. 419 W.H.O. (1969), Geneva.
1.

3.

Technical
Geneva.

Report

Series

No.

668

W.H.O.

(1981),

SWASTE HIND

IDEAS FOR ACTION

Learning about your Community
OMEN’S
groups,
scouts,
health volunteers, local orga­
nizations and health teams, should
know their community if they are to
he effective in improving its health.
You may already know many things
about your community, especially if
it is a small one. But do you know
enough about it? You will learn
more by talking in a systematic way
with its leaders and other people. Do
not ask too many questions though; it
is better to observe, listen and
learn! Here arc some of the things
you should find out.
How many people are there in the
community, and how many of
them are young, middle-aged,
and old?
How do people get food? How
do they earn money? Are they
farm workers, fishermen, cattle­
farmers, estate workers, factory
workers? How do they spend
their free time? Do they work
at night?
'
Do children work? How many of
the children attend school?
Is the community poor? Is it
becoming poorer or less poor?
Is its standard of living higher or
lower than the average for the
country?
Are
there
good
markets, good roads? Is there a
clean water supply? Is there
electricity, a telephone service, a.
bus service?
How do families live? What are
the houses like? Do they have a
system of sanitation? Are the
houses clean and free of pests?
Who makes decisions within the
family? How many children are
there in the average family? How
arc the children fed and how are
they taught? What are the most
common beliefs, values and
traditions?
What are the main health pro­
blems and what arc their causes?
Some causes of bad health are:
— too marty people living close
together;
— not enough water or the water
is not safe;

W

FEBRUARY 1993

— not enough food of the right
kind;
— unclean houses in dirty sur­
roundings;
— no way to keep cool in the heat
or to keep warm in the cold;
— no latrines or the latrines are
dirty;
— no protection against insects
that carry diseases;
— the health centre is difficult
to reach;
— people cannot read and thus do
not learn about health and
healthy habits.
Talk to various groups and people:
families or households (both rich and
poor), those who make decisions for
the community about the community
and members of special groups. Try
to find out:
— what part of their income do
they spend on health?
— what community problems are
they
especially concerned
about?
— what have they been doing
about these problems?
— what do they think can be
done?
— who are the leaders, or those
who make the decisions for the
community? They may be
tribal
leaders,
religious
leaders or political leaders.
They are the ones who are most
likely to help in improving
health. Other people whose
opinions and support are
valued may include the elders,
landowners, money-lenders or
businessmen.
Find out how the community is
organized and who runs its
affairs.
For example:
— Which group makes decisions
for all the people? Is it a
development committee, a
political body, or some other
group?
— Docs this group deal with all
the affairs of the community?

Or does it have sub-committees
that look after different needs
of the community, such as
health, water supply and
education?
— Is there a health commit­
tee? Who are its members
and how are they chosen?
What are their tasks? How
often do they meet? Are all
sections or groups in the com­
munity represented?
— What other groups are there?
For example, a women’s group
or a farmer’s cooperative.
If you are a schoolteacher, why not
ask your students to do a community
survey based on questions like
these? Then you could call a meet­
ing of parents and ask the students to
present their findings. May be a
movement to improve health could be
started?

DRAWING A MAP OF
YOUR AREA
A map is a useful tool to study the
health and sanitary situation in a
community. If there is not already a
good map of your area, ask other
people (for example, the school­
teacher and schoolchildren) to help
you to draw one. This map will
show the rivers, schools, health cen­
tres, temples, roads, shops and other
important-places. Take the map to
the community committee and place
it where the people can see it.
As new information comes in,
mark it on the map. For example,
show the wells or houses that are not
in good condition. Keep the map
up-to-date. It will make it easier to
detect some of the health problems,
and also to show by how much com­
munity health improves from year to
year.
—Th e above is adapted front: On being in
charge—A guide to management in primary
health care. WHO, Geneva. 1992. price Sw.
fr. 30 (developing countries Sw.fr. 21): and The
community health worker, WHO, Geneva. 1987,
price Sw.fr. 22 (developing countries Sw.
fr. 15.40).

45

EDUCATIONAL INTERVENTION IN
MANAGEMENT OF ALCOHOL DEPENDENCE
M. Ameer Hamza
Dr R. Parthasarathy
Whatever may be the helping processes adopted for the treatment of alcohol depen­
dence by the mental health professionals, medical personnel, counsellors, para­
professionals and non-professionals; one of the common core elements seems to be
alcohol education at individual, group, family and community levels. Alcohol educa­
tion influences an individual/group emotionally, intellectually, psychologically and
socially and may result in the modification of attitudes that influences behaviour.

N India increasing importance is
Irelated
being given now to problems
to drinking of alcohol.

Academicians and researches
focus on the antecedents and con­
sequences of alcohol drinking
among different groups of popu­
lation—students,
industrial
workers, transport workers, daily­
wage labourers, professionals,
businessmen and others in urban
and rural areas. Considering the
increasing magnitude of these pro­
blems, the voluntary agencies and
the government have been plan­
ning and organizing a wide variety
of programmes in the hospital and
community settings. Efforts have
been made to introduce alcohol
treatment programmes in general
hospitals and mental health cen­
tres. De-addiction centres to cater
to the needs of the people affected
with drinking related problems are
being established in different parts
of our country. In different train­
ing programmes, information re­
lated to alcohol and health are
appropriately
incorporated. In
addition, various legislations are
enacted to control the alcohol and
46

allied problems. To create aware­
ness, mass media brings out dif­
ferent types of programmes in
different languages. Inspite of all
these efforts, the public do not seem
to have gained scientific informa­
tion and positive attitudes towards
alcohol related problems.
Alcohol education

Whatever may be the helping
processes adopted by mental
health professionals, medical per­
sonnel, counsellors, para-professionals and non-professionals, one
of the common core elements
seems to be alcohol education at
individual, group, family and com­
munity levels.
Alcohol education, a learning
process that influences an indi­
vidual/group emotionally, intellec­
tually, psychologically and socially,
may result in the modification of
attitudes that influence behaviour.
It involves the formal mechanism
of presenting information, and
includes a series of experiences and
influences that help to shape the
learning environment, the atmos­
phere of the school, the lifestyle

present, the attitude of parents, the
pressures within a peer group, the
popular culture, the personal
experience with or without alcohol
and
availability
mechanisms
employed to carry out certain kinds
of behaviour.
The available knowledge related
to alcohol problems presents many
facets, some of which are:
1. Alcohol abuse and dependence
are serious problems that affect
a significant size of our pop­
ulation. Adverse social and
medical
consequences of
abusive drinking arises from a
single bout of drinking as well
as from longer term effects of
alcohol
consumption. Ad­
verse consequences may affect
not only the drinker but also
others with whom the drinker
comes in contact.
2. The prevalence of alcohol
related problems among hos­
pitalized patients has been
increasing in recent years.
Co-morbidity
of
alcohol
related diagnosis with other
(Contd. on page 48)
SWASTH HIND

MESSAGES
ON

ANTI-LEPROSY DAY—30TH JANUARY
PRESIDENT
REPUBLIC OF INDIA

N Martyr’s Day it is important for all of

PRIME MINISTER

30 as Anti-Leprosy
O us to recall the struggle waged by the O Day is a January
fitting tribute to the Father
Father of the Nation, Mahatma Gandhi, for
the alleviation of the suffering of patients of

leprosy. Bapu’s words to us were: “Leprosy
work is not merely medical relief. It is
transforming the frustration in life into the
joy of dedication.... It is not enough merely to
wipe out the tears from the eyes of the dis­
abled, it is necessary also to see that the dis­
ability is prevented.”
Drawing upon modern science and
technology, and with a spirit of service and
devotion we can give to patients of leprosy a
life of dignity as participants in national
reconstruction, and strive to protect human­
kind from this disease.
In this task, the contribution by social
and voluntary organisations and by
specialised institutions, is of great value ana
strengthens the efforts by the official agencies
to combat leprosy.
On the occasion of the Anti-Leprosy
Day, I extend my greetings and good wishes
to the Hind Kusht Nivaran Sangh and all
other organizations fighting Leprosy, for
every success in their mission in tne months
and years ahead.

SHANKER DAYAL SHARMA
13th January, 1993

BSERVING

of the Nation, Mahatma Gandhi, who
dedicated his life to the welfare of the
downtrodden and drew the attention of the
country to the plight of lepers through his
own dedicated service to the hapless victims
of this disease. It is gratifying to note that
the Hind Kusht Nivaran Sangh is continuing
the noble work of Gandhiji with the same
spirit of love and sympathy.
I send my best wishes to the Hind Kusht
Nivaran Sangh on the occasion of the Anti­
Leprosy Day.

