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VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14 Community Centre, SDA, New Delhi 110 016.
Phone : 652007, 652008
Grams : Volhealth
For a detailed catalogue please write to the Publications Officer.
Code H-16
Health Education—The Missing
Link in Medical Care
Dr C.M.E. MATHEWS, Department of Community Health
Christian Medical College, VELLORE.
Imagine that we are visiting a hospital and that when we ask
these question we are given the following answers:
Q. What sort of results do you get?
A. Occasionally it works out alright, but some are very
difficult cases. The body is very obstinate and ignorant and
just does not know how to heal itself or deliberately refuses to
do so. So what can we do?
What would we think of a hospital where such a conver
COMMUNITY HEALTH CELL
Q. Are you thinking of getting a qualified surgeon to come
and give you a course on surgery?
A. Well we might do that sometime, but we are all so
busy that it is difficult to find the time for it.
4 7 /1 , (First FloorlS t. M a r k s Road
BANGALORE - 660 001
Q. Who does surgery here? Do you have a qualified sur
geon?
A. Surgery? Oh we all do surgery - everyone takes his
turn with the knife, from the medical officer right down to
the most junior attendant. Surgery is very important.
No, they do not have any special training, its just common
sense really. Even the medical officer does not have much
training because as a student he was not interested in surgery
and so he did not bother to attend those classes. Yes, he does
regret it a little now.
sation could take place? It could not happen we say. And yet
if we substitute “health education” for “surgery” we find
that such a conversation could easily take place in very many
hospitals. Why the difference in attitude? Which is more
important?
*Considei the major health problems which affect large num
bers of people in India. Let us take a few examples :
Tuberculosis
Leprosy
Malnutrition in children
Diarrhoea in children
Infant mortality
Overpopulation
Why are they problems? Is it because the medical solution
is not known? Is it because medical services are not available?
Or is it because the people do not use the services properly
and do not follow the required behavior at home?
A tuberculosis patient will take treatment until he feels
better and then he will see no point in continuing; later he may
become resistant to available drugs and a threat not only to
himself but to the community. A leprosy patient may be
afraid to come for treatment at all, or in the early stages may
just not realise he has a serious disease. Malnutrition although
largely due to poverty also could be much reduced if mothers
appreciated the importance of giving their children more food;
vitamin A deficiency could be easily prevented by giving
greens with negligible cost. Diarrhoea could be prevented by
better hygiene but villagers do not think this is important;
when the child is dehydrated they believe in the power of man
tras alone and often do not seek medical care.
Infant mortality could be reduced by a better diet for pre
gnant woman and more antenatal care, but village women do
not see the need for this. Family planning services are avail
able but they are not fully used.
So what is needed? It is to change people’s behavior, and
this is difficult to do. We can say as in the conversation above
that people are ignorant and obstinate so that nothing can be
done. But this may be just a way of excusing our own faulty
technique. There is a science of behaviour and ways of bringng about change have been extensively studied.
Health education is not just giving talks and showing pic
tures. Would that be enough to change your behaviour? Nor
is it only telling facts. Health education is based on the be
havioural sciences - social psychology, sociology and anthro
pology. Insights obtained from studies in these fields can be
applied to the problem of changing people’s behaviour. Mere
ly to hand out information by means of talks etc., is like
handing out drugs without first making a diagnosis, and
without relating the particular local symptoms to the physio
logy and pathology of the body as a whole.
The minds of the people to be educated are not just like
blank pieces of paper on which we can write, what we will.
Their minds are more' like an organ of the body which has
certain fixed functions and whose structure and activities are
all related to these functions. The “functions” depend on a
person’s goals and values. Therefore to change knowledge,
attitudes or behaviour we must understand a person’s goals
and values and their system of beliefs. So the first principle
of health education is :
1.
Know the culture
That is we must know the customs, beliefs, goals, values,
and way of life of the people we are trying to educate. Their
culture may be different from our own not only because
of national, state, or regional differences, but because
of differences in class, caste, education, religion, and
general background. There is usually a considerable
cultural gap between say a doctor and a villager. Unless this
is bridged in some way there will be little real communication,
since communication depends on shared knowledge and atti
tudes.
The doctor may think he has explained everything, but it
will not mean anything to the patient, and the doctor will,
wrongly, conclude that the patient is stupid or obstinate. We
cannot expect the patient himself to bridge this gap, we must
go to meet him by learning about his ideas, before we can
effectively teach him our own ideas.
2.
“Start from where they are.”
If we start with ideas that are quite unrelated to anything
the patient already knows, then he will not be able to inte
grate what we are saying into his existing system of concepts
and will probably reject it. We should try to introduce change
gradually by building on what he has already. This takes us
back to principle (1) because clearly we cannot do this without
knowing the culture.
3.
Give people a learning experience
Just giving information is usually not adequate to change
behaviour. Doctors know all about the evidence that smok
ing causes lung cancer, but that does not stop them from smok
ing. A learning experience is much more effective. If the
mother of a child with malnutrition sees her child improve
with a better diet; alone, she will be much more easily con
vinced than if someone merely tells her to give the child more
food.
4.
Motivate by linking the required behavior with goals of
groups and individuals.
The action which we want the person to take must be re
lated to some goal the persons has; the action should be seen
as a way of reaching the goal. The goal may or may not be
related to health. For example people may build a latrine
because they think it will give them more prestige, or to imi
tate some important persons, and only afterwards they may
discover its value for health.
5.
Suggest specific, easily carried out behavioural changes
Studies have shown that people are more likely to follow
advice given if it is quite specific and precise, and they know
exactly what to do. Also there should not be too many bar
riers making it difficult for them to do it. Tf we say to a
mother, “you should have your child immunised”, she may
agree but do nothing about it; if we say the following she is
more likely to come; “bring your child to the clinic tomorrow
at 3 p. m. to be immunised; it is quite near your house and
it will not cost you more than (a small amount); your neigh
bour is coming and you can go with her”.
6.
Work through leaders and use group influences.
Many studies have clearly shown the importance of group
influence on a person’s behaviour. A group discussion and
decision is often more effective than a lecture. The social in
fluence of the other members of the various groups to which
people belong is very powerful. Reference groups, that is the
groups with which people compare themselves also have an
important influence.
Groups may often be influenced through their leaders.
Leaders are people that others will listen to and imitate, they
need not have any official position. They may be people who
have more, communication with others than the average or
they may be powerful because they have more resources than
others, or more education. If we do not use them, they may
work against the project and prevent any progress being made.
If we can involve them and make them feel it is their own pro
ject, they are more likely to carry on with it even when we
are not there.
7.
Obtain participation of the community at all stages
The community should be involved even in the planning
stages of a project. Only if they are fully involved will they
take a real interest in- what is to be done. It has been said
that we cannot give health to people, they must achieve it for
themselves. We must act as catalysts and stimulate them to
do this. One way is to form a health committee and get them
to discuss their health problems and decide their own priori
ties and what help they want from us.
8.
Meet felt needs first
If people do not have enough to eat, e.g. no spare cash to
buy food to-morrow and no prospect of work, they will not be
very interested when we talk to them about long, term pre
ventive measures such as immunisation or family planning
which may only help in the remote future. Health program
mes and community development programmes should be much
more closely linked so that felt needs can be met.
There is not enough space in this paper to describe the
various theories on which health education is based. The
above are just a few principles which will give some idea of
the scope and methods of health education. Those who are
interested and have time for further study can become-fami
liar with the behaviour sciences, and themselves try out dif
ferent ways of applying them; others can be use the services
of a qualified .health educator.
In my opinion, only when education becomes as important
a subject in medical practice as for example surgery is at pre
sent, will many of the health problems of India be solved.
BIBLIOGRAPHY
Selected papers on health education. CHEB Training Series I, March
1960. Central Health Education Bureau, New Delhi.
2. Social Psychology, Kuppuswamy B. Asia Publishing House 1961.
3. Havighurst R.J., The learning process. Amer. J. Pub. Health 57, 1964,
1961.
4. Cartwright D., Some principles of mass persuasion. Human Relations
2, 253; 1949.
5. The process and effects of mass communication. Ed. W. Schramm.
University of Illionis Press, USA 1965 p. 116.
6. Health culture and community,Ed. Paul, B.D. Russell Sage .Founda
tion 1955.
7. Human problems in technological change. Spicer, E.H. Russell Sage
Foundation, 1952.
8. Lionbergcr, H.F.. Adoption of ideas and practices. Iowa State Uni
versity Press, Ames, Iowa. USA 1960.
9. Rogers, E.M. Difusion of innovations. Free press of Gleneoe, New
York 1962.:
10. Ranganathan, K.V. S.rinivasan, K. and Mathew, B. Role of community
leaders, in promoting family planning in rural India. Action Research
Monograph No. I, Inst. Pub. Health and Family Planning, Gandhigram 1965.
11. Nutrition education in public health programmes - what we have
learned. Amer. J. Pub. Health 51, 1715. 1961.
12. Community development in India. Mukerji, B. Orient Longman, 1961.
1.
This reprint comes to you from the
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VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14 Community Centre,■ SDA, New Delhi 110 016;
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’.’hone : 652007, 652008
'
’ (iij.ni-. ■ Volhc.nlth
For a detailed catalogue'please write to the'rPdt>lica'tions',&'Mcer;1 " UCS
.■
From Indian Paediatrics Vol. 10. 347-9, 1'973.
Code Ch-09
Nutrition Education or Education in
Child Care
by J.P. Greaves, M.A., Ph.D.
FAO/UNICEF Nutrition Officer,'
UNICEF. New Delhi'/.
;
. .
,
; : • •r
;■ • : • ’’ I •'
; The Planning Commission of/the//.Government;. of. India”,
in discussing the problem of malnutrition in its .Approach to
the Fifth Plan (January 1973), speaks of tKe need' to'integrate
feeding programmes “with heath care, immunization and nutri
tion education; to. form a package’-!. .-.-In-the'belief'that education
component, of the package would' be better/described aS^lEdtU
cation,-in;JChildrCare”, this;;mote' sets lout'proposals ’f<3^ utfiatthia .might., mean;-, in particular', for what might be:-U-wy bs bnI
hiidD no IsunsM
; ri h
; < I.'.-,.eight basic-universal-messages no aqfifhsq bus ."a-ioaiv
... '• ; _-(i.e,; messages generally/ applicable -throughout ■■ : -■
- India, in rural and urban situations);
: i aril lios-H -Ji " i.'ri'V” .gg rioua anoi..':. ;;;■
.wiv't-im-%’■
II.
•■
;
- in elaboration ■. :of . these,: twenty' Universal ‘ comipd'nentsof the packet of-messages/that neecUtd,fbe!,<iom'-'
municated...to village worheh^-rio■-<; -. .n-.-.- to
■
III.
■ ■
-non no
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local: modifications vof-'/sdnieviof - .these-1' componentsidentified in list II by letters in parenthesis.
The “messages” listed represent.).i(de^, .,<ar$>,50^5. peed ;
more specific identification. They have been kept deliberately
as few and as simple as possible. -Thb ideas are'ndt'expressed
c0MMuwitv
(First Pi
H^ALTW CELL
8ANG^o23t_ Marks
t(Jr<E.56Q nn-i
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in the terms which are supposed to be necessarily the most
appropriate for getting them across. Once the ideas them
selves have been agreed, this aspect—part of the “how” of
communication—will need much thought. Probably the ad
vice of, those familiar with social customs and: beliefs regarding
illness, and with food habits and tabus should be sought. Mark-:
ed regional variation in these respects may mean that basically
universal mesages should be communicated in different ways
in different parts of the country. Valuable assistance in these
regards could be given by the Central Health Education
Bureau.