New Delhi,
P. V. NARASIMHA RAO
January 16, 1993

MINISTER OF HEALTH AND FAMILY WELFARE
HE menace of leprosy in India has since been substantially reduced as a result of concentrated efforts
of the Government and Non-Governmental Organisations. However, leprosy still continues to be a
major public health problem in our country. With the expansion of Multi Drug Therapy (MDT)
coverage to all leprosy cases by 1994, it should be possible to eliminate the incidenceof new leprosy cases
by the turn of the century. Rehabilitation of cured leprosy patients and prevention of deformities by
active involvement of the community would require continuous attention of all the voluntary
organisations, philanthropic bodies and other welfare institutions.

T

On the occasion of Anti-Leprosy Day on the 30th January, 1993,1 extend my best wishes to all those
engaged in Leprosy eradication programme for success in this noble mission.

New Delhi,
13 January, 1993
FEBRUARY 1993

M. L. FOTEDAR
47

(Con id. from page 46)
disorders has been found to
include disorders of the liver,
pancreas, digestive system, res­
piratory system, nervous sys­
tem and cardiovascular system
as well as drug abuse, mental
illness, injuries, and accidents,
infections,
anemias,
and
malnutrition.
3. In alcoholism, the interaction
of genetic and environmental
factors is emerging as fun­
damentally important re­
search issues. Although the
mechanisms of genetic trans­
mission are not yet known,
evidence for genetic transmis­
sion of vulnerability of
alcoholism has been provided
by different studies. Like­
wise such psychological and
social factors as cultural and
group norms, peer influences,
expectancies about alcohol's
effects, and subjective ex­
periences have been found to
influence drinking behaviour.
Problems in the childhood,
home and childhood be­
haviour difficulties have been
observed as antecedents of
alcohol
dependence,
but
causal role has not been
established.

4. Various biological researches
have found that certain
neurohormones
such
as
vasopressin may play a critical
role in maintaining tolerance
and that other neuro-trans­
mitters, receptors, and ions
such as calcium may play a
role in mediating tolerance to
alcohol. Studies have shown
that the sons of the alcoholics
display some unique electro­
physiological
behaviours.
Further researches are being
conducted to know about
other brain mechanisms.
5. Alcohol has been found to
have profound metabolic
effects
on
carbohydrates
‘Lipid’, and protein meta­
bolism;
chronic
alcohol
abusers can develop clinical
signs of cardiac dysfunction
and upto 50% of excess mor­
tality in alcoholics and heavy
48

drinkers can be attributed to
cardiovascular
disorders.
Chronic alcohol consumption
is associated with a significant
increase in hypertension.
Alcohol affects immune, endo­
crine and reproductive func­
tions. Heavy alcohol con­
sumption is also a well
documented cause of neuro­
logical problems including
dementia, blackouts, seizures,
hallucinations
and
peri­
pheral neuropathy.
6. The deleterious consequences
of maternal drinking during
pregnancy are long-lasting.
Problems related to foetal
exposure to alcohol is one of
the leading known causes of
mental retardation.
7. Research findings suggest that
alcohol increases the risk for
falls, fires and burns. A
significant
percentage
of
suicide victims have a history
of alcohol abuse or were
drinking shortly before their
suicides, and that alcohol
tends to be associated with
suicides, that are impulsive
rather than pre-mediated;
untreated alcoholics and other
families have higher general
health care cost than non­
alcoholics and their families.
General health care cost tends
to decrease following the treat­
ment of alcoholism.
8. Several screening instruments
have been found particularly
useful in identifying alco­
holics. Usually self-reports,
clinical examinations, and
laboratory tests have been
used in assessment of the
problems.
9. Recent researches have stu­
died prevention efforts fo­
cused on school-aged children
that employ a cognitive
behavioural approach and
often involve interventions
intended to improve the
general coping skills. Al­
though results have been
mixed, there is some evidence
of short-term effects and of
reductions in the amount of
drinking among young people.

Other prevention approaches
such as those emphasizing
alcohol education have been
found to increase young
people’s knowledge about
alcohol and its effects.
10. Elements of early and mini­
mal interventions include
combinations of brief advice
and assessment interventions,
feedback and admonition
sessions and self-help be­
havioural training manuals.
These simple approaches can
effect drinking patterns and
alcohol related problems.
11. The components of treatment
include management of al­
cohol withdrawal, long-term
management of alcohol de­
pendence and prevention of
relapse. A range of treatment
options is available including
pharmacologic interventions,
psychotherapy and counsell­
ing, alcoholics anonymous
and a variety of behavioural
training programmes. Re­
search on the effectiveness of
various treatment approaches
has improved knowledge
about the effectiveness of
group therapy, spousal in­
volvement in alcoholism treat­
ment, marital therapies, social
skills training and Alcohol
Anonymous. The researches
show the effectiveness of a
combined approach involving
biological, psychological and
interpersonal approaches.
Alcohol Education Approaches

(a) Frightening approach: One of
the methods adopted in the
past was to righten people
away from alcohol use by
recounting or fabricating
horror stories about alcohol or
its use. This approach has
not been very effective, spe­
cially when the concerned
individuals have been able to
identify discrepancies or un­
truths in the stories. Scare
tactics might work in short
run but can only hope to be
effective when the stories are
real and are appropriate to the
audience and the situations.

Swasth Hind

(b) Appeals:
The traditional
appeals usually involve the use
of credentialed authorities
such as psychiatrists, psychiat­
ric social workers, psy­
chologists, psychiatric nurses,
clergy and variety of law enfor­
cement personnel who des­
cribe alcohol abuse from their
perspectives. Similarly ex­
addicts provide a different type
of appeal. From personal
experience, they are generally
able to tell a variety of horror
stories about their own addic­
tions. These methods if appro­
priately used would be
effective.

(c) Self-esteem:
Building selfesteem in the individuals
affected with alcohol pro­
blems and helping them to be
assertive in their day to day
activities are essential com­
ponents of alcohol edu­
cation.

(d) Factual information: Factual
presentation of information on
alcohol have been the hall­
mark of many educational
efforts. The major emphasis
should be on the transmission
of information that would be
useful for individual decision­
making about alcohol and its
use. This is effective for
mature audience, who have all
the skills and the information
for
responsible
decision­
making.
(e) Selection of models: The use of
carefully selected peers who
could serve as responsible
models is another approach
tried in many settings. The
idea is to take a cadre of
youngsters who are already res­
pected by the target pop­
ulation. Through intensive
training, these youngsters
would become an important
component of the alcohol
education
programmes. In
practice, this approach de­
pends for its success on ade­
quate selection and training of
the core group.
(f) Self-examination and attitude
confrontation involve chang­
ing of attitudes or clarifying
values, or improving the level

February 1993

of understanding. This app­
roach is enormously successful
in affecting the character of
education in general but it pro­
bably does not have wide­
spread impacton alcohol abuse
as yet
(g) Informal education philosophy:
The use of informal education
philosophy on current or
future members of religious,
social or political groups has
been identified as a successful
approach in drug education.
This approach is simple to
comprehend but some times
difficult to achieve. What is
required is the identification of
an individual’s real needs. A
group must be found that is
dedicated to satisfying those
needs while at the same time,
the individual becomes tho­
roughly committed to that
group’s goals. Then the group
tries to achieve its goals.
Group education

In hospital settings or de­
addiction counselling centres, the
group education provides a suit­
able medium for incorporating
many of the positive elements of
education—motivation, support,
guidance, provision of role models,
and other coping mechanisms for

the members of the group. The
groups could be for the patients
only in the initial stages and subse­
quently including their family
members/spouses and others. Such
group education would serve as
effective therapeutic force and
helpful for treatment adheren­
ce. The group could be guided by
the mental health professionals
like Psychiatric social workers, Psy­
chologists, Psychiatrists and psy­
chiatric nurses. Whoever conducts
such groups, he/she should be well
versed with the scientific informa­
tion about alcohol-diagnosis, treat­
ment and rehabilitation, and also
knows about the health education
methodologies and group dyna­
mics. These educational elements
are seen in all the methods of
management of alcohol depen­
dence. If such efforts are well
documented indifferent centres, it
is possible to arrive at culturally
and socially suitable educational
package programmes for indi­
viduals, groups, families and com­
munities. The colloborative efforts
of professionals, para-professio­
nals and non-professionals work­
ing in the government and volun­
tary sectors are essential to con­
solidate and propagate the edu­
cational inputs in the effective
management of alcohol depen­
dence in Indian setting.
A