The packet of messages or ideas represents “that every
mother needs to know”. Every father, too. But all village and
block level workers with whom she comes in contact, includ
ing balsevikas, gram sevikas, mukhya sevikas, and also nurses.
ANMs and PHC doctors, who will need training or at least
“orientation” in the integrated package programme, should
also be awar of, and sympathetic to, this packet, so that the
messages will be reinforced at various levels and the mother
will not be subjected to conflicting advice. In other words,
all should speak with same voice. This means that the training
giyen in on-going programmes, such as. the Applied Nutrition
Programme, needs to be reviewed with this packet of messages
in mind.
Based on these messages a simple “Manual on Child Care,
for. village level workers”, might be developed. Such a manual
shoud be written in the local language with local modifications
and adaptations of the messages. It should be complemented
with a “Manual on Child Care, for Block/District level super
visors”, and perhaps one for State level coordinators and train
ing institution staff. Successive manuals, and training syllabi,
should be developed from bottom up, by seeking answers to
questions such as, “Who will teach the mothers/supervisors/
teachers?” “What do they need to know in order to do this
job. properly?” However, implementation of the training
should of course proceed from the top down: Throughout, as
much emphasis shoud be placed on how messages should be
communicated as on what these messages should be.
1.
Child Care Education
Basic universal messages.
1..
Breast feed as long as possible
2;
Introduce semi solid food from 5 to 6 months
3.
4.
. Feed young children 5 or 6 times a day
Don’t reduce food-in illness
5.
Use the health services available
6.
7.
Get children immunised
Keep yourself and your surroundings clean; drink
clean water
8.
Have no more than 2 or 3 children, 2 to 3 years
apart.
II.
Universal components
1.
Mother-to-be :
eat more than usual amount
of cereal and pulse, and
plenty of dark green and
yellow vegetables and fruits;
(A)
(ii) visit PHC doctor/ANM dur
ing last three months of pre
gnancy.
(i)
2
New babv :
(I)
Mother’s milk is best'—don’t
discard colostrum
(II) If you feed additional liq
uids, use a traditional feed
ing vessel, never a spoon.
3.
Keep on breast feeding as long as possible. But this is
not sufficient by itself after the age of 5 to 6 months.
4.
While breast feeding the child:
(1) mother should eat more than usual amount of cereal
and pulse, and plenty of dark green and yellow vege
tables and fruits(A).
(2) visit the doctor/ANM for check up.
5.
Start semi-solid- food (local staple or mas.hed. up (ready-toeat foods) after 5 to 6 months, and also undiluted cow’s
milk if you can. These 'foods must be prepared carefully
milk if you can. Thesegfoqdp must.be .pijepared. .carefully (3).
Give what you would'norihall^'give fateE'miich earlier.
And add vegetables and fruits, ,
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"6." As the child grows the amount and variety of Ipods should
be increased. By the time he is one year old he should be
fed similar food to the rest of the family - cereal, pulses,
green vegetables, perhaps supplemented ’ by;' processed
ready-to-eat foods - but in order to get as much, .as he
needs he should be fed these solid'foods 3'''dr ' times a
day (A).
. ,
7. When you are unable to feed the child with your own
milk, solid food which' may include supplementary readyi: to-eaf foods should be given 5 or 6 times a day. Also, if
"■ possible, Undiluted cow’s-milk or buffallo’s milk or miltone.
(Miltone is 50% milk extender from vegetable sources).
•8. .' Do riot use excessive water for cooking rice and vegetables.
If you drain the water after cooking do not discard it. It
is good for you and shoUld be consumed.
9. To prevent the child getting some diseases he should be
'i immunised- This will probably make him a little ill, but
will prevent him getting terrible scares later and perhaps
dying. .
D
16. ’"To1 ‘preventhim getting’".other diseases he should be kept
clean and’his surroundings should be as clean as possible.
Don’t spit cough.
, . . .. ..
LI. Do mot'”let( excreta lie around where your baby may be
playing. Remove it qiiickly to a;;pl,'9£9i onside his,:reach.
After baby defaecates wash him clean with soap and wash
your hands. Ygug ^ild niay get sick, ;if .he;puts dirty
hands in his mouth. '
, . .
12.
Hands should be washed before eating and before prepar
ing food, and before holding and 'feeding' the b'iby.
13.
Kitchen and feeding utensils should be kept clean and
not allowed to attract flies. Flies mean dirt means dan
ger.
14.
Food should be kept covered from flies and dust.
15.
Only the safest available water should be drunk. A child
needs plenty of water (C)
16.
Learn to recognise signs of common diseases: cough, diar
rhoea, dehydration, fever, running ear, skin diseases, sore
eyes and poor sight. Learn their management and how to
deal with accidents in the home, and when to seek advice
from ANM/doctor.
17.
When the child is ill with fever or diarrhoea continue to
feed him as before, but you may have to prepare the food
more appetisingly. You may have to force him a little
He will get better quicker if he eats plenty of cereal, pulse,
green vegetables. (A)
18.
Encourage the child to play with simple household arti
cles and things he can gather in the neighbourhood.
19.
Children cared for in this way are likely to be alert and
curious and grow well (E).
20.
Children cared for in this way are likely to survive much
better than those who are not. You may not then want
so many children - family planning can show you how to
achieve this, and how to space those you do have by 2 or
3 years.
III.
Some local modifications :
(a)
Give examples of particular cereals, pulses and vege
tables, and methods of their preparation. If it is cus
tomary to eat animal foods such as eggs, meat or fish.
and these can readily be obtained, they should be re
ferred to.
(b)
Give examples of suitable recipes from local foods.
(c)
Source of this water to be discussed in detail.
(d)
(i) If there are local schemes for the provision of Vita
min A capsules, or iron/folic acid tablets, explain
how these can be obtained, and why.
(ii) If rickets is a problem (parts of Central India?) ex
plain importance of allowing child some exposure
to sunlight.
(e)
“Will grow well” if the mother is likely to come
in contact with a centre using reeord/weight charts,
these should be referred to and explained.
4-4
VOLUNTARY
C-14,
HEALTH
Community Centre,
Phone : 652007, 652008
Safdarjung
. V
ASSOCIATION
OF INDIA
Development Area,
New Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
E-18
VILLAGE SANITATION IMPROVEMENT SCHEME, INDIA
by S. B. Watt, ITDG Water Consultant
The National Environmental Engineering Research Institute (NEERI),
Nagpur, India , has a long and successful history of developing
techniques in public health engineering appropriate to Indian conditions.
These techniques includi simple methods of large scale sewerage
treatment suitable for townships with piped and water borne wastes,
but they ate also trying to find ways to help the majority of people who
live in small villages and isolated hamlets.
Toilet facilities for many people in India are very poor and contribute
greatly to ill health amongst the population. Modern, piped sewerage
systems are expensive and are usually outside-the ability of the local
users to maintain without constant attention and advice. World wide
experience with village sanitation improvement schemes demonstrates
that unless the users of the system are involved in the planning and
construction work, they will not take responsibility for the upkeep of the
installation. Engineers at NEERI are supporting a small sanitation
improvement scheme at a village near Nagpur, called Mahalagoan. They
are providing the toilet bowls and ,.nother local organization is providing
the materials to construct the toilets. The local people have these
materials free of charge, and are shown how to do the construction work.
All the work up to ground level is paid for, and the users of the toilet
then construct a hut over the base plate as and when they have the
materials or resources to do so.
It is well known that man is the reservoir of most of the diseases that
cause him to be ill, and the basic strategy of any sanitation programme
is therefore to carefully control the disease-causing bacteria in his excreta,
to prevent them from contaminating foods, drinking water etc. Improved
sanitation is a fundamental step.towards improved well being, but without
educating the users of the toilet in the need for hygiene and care, the full
benefits of any scheme will not be achieved.
TheT© are many methods of collecting and treating excreta from simple
pit privies to large scale water borne , piped systems. The method
described below was evolved in Ceylon, and has the advantages of a
water seal closet which prevents flies and odours, low cost, and easy
removal of the decomposed excreta. It cannot safely be used, however,
in areas which are regularly flooded, in impermeable or frozen soils,
or near to wells which provide water for drinking.
The excreta is flushed through the water seal into the soakage pit by the
1 or 2 litres of water used for anal cleansing. The liquids in the pit soak
slowly into the soil, and the solids decompose into gases and humus. The
gases diffuse slowly through the soil causing no nuisance, and every 2
or 3 years the pit is uncovered and the humus removed.
: 2 :
Method of construction
1. The most important step is to convince the people who will use
the toilet of the need for improved sanitation. Without their full
support the toilet will probably be neglected and abused.
2. Choose the site very carefully. It should be located in a convenient
position to the household who are to use it, and the soakage pit should
be easy to empty. Check most carefully that the infiltrating liquids
' from the soakage pit do not percolate into any nearby water wells. The - ■
toilet must always be downhill of the well, and at least 15m away . If
the rock or soil around the well is fissured or broken, take special
care that the liquids from the soakage pit do not reach the well water
before they have been purified in the soil.
3. Excavate the hole for the soakage pit adjacent to the site that the
user has chosen for his toilet. Clear the ground for privy slab, excavate
for the water seal -trap, and dig a trench for the pipe which connects
the-water seal trap to the soakage pit.
4. The water seal trap must be pre-cast from sand/cement mortar.
A specially prepared mould is needed for this, but it is riot a difficult
job to do. Full and lengthy instructions on how to make the water seal'
trap may be obtained from VITA publications - the' address is given
at the end of this article . To he’J prevent debris and rubbish from ■
blocking the water seal and pipe, design the narrowest part of the toilet
to be next to the bowl.
5. Well up the inside of the soakage pit with bricks, leaving small
gaps between the bricks for the liquids to escape . Lay and joint the
pipe between the soakage pit and the water seal trap. Connect the
water seal trap to the pipe, ano .fill around the trap with weak concrete
to hold the trap steady in position.
6:. Cast the privy base slab around the water seal trap, and trowel the
surface smooth. Build up the foot rests, and make sure that all washing
water will run into the trap. Alternatively if several privies are. to be
built, construct a simple mould to precast the slabs.
7. Lay the pre-cast cement cover over the soakage pit and cover •
this with soil. The cover is made from mortar (1 cement, 4 sand)
at least 5 cms thick. Include, steel reinforcement if this is available.
• B. The toilet is now ready for use, and the owner may use any
materials that he has available to construct a hut around the squatting
plate.
' 9. Stress the importance of correct maintenance . If too much water
is used, the pit will flood. Debris and garbage will block the water
seal and will be difficult to .remove. When the pit is full, it should be
allowed to stand unused for 1 or 2 months to kill the bacteria, before
it .is emptied . During this period , the toilet user will need to arrange
: 3 :
for his family to share a neighbours privy. The excreta that has
decomposed will then be safe to use as fertiliser.
Like all toilet facilities, the water seal privy needs careful use and
regular cleaning. It is absolutely essential that education in .hygiene is
considered to be part of the toilet construction programme. Preferably,
hygiene education should come first, leading to a demand for improved
sanitation.
For further information
1.
The National EnvironmentalEngineering Research Institute, Nagpur
440929 Maharashtra State, India, have many excellent publications
on low cost water and sewage treatment methods.
2.
VITA publications: 3706 Rhode Island Avenue, Mt. Rainier,
Maryland, USA 29822. For instructions and drawings of water seal
traps etc.
3.
Excreta Disposal for Rural Areas and Small Communities, byE.G.
Wanger and.J. N. Laroix. World Health Organisation Monograph
Series No. 39. WHO SEARO, 36 Ring Road, New Delhi - 119901.
One of the nest books available on low cost sanitation.
4.