DR HIROSHI NAKAJIMA NOMINATED FOR A SECOND
TERM OF OFFICE BY WHO’S EXECUTIVE BOARD

R Hiroshi Nakajima was nominated on 20 January 1993 for a
second 5 year term of office as Director-General of the World
D
Health Organization (WHO) by the 91st session of the Executive Board,

meeting in Geneva.
Dr Nakajima’s present term of office ends in July 1993, when he will
have completed 5 years as Director-General. Today’s nomination will be
submitted for the approval of the 46th World Health Assembly meeting in
Geneva next May.
Dr Nakajima was bom in Ciba City, Japan, on 16 May 1928. He
obtained his medical degree at the Tokyo Medical College in 1955 and he
holds a postgraduate degree in medical science.
Dr Nakajima joined the World Health Organization in 1974 in the
position of Scientist, Drug Evaluation and Monitoring. He became Chief,
Drug Policies and Management unit in 1976. In 1978 the WHO Regional
Committee for the Western Pacific nominated Dr Nakajima as Regional
Director. In May 1988, while still in office as Regional Director, he was
appointed Director-General of the World Health Organization by the 41st
World Health Assembly.
Dr.Nakajima is the author of scientific articles and reviews relating to
the medical and pharmaceutical sciences, published in the English, French
and Japanese languages.
A
49

TRADITIONAL HEALTH PRACTICES
FOR THE CARE OF CHILDREN
Dr Meharban Singh

Traditional health practices for the care of children can be categorised into four main
sub-groups namely useful, harmful, innocuous and of uncertain utility. The health
workers must be conversant with common customs and beliefs pertaining to health
care of children in the area or community in which they work, says the author.

HE traditional practices are
time honoured rituals and
T
beliefs which are prevalent in a
community and they may pertain
(o a wide range of activities. Every
community has its own way of rear­
ing children which is ingrained in
{he society through traditions
established over the centuries. The
customs and cultural practices per­
taining to mothercraft and child
care are passed from one genera­
tion to another, from grandmother
io mother and to their grand
children. The ancestral or con­
ventional child care practices are
by and large based on core
knowledge and wisdom although
some of them may have emerged
purely from intuition and supersti­
tion. The traditional practices are
influenced by the education level,
socio-economic status and value
system of the family and the
community.
It is neither possible nor feasible
lo provide modern medical care to
all the people of a huge country like
India which is bogged by numbers,
illiteracy and economic poverty.
There is no doubt that a combina­
tion of modern and traditional
healing is appropriate to serve our
health needs. However, the rapidly
changing lifestyle and introduction
of modern medicine has caused
confusion in the minds of tradilion-bound people and their pro­
moters in the Indian system of
50

medicine. There is evidence to
suggest that traditional health care
practices have a definite link with
the science of Ayurveda.
Utility
of
Practices

Traditional

Health

(i) Useful traditional practices

Most of our health care practices
have their origin in our traditions
based on core knowledge and wis­
dom of our ancestors. The con­
ventional or traditional practices
have become part and parcel of our
lifestyle. They are readily avail­
able at the door-steps of the people
and they are readily acceptable to
the society. Above all, they are
cheap and affordable and can be
utilised by a large segment of our
community. The traditional prac­
tices and home remedies are prom­
oted by village healers, midwives,
physicians practising Indian sys­
tems of medicine (ayurveda,
siddha, unani), charltans, quacks
and of course wise old people of the
community. The traditional prac­
tices are so ingrained in the minds
of people* that it is difficult to
change them even when they are
identified to be useless or
harmful.
Types
of
Practices

health workers must be conversant
with common customs and beliefs
pertaining to health care of
children in the area or community
in which they work.

Traditional

Health

Traditional health practices can
be categorised into four main sub­
groups : useful, harmful, innocuous
and of uncertain utility. The

A number of traditional health
practices for the care of newborn
babies are useful and based on
sound scientific basis and logic
(Table 1). They must be promoted
and actively encouraged in the
society. Their promotion shall
facilitate the participation of the
community and their acceptability
by the health care providers of
modem systems of medicine. These
practices are more appropriate to
serve our health needs as they are
based on simple technology. A
large number of diseases are minor
and self-limiting and it is approp­
riate to treat them with safe and
cheap home remedies.
Table 1 : List of useful traditional
practices

1. Confinement
place

at

mother’s

2. Isolation of the mother-child
dyad for 40 days
3. Oil massage
4. Universal breastfeeding and
wet nursing
SWASTH HIND

5. Instillation of colostrum in
the eyes
6. Use of cup and spoon or
“paladey” for top feeding
7. Baby sleeping on mother’s bed
and latter avoiding to turn her
back towards the baby.
(it) Harmful traditional practices
A large number of customs and
cultural practices prevalent in our
country for mothercraft and child
rearing are positively harmful
(Table 2). Many traditional prac­
tices have undergone lot of change
and developed aberrations over the
years and they have become unac­
ceptable in the context of current
scientific understanding. It is
essential that community must be
educated so that harmful rituals
pertaining to child care can be
stopped. There is an urgent need
to inform and educate the pro­
motors of traditional practices and
remedies such as* village healers,
midwives, physicians practising
Indian systems of medicine and
quacks, etc., regarding the dangers
of some of the traditional practices
which are rampant in our
country.
Table 2: List of harmful tradi­
tional practices
1. Eating less and restricting cer­
tain foods during pregnancy
2. Conducting delivery in* a dark
and ill-ventilated room
3. Use of rags/dirty clothes during
delivery
4. Using ineffective and harmful
resuscitation
procedures:
splashing water on face,
squeezing onion in front of
nose, vigorous and prolonged
slapping, making loud noises,
roasting placenta, etc.
5. Use of unsterile knife for cut­
ting the cord
6. Application of ash, cow dung,
catechu, etc., on the umbi­
lical cord
7. Discarding colostrum and
delaying breastfeeding

February 1993

8. Avoiding certain foods during
lactation such as pulses,
legumes, vegetables, some
fruits, etc.
9. Discrimination against girl
child
10. Opium for diarrhoea/crying
child
11. Kajal
12. Pacifiers
13. Dilution of milk
14. Castor oil for constipation
and diarrhoea
15. Delayed weaning and giving
inappropriate weaning foods
16. Branding
17. Instillation of oil and urine for
ear ache
18. Exanthematous diseases as
personification and wrath of
goddesses
(iii) Innocuous or inconsequential
traditional practices

A large number of traditional
practices are apparently harmless
or innocuous but are widely prac­
tised (Table 3). Unless their
hazards are recognised, it is best to
ignore them because a concerted
drive against these practices may
actually be counter productive.
Though most of these practices are
harmless but their utility is doubt­
ful and they may lead to delay in
seeking medical aid with resultant
deterioration
of
the
child
health.
Table 3 : List of innocuous or incon­
sequential traditional practices
1. Prelacteal
feeds : glucose
water, honey, jaggery water,
cow’s urine, donkey’s milk
etc.
2. Nose and ear piercing, talis­
man,
amulets,
removing
“nazar” by burning lahi,
chillies and alum
3. Tying neen leaves on the door
of the house

4. Massage of anterior fontanel
5. Keeping knife under pillow to
protect the infant against
harmful spirits
(iv) Traditional practices of doubtful
or uncertain utility
A number of popular child rear­
ing practices are of uncertain or
doubtful utility (Table 4). There is
certainly a need to systematically
study the utility, futility and poss­
ible dangers of these traditional
practices. The blind faith in the
traditional health practices of
doubtful utility may lead to nonac­
ceptance of modem system of
medicine.
Table 4: Traditional practices of
uncertain/doubtful utility
1. Janam ghutti
2. Gripe water
3. Boiled water containing anisi,
cummin seeds, ilachi for the
mother after delivery
4. Use of a variety of traditional
galactogogues: garlic, ginger,
coconut, jaggery, bajra, ghee
fenugreek, pepper, margosa
etc.
5. Brandy for URI/pneumonia
6. “Hot” and “Cold” feeds
7. Avoiding exposure of pregnant
woman to eclipse
8. Use of copper, steel and
magnetic bracelets
Under the garb of tradition,
many unstandard and unwanted
commercial preparations like gripe
water and ghuttis are being prom­
oted and sold across the coun­
ter. However, we must try to
preserve the good old traditions for
the care of children by integrating
them in the primary MCH care
programmes and weed out the
harmful cultural beliefs and prac­
tices by health education. A cam­
paign should be launched through
media against balatant adver­
tisements by manufacturers of
various formulations of doubtful
utility and safety.
A

51

COUNSELLING FOR
PSYCHOSOCIAL PROBLEMS
Dr V. N. Rao
Dr R. Parthasaratiiy

Counselling is a planned and systematic application of psychological facts and social
understanding to the alleviation of a large variety of human ailments and disturbances,
particularly those of the psychogenic and interpersonal origin. It also strengthens
the problem solving capacities and coping abilities of the individuals and families in
the society.
late, we have been hearing
about the word
OFmuch

“COUNSELLING” specially in the
context of deaddiction, students’
academic and vocational pro­
blems, marriage and sexual pro­
blems, legal problems, family
interaction related problems, inter­
personal problems of industrial
workers, planned parenthood,
health education, and other acti­
vities related to personality and
competence
development. The
Government and voluntary agen­
cies are actively involved with
training and utilizing the skills and
expertise of counsellors in health,
welfare, education and develop­
mental programmes in institu­
tional and community settings.
Though the counselling is used
widely and becoming popular
among the general public, the exact
meaning of counselling is rarely
understood. Because of lack of
understanding of the essential
nature of counselling, it is not
52

uncommon to see exploitation of
the concept of counselling by
quacks,
unqualified
people,
pseudo-therapists and others in big
cities, towns and remote vil­
lages. More often than not, the
gullible people are carried away by
the false promises and high claims
made by such unscrupulous and
anti-social elements, in the pretext
of managing any problem under
the sun with the label of coun­
selling.

According to the Dictionary, the
word, “counsel” has different
meanings
like—“consultation ”
“deliberation”, “advice”, “plan”
and “purpose”. The counsellor is
one who counsels.

Scientifically speaking, there are
several definitions given by mental
health professionals and counsell­
ing experts. For example—Gustard gives the comprehensive de­
finition as: “counselling is a learn­
ing oriented process, carried on in a

simple, one-to-one social environ­
ment, in which a counsellor, pro­
fessionally competent in relevant
psychological skills and know­
ledge, seeks to assist the client by
methods appropriate to the latters'
needs and within the context of the
total personnel programme, to
learn more about himself to learn
how to put such understanding into
effect in relation to more clearly
perceived, realistically defined
goals to the end that the client may
become a happier and more pro­
ductive member of his/her
society.”
In other words, counselling is
planned and systematic applica­
tion of psychological facts and
social understanding to.the allevia­
tion of a large variety of human
ailments and disturbances, par­
ticularly those of psychogenic and
inter-personal origin.

Usually, counselling services are
offered by persons trained in men­
tal health. In addition to the

Swasth Hind

professionals, people who undergo
special training programme in
counselling run by recognised cen­
tres impart short term training pro­
gramme in counselling for volun­
teers, teachers, medical personnel,
welfare agency personnel and
others involved in develbpmental
programmes. Depending on the
training and knowledge, the coun­
sellors offer their services to the
clients affected with variety of pro­
blems related to studies, vocation,
job, marriage, family, child rearing,
adjustment, etc.
Stages of Counselling

There are five stages of coun­
selling. In the first stage, the
counsellor establishes working
relationship or rapport with the
clients. As a result, the client
tends to trust the counsellor and
reveals his problems to the Coun­
sellor. In the second stage, the
counsellor makes an assessment of
the problem by collecting informa­
tion related to presenting problem,
clients current life setting, family
and personnel history including
his careful observations/perceptions during the interview sessions.
In this stage, the counsellor makes
an assessment of the psycho-social
situations and problems of the
client In the third stage, depend­
ing on the problems, he with the
help of the client sets certain goals
for solving the problems. In the
fourth stage, he adopts certain sys­
tematic techniques (like—assertive
training, catharsis, clarification,
environment manipulation, inter­
pretation, reassurance, relaxation,
suggestion, support, self-esteem
reconstruction, insight facili­
tation, etc.).
In the final stage, he terminates
the professional contact and ad­

February 1993

vises suitable follow-up action.
The client is asked to consult the
counsellor in case of problems
which he finds difficult tb
manage.
Many researches have focused
on the characteristics of effective
counsellors. They listed out the
following characteristics which
contribute towards the effective­
ness of the counsellors.

(1) Sensitivity
problems.

to

the

client’s

(2) Open mindedness in under­
standing the client’s situa­
tion.
(3) Objectivity in approaching the
situation.
(4) Competence by virtue of train­
ing and experience.

(5) Humane and helping quali­
ties.
(6) Trustworthiness
confidentiality.

involving

(7) Self-awareness and under­
standing.
(8) Good psychological health.

By such qualities and systematic
approach usually involving 5-15
sessions, each session being of 4560 minutes, spread out for few days
to weeks, the counsellor helps the
clients in the following ways:
(1) Clients are able to accept res­
ponsibility for themselves,
their problems and their
lives.
(2) Clients develop greater under­
standing of atleast four as­
pects of the problems : feel­
ings and somatic reactions,
thoughts, behaviour arid inter­
personal dimensions.

(3) The clients develop new be­
havioural responses/different
interactions to avoid repeating
the same pattern.
(4) The clients develop effective
and satisfying interpersonal
interactions, social support
and
relationships
with
others.

Counselling, usually results in
more than one single, all inclusive
outcome for clients. Effective
change is multifaceted and com­
prehensive from clients point of
view.
In some settings like hospitals.
Child Guidance Clinics, and
Schools, counselling is also offered
in group situations wherein clients
with more or less similar problems
are guided to discuss their pro­
blems and solve the problems by
mutual learning, sharing and col­
lective thinking and decision mak­
ing. This is called group coun­
selling method. In some situa­
tions, either the family of the client
of groups of families of clients
become the focus of counselling
efforts. It is called Family Coun­
selling. Likewise there are many
types of counselling, all of which
aim at helping the clients to help
themselves.
By effective counselling, it is
possible to find solutions to many
problems to prevent several psy­
chosocial problems and also to
strengthen problem solving capa­
cities and coping abilities of the
individuals and families in the
society.
a
53

TRADITIONAL HEALERS
AND COMMUNITY
HEALTH
Wilbur Hoff

A review of projects in various countries suggests that traditional healers, if pro­
perly
teams.

trained,

can

contribute

significantly

to

the

work

of primary

care

Recommendations are offered with a view to making the best possible use

of this valuable resource.

Third World, traditional healers are a signifi­
that should be fully employed in the
INcanttheresource
struggle to provide adequate health care. Indeed,
efforts are already being made to incorporate them
into primary health care programmes. Considerable
light has been thrown on the value of these
endeavours by a review of the literature describing
projects that have used traditional healers as com­
munity health workers (1).
Information was obtained from developing
countries on 17 projects in which traditional prac­
titioners were trained to carry out one or more
primary care activities in communities. Fifteen of
the projects were sponsored by governments and two
by non-governmental organizations. They involved
herbalists, diviners, spiritual or faith healers,

traditional midwives, traditional birth attendants,
curanderos, shamans, traditional Chinese doctors,
Ayurvedic doctors, Unani practitioners and other
types of traditional healer.
Positive outcomes and changes

Training produced positive changes in healers,
their clients, and modem health staff.
Traditional practitioners were available and will­
ing to work in primary care when trained, and
established good working relationships with other
health staff. A great variety of healers from many
different cultures were successfully trained to work in
primary care projects in Afghanistan, Brazil, China,
Ghana, India, Nepal, Nigeria, Philippines, Sierra
Leone,
Sudan,
Swaziland,
Thailand
and

The author is Consultant on Health Education and Training, International Child Resource Institute, 1810 Hopkins Street, Berkeley, CA
94707. USA

54

Swasth Hind

Zambia. Herbalists, spiritual healers, Ayurvedic and
Unani practitioners, traditional midwives, bonesetters, magico-religious practitioners and other
healers enthusiastically accepted new roles in
primary care. The skills taught included the
following:
• Promotion of education in local health problems
and methods of preventing and controlling
them.

• Promotion of improved food supplies and nutri­
tion, with information on balanced diets, breast­
feeding, weaning foods, and the growing of
vegetables and fruit in kitchen gardens.

• Promotion of safe water supplies and basic sanita­
tion, including the construction and use of lat­
rines, personal hygiene, and the preparation and
storage of food.
• Promotion of maternal and child health care, with
regard to family planning, the monitoring of pre­
gnancy and recognition o‘f abnormalities, antena­
tal care, basic delivery techniques, referral for
abnormal delivery, and the distribution of oral
contraceptives and referral for other methods of
birth control.
• Promotion of immunization against major infec­
tious diseases, including referral of children under
five to clinics for immunization against
childhood diseases.