Guide to Simple Sanitary Measures for the Control of Enteric Diseases
S. Rajagopalan MA Shiftman, WHO, 1974. Describes low cost
sanitary measures that can be implemented with limited resources
to control enteric diseases.
5.
Water Treatment and Sanitation H. Mann and D. Williamson. Rev.
ed. 1976. Intermediate Technology Publications, 9 King Street,
London WC2E 8HN, U.K.
Illustration on reverse side.
Acknowledgement
We are grateful for permission to reproduce this article from
Appropriate Technology 2, 4 p. 15-16 1.976.
1« s - ts
Illustration
SOAKAGE PIT
1 HUT CONSTRUCTED
1
! BY TOILET OWNER
'
I METRE DIAMETER
2. METRE DEEP
5 C.m THICK CONCRETE
SLAB COVERED BY SOIL
CONCRETE
SLAB s
lOcmTHic^
Gases escape
Srn Y Iwi SqujOtV'43"
BY DIFFUSING
INTO SOIL
WATER SEAL TRAP
0RICK LINING
DECOMPOSING
«<ASTE
LAID WITH GAPS
CROSS SECTION
THROUGH TOILET
LIQUIDS PERCOLATE INTO SOIL
HEALTH
VOLUNTARY
C-14, Community
Centre,
OF INDIA >
ASSOCIATION
Safdarjung
Phone : 652007, 652008
Development Area,
New
Delhi-1100116
Telegrams ; VOLHEALTH New Delhi-110016
M-q o
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YOU CAN PREVENT LATHYRISM
A 16 leaves Flip Chart in specially simplified Hindi, designed
to inform peripheral health workers and the public about danger
of Matra (Kesari dal), Lathyrism and its control.
Quality reproduction of black and white photographs on art
paper/card.
Size (approximately) 2 3 cms x 22 cms.
Price
Rs. 15/- (tentative)
Spiral binding.
Contents
The idea is not to stop the poor from consuming matra but
to continue to do so in a form that is safe. Matra can be
detoxified by a very simple home process and the general
population must be made aware of this. The contents include :
- What is Lathyrism?
- Cause of Lathyrism.
- Early signs of Lathyrism.
- Stages of damage.
- Method of detoxifying matra at home.
- Prevention and control of Lathyrism.
By Whom
The text and pictures of this flip chart were evolved at the
Gandhian Non-formal and Adult Education Centre, Rewa,
Madhya Pradesh.
The flip chart is designed and planned by Vikram Parchure,
formerly of the National Institute of Design, Ahmedabad,
under the guidance and with the help of pictures taken by
Prof. M P Dwivedi, Professor and Head of the Department
of Preventive and Social Medicine.
Why the Urgency
This year has been one of severe drought and doctors fear
another outbreak of lathyrism on a scale comparable to that
of 1974. Unless the people are made aware and some action
taken, hundreds more will be crippled for life.
Aim of VHAI Flip Charts/Flash Cards
VHAI flip charts/flash cards are high quality field level learning/
teaching materials. These can be effectively used by frontline
health, workers and adult e lucators. These can be used as :
- a visual aid in teaching groups
-- learning e id during training
- an aid to iieir.ory in their work
- a source cf pictures and important health
messages for posters, health campaigns, etc.
Simple language and prete sted illustrations used.
HEALTH
VOLUNTARY
C-14.
Community
Centre.
Satdarjung
ASSOCIATION
Development Area,
OF INDIA
New
Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
Phone : 652007, 652008
n/^o Q .y
E-19
A SIMPLIFIED APPROACH TO AQUA
PRIVY CONSTRUCTION
P.A. Oluwande,
Senior Lecturer ,
University of Ibadan, Nigeria
The aqua privy may be correctly described as the intermediate method
for excreta disposal from the point of view of the pit latrine on one hand
and the septic tank on the other. Figure 1 illustrates the differences
and similarities between the pit latrine, the aqua privy and the septic
tank systems.
The pit latrine is not popular among many people in the developing
countries for many reasons. Many people cannot use the septic tank
system because it is expensive to construct and to. operate, for houses
have to be connected to a constant water source for proper operation.
In Table 1 the costs of the three systems are compared.
The aqua privy has great potential for use in the developing countries.
If it is properly designed, well cor. tructed and well maintained, it will
function without odour and fly breeding - the two main objections to the
pit latrine. Since it does not require water for flushing faeces into it,
it can be operated satisfactorily in houses which obtain water from
public stand taps, or.houses in communities without pipe borne water
supply. Since it does not involve much pipe system, materials like
pieces of wood, cob of maize and objects other than toilet paper may be
Jised for anal cleaning without blocking the system. Such solids, however,
shorten-the-intervals between desludging the tanks.
Unfortunately, the aqua privy system is not as commonly used in many
developing countries as the pit latrine and the septic tank. Investigations
carried out by the author in many countries show that construction of
the different components of both the pit latrine and the septic tank
systems has been standardised and perfected. This cannot be said of
the aqua privy, which is totally unknown, in many communities that can
benefit most from its use. The main reason why the aqua privy is not
as common as it should be in many developing countries is because its
construction, especially incorporating the drop pipe through the floor
slab, has not been sufficiently simplified. The techniques suggested in
many publications involve the use of complicated moulds which are not
J
easy to produce (Wanger and Lanois, 1958; Macdonald, 1952). Some
UJ
workers have used metal for the drop pipe (Vincent et al., 1961). But
metal sheets which can be folded to form drop pipes are not readily
available in areas where the aqua privy is most needed. Moreover,
<
welding the metal to the correct shape requires qualified welders, who
m
-y zto—1^-T-ir
.‘In K_1
_-------------------------- -----------—
S' LC
: 2 :
There is therefore a need to simplLSy the construction of the aqua privy
to enable any semi-skilled person to build it.
General features of the aqua privy
As shown in Figure 1, the aqua privy consists of four main components:
the tank, the floor, the superstructure of the house and the sqak-away
or seepage pit. All these components, except the floor, are similar
to the corresponding features in a septic tank system. The methods and
and materials employed for their construction for the septic tank can be
adopted for the aqua privy system.
Aqua privy floor slab
The main difference between the floor slab of a pit latrine and that of the
aqua privy is the inlet drop pipe which the latter carried. Once a simple
method of incorporating the inlet drop pipe to the floor slab is available,
the construction of the aqua priv’ floor slab becomes as simple and
straightforward as the construction of the common pit latrine floor slab.
Construction methods
Three simple but related approaches have been employed for casting the
floor slab for the aqua privy. These are :
a.
b.
c.
the trench method
the hole method
the raised platform method.
For any of the three methods, materials like metal, wood, bamboo and
astos cement may be employed for the inlet drop pipe. The two
e
*
materials which the author has employed most are 15 cm diameter. For
individual construction of the aqua privy floor slab in the rural areas of
the developing countries where asbestos cement pipe may not be readily
available, bamb oo is very useful indeed.
The trench method
The sequence of four steps for this method is as follows (Oluwande, 1975):
i)
A trench about 15 cm deeper than the length of the inlet pipe
and 75 cm wide is dug (see Figure Ila). Hie length of the
trench will depend on the number of slabs to be cast at a time.
The length of the drop pipe recommended is 75 cm. This will
ensure that the free end is sufficiently inside the water in the
aqua privy tank and that the distance between the top water
level and floor of the slab is enough to prevent water splashing
on the users.
ii)
Planks about 2.5 cm thick and 30 cm wide are cut into pieces
one metre long. Four such pieces will be required for a floor
slab 90 cm square. The pieces are placed side by side on
: 3 :
the trench and a circular hole 20 cm in diameter is cut
through, the two-pieces in the middle to accommodate the
drop pipe (see-Figure lib).
iii)
A.piece 75 cm long is cut from a 15 cm diameter asbestos
cement pipe or from bamboo. Four holes with diameters
big enough for 10 cm long nails are made equally spacer on
the circumference of the. pipe. The centre line of the four
holes must be about 2.5 Cm from the end of the pipe. Nails
10 cm long are passed through the holes with their big ends
inside the pipe (see Figure He).
iv)
The platform planks are arrange^, over the trench and sheets
of newspaper or cement bags are laid over them. The.portion
of paper over the middle hole is removed. The free end of
the prepared drop- pipe is passed through the central hole
until the pipe is supported on the platform by the nails. The
steel reinforcing rods for the floor slab are arranged so that
they pass.under the nails. A special wooden cover is made
for the top end of the pipe. The main mould for the slab is
placed in position. A concrete mix of 1:2:4 is used to cast the
slab. In some cases, the aqua privy tank may serve as the
the trench but extra care must be taken when removing the
platform planks later. Otherwise the floor may drop into the
tank;
The hole method
This is similar to the trench method except that a hole 20 cm in
diameter replaces the trench. The depth of this hole should be about
3.8 cm shorter than the length of the drop pipe. The- hole should be
dug where the surface of the ground is level because platform planks
are not necessary and the slab is to be cast on the surface. All other
procedures are as described for the trench method (see Figure IVa).
The number of holes will depend on the number of slabs to- be cast at
a time.
Raised platform method
This is also similar to the trench method except that the slab is cast
on a raised platform instead of on the ground (see Figure IVb).
The choice of the three methods will depend on many factors such as
the nature of the ground, the funds available and the availability of men
to carry the slab. The hole method is the cheapest and simplest but
requires at least four men to lift the slab from the hole. When
bamboo or metal is used for the inlet drop pipe, it should be painted
with tar or other anti-corrosion substance.
•
■ ■ .
'
See section through a typical slab
in Figure 6. The mould for casting the slab can be removed after
: 4 :
24 hours. The slab should then be covered with sand and other
suitable material like sacking and cured for at least two days before
it is placed over the aqua privy tank.
TABLE I
Cost of Pit Latrine, Aqua Privy and Septic Tanks Compared
(1973)
Items
1. Labour for digging
2. Cement
3. Gravel
4, Sand
5. Bricklayer's Labour
6. Pipe fittings
7, Water closet flush tank
and seat
8. Plumbers Labour
9. Super structure (if separate
from house)
Total
Pit
Latrine
Rs
Aqua
Privy
Rs
Septic
Tank
Rs
90.00
12.00
12.00
6.00
24.00
-
180. 00
180.00
36.00
48.00
108.00
36.00
180.00
180.00
36.00
48.00
144.00
210.00
-
-
252.00
90.00
123.00
275.00
123.00
711.00
123.00
1263.00
References:
Macdonald, O.J.S. (1952) Small Selvage Disposal System Harrison
and Crosfield Ltd., London.
Oluwande, P. A. (1975) Development of Aqua Privy for Urban Sanitation
in proc. of 2nd International Conference on Water Waste and Health in
Hot Climate, pp. 110-122, Loughborough University, U.K.
Vincent, L.J. Algie, W.E. and Marair, G.V.R. (1961) A System of
Sanitation for Low Cost High Density Housing in Symposium cn Hygiene
and Sanitation tn relation to Housing CCTA/WHO, Niamey 1961.
Wanger , E.G. and Lanoix, J.N. (1958) Excreta Disposal for Rural
Areas and Small Communities: WHO Monograph series.
Acknowledgement
We are grateful for permission to reproduce this article from
Appropriate Technology 3, 3 p 26-28 1976.
(for Figure I, II & IV see next page)
Figure II
Figure IV
SECTION A-A
Key-.
a. drop pipe
b. lOcr/i r.oits
C. rW"forci>
*o
bars
h. the hole
m.main mould
PLAN
Key;
p platform
plonk
s. platform
stand
a. d rop pi p?
b lOern nailj:
SketchW showing tnnck method of
aqya privy floor Slab construction
rt.maifl
*vta>o(a
THE KAISED PLAIfORM KE I WOO
Voluntary Health Association of India
C-14, Community Centre
Safdarjung Development Area
Telegrams ; VOLHEALTH
New Delhi-110016
New Delhi-110016
Phone : 652007, 652008
t|-
Management Of Common Snake-Bite Poisoning
Dr J Jacob, M.B.,M.R.C.P.(Lond)
Tiruvalla Medical Mission has long experience in managing snake
bite poisoning. This hospital is the only one around about 20 km.
radius that is accepting and treating snake bite patients. We have
accumulated a wealth of experience in this line because we could
not rightly evade this great problem of fatal snake bite poisoning
in our neighbourhood.