• Promotion of prevention and control of locally
endemic diseases, including the recognition of
symptoms of dangerous diseases such as
diarrhoea, tuberculosis, leprosy, malaria and
malnutrition, and the referral of affected
individuals for treatment, the mixing and use of
oral rehydration solution to treat dehydration and
diarrhoea, the distribution of packets of oral
rehydration salts, the referral of women in highrisk groups, and the use of readily available
allopathic medicines (e.g., antimalarial pro­
phylaxis).
• Provision of treatment for common diseases and
injuries, as well as first aid and accident
prevention.

February 1993

° Provision of essential drugs, including aspirin and
other first-aid medication; and the operation of
basic dispensaries.

In a project in Ghana, healers were taught pre­
ventive and promotive measures, family planning, the
use of allopathic medicines, and basic first aid (2). A
project in Swaziland focussed on training healers to
recognize symptoms of dangerous children’s diseases
and their prevention and control through oral rehyd­
ration therapy, improved nutrition, safe water and
sanitation, and personal hygiene (3); it also developed
a referral system that enabled traditional practitioners
and clinic nurses to improve communication and
cooperation between the traditional and modem
health sectors in the treatment of mothers and
children. In Nepal, traditional practitioners learned
how to recognize and manage tuberculosis, leprosy,
and childhood diarrhoea and malnutrition, and how
to refer patients with symptoms of tuberculosis and
leprosy (4). In Brazil, local healers were trained to
integrate the use of oral rehydration therapy with their
own indigenous practices aimed at achieving child
survival. In general the healers were reliable clinical
observers, knowledgeable about antidiarrhoeal plant
remedies, skilled in the preparation of oral rehydration
solution, and pragmatic in integrating effective mod­
em therapies into their practices (5).
In seven projects, training produced specific
advances in the attitudes, knowledge and behaviour of
healers, the health status of population groups, and the
attitudes and behaviour 6f health sector staff. This
indicates a need for more documented results from
demonstration projects representing a diversity

An atmosphere of understanding, trust and respect
should be created between modern health workers,
traditional healers and the communities they
serve.

of circumstances throughout the world. Such, data
could help to answer questions on the selection, train­
ing and utilization of healers in primary care and to
evaluate the cost-effectiveness of these activities.

55

Projects in Brazil, Ghana, Nepal, Sudan and
Swaziland indicated that participants had a high
degree of interest in and enthusiasm for acquiring new
information and skills in primary care (2, 3, 5—
7). They also demonstrated the following changes in
the practices ofJiealers after they had attended train­
ing workshops:
— increased use of oral rehydration solution for
children with diarrhoea;
— use of washbasins for cleaning hands in tradi­
tional healing clinics;
— decreased use of strong purges and enemas for
treating diarrhoea;
— construction and use of latrines in healer’s
homes;
— increased referrals to clinics for patients with
dangerous symptoms;
— increase in numbers of births attended by
village midwives.

Only two projects reported specific changes in
the health status of target populations : in Sudan the
proportion of women aged 30-34 using contraceptives
increased from 25% to 38% over a two-year period and
the overall use of contraceptives rose from 13%

Healers have traditionally been private prac­
titioners, and attempts to alter this state of affairs
could create confusion or misunderstanding.

to 21%; in Nepal a project achieved an increased atten­
dance at rural clinics after the trained healers began
working in local communities. Most projects
indicated a high degree of acceptance of trained
healers by communities.

Many projects indicated that there was an
increase in trust and respect between nursing staff and
traditional practitioners, and that working rela­
tionships between the two groups improved. In the
Swaziland project, nurses reported that there was an
increase in referrals by healers to rural clinics,
particularly for children with diarrhoea and

56

vomiting This reflected the development of a mutual
referral system. In Nepal it was found that the dhamijhankri or faith healers could play a culturally appro­
priate and cost-effective role in health education and
family planning. It was estimated that the country
had well over 100 such healers for every health worker,
and that they were paid only modest fees by the people
for their services.

In Swaziland the cost to government for training
traditional practitioners was relatively low, the coun­
try’s Traditional Healers’ Organization having com­
mitted a large amount of time and resources to the
project and the community paying for the healers’ ser­
vices (8).

In a Philippines project the main strength of the
community-based health programmes was their low
cost (9), achieved through the employment of
traditional medical practitioners using inexpensive
therapies.
Constraints

The absence of clear recognition by many
governments of the potential value and role of
traditional practitioners in primary care creates a poor
climate for healers and health staff to work together,
and tends to reinforce secretive practices. A lack of
government commitment in some projects has dis­
couraged healers from coming forward to participate
in training programmes. In countries where, until
recently, healers were prohibited from practising,
many are .reluctant to participate in governmentsponsored health programmes.
A lack of dialogue between healers and govern­
ment staff has led to misunderstandings. Open dis­
cussion on common health goals has been absent and
the coordination of services has been impaired. One
example of this is the difficulty in establishing referral
systems between healers and clinic * nurses. In
Swaziland such referrals increased following a train­
ing workshop during which members of the two
groups agreed to cooperate.

Where the role of the healer in relation to other
members of the primary care team was not clearly
defined, and the tasks they were to perform were not
specifically described, problems arose in both the
S WASTE HIND

training and work settings. For example, a weakness
of many community health worker programmes was
that the range of assigned duties was too broad and
tasks were poorly defined. Thus in Nigeria, because
the role of healers was not made clear, some feared
their integration into the primary care programme
might threaten their status, income and freedom of
action in the community (10).
The conflict between the traditional, holistic,
spiritual-oriented healing and the modem, biomedi­
cal, treatment-oriented approach reflects a basic dif­
ference in philosophy on the causation of disease and
the promotion of health. This difference can cause
barriers between traditional and modem practitioners,
not least in the planning and implementation of train­
ing projects for healers.
Some practices, such as witchcraft and sorcery,
can cause dangerous psychological stress and bodily
harm. Clearly in opposition to the modem biomedi­
cal approach, they are strongly rooted and often quite
resistant 9 to change, particularly where belief in the
supernatural is concerned.

The activities of charlatans and fraudulent prac­
titioners may obscure the worthwhile contributions of
the large majority of bona fide healers. Isolated
incidents of witchcraft, malpractice or unscrupulous
behaviour are widely publicized in the media and tend
to prevent understanding and cooperation between the
traditional and modem health sectors.
There has been little or no evaluation or follow-up
after the completion of training projects. Relatively
few reported specific data indicating how effective the
training had been, what the healers were accomplish­
ing in the community, and how satisfied the ‘com­
munity members were with the performance of
primary care activities by healers.
Future involvement
primary care

of traditional practitioners in

The following recommendations relate to the pro­
motion of community health by incorporating
traditional practitioners into primary care teams:
FEBRUARY 1993

Government ministries and departments of health
should take the lead in formulating policies and act­
ing to promote the training and use of healers in
primary care. They should ensure that traditional
practitioners are incorporated as fully and effec­
tively as possible into health service systems that
meet the needs of communities. An atmosphere of
understanding, trust and respect should be created
between modem health workers, traditional healers
and the communities they serve. This requires a
mechanism whereby activities such as informal
meetings, seminars and workshops are planned and
key people representing the modem and traditional
sectors come together to express their views,
establish common goals and develop ways of using
traditional healers in primary care teams. Official
policies should be formulated which knowledge the
value of traditional healers in this field and indi­
cate how government intends to utilize them.
A government intention to cooperate with and
include healers in coordinated primary care teams
might be declared. Because relatively little
experience has been gained in training and using
traditional practitioners, government may wish to
indicate a desire to explore the roles that healers can
play, and to define, through pilot or demonstration
projects, appropriate functions and tasks. It may
not be possible to formulate detailed policy
statements and strategies until data from trial pro­
jects have indicated more specifically how
traditional practitioners should be trained, their
performances monitored, and their services
rewarded.
The role that traditional practitioners should play in
providing primary care ought to be carefully
defined. Healers have traditionally been private
practitioners, and attempts to alter this state of
affairs by employing them or enlisting their
cooperation as community health workers could
create confusion or misunderstanding. The views
of people in the modem and traditional health sec­
tors, as well as those of the community in general,
should be considered when defining the roles to be
filled by traditional practitioners in a particular
region or country. The roles may vary in accor­
dance with the levels of responsibility, traditional
status, and cultural practices of the healers, the
priorities, goals and resources of the ministries of
health, and the wishes of the communities.
57

• The planning, implementation and evaluation of
programmes for the training and use of traditional
practitioners in primary care should be done jointly
by representatives from health and other related
sectors of government, nongovernmental orga­
nizations, traditional healers, and the communities
served. A system of primary care requires
cooperation between modern and traditional health
practitioners. The two sectors should establish a
partnership in which all members are part of a team
serving the community. Some projects have
established mutual referral systems, whereby
healers refer patients with certain conditions to
Western medical clinics and hospitals, and
Western-trained nurses and doctors refer certain
patients to healers, an arrangement that can lead to
an overall improvement of health services. In­
creased communication enables both modem and
traditional health workers to learn from each
other.