Most of the cases we come across in our hospital are caused by
snakes belonging to the Viper family. We have been able to develop
an effective system by trial and error for treating patients who
are admitted with snake bite poisoning. In 1968 and before, we
used to give two ampules of antivenom irrespective of the condition
of the patient. We never gave any anti-histamine or heparin or
Cortisone. Our retrospective study then, showed a mortality of
25 per cent out of which 89 per cent was caused by acute renal
shut down. We did a prospective study at that time and increased
the number of antivenom to an average of 10 vials per patient.
At the end of the study, we found that we are able to reduce the
mortality from 25 per cent to 6.7 per cent. We were convinced
then that adequate antivenom w^s the basis of treatment.
At that time the major problem appeared to be occasional peripheral
circulatory failure, CNS damage and rare secondary haemorrhage.
We still have not understood the problem of shock and CNS damage.
The problem of secondary bleeding is now well known to be caused
by disseminated intravascular coagulation (DIC). Subsequently,
for a time, we instituted heparin in every patient who, we felt,
had significant envenomation.
Our recent retrospective study shov/ed that our method of giving.
large amount of antivenom as bolus injection intravenously is not
as efficacious as giving smaller amount of antivenom in a
slightly longer period of time. We understood that the tendency
for bleeding was definitely due to an anticoagulant and/or the effect
of a procoagulant. Animal study as well as studies on victims of
bite have clearly shown that there is an on-going DIC which in
most cases is controlled by antivenom. In the light of this finding,
we have for the last one year stopped the routine use of the heparin.
We find that the difficulty in managing patients admitted with snake
bite’ is the problem of evaluating the extent of envenomation. The
only parameter that we have in our hospital apart from the physical
conditbn of the patient, is the coagulation profile, namely bleeding
and clotting time.
-2It is found that for any significant bite bleeding and clotting time
will be prolonged. However, some patients who were brought
with an efficient tourniquet could have normal clotting; time
initially but developed prolonged clotting time and proteinuria
after releasing the tourniquet.
So far our understanding of the adverse effect of venom are
1.
2.
3.
4.
Cerebral damage
Excessive bleeding tendency
Renal shut down
Peripheral circulatory failure.
CNS darnage still stands as an enigma. There has been no clear
cut description of the pathophysiology to account for it. While it
is possible that the central nervous system damage may be due to
the direct effect of the venom the most likely cause is either
generalised or localised haemorrhage or thrombosis due to DIC.
1.
Excessive bleeding tendency is now clearly proved to be due
to consumption coagulopathy. The treatment for all patients
is adequate antivenom. The proteinuria and the acute renal
shut down have always been felt to be doe to the direct toxic
effect (necrotising) of the venom. Whether or not there is
also additional damage to the- kidney by blood clots by the
ongoing DIC is not clear. Many patients have haematuria
along with proteinuria but the haematuria, in our experience, has always come 12 to 16 hours after the bite. But the protein
uria manifests itself even as early as the first half hour after
the bite depending on the extent of the envenomation.
2.
Acute peripheral circulatory failure which happens in patients
quite unexpectedly, has not been successfully explained by
any one so far. It could be mediated through the effect of the
venom at the brainstem level. The mechanism of action should
be the same as septic shock.
Mode of treatment
We divide the patients into tourniquet and the non-toumiquet group.
For non-tourniquet group after doing a complete physical examination
and doing haemoglobin, clotting time and urine tests, we start afive per cent dextrose water IV drip and give an injection of anti
histamine. When there is no obvious signs of envenomation such
as bleeding from site, swelling or shock, we wait for the lab
result before starting any special treatment. If the result is abnormal
we start four ampules of antivenom in a 100 c.c. of 5 per cent
dextrose and water and give it within a period of one hour. At the
end of an hour after the antivenom infusion another clotting time
is done; if it is still prolonged, wo give another four ampules in
two hours.
-3-
3.
Two hours after completion of the second four ampules of
antivenom, clotting time is repeated. If normal, no more
specific treatment is given. If prolonged, another four
ampules are given in three hours time. Three hours after
completion of that clotting time is repeated. Jn case where
the clotting time is still prolonged, we would consider treatment of DIC and start heparin 5000 units over four-six
hours and then do a platelet count. If platelet count is very
low, we give 250 ml of fresh blood in si liconised bottle. When
the blood results return to normal, we stop giving antivenom.
We do not advocate giving more than 16 ampules of antivenom
to any patient . Ordinarily we give a maximum dose of twelve
ampules only. In. exceptional cases we give another four
ampules. We have found that in the case of most patients
(90 per cent) the clotting time comes back to normal by 12
ampules of antivenom.
There would be some patients who have a normal clotting time and
no proteinuria initially. For them the lab test is repeated after one
hour. If the clotting time is still normal, the test is repeated again
after another two hours. If it is still unchanged, then we repeat the
test three hours after that to be absolutely certain. There will be
a rate patient who develop prolonged clotting time five to eight hours
after bite and many develop renal failure.
For the patients who have a tight tourniquet our policy now is to
give two ampules in 100 c.c. even if the initial clotting time is
normal. After that the tourniquet is released and we wait for an
hour to do a clotting time. If that is prolonged, then we give them
four ampules and continue the regime as for any poisonous bite. If
the clotting time is normal, then we wait for two hours and repeat
it and then three hours after that. By giving patients two ampules
of antivenom as a routine we certainly do giv£ it to a few patients
who do not require any antivenom at all but the danger of the CNS
damage that can occur can be devastating on the release of
tourniquet without proper coverage, with antivenom. We therefore,
feel justif ied in giving antivenom to an occasional patient who
does not require it.
Patients who are brought within the first four hours after the bite
have the maximum chance of survival- without complication such as
peripheral circulatory failure (shock) or acute renal shut down.
Even to patients who are brought later, we still give the antivenom
if the clotting time is prolonged. If they have-only heavy albuminuria,
theyare treated with monitol 150c.c. twide daily and lasix
80 - 200 mg. IV to avoid renal shut down.
We have found the best way to handle the patients in a state of
shock is to give them fresh c blood. This is particularly because
most of the patients in circulatory failure already are anuric on
account of the delay in getting to the hospital. Giving 250 to 300 ml.
-4-
of whole blood is safer than giving salt solution which is otherwise
the method of treatment. Whenever we have used small amount
of fresh blood taken in siliconised bottle, the blood pressure came
to normal gradually. We have also used in such patients fatly heavy
doses of cortisone. Patients who are adequately treated with
antivenom in the hospital seem to improve with blood and cortisone
in this situation. Our greatest mortality is in shock patients and
most of those are the patients who are brought late to the hospital
after native treatment or who were treated inadequately with
antivenom elsewhere.
The percentage of patients with complication such as shock and
renal shut down varies according to the degree of envenomation.
But our statistics show that moderate to severe bite causes
shock if not treated adequately to have 70 to 80 per cent of the
patients with inadequate treatment will require some mode of
treatment for acute renal.shut down either conservatively or by
dialysis. 15 t o 20 per cent will require treatment for shock
or treatment for CNS damage. The mortality is over 80 per cent.
Even if these survive, they usually have some mode of deficit which
in time tends to clear up to some extend.
We have found peritonial dialysis to be more useful' than haemo
dialysis/ This has been the experience of other people in the
field of dialysis.
I have not mentioned anything about Cobra bite. Patients with
severe Cobra bite never reach the hospital. Moderate bites will
require antivenom till they are out of their neurological deficit,
which is quite obvious. In these patients blood and urinary
findings are all normal but we can easily make out a Cobra poisonous
bite by such findings as drooping of the eye lids, dysphonia and dysarthia
etc. If not adequately treated immediately, they develop respiratory
paralysis.
Summary
The routine management of snake bite poisoning is explained in
detail in this paper. This work is the result of our experience
at this hospital for the past 15 years or more. Some discussion
of the major complication of the snake bite poisoning has also
been included.
Excerpt from
'The Journal Of The Christian
Medical Association Of India’
Vol. LV March 19 8? No. 3
This reprint comes to you from the
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14 Community Centre, SDA, New Delhi 110 016.
Phone : 652007, 652008
Grams : Volhealth
For a detailed catalogue please write to the Publications Officer.
Code H-16
Health Education—The Missing
Link in Medical Care
Dr C.M.E. MATHEWS, Department of Community Health
Christian Medical College, VELLORE.
Q. What sort of results do you get?
A. Occasionally it works out alright, but some are very
difficult cases. The body is very obstinate and ignorant and
just does not know how to heal itself or deliberately refuses to
do so. So what can we do?
What would we think of a hospital where such a conver-
BANGALORE - 560 001
Q. Are you thinking of getting a qualified surgeon to come
and give you a course on surgery?
A. Well we might do that sometime, but we are all so
busy that it is difficult to find the time for it.
COMMUNITY HEALTH CELL
Q. Who does surgery here? Do you have a qualified sur
geon?
A. Surgery? Oh we all do surgery - everyone takes his
turn with the knife, from the medical officer right down to
the most junior attendant. Surgery is very important.
No, they do not have any special training, its just common
sense really. Even the medical officer does not have much
training because as a student he was not interested in surgery
and so he did not bother to attend those classes. Yes, he does
regret it a little now.
47/1, (First Floor)3t. Marks Road
Imagine that we are visiting a hospital and that when we ask
these question we are given the following answers :
sation could take place? It could not happen we say. And yet
if we substitute “health education” for surgeiy we find
that such a conversation could easily take place in very many
hospitals. Why the difference in attitude? Which is more
important?
Consider the major health problems which affect large num
bers of people in India. Let us take a few examples
Tuberculosis
Leprosy
Malnutrition in children
Diarrhoea in children
Infant mortality
Overpopulation
Why are they problems? Is it because the medical solution
is not known? Is it because medical services are not available?
Or is it because the people do not use the services properly
and do not follow the required behavior at home?
A tuberculosis patient will take treatment until he feels
better and then he will see no point in continuing; later he may
become resistant to available drugs and a threat not only to
himself but to the community. A leprosy patient may be
afraid to come for treatment at all, or in the early stages may
just not realise he has a serious disease. Malnutrition although
largely due to poverty also could be much reduced if mothers
appreciated the importance of giving their children more food;
vitamin A deficiency could be easily prevented by giving
greens with negligible cost. Diarrhoea could be prevented by
better hygiene but villagers do not think this is important;
when the child is dehydrated they believe in the power of man
tras alone and often do not seek medical care.
Infant mortality could be reduced by a better diet for pre
gnant woman and more antenatal care, but village women do
not see the need for this. Family planning services are avail
able but they are not fully used.
So what is needed? It is to change people’s behavior, and
this is difficult to do. We can say as in the conversation above
that people are ignorant and obstinate so that nothing can be
done. But this may be just a way of excusing our own faulty
technique. There is a science of behaviour and ways of bringng about change have been extensively studied.
Health education is not just giving talks and showing pic
tures. Would that be enough to change your behaviour? Nor
is it only telling facts. Health education is based on the be
havioural sciences - social psychology, sociology and anthro
pology. Insights obtained from studies in these fields can be
applied to the problem of changing people’s behaviour. Mere
ly to hand out information by means of talks etc., is like
handling out drugs without first making a diagnosis, and
without relating the particular local symptoms to the physio
logy and pathology of the body as a whole.
The minds of the people to be educated are not just like
blank pieces of paper on which we can write what we will.
Their minds are more like an organ of the body which has
certain fixed functions and whose structure and activities are
all related to these functions. The “functions” depend on a
person’s goals and values. Therefore to change knowledge,
attitudes or behaviour we must understand a person’s goals
and values and their system of beliefs. So the first principle
of health education is :
1.
Know the culture
That is we must know the customs, beliefs, goals, values,
and way of life of the people we are trying to educate. Their
culture may be different from our own not only because
of national, state, or regional differences, but because
of differences in class, caste, education, religion, and
general background. There is usually a considerable
cultural gap between say a doctor and a villager. Unless this
is bridged in some way there will be little real communication,
since communication depends on shared knowledge and atti
tudes.
The doctor may think he has explained everything, but it
will not mean anything to the patient, and the doctor will,
wrongly, conclude that the patient is stupid or obstinate. We
cannot expect the patient himself to bridge this gap, we must
go to meet him by learning about his ideas, before we can
effectively teach him our own ideas.
2.
"Start from where they are.’’
If we start with ideas that are quite unrelated to anything
the patient already knows, then he will not be able to inte
grate what we are saying into his existing system of concepts
and will probably reject it. We should try to introduce change
gradually by building on what he has already. This takes us
back to principle (1) because clearly we cannot do this without
knowing the culture.
3.
Give people a learning experience
Just giving information is usually not adequate to change
behaviour. Doctors know all about the evidence that smok
ing causes lung cancer, but that does not stop them from smok
ing. A learning experience is much more effective. If the
mother of a child with malnutrition sees her child improve
with a better diet alone, she will be much more easily con
vinced than if someone merely tells her to give the child more
food.
4.
Motivate by linking the required behavior with goals of
groups and individuals.
The action which we want the person to take must be re
lated to some goal the persons has; the action should be seen
as a way of reaching the goal. The goal may or may not be
related to health. For example people may build a latrine
because they think it will give them more prestige, or to imi
tate some important persons, and only afterwards they may
discover its value for health.
5.
Suggest specific, easily carried out behavioural changes
Studies have shown that people are more likely to follow
advice given if it is quite specific and precise, and they know
exactly what to do. Also there should not be too many bar
riers making it difficult for them to do it. I'f we say to a
mother, “you should have your child immunised”, she mav
agree but do nothing about it; if we say the following she is
more likely to come; “bring your child to the clinic tomorrow
at 3 p. m. to be immunised; it is quite near your house and
it will not cost you more than (a small amount); your neigh
bour is coming and you can go with her”.
Wo? k through leaders and use group influences
6.
Many studies have clearly shown the importance of group
influence on a person’s behaviour. A group discussion and
decision is often more effective than a lecture. The social in
fluence of the other members of the various groups to which
people belong is very powerful. Reference groups, that is the
groups with which people compare themselves also have an
important influence.
Groups may often be influenced through their leaders.
Leaders are people that others will listen to and imitate, they
need not have any official position. They may be people who
have more communication with others than the average or
they may be powerful because they have more resources than
others, or more education. If we do not use them, they may
work against the project and prevent any progress being made.
If we can involve them and make them feel it is their own pro
ject, they are more likely to carry on with it even when we
are not there.
7.
Obtain participation of the community at all stages
The community should be involved even in the planning
stages of a project. Only if they are fully involved will they
take a real interest in' what is to be done. It has been said
that we cannot give health to people, they must achieve it for
themselves. We must act as catalysts and stimulate them to
do this. One way is to form a health committee and get them
to discuss their health problems and decide their own priori
ties and what help they want from us.
8.
Meet felt needs first
If people do not have enough to eat, e.g. no spare cash to
buy food to-morrow and no prospect of work, they will not be
very interested when we talk to them about long, term pre
ventive measures such as immunisation or family planning
which may only help in the remote future. Health program
mes and community development programmes should be much
more closely linked so that felt needs can be met.
There is not enough space in this paper to describe the
various theories on which health education is based. The
above are just a few principles which will give some idea of
the scope and methods of health education. Those who are
interested and have time for further study can become fami
liar with the behaviour sciences, and themselves try out dif
ferent ways of applying them; others can be use the services
of a qualified health educator.
In my opinion, only when education becomes as important
a subject in medical practice as for example surgery is at pre
sent, will many of the health problems of India be solved.
BIBLIOGRAPHY
Selected papers on health education. CHEB Training Series I, March
1960. Central Health Education Bureau, New Delhi.
2. Social Psychology, Kuppuswamy B. Asia Publishing House 1961.
3. Havighurst R.J., The learning process. Ainer. J. Pub. Health 51, 1964,
1961.
4. Cartwright D., Some principles of mass persuasion. Human Relations
2, 253; 1949.
5. The process and effects of mass communication. Ed. W. Schramm.
University of Illionis Press, USA 1965 p. 116.
6. Health culture and community,Ed. Paul, B.D. Russell Sage Founda
tion 1955.
7. Human problems in technological change. Spicer, E.H. Russell Sage
Foundation, 1952.
8. Lionbergcr, ILF.. Adoption of ideas and practices. Iowa State Uni
versity Press, Ames, Iowa. USA 1960.
9. Rogers, E.M. Difusion of innovations. Free press of Gleneoe, New.
York 1962.
10. Ranganathan, K.V. Srinivasan, K. and Mathew, B. Role of community
leaders in promoting family planning in rural India. Action Research
Monograph No. I, Inst. Pub. Health and Family Planning, Gandhigram 1965.
11. Nutrition education in public health programmes - what we have
learned. Amer. J. Pub. Health 51, 1715. 1961.
12. Community development in India. Mukerji, B. Orient Longman, 1961.
1.
VOLUNTARY
C-14,
Community
HEALTH
Centre,
Phone ; 652007, 652008
Safdsrjung
ASSOCIATION
OF INDIA
Development Area, New Dolhi-110016
Telegrams : VOLHEALTH New'Delhi-110016
E-16
AN INTERMITTENT WATER FILTER
Professor N.M. Merchant, Professor of Environmental
Health, Department of Community Medicine, Pahlavi
University, Shiraz, Iran. Reprinted from the Journal of
Indian Waterworks Association, Volume VIII Number 2,
April/June 1976.
Iran is an oil rich country which enjoys the unique position of being
rich in history, culture, population, resources and wealth; but is
faced with the problems of water shortage and pollution of available
water resources, especially in the rural areas.
About 60% of the country's 32 million population live in villages1. Of
the more than 55, 000 villages scattered across the country about
27,000 have a population of less than 100. With such a large number
of small communities, spread out in arid areas, provision of piped
water supply and other health facilities are rather difficult to provide.
As a result water resources remain heavily polluted, unprotected
and the source of a number of infections among rural communities.
A survey on the water situation conducted by the author among 32
selected villages around Shiraz has revealed the following results:
4^ of all the available water supply sources were open
ditches or streams which served almost 74% of the population
(total population in the sample 21,965) in the villages surveyed.
39% of the sources were deep wells which served only 7.4%
of the population.
12% of the sources were ponds or artificial catchments which
served 61% of the population.
8.7% of the sources were natural springs serving 4% of the
population.
only 3.5% of the sources was a piped water supply available
only in two communities and serving 8.1% of the total
population.
■
' :
In the rural areas, water is usually drawn from nearby deep wells or
collected from ditches or other sources which in time become conta minated from human and animal droppings. Other village water
resources were found contaminated with industrial and household
chemicals.
w —
■J: 9
jc « £
-J 'j §
32
2 :
According to the official health statistics on reported cases of commu
nicable diseases in the country, diarrhoea was the most frequent occurrence
during the year 1972-73, The first ten most common infections included
typhoid and hepatitus. Laboratory examinations of drinking water samples
taken at the time of routine collection taken from individual household
'masks’ (leather bags) revealed the presence of Escheritia coli at a nonacceptable leyel in 75% of the cases. The source was primarily conta
mination , poor handling and storage of water and lack of personal
hygiene among people15.
As part of its programme for community service the Department of
Community Medicine at the Pahlavi University is engaged in sanitation
improvement activities in the villages near Shiraz. During this course
of activities and training, this filter system was developed and tested4.
Materials and methodology
A galvanised iron drum, 42 cms in diameter and 76 cms in height, with
cover, was fitted into a tap, 1.5 cms diameter opening. The cover
had an opening of 15 cms diameter with a lid (Fig. 1).
The drum was filled with layers of material. First , with gravel of
sizes varying between 5 cms and 29 cms in diameter, previously washed
to remove dust and dirt attached. The height of this layer was approxi
mately 25 cms. A layer of coarse sand (also washed) with size . of
particle varying from 0.5 to 2 cms in diameter was placed on the gravel
to a thickness of approximately 25 cms. This layer of sand was covered
with a bed of charcoal, previously washed. The size of charcoal pieces
ranged between 2 to 15 cms inlength of 9.5 to 6 cms in diameter. The
. thickness of charcoal bed was 15 cms approximately. This layer was
again covered with a thin layer of gravel, but to a thickness of 5 to 19 cms,
just to keep the charcoal pieces from floating and in position. Thus,
about 2/3 to 3/4 of the drum capacity was filled with the filter medium.
Turbid water from the surface source was poured in to the top of the
drum and filtered water was drawn through the tap at the bottom.
The efficiency of the filter beds was tested at regular intervals of
four weeks after the initial and subsequent refills of water, during a
period of four months after the first assembly.
Results
Table 1 shows the recorded findings of the turbid water quality as
tested at the time of sample collections. Suspended solid materials
responsible for turbidity were measured in milligrammes per litre
of water. Bacteriological analysis was performed on three counts,
namely Coliform Bacilli, Fecal Coliform and Fecal Streptococci. The
bacterial counts were recorded in MPN (Most Probably Number)
following the standard Methods^ for examination of drinking waters.
Fig. 1 on reverse of page 3
: 3 :
A gradual increase in the efficiency of the intermittent filter was
noted as the filter became 'matured'. The .turbidity decreased by
19% after one weak’and reached up to 97. 3% upon maturation after 17
weeks. Similarly the Coliform Bacilli count decreased by 95% of the
initial count in raw water. The Fecal Coliform count likewise was
reduced by up to 97% of the original content and the Fecal Streptococci
count decreased by up to 37% of the original number.
The matured 'intermittent filter' maintained its efficiency for another
six to ten weeks and thereafter reached exhaustion with reduction in
filter speed and efficiency. At that point the drum was emptied and .
the filtering material (gravel, charcoal and sand) was spread on the
ground to be dried under the sun, dusted and washed to remove the
dried films of plankton material. It was then ready for refilling.
Discussion
The' role of sand and gravel has been well recognised and utilised in the
construction of rapid and slow sand filters in conventional water treat
ment plants. The use of charcoal has,also been recognised in removing
colour, odour, taste and certain dissolved material from polluted water.
All these materials are readily available at little or no cost in all the
villages of southern Iran. The method of construction is simple and
the filter easy to maintain. Individual households, -institutions like
schools, mosques and village health clinics are encouraged to install
an'intermittend filter' to provide clean water for drinking purposes.
It is advisable to add a few drops of chlorine solution (5.25%) to a jug
of water as a disinfectant.
Conclusion
As a simple solution to the widely spread problem of polluted waters in
Southern Iran, an 'Intermittent Water Filter' was constructed, installed
and tested for efficiency, simplicity and economy. Preliminary tests
have been successful in demonstrating removal of suspended material
and harmful bacteria to a level satisfactory for human consumption.
References
1.
2.
3.
4.
5.