Recommendations are offered in this article with
a view to making the best possible use of traditional
practitioners in the provision of primary care in com­
munity settings, and to limiting problems and dif­
ficulties. They are intended as guidelines for
government and nongovernmental organizations
wishing to give improved primary care to communities
and ultimately to improve people’s quality of life.

• Training programmes should be designed which
meet the special* needs of traditional prac­
titioners. Many healers lack formal education and
have low levels of literacy, and this can pose dif­
ficulties in training. In some projects it was found
that these circumstances required specially de­
signed training methods and materials. Conven­
tional methods, involving lectures and written
materials, were not appropriate. Because tradi­
tional practitioners have cultural and health orien­
tations differing from the western ones, and because
many of them have a lower level of education and
training than modem health staff, it is important to
design training programmes that meet their
special needs.

REFERENCES

• In order to develop effective strategies and methods
for the incorporation of traditional practitioners
into national primary care programmes, it is desir­
able to conduct demonstration, evaluation and
research projects. Because of the scarcity of data
on training and using traditional practitioners in
primary care, carefully designed pilot projects
should be conducted to demonstrate and test
methods before they are widely employed. Good
evaluation components should be incorporated so
that progress can be measured. It is important to
collect information about the impact that training
programmes have on the attitudes, knowledge and
practices of healers and on the health status of
communities.

Health workers should look carefully at the
resources in the traditional health sector. Given the
major status and influence of most traditional prac­
titioners among their own people, their role in provid­
ing sound and culturally appropriate primary health
care should not be underestimated. In countries
where needs are great and resources scarce, traditional
practitioners can play a significant role in helping peo­
ple in rural communities to improve their quality
of life.

1.

Hoff, W. & Shapiro, G. TYaditional healers and community
health, a review of the literature describing projects using
traditional healers as community health wokers. Berkeley,
International Child Resource Institute, 1990 (unpublished
document).

2.

Warren, D. et al. Ghanaian national policy towards indigenous
healers, the case of the primary health training for indigenous
healers programme (Paper presented to the annual meeting
of the Society for Applied Anthropology, Edinburgh,
1981).

3.

Hoff, W. & Mascko, N. Nurses and traditional healers join
hands. World health forum, 7: 412—416 (1986).

4.

Oswald, LH. Are traditional healers the solution to the
failures of primary health care in rural Nepal? Social science
& medicine. 17 : 255—257 (1983).

5.

Nations, M.K. et al. Brazilian popular healers as effective
promoters of oral rehydration therapy (ORT) and related
child survival strategies. PAHO Bulletin, 22: 335—354
(1988).

6.

El Tom, A.R. et. al. Family planning in the Sudan: a pilot
project* success story. World health forum, 10: 333—343
(1989).

7.

Sh res th a, M. & Lediard, M. Faith healers: a force for
change Kathmandu, UNICEF. 1980 (Preliminary report of
an Action Research Project).

8.

Hoff, W. Training traditional healers to assist in the control of
childhood diseases in Swaziland. (Unpublished paper presen­
ted to the National Council for International health,
Washington DC, 1986).

9.

Tan, M.M. et al. The integration of traditional medicine
among community-based health programmes in the Philip­
pines. Journal of tropical pediatrics, 34 : 71—74 (1988).

10.

Green, C. Collaborative programmes for traditional healers
in primary health care and family planning. In: Fyfe, C. &
Maclean, U„ ed. African medicine in the modem
world. (Proceedings of a seminar. Centre of African Studies,
University of Edinburgh, 1986, pp. 115—144.).
A

♦ ♦ *

The present review suggests that traditional prac­
titioners are a valuable resource for providing primary
care to communities. Services can be strengthened so
as to promote health and prevent illness if traditional
practitioners are properly trained and utilized.
58

Courtesy: World Health Forum Vol. 13, 1992.

Swasth Hind

EVALUATION OF DENTAL HEALTH
EDUCATION APPROACHES IN
SCHOOL CHILDREN
Panna Lal.
Dharmvir Jain
AND

Smt. Urmtla Pant
ental caries is a major health problem in both

D developed and developing countries1. In India,
around 30% of school Children have been reported to
be suffering from dental caries2. It is irreversible
after development3 but can be prevented by main­
taining proper dental hygiene. It is essential to pro­
vide dental health education to the children at
regular intervals through various methods
available. The present study was undertaken with
the objectives of: (1) Strengthening the basic essential
knowledge regarding dental hygiene and to bring out
effective change in attitude and practices of dental
care in the school children, (2) Selecting most suit­
able method of health education to them based on
efficacy of different methods.
Material & Methods

This study was carried out amongst students of a
local school situated in Alipur Block, the rural field
practicing areas of P.S.M. Deptt, Maulana Azad
Medical College, New Delhi. A health education
programme on dental hygiene was launched amongst
all 120 students of Class IX The contents of health
education included knowledge regarding (1) basic
facts about anatomy and physiology of teeth, (2)
Common causes of tooth decay and gum diseases, (3)
prevention of dental and gum problems by basic
dental care’ which included practices of the rules of
FEBRUARY 1993

dental hygiene, proper diet, regular dental check up
by a qualified dentist and importance of timely treat­
ment in case of any dental problem4.

The students were divided into four groups
namely, A, B, C & D each having strength of 30
students selected randomly. A different health
education method was used for each group but the
contents of the programme were same for
all. Group ‘A’ had method of self instruction
through reading material in the form of colourful
and attractive pamphlets covering all planned con­
tents of health education programme. The matter
was arranged serially and presented in steps consist­
ing of self explanatory pictures and simple text
Group ‘B’ was shown a film entitled “ALL ABOUT
TEETH” a production of Films Division of India
which covered all requisite contents concerned with
dental hygiene. Group ‘C’ had a teaching session in
the form of health talk. To make it interesting and
informative, a series of flash cards specially prepared
for the programme from the material collected from
WHO and other agencies were utilised. For Group
‘D’ filmshows and health talk in combination were
used. The medium of health education throughout
was Hindi.
All four groups were subjected to pre and post
evaluation test5*® with the help of a questionnaire
59

containing multiple choice questions in three parts
covering knowledge, attitude and behaviour. A stu­
dent who had information on dental hygiene was
defined as ‘having knowledge’. Those in favour of
adopting dental hygiene practices (eg. brushing)
categorised of having favourable attitude. Those who
were actually practicing kept under behaviour. The
post test was administered seven days after the
implementation of the programme. Each correct res­
ponse carried score ‘T while wrong answer had
zero. The change in knowledge, attitude and
behaviour was worked out and compared.
Results & Discussion

Table 1—Percentages of Correct Responses Before &
After Health Education

Knowledge Attitude
Behaviour
Study
------------- ■------------------------------groups &
Pre Post Pre Post Pre Post.
Approaches test test test test test test
(%) (%) (%) (%) (%) (%)

(a) Reading
material

The results of the study indicate that all the four
methods used, brought about a positive shift in
knowledge, attitude and behaviour of the students
except in group ‘B’ for whom the film show alone was
used. In this group the change in the behaviour was
not significant The combination of health talk and
film show was found to be maximally effective method
in bringing out statistically highly significant change
(P<0.001) in all three components viz knowledge,
attitude and behaviour. The second best method was
the health talk alone whereas the reading material
ranks third. The film show alone brought about
significant change (P<0.05) in knowledge and attitude
but not in behaviour.

The film show has better efficacy and can prove to
be most useful method of health education if accom­
panied by a prior health talk and post film show
discussions.
REFERENCES

1.

Nutrition in Preventive Medicine, WHO Monograph scries 1976,
652:494-415.

2.

Pandit K. Kan nan AT. Sama A eL al: Prevalence ofDental caries
and associated teeth cleaning among children in four primary
schools. Int, J. Epidemiol. 1986, 15(4): 581-583.

John M.:Last, edit "Dental Public Health" in: Public Health and
Preventive Medicine 11th edition Appleton Century Craft, New

52.3 72.9 56.8

77.5

48.3 75.8

(b) Film Show 53.3 74.0 36.5

82.7

57.5 63.4
(NS)

3.

55.3 78.5

4.

(c) Health talk 57.7 89.3 39.2

89.2

York 1980; 1423-1424.

Cimasoni G.'.'Treatment and Prevention: world Health", Dental
Health June 1981”.

(d) Film show 50.0 94.4 37.5
& Health
talk

87.5

47.9 79.2

5.

Cox C.V4 Pilot study using elderly as Community Health
Educators. Int. J. Health Education Vol. XXII 1 79/1.

6.

Charlton A Teaching About Cancer. Int. J. Health Education
Vol. 1 January, 1983.
A

NS: Not significant.

60

Swasth Hind

WHO EXECUTIVE BOARD SESSION

US $ 1.8 BILLION BUDGET FOR 1994-95 ADOPTED

Ninety-first session of the World Health
(WHO) Executive Board con­
THEOrganization
cluded its work in Geneva on 29 January 1993 by
approving a US S 1.8 billion budget for 1994-95. The
Director-General, Dr Hiroshi Nakajima, was reques­
ted however to strive to make reductions and
economies that could decrease the level of the pro­
posed budget and to present the results of his efforts to
the 46th World Health Assembly, scheduled to meet in
Geneva from 3 to 14 May 1993.

The proposed regular working budget for the
biennium amounts to US S 872 496 000, made up of
assessed contributions from Member States. In addi­
tion, Member States and other contributors provide
extrabudgetary funding targeted at specific program­
mes of their choice. According to WHO estimates,
extrabudgetary contributions should amount to nearly
US S one billion for 1994-95, bringing the total budget
to USS 1.8 billion.
On Wednesday 20 January 1993, the Executive
Board nominated Dr Hiroshi Nakajima for a second
5-year term of office as Director-General of WHO.

During this session, which began on 18 January,
the Executive Board also adopted a series of
resolutions on major health issues. All the Executive
Board’s resolutions and recommendations will be sub­
mitted to the 46th World Health Assembly.

Meeting under the chairmanship of Professor
Jean-Francois Girard, Director-General of Health in
the French Ministry of Health and Humanitarian
Action, the 31 member Executive Board, discussed the
principal health issues facing mankind. It reviewed
the progress of the global programme to combat the
spread of AIDS. The programme is WHO’s biggest
and has a planned budget for 1994-95 of US S 180

February 1993

million. WHO estimates that 2.5 million people have
developed AIDS and that another 13 million, includ­
ing one million children, are infected with HIV.
Among the health issues addressed in the
resolutions adopted today:
Malaria—The disease threatens 2.2 billion people
and kills more than a million a year. WHO plans to
spend USS 118 million on it in the 1994-95
budget The Executive Board resolution urges WHO
Member States where malaria remains a problem or is
a potential threat, to reinforce their efforts for preven­
tion and control, and requeststhe Director-General to
reinforce WHO leadership in malaria control and to
ensure that Member States get the necessary technical
support for malaria control programmes.

Poliomyelitis—Having wiped out smallpox in 1977
through immunization campaigns, WHO is now seek­
ing a comparable triumph over polio. In 1991,13,201
cases were reported to WHO, a 60 per cent decrease
since 1988. An Executive Board resolution reaffirms
that the goal of eradication by the year 2000 is achiev­
able and calls on United Nations agencies and
governmental
and
nongovernmental
organi­
zations to support countries committed to
eradication. Poliomyelitis accounts for a large share
of WHO’s Expanded Programme on Immunization,
the total budget of which is close to US S 40
million.
Tuberculosis—There is a resurgence of the disease
in many countries, partly due to the spread of HIV
infection, with which it is linked, and drug-resistance.
WHO aims to spend over US S 20 million in combat­
ting tuberculosis. Member States are urged to take
rapid action to strengthen national tuberculosis
61

programmes. Concern is being expressed that inade­
quately managed programmes appear to be
exacerbating dangerous drug-resistant forms of the
disease, while there is still inadequate appreciation of
the seriousness of the situation, particularly in
developing countries.
Dengue—Epidemic dengue, transmitted by mos­
quitoes, continues to pose a serious problem in tropi­
cal regions. The Board adopted a resolution
confirming that dengue prevention and control should
be among the priorities of WHO and urging Member
States to strengthen national and local programmes
aimed at this disease. The resolution also requests
the Director-General to establish strategies to contain
the spread of dengue and dengue haemorrhagic fever
which threaten more than 85 countries throughout the
developing world. Programmes covering research
and control of tropical diseases, including dengue,
account for nearly US S 200 million of the 1994-95
budget.

Nutrition—WHO is playing a leading role in the
global fight against hunger and malnutrition. A
resolution urges Member States to strive to eliminate,
by the year 2000, famine and famine-related deaths,
starvation and nutritional deficiency diseases in com­
munities affected by natural and man-made disas­
ters. WHO’s nutrition budget for 1994-95 is overUS $
20 million.
Emergency and Humanitarian Relief Operations—
WHO’s role in this area is growing, as recently
demonstrated in Mozambique, Somalia and the for­
mer Yugoslavia. It is also providing assistance in
Ethiopia, Iraq, Liberia and Tajikistan. The health
assistance needs of other former Soviet republic are
currently being examined. A resolution adopted
tdday calls on the Director-General to ensure that
WHO fulfills its responsibility for co-ordinating the
health aspedts of disaster preparedness and response
within the United Nations system, and to consider
further improvements in staffing and technical
capabilities related to the management of health
emergencies.
62

Environmental health—In the developing world,
environment-related infectious diseases remain the
most serious health threat, particularly water-borne
diseases, as dramatically demonstrated by the global
cholera epidemic, now in its third year. Tropical dis­
eases affect millions of people but in many instances
can be prevented and controlled by using sound
environmental management measures. In developed
countries diseases related to environmental pollution
and to life-styles are an increasing cause of con­
cern. In addition, the long-range transport of air
pollutants, the transboundary movement of hazardous
products and wastes, and stratospheric ozone deple­
tion have direct and indirect global health impli­
cations. The 1994-95 programme budget allocates
US S79 million for the activities of WHO’s Division of
Environmental Health.
WHO response to global changes—Economic dif­
ficulties and the growing debt burden affecting many
countries have led to a decline in the resources avail­
able, nationally and internationally, for health.
Together with the sharp increase in the costs of medi­
cal care worldwide, these developments threaten the
sustainability of primary health care programmes. In
addition, health and disease patterns are being affec­
ted by environmental factors, demographic changes,
unplanned urbanization, mass migrations, the spread
of the AIDS pandemic and the resurgence of long­
standing problems like- tuberculosis and malaria.

Calling for a review of WHO’s capacity to respond
to these challenges, the Executive Board last year
established a “Working Group on the WHO response
to global changes” which presented a preliminary
report during this session. The preliminary report,
which analyses various aspects of WHO’s mission and
structure, received considerable attention in a course
of the session which ended today. Among other
observations, it warns that the Organization and its
Members States have not been sufficiently able to plan
and implement their programmes to achieve WHO’s
strategic objective of “Health for all by the year
2000”. Under this programme, formulated in 1978,
every human community should have access to
appropriate and affordable health care by the turn of
the century. The Director-General has been reques­
ted to prepare an analysis of the resources required by
WHO and Member States to make this goal a
reality.
A
SWASTH HIND

(Contd. from page 39)
Some Problems and Suggestions
by PVOs

Some of the constraints being
faced by voluntary organisations in
conducting their activities are:
1. Inadequate finance
2. Unresponsive community
3. Untrained and inadequate
staff
4. Inadequate
Government
Support
5. Inadequate transport faci­
lities
Some of the suggestions offered
by voluntary organisations for
development of primary health
care in rural areas are:
1. More staff in health centres
2. Continuous training to
health functionaries

3. Proper supervision
4. Adequate supply of medi­
cine to health centres
5. Adequate transport faci­
lities
6. Emphasis on community
involvement
7. Adequate
supplies
of
appealing IEC materials in
local dialect to the health
centres
8. Rewards based on target
achievement and excel­
lence
Conclusion and Recommendations

Viewing the success and
achievement of PVOs in promotive
and preventive health care services,
the Government of India has
evolved the Private Voluntary

Organisation for Health Scheme
(PVOH) under which financial
assistance is being given to projects
undertaken by PVOs for expansion
of Health, Family Welfare and Nut­
rition services in different parts of
India. Now a days need for giving
more financial assistance to the
smaller PVOs is urged. For pro­
per functioning of PVOs, approp­
riate human resource development
and training should be conducted
for the key trainers of the PVOs.
Later on, necessary support would
be provided to the PVOs to train
their volunteers for carrying out
their programmes. Given ade­
quate training, tire voluntary agen­
cies have an important role to play
in formulating, implementing,
evaluating and monitoring the
health and family welfare pro­
gramme in rural sector.
A

Authors of the month
Dr Gajanan D. Vclhal
Associate Professor,
Dcplt. of Preventive & Social Medicine,
Topiwala National Medical College &
B.Y.L. Nair Charitable Hospital,
Dr. AL. Nair Road,
Bombay Central,
Bombay-400 008.