Anon, Iran Almanac. The Echo Publishers, Tehran, 1974,
Merchant, N.M. 'Sanitation Survey in villages near Shiraz'.
Unpublished report, 1974.
Merchant, N.M. , Behfarouz N.C., 'Bacteriological Analysis
of drinking water in villages near Shiraz'. Survey report, 1974.
Ronaghy, H.A., Solter, S.L. 'The Auxiliary Health Worker in
Iran', The Lancet, August 25, 1973.
Anon. Standard Methods for Examination of Water, American Public
Health. Association, 13th edition, Washington, DC.
Acknowledgement
We are grateful for permission to reproduce this article from
Appropriate Technology 3_ 3 p.22-23 1976.
E ~16
Eigure 1.
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UNIT VI
PROJECT GOALS
&
PRIORITIES
STEP 1
BROAD OBJECTIVES
STEP 2
WORK to be DONE by
VHWs
PREVENTION OF BLINDNESS
STEP 3
What VHWs need to
KNOW FEEL & DO
STEP 4
SPECIFIC OBJECTIVES-What
VHWs DO in the Village -
VHW’s need to
show sympathy,
understanding, and
an altitude of
acceptance toward
blind people.
a. Gives accurate
information to people on
causes and treatment
of eye diseases and
blindness.
b. Shows her under
standing and sympathy
through her behaviour
toward eye patients and
the incurably blind.
STEP 5 CURRICULUM
Course Outline
to be learned by VHWs.
GOAL: To improve
the Health of the
villages in the areas
sense of shame or
guilt given to blind
people because of
misconceptions of
the causes of
blindness.
Help by their own
behavior and
knowledge to lessen
shame and
misconception
about blindness.
PRIORITIES:
1. Care of
Under-Fives
I. Social Aspects of
Blindness .
■ A Difficulties and
problems of patients.
B. Misconceptions about
the cause and treatment
of eye diseases and
blindness.
C. Treatment, prevention
and care will lessen
the problems.
1. Blindness is caused by
untreated infection and
‘ injuries.
2. Lack of certain foods in
the diet can cause blindness
3. Blindness is preventable
by control of infections,
proper diet and preventing
injuries.
4. Incurably blind people are
victims of ignorance and need
our care and sympathy.
2. Prevention of
Malnutrition in
Children
3. Antenatal
Maternity, and
Postnatal care
To lessen the
incidence and
spread of eye
infections.
i II. Infections of eyes
identify cases ol
eye infections and
persuade them to
take treatment.
J c. Recognizes symptoms
fl of eye infections and
eg begins treatment, and
teaches others.
*
Az
d. Brings serious cases
of eye infections to the
JXS Health Team for further
XRJ treatment.
4. Family
Planning
5. Control of
Leprosy
6. Prevention of
Blindness
To lessen incidence
of eye diseases due
to nutritional
deficiences.
Give accurate
information to others
on cause and
prevention of eye
disease caused by
nutritional
deficiencies.
. VHW's Need to
> know facts about
C the kinds of eye
r diseases, their
y cause, prevention
and treatment.
e. Recognizes symptoms
of eye conditions due
to deficiencies in
food.
f. Teaches others about
causes and prevention
of nutritional blindness.
tcfxj r
AXKf S
J
S
jXftr T,
130 cured quickly if early
jyGQv symptoms are recognized and »
JXaXK treated.
jVVVVJ 6. More serious infections
B. Symptoms
.
z* C. Serious symptoms to
jXJv C be referred to Health
(.-fVtQQi are dangerous and can
’VjQcxJ cause blindness if not treated.
JWVxfi 7. Spread of eye infections
A Team.
JJ • D. Prevention of spread
!mXxzC to
cd of infections
E. Medication
XqXXJ
III. Nutritional Eye
Disease and Blindness
A. Symptoms
B. Cause
C. Prevention
D. Medication
7. Control of
Tuberculosis
To prevent blindness
due to injuries,
accidents and
neglect.
Give advice on
prevention and
treatment of injuries
to the eye.
g. Knows common.
causes of eye injuries.
h. Teaches others about
the prevention of injuries
of the eyes.
IV. Injuries to the eye
A. Foreign Bodies
1. Symptoms
2. Prevention
B. Measles & small pox
1. Symptoms
2. Prevention
C Accidents
D. Wrong treatments
m. Recommends cases of
* cataract or glaucoma.
or blindness for the
rehabilitation schemes.
n. Helps in teaching
new skills to blind
patients.
o. Provides care to
blind patients if requiredp. Enlists the community
organizations in
rehabilitation.
vll. Rehabilitation
A. Cures of Temporary
blindness
I. Cataract
2. Glaucoma
3. Nutritional
B. Use of G asses
C. Crafts and skills foi
:vii ii.ill v .iiKi (Oinpl u'l',
blind
D Rehabilitation Scheme
t. Community
Resoonsibilities
Identify cases of
cataract and
To provide
necessary care, '
and opportunities
for lessening the
dependency of the
blind on the
charity of others.
Assist in rehabilita
tion of the blind
by referring and
recommending needy
cases to the Health
Team.
Make sure the
patients in her
village are being
cared for, and
helped in
rehabilitation.
and to help in their
rehabilitation.
fiSSS 5. Infections of the eyes can
A. Kinds
1. Conjunctivitis
2. Trachoma
3. Other
Development of unit-from the Selection of Priority to the Message^^^^^^to Village Health Workers UNIT VI. Prevention of Blindness.
people can be
SSSc prevented. ★
KXooc
8. if you look you will see
things which can tell you a
person has night blindness .*
9. Lack of some kinds of food
in the diet causes night
blindness and even complete
loss of sight.
10. Eat yellow and green
vegetables and fruits to
prevent nutritional blindness.
11. Vitamin A Capsules treat
and prevent nutritional
blindness.
17. Many people who are
not permanently blind can be
helped to see again.
18. The blind can learn new
skills that help them to
become economically indepen
dent, and give them pride
and dignity again.
19. The Community has
responsibility in rehabilitating,
its blind members.
4-J cc<rl'}a'’
^6'0 qq y
PROJECT GOALS
&
PRIORITIES
°a&
STEP 1
BROAD OBJECTIVES
UNIT V. CONTROL OF LEPROSY
STEP 2
WORK to be DONE by
VHWs
STEP 3
What VHWs need to
KNOW FEEL & DO
STEP 4
SPECIFIC OBJECTIVES-What
VHWs DO In the Village ■
STEP 6 CURRICULUM
Course Outline
| Messages to be learned by VHWs.
GOAL: To improve
the Health of the
villages In the areas
1. Care of
Linder-Fives
Lessen the
social ostra
cism faced by
Leprosy
patients.'
Help by their
own behavior
and knowledge
to dispel
fear and
ostracism of
Leprosy pat
ients.______
2. Prevention o<
Malnutrition in
Children
3. Antenatal
Maternity, and
Postnatal care
4 Family
Planning
2. Locate all
cases of Lep
rosy in the
villages of
the Project
i
Identify all
the Leprosy
patients in
her own
' village.
5. Control of
Leprosy
3. Bring all
Leprosy cases
in the area
under treat
ment.
Persuade
Leprosy
patients to
take regu
lar treatment.
6. Prevention
of Blindness
4. Prevent
the spread of
Leprosy to
new cases.
Locate cont
acts and
make sure
they also
take treatment.
Give health
education-on.^
leprosy.
7. Control of
Tuberculosis
VHW’s need to
show, sympathy
understand
ing, and an
attitude of
'acceptance
toward Lep
rosy patients
and their families.
VHW’s need to
know facts
about Leprosy,
and information
related to its treat
ment and con-
a. Gives accurate
information to
the people about
the causes and
treatment of Lep
rosy and its
control.
b. Shows her own
the patients
through her at
titudes and be
havior toward
them.________
c. Recognizes
early signs and
symptoms of
Leprosy
II. Signs and
Symptoms of
Leprosy
A. Early symptoms
B. Later symptoms
and Deformities.
d. Brings people
she suspects of
•having Leprosy
for examination
and diagnosis.
C. How the Leprosy
paramedical does
the tests for
Leprosy.
e. Persuades Lep
rosy patients
and contacts to
start and continue
treatment.
f. Uses social
pressure through
village leaders to
make sure all
cases are follow
ing treatment.
1. Leprosy is caused
by germs which can be
killed by taking
medicines.
2. Taking treatment
early will prevent
increased symptoms.
3. Care of hands and
feet will prevent
deformity,
1. Leprosy is not very
contagious.
5. Learning about Lep
rosy lessens fear.
y. Social Aspects
of Leprosy
A. Difficulties
and problems
of patients
B.- Misconceptions
about cause
and contagious
ness of Leprosy.
C. Early Treat
ment and cure.
K
X?
VC
Sf
VC
cR
RS
■K
itp
JX
6. Early recognition
of symptoms, and
early treatment can
cure Leprosy.
7. Later symptoms can
be prevented, but
these patients need
more care.
8. Suspected patients
should be persuaded
to go for examination
and laboratory tests
9. Diagnosis depends on
observing symptoms
and laboratory tests.
D. Treatment with
tHfO55
DDS and Lamprin.
1. Importance of
early treatment.
2. Importance of
continuous
treatment.
3. Treatment of
contacts as a
protection to
the community.
4. Recognition of
reactions.
JRV jR
VjX RS
JWV
mVSi jX
{RR 2R
RS
jRR
jJRJ JO
(JOj CR
VR JO
DOC OC
(00
10. DDS or Lamprin tab
lets^are used to
treaty Leprosy.
11. When a patient
has a reaction to
DDS, he must stop
medication and be
taken to the hospi
tai for treatment.
12. Contacts of patients should also
take medication.
■
5. Prevent
deformities
•o'ccurring
in patients.
Leam how to
prevent de
formities
and teach
patients
g. Teaches and dem
onstrates tp Lep
rosy patients how
they should care
for hands, feet
and eyes to pre
vent deformities.
h. Supervises the
patients to make
sure they carry
out instructions
to prevent deformities.’
6. Provide
care for pat-
Care for pat
ients with
deformities.
i. Does the daily
dressings for
ulcers or wounds
of Leprosy
patients.
ready having
deformities.
7. Help Lep
rosy patients
to become
economically
independent.
VHWs need to
learn how to
give care to
Leprosy pat
ients and
help in their
rehabilitation.
Assist the
project Dir
ectors in
rehabilitation of
Leprosy patients.
j. Provides care
such as cooking
for, or feeding
patients who
pre incapacitated.
k. Assists in
rehabilitation
programs by
bringing needy
cases to the
attention of
the Health Team.
I. Makes sure
patients under
treatment take
the medications
regularly as
ordered so they
are eligible
for the rehab
ilitation program.
Development of
C. Dressing of
ulcers.
16. An ulcer must
be kept clean and
covered.
D. Caring for
incapacitated
patients.
17. Incapacitated
patients need to
be given special
care.
IV. Rehabilita
tion of Lepro
sy patients.
A. Goat Scheme
B. Employment
programs.
C. Community
action in
Farmers’ Clubs
and womens’
organizations
18. Patients who
have no income or
family should be
recommended for
a rehabilitation
or employment
scheme.
19. Prejudice can
be broken down
through Farmer's
Clubs and Womens'
Organizations.
Unit from the Selection pf Priorities to the Messages to be Taught to the Village Health Workers UNIT V. Control of Leprosy.
1
1
j
1
J!
UNIT II
PROJECT GOALS I
&
I
PRIORITIES
I
CTCD ,
STEP 1
BR0AD OBJECTIVES
I
I
I
STEP 2
WORK to be DONE by
VHWs
PREVENTION OF MALNUTRITION IN CHILDREN
STEP 3
What VHWs need to
KNOW FEEL & D0
STEP 4
SPECIFIC OBJECTIVES-What
VHWs DO In the Village •
STEP 6 CURRICULUM
Course Outline________ (Messages to be learned by VHWs.
GOAL: To Improve
the Health of the
villages in the areas
To create awareness
of the seriousness of
the problems caused
by malnutrition and
deficiency diseases in
children.
Help to inform the
people about the part
malnutrition plays In
increasing illness and
death in children.
Help to determine the
nutritional status of
the children in her
village.
The VHW needs to
know the effects of
malnutrition on the
health of children,
Know the symptoms
of malnutrition and
deficiency disease in
children.
Understand and be
concerned about the
causes of malnutrition
and the children who
are suffering from it.
V a. Recognizes illnesses 7i ■ '/■I
*
The problem of
■
/■in which lack of
■ J i J ■ /,« Malnutrition in Children ’
V proper or sufficient
Bo
A. Most important
■
/■food is a major cause >5 J “i',' cause ofTllness and
J
V or makes them more
JiJi 1J1J death.
■
«J» serious.
'/, Vi1 B. Symptoms of
J
X b. Identifies malnouJ1 //■ malnutrition—
b
5 rished children by
1 /1 'i',' 1. Weight charts
X recognizing symptoms //
J
of deficient or poor diet J/i ’/i' circumference for
■
/j c. Informs parents
// //■ malnutrition
J
'/ about the causes of
J/i ’/i' 3. Physical and
■
i'■ poor nourishment in
// /i'b mental effects.
JJ
'i1 children.
■1 ■ ■J<» C. Causes
i Ji d. Assists in identifying
5? the nutritional status
/■of the children in the
Ji J village.
PRIORITIES:
Under-Fives
2. Prevention ol
Malnutrition in
Children
3. Antenatal
Maternity, and
Postnatal care
To lessen the incidence
of malnutrition among
children by improving
the feeding of infants
and Under Fives.
(To organize a feeding
program for children,
if necessary.)
Give nutrition education
to parents of infants
and young children.
Act as a good example,
following suggestions
for improving the
feeding of children in
her own family.
(Help in planning and
carrying out the
feeding program).
4. Family
Planning
The VHW needs to
know about the best
ways to provide the
nutritional needs of
children with the
available foods.
Accept in her own
family the new ideas
Demonstrate th'e
correct feeding of
children of various
ages.
5. Control of
Leprosy
6. Prevention of
Blindness
7. Control of
Tuberculosis
To prevent deficiency
diseases among
children.
Teach parents about
foods necessary to
prevent children (as
well as adults) from
contracting common
deficiency diseases.
Assist in identifying
and treating cases ol
deficiency in food
requirements.
The VHW needs to
know foods which
prevent the common
deficiency diseases.
Know the best ways
to use available foods
to provide nutritional
requirements in the
child's diet
Be able to teach
through demonstration,
how to prepare good
quality foods for
children.
Know symptoms of
serious deficiency
conditions.
p°ver^y
■
h J ■ '/■
J
JiJi /1 ■ 2. Poor nutrition of
■,1J
3.
Too
many
children
J
■ /
//Z 4. Taboos and mis- ■
■ /ij conceptions.
J i J ■ J 5. Lack of knowledge a
! i! 4 of needs of children. '
A1. A child Wbo dose not get enough
■ JJ of the right kind of food,very often
A is sick with colds and fever.
proper growth, anemia and vitamin
Qj deficiency,
iji 3. Nutritional diarrhoea and other
9j more serious conditions can result
food.
'S 4- Symptoms of malnutrition are
xj very common among children.
i]j especially in poor families.
/j 5. Malnutrition is a problem which
jjjmust be the concern of the whole
J«J5 community.
jCj 6. The proper use of available
si J foods will help to prevent malnu
*
e. Teaches and
demonstrates to
mothers how to give
water as well as
breast milk to the
newborn baby.
f. Teaches the impor
tance of good
nutrition for the
mother who is nursing
her baby, as well as
in the antenatal
*
period.
g. Teaches with
demonstration, the
feeding of semi-solid
and solid foods begin
ning gradually from
the fourth month after
birth.
h. Encourages breast
feeding until the child
is two years, stopping
gradually if the
mother becomes
pregnant.
i. Teaches mothers to
give the same foods
as are given to adults
by the time the child
is 15 months old.
II. Diet Requirements
of Children
A. Infants and
Under-fives.
1. Breast milk and
water (other milk only
if necessary and given
in adequate amounts)
2. Starting other foods
from fourth month.
3. Normal adult diet
in addition to mother's
milk from 15 months.
4. Weaning a child
gradually.
B. Planning with
community leaders for
feeding the village
children.
7. Breast milk is the best /food
for infants - ★
8. Start breast feeding immediately
after birth and supplement with
boiled water between feedings. *
9. Soft solid foods should be
given to the baby starting
gradually from about the fourth
month. ★
10. Soft solids, such as ground
rice, dais, potatoes, green vegetables
may be given to the baby by nine
months.
11. Porridge made of mixed
grains and dais is better than
single grains given at one time.
12. Breast feeding until the 24th
month, or until the next child is
born is a good practice. .
13. All under five children need an
adequate diet to build healthy
bodies.
j. Selects and
prepares the best foods
available to prevent
deficiency diseases.
k. .Teaches mothers
how to prepare food
that will prevent
the child from begin
ning symptoms of
deficiency.
I. Recognizes early
symptoms of deficiency
diseases and advises
, the mothers on what
to give to the child.
m. Identifies children
with symptoms of
serious deficiencies.
and refers these to
the Health Team for
diagnosis and
treatment.
n. Follows up on the
treatment ordered in
deficiency disease
patients.
III. Nutritional Defi
ciency Disease.
A. Causes and
Prevention of :
1. Anemia
2. (PCM) Marasmus
Kwashiorkor
3. Goitre
4. Nutritional
**
Blindness
5. Other Deficiencies
B. Symptoms of each
of these.
C. Preparations of
Foods for prevention
and treatment of
deficiency diseases.
D. Serious symptoms
requiring referral.
E. Medications required
in the treatment or
prevention of these
diseases.
14. Important and common foods
which help prevent several
diseases are:
"Super-porridge" or kanji of
mixed cereals.
Green leafy vegetables
Dais or pulses
17.o Peanuts and other nuts or
dried fruits
Yellow vegetables and fruits
19. Leafy vegetables are good for
preventing anemia and bad eyes.
20. Yellow fruits and vegetables
help prevent bad eyes.
21. Dais, pulses, peanutsf mixed
grains and dried fish prevent serious
deficiency diseases.
Notes: *See Unit 11U Antenatal Care, Messages 5-7
"See Unit VI: Prevention of Blindness, Messages 8-11
Development of Unit from the Selection of Priority to the Messages to be taught to Villag, Health Workers
UNIT
II. Prevention of Malnutrition in Children.
22. Symptoms of these diseases
need to be recognized early.
23. Medicines may be needed for
serious symptoms, and need to
be followed up. Examples;
Vitamin A
Iodine in salt
Iron, Calcium
Extra vitamins
Protein food
Powdered milk
24. Other illnesses and infection
may cause nutritional deficiency
because of lack of food or proper
digestion.
/-(>
UNIT-1: CARE 0? UNDERFIVES
PROJECT GOALS
8
PRIORITIES
STEP1
BROAD OBJECTIVES
STEP 2
WORK to be DONE by
VHWs
STEP 3
What VHWs need to
KNOW FEEL 8 DO
STEP 4
SPECIFIC OBJECTIVES What
VHWs DO in the Village
STEP 5
Course Outline
CURRRICULUM
jes io be learned by VHWs
goal
To improve the
health of the
villages in the area
»' To lessen the incidence
* of malnutrition and
a prevent deficiency
To protect all of the
children from those
communicable diseases
preventable through
immunizations,
(This Objective is of such major importance that we decided lo treat as Priority No. II) -
Motivate village people
to have their children
immunized against com
municable diseases
Assist in planning and
carrying out immunization
campaigns.
• VHWs need to know
! which diseases can
•bo prevented by
■ immunizations:
»Accept immunizations
’ for her own family;
“Teach and persuade
»others immunizations
J Help organize immu■ nization campaigns.
® Gives accurate inferthation to people about
'vhich diseases can bo
Prevented by immunization
n Persuades people that
Prevention is much less
costly than having the
illness.
c A'ranges for smallpox
vaccinations to be
Siven to newborns, as
well as others who have
- not yet taken them.
d Motivates mothers and
arranges for Triple
Vaccine and Polio to
be given to all children.
t Helps motivate and
| arrange with the village
; leaders, for
I cholera and typhoid
immunizations during
epidemic seasons.
I- Prevention of COfnmunicable
Diseases.
. Knows early symptoms and
.teaches mothers how to re
cognize when her child is
getting sick.
g Teaches mothers to give
her child nutritous food,
'prepared in a clean way
and protected from flies.
h Teaches mothers to pre
sent and treat dehydration
’ by giving the child plenty
' of clean water or rehydra. tion fluid to drink.
i Demonstrates how to pre
pare and give easily diges! ted. nutritious food to
the child who is sick.
j.f Gives correct medicines to
f treat diarrhoea or worms
’ when necessary.
II- Treatment and Prevention
of common Childhood A»l-
PRIORITIES :
1. Care of
Under-Fives
x To lessen incidence of
J common disease condi• tions and prevent
I serious illnesses
' and infections
2. Prevention of
----- Mefnutriticn-1 in Children.
3. Antenatal
Maternity, and
Postnatal Care
4. Family Planning
5. Control of
Leprosy
6. Prevention of
Blindness
7. Control of
Tuberculosis
Help prevent illnesses in
children.
Recognize and teach
others the early
symptoms of common
Give care and treat■mwrto-children— —
with minor disorders
in order to prevent
serious symptoms and
complications.
Teach and assist
mothers in caring for
ill children.
Fhe VHW needs to
— know the most com
mon causes of illne
sses and death in
1
children and how to
prevent them.
— show concern for the
unncessary illness and <
ae^hnarh6wg"chirdfgrT£
and assist in their
»
prevention.
C
— Teach mothers how G
to prevent common
diseases and help
ments and diseases
in their children.
1 k Knows and recognizes sympi toms of each of the common
1 conditions which cause
' I. Demonstrates and teaches
i mothers how to recognize
’ Symptoms of illnesses
causing fever.
■-m/deres for-children with lever, and demonstrates
■ giving fluids.
• cool sponge
- preparation and giving of diet
• inhalation with steam.
n. Recognizes and gives specific
i medicines in the correct
dosage, to lower fever or
treat particular symptoms
or conditions.
. .
o. Recognizes symptoms and
gives required care to a
■ child with measles.
p. Teaches mothers about
care heeded by the child
with measles to prevent
complications.
q. Recognizes and refers
serious symptoms and
complications for
advice or care, to the
health team.
To lessen serious dis
abilities and death by
i prevention and First
! Aid treatment of emer' gencies and accidents.
Help in the prevention
of accidents
Give immediate first
aid care necossery in
common accidents and
emergencies.
Help to lessen the
harmful effects of
mistaken ideas of
treatment necessary
Help prevent unneces
sary complications
and disabilities resulting
from inadequate first aid
measures.
The VHW needs to
- know what to do in
emergencies and
accidents to
children, to stop
further damage 8
treat the condition
• know whan the
child needs
furthar care by
the health team
and how to
transport the patient.