B.B.L. Sharma
Asslt. Professor (Health Economics) &
Faculty In-charge National Documentation Centre
and
Dr B.K. Pattanaik
Asstt. Research Officer,
DeptL of Education & Training,
National Institute of Health & Family Welfare,
New Mehrauli Road, Munirka,
New Delhi-110067.
Dr Devi Saran Sharma
Lecturer in Social Work,
Institute of Social Sciences,
Agra University,
Agra.
Uttar Pradesh.

M. Ameer Hamza
Psychiatric Social Worker
Clinical Psychiatric Unit

and
Dr R. Parthasarathy

Associate Professor.
Community Mental Health Unit

and
Dr V.N. Rao
Associate Professor
Dcptt. of Psychiatric Social Work,
National Institute of Mental Health & Neuro Sciences,
Bangalore-560 029.
Dr Mcharban Singh
Professor & Head
Deptt. of Pediatrics and Neo-natal Division.
Al India Institute of Medical Sciences,
Ansari Nagar,
New Delhi-110029.

Panna Lal
Senior Resident

Dr S.B. Dabral
Professor & Head
S.P.M. Department,
S.N. Medical College,
Agra-282 002,
Uttar Pradesh.

Dharmvir Jain
Junior Resident

M. Mohanram & V. Ramadasmurthy
C/o National Institute of Nutrition,
Hyderabad-500007
Andhra. Pradesh

Smt. Urmila Pant
Ex-Lecturer in Health Education,
Deptt. of Preventive and Social Medicine,
Maulana Azad Medical College,
New Delhi-110002.

FEBRUARY 1993

and

and

63

RESEARCH STUDY

DIET AND NUTRITIONAL STATUS OF
GIRL CHILD
is, generally, believed that
are discriminated with
ITfemales

respect to several benefits as com­
pared to the males and consequen­
tly suffer from the ill effects on
health and nutritional status. A
study was therefore, carried out on
a group of preschool children to see
if this is true.
Three hundred and eight house­
holds in six villages around
Hyderabad
were
sur­
veyed. Demographic and socio­
economic particulars and infor­
mation on attitudes and practices
of child rearing were collected from
(he mothers of the preschool
children. Dietary intakes were
assessed by 24-hour recall method
on a sub-sample of 100 house­
holds.
Nutritional status of 192 boys
and 204 girls of the preschool age
group from these 308 families was
assessed by taking anthropometric
measurements like weight, height
and
mid-arm
circumferen­
ce. Clinical examination was car­
ried out for nutritional deficiency
signs.

The main findings are as fol­
lows :
1. All the families belonged to
poor socioeconomic status; 58% of
(he fathers and 81% of the mothers
were illiterate.
64

2. Cradle ceremony was celeb­
rated in a significantly higher pro­
portion of boys (73%) as against
girls .(56%), and higher proportion
of parents of boys (12%) as com­
pared to those of girls (1%) also
arranged feast on the occasion,
indicating the preferential attitude
of the parents at the birth of
boys.

3. Higher proportion of boys
(51%) were being breast fed at the
time of the survey than the girls
(30%). Prolonged breast feeding
(36-59 months) was more common
in boys (85%), than in girls
(76%).

4. The practice of giving pocket
money to purchase eatables was
also more in the case of boys (71%)
than in girls (43%).
5. During illness, higher propor­
tion of boys (80°4) compared to girls
(63%) were taken to medical prac­
titioners and the mean number of
visits to the doctors was also higher
in boys (2.3%) than in girls
(1.8%).

6. Twenty one per cent of older
girl children looked after their
siblings when the parents were at
work; whereas elder brothers were
not assigned this work.

7. Higher proportion of mot­
hers of girls wanted their daughters
to discontinue their schooling.
The parents were willing to send
boys for high school education
even outside their villages, but they
were not willing to send girl
children.
8. There were no significant dif­
ferences in the dietary intakes bet­
ween boys and girls. Access to
nutritionally better foods like milk
and meat was similar in both the
sexes. But in general, due to
poverty, consumption of such
foods is low in these households.

9. The distribution of children
according to Gomez and Waterlow
classification based on weight for
age, weight for height and height
for age—was similar in both the
sexes.
10. There were no differences
between the sexes in clinical
deficiency signs.

The study indicates that though
there is social preference for boys,
there is no deliberate discrimina­
tion against girl children with
reference to diet and nutrition. A
—NUTRITION NEWS
July 1992

SWASTH HIND

BOOK REVIEW
WHO EXPERT COMMITTEE
ON RABIES
Eighth Report

Technical Report Series, No. 824
1992, vii+84 pages (English, French and
Spanish in preparation)
ISBN 92 4 120824 4
Sw.fr. 12.—/US $ 10.80
In developing countries: Sw.fr. 8.40
Order no. 1100824

This book evaluates new knowledge from basic and
applied research on rabies in terms of its relevance to
the prevention and control of this disease. Noting the
iww new tools now available for both clinical and
application, the report issues advice and recom­
mendations intended to help national control autho­
rities bring their policies—whether concerning firstchoice vaccines or procedures for quarantine—in line
with the latest scientific knowledge. The report also
identifies specific research problems that need to be
solved in the drive to develop more sensitive diagnostic
techniques, to improve the immunogenicity and cost­
effectiveness of vaccines, and to eliminte rabies in
canine and wild animal populations.
Information is presented in'eleven sections. The
first reviews recent advances in rabies research, includ­
ing progress in understanding the molecular structure
and genetics of lyssaviruses, significant strides forward
in methods for the production and delivery of vac­
cines, the development of several unique recombinant
vaccines, arid the potential use substances such as
monoclonal antibodies, interferon, and interferoninducers for post-exposure treatment The second
section, devoted to diagnosis, evaluates existing and
evolving techniques for diagnosis in animals and
humans and for the characterization of virus
strains.
Recent improvements in human and veterinary
rabies vaccines are reviewed in the third section, which
features extensive information on the quality controls

that must be followed during production and the safety
and potency tests that must be performed on each vac­
cine batch before its release. The report also strongly
recommends that encephalitogenic vaccines derived
from brain tissue be replaced, as soon as possible, with
vaccines prepared in cell culture. Other sections
bring readers up-to-date on the status of WHO
reference materials for potency testing of vaccines and
immunoglobulins, and outline procedures for the
licensing and testing, prior to release, of inactivated
tissue culture vaccines.
In view of the extremely high fatality rate of human
rabies, information on prevention is especially
detailed. Practical advice includes recommended
immunization schedules for the protection of indi­
viduals at high risk of exposure, guidelines for post­
exposure treatment, and an explanation of the factors
to consider when deciding whether or not to initiate
post-exposure treatment. The treatment of confirmed
rabies in humans, although almost inevitably fatal, is
also briefly discussed.
Strategies for rabies prevention are further detailed
in sections describing new approaches to the control of
rabies in dogs and wild animal populations. Draw­
ing upon lessons learned in several large mass
immunization campaigns, the report explains how the
recently developed oral vaccination technique can be
used to control the disease in foxes, racoons, other wild
animals, and possibly also in dogs. The report
further concludes that the removal and destruction of
dogs and wildlife should no longer be carried out on a
large scale, as such an approach has never been shown
to have a significant, long-term impact on either pop­
ulation densities or the spread of rabies. The final
main section issues recommendations, in line with
new knowledge, for the international transfer of
animals, including guidelines for the possible reduc­
tion of quarantine procedures and a recommended
special exemption for guide dogs for the blind.

Further practical advice is set out in a series of eight
annexes, which provide guidelines for the testing of
vaccines, post-exposure treatment, the format of vac­
cination certificates, the use of a standard reporting
form to record data on exposed humans, and the
design of a national programme for the control of
rabies in dogs.
a

ISSUED BYTHE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLAMARG.
NEW DELHI - 110 002 AND PRINTED BY THE MANAGER/jOVERNMENT OF INDIA PRESS, COIMBATORE - 641 019.

SWASTH HIND

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Rej$ .No.y R.N. 4504/57

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