• plan with others
m the village on
measures to prevent
accidents_____ ____
» NOTE : Only common conditions and the general treatment are included here. These or other
conditions which are serious problems in any particular area may ba enlarged upon as we
have done for measlesn Specific Objectives, o.p.q. and Messages 26-31 (For example scabies
and other skin infections)
r Treats new burn cases
with cold water on the
burned area.
s. Helps to plan ways to
prevent burns in and
around the home.
t. Does clean dressings
for clean and infected
cuts and wounds.
u Makes sure that those
with cuts, wounds or
serious'Lurns have
immunizations for tetanus
V. Knows how to give
artificial respiration
to a child who stops
breathing, and carries
out the procedure if necessary.
w Immobilizes a frac
tured bone, and trans
ports the patient safely '
Uses the tournequette safely.
y. Persuades those with
animal bites, snake
bile or stings to
take further treatment
when necessary.
Carnes out measures
necessary to prevent shock.
Diseases.
0. Immunization to prevent
- Smallpox
- Tuberculosis
• Tetanus
- Whooping cough
- Diphtheria
■ Poliomyelitis
Cholera 8 Typhoid
C. Cost of having the sick
ness (rather than immu
nization)
- cost in money
- permanent injury, or
disfigurement
D. Care of child after
immunization
- of vaccination spot
- lessen pain, fever (if any)
A. Compton symptoms
0. Common ailments
1. Diarrhoea
Improper diet
infections
intestinal worms
• Dehydration :
importance of fluids •
symptoms
treatment with rehy
dration fluid
- Nutrition in diarrhoea
* Medicines
• Prevention.
C. Fevers
1. Good nutrition as
prevention.
2 Fever symptoms i
• typhoid
• cold cough
• ear infection
measles and chickenpox
■ flu and pneumonia
.-mumps_______ .
3. Care
- increase fluids
- easily digested food
- cooling body
- tepid sponge
- fresh air
- light cover
• inhalation for breath
ing difficulty
(or humid room)
4 Medication
■ to lower iGVer
- for pain
• treat cause of infection
- kinds 8 dosage
D Measles
1. Symptoms, including fever
2. Care
- control fever
- rest
- protections! eyes 1 '
- skin rash' - to Seep
clean, stop itching
prevent outside
infection
• prevent pneumonia,
cough
3. Medications
• for fever
- prevent other
infections
* lotions for .skin
4. Serious symptoms or com
plications to be referred
- little response to care
- eye or ear infection
III. First Aid in Emergencies
A. Immediate treatment
1. Burns
, - treat immediately with cold
water, then.
■ treat as a wound if the skin..
is destroyed
- Prevention.
2. Cuts and Wounds
- Treatment of a fresh cut
- Prevention
- Treatment of an infected wound
■ immunization against tetanus
• send to another health team
member.
3. Slopping of Breathing
* artificial respiration for a child
. Fractures
• immobilization
- transportation
5. Hemmorrhage
- use of a tournequette
6. Snake, scorpin or dog bite
- tournquette
- prevention of shock
- treatment
R When to take each of the
above to the Health Team
members or center.
Development of Unit from the Selection of Priority to the Course Outline and Messages to bu Taught to Village Health Workers UNIT I Care of Underfives
I. Many dangerous diseases of childhood
can be prevented by giving a particular
injection or dose of medicine (immunization)
2. Immunization is a very low cost in
money and time compared to having
the disease.
Protection from these diseases also
prevents many complications and
permanent injuries to the child’s body.
some immunization injections can be
lessened by giving medicine and
other care
5. Smallpox and BCG (against tubercu
losis) shouid be given to the baby (
soon after birth, and again when
the child comes to school age.
6. DPT (Triple vaccine against Diph
theria, Whooping Cough and Tetanus)
and Pofio vaccine should be given
after the second month.
7. Typhoid and cholera injections
should be given to children (as well as
adults) if these diseases start in the area.
s8 Early recognitions of symptoms, and
< proper care at ho’me, will help prej vent diseases from becoming serious.
2 9 Diarrhoea is a symptom of the wrong
j kind of diet and infections caused
2 by germs or intestinal worms.
Ji 0. Symptoms of dehydration should be•j recognized by every mother.
5l 1 Dehydration is a serious condition
J caused by diarrhoea which can be
J12. "Medicine water" (rehydration fluid)
5 can save the life of a child with dehydration
213 Water given to a child should be
J
from a clean source. *
214. Water for drinking can be made clean
J
(or purified) in the home *
}
rishing and easily digested food
(16. Food should be kept clean by using
5
clean dishes, hands, and preventing
’
flies from sitting on it
7. Medicines are needed to kill the germs
)18 A child who has enough food of the
right kind gets sick much less than
(
one with poor nutrition
‘19 Fever is an early symptom of many
i
diseases, (e.g. malaria, typhoid.
’ < cold, cough, sore throat, ear
i
infection, measles, chicken pox.
J
flu. pneumonia, mumps)
C of waterto drmk and easily digested food.
£ 21. Wiping the body gently with a
l
cloth wet in cool water helps to
B
lower the fever.
■ 22. A child with fever should be covered
}
with only a light cover, and
J
needs fresh air.
23. Breathing difficulty and pneumonia
j
can be lessened by steam from
[
water boiled in the room (or inhalation)
24. Fever and pain can be lessened
by giving some medicines.
25. Some fevers need to be treated
with special medicines (e.g. malaria).
26. Measles is a dangerous disease
’ in children because of bad
after effects (complications).
27. A child with measles needs to
be kept in bed (or lying down)
in a room with only a little light.
28. A child with measles may need to
have an eyewash done (see UNIT VI)
29. To prevent pneumonia and to make
breathing easier, boil some
water so there is steam in the room.
30. Medicines may be needed to prevent
other infections from starting
in the child with measles.
31. A child with serious symptoms
or complications should be shown
to the health team (e.g high
fever more than three days, cough
more than a week, difficult
breathing not helped by steam
inhalation etc)
2. Treat burns by placing the burned
part in cold water for at least ten minutes.
3. Prevent burns by safe practices
with fire, lamps, hot stoves, etc *
4. Cuts and wounds should be kept
clean and dry to help them heal quickly. *
35. Cuts and wounds should be pre
vented by keeping dangerous
cutting instruments out of
children's reach, and removing
broken glass and sharp stones.
36. If a cut or wound is infected
it should be soaked and cleaned
several times a day.
37. Make sure that a child (or ailult)
with a wound has been Immunized
against tetanus.
*
8. If a child stops breathing.
IMMEDIATE treatment is necessaiy. *
9. A broken bona should be bandaged
in a way to prevent movement
before taking the child to the health team.
0. It there is serious bleeding
external-it should ba con
trolled before taking to the
health team.
1 Bites, snakes bites or scorpion stings
need to be treated quickly to
prevent the poison spreading
in the body, and to prevent shock.
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14,
Community Centre,
Safdarjung Development Area,
Phone : 652007, 652008
New Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
E-15
SIMPLE BACTERIOLOGICAL ANALYSIS OF DRINKING
WATER SUPPLIES
Duncan Mara, Department cf Civil Engineering,
University of Dundee, and
Member of ITDG's Water Panel .
The rationale of bacteriological analysis
If a drinking water supply, such as a stream or a shallow well, becomes
polluted with human wastes (faeces, night soil, sewage, even some
sewage effluents), it may serve as a vehicle of transmission of such
water borne diseases as typhoid, cholera and dysentery or of such waterbased diseases as schistosomiasis and guinea worm. This argument
assumes that the waste contains the organisms which cause these diseases.
The very high incidence of intestinal diseases and parasitic infestations
in hot climates means that in practice the chances that human wastes do
contain disease-causing organisms are also very high. Water supplies
which become contaminated with human wastes are therefore always
regarded as very real health hazards.
The number of disease causing organisms that have been isolated from
polluted waters is very large indeed. It is simply not possible to examine
a water sample for the presence or absence of all of these organisms..
Moreover, they mayoften be only irregularly present in a water, even
though the water is being polluted continuously. Therefore we look for
the presence or absence, of a special bacterium which is always present
in faeces and’ whose normal habit is the intestine of man and higher
mammals - a bacterium which is therefore an indicator of faecal
pollution. One such bacterium is Escherichia coli (hi. coli), which
itself is normally harmless to man. A simple method for estimating
the numbers of E. coli in drinking water samples is described in the
next section.
If a water sample is shown to contain E. coli, then we know that the body
of water from which it was obtained has been polluted with human or
animal wastes. The wate'r may therefore contain disease-causing orga
nisms. An attempt should therefore be made to protect the water from
further contamination or to develop an alternative source of supply.
Advice on water source protection and the development of new supplies
is given in w&ter Treatment and Sanitation by H.T. Mann and D.
Williamson (2nd edition)' published by intermediate Technology
Publications.
Bacteriological Analysis
The tests described in this section are best suited for use in small towns
of not less than about 20, 300 population. Such towns would normally have
a water distribution system including both private connections and public
standpipes. They would also have mains electricity, which is needed to
carry out the tests. These towns should also serve as a centre for the
collection and analysis of water samples from neighbouring villages.
The collection and analysis of water samples is described below as a
series of simple instructions to a laboratory technician. Reasons for
the choice of the methods recommended are given in the Technical Appendix
on page
Sample collection
Samples must only be collected in sterile bottles; see the next section
for details of how to sterilize the sampling bottles.
Sampling from a tap
1.
Make sure the tap is clean, especially on the inside.
2.
Turn the tap full on and allow the water to run to waste.for 1 minute.
3.
Close the tap until only a slow trickle of water is coming out.
4.
Carefully open the sampling bottle. You must not touch the screw
thread at the top of the bott: ; nor the inside oJ the can. (If you should
touch these parts of the bottle by accident, discard the bottle and use
another one; the first one, must be sterilised before it is used again.
You should always carry a spare sampling bottle).
5.
Fill the sampling bottle with the water and carefully replace the cap.
Screw it tightly.
Sampling from a stream
1.
Stand in the middle of the stream and face upstream. If necessary
wear waterproof boots and gloves to protect yourself against
schistosomiasis.
2.
Carefully remove the cap from the bottle and, with the mouth of the
bottle facing upstream, lower the bottle into the stream and allow
it to fill. Tilt the bottle upwards to let it fill completely. Carefully
replace the cap,
Sampling from a well ■
1.
Tie a sample bottle on to a weighted length of rope or strong
string. Use a stone or piece of metal weighing about 500 g as the
weight and attach the bottle just above the weight. A convenient
arrangement is shown in Figure 1.
: 3 :
2.
Carefully remove the cap from the bottle and lower the bottle in to
the well to a depth of about 1 m. When no more air bubbles rise
to the surface, raise the bottle out of the well and carefully replace
the cap.
Frequency of sampling
The frequency at which a water supply is sampled depends on the population
it serves. The following table provides a rough guide:
Population served
Under 100
1000-5000
5000-10000
10000-50000
Above 50000
Maximum desirable interval
between successive samples
2 months
1 month
2 weeks
1 week
3 days
Samples should be taken on each occasion at the point of abstraction, as
the water leaves the works (if any) and at various points in the distribution
system (private connections and public standpipes). The minimum number
of samples to be taken from within the distribution system also depends on
the population served; one sample should be taken each month for every
5000 people supplied.
Preparation for the test
Making up MacConkey broth
Mac Conkey broth is a special mixture of chemicals in water (properly
called a 'medium') which is used to determine whether Escherichia coli
is present in a water sample or not . To prepare 500 ml of double
strength MacConkey broth (sufficient for 10 tests), proceed as follows:
1.
Weigh out 40 grams of dehydrated Oxoid 'MacConkey broth (purple)'
powder. This powder is available throughChemicals de Cen tre,
3/15 Asaf Ali Marg, New Delhi 110002 (among other places) and
costs Rs. 272 for 500 grams.
Indian manufactured MacConkey's broth powder is also available
from Centrcn Research Laboratories - a division of Centron
Agro Industries Pvt. Ltd., 103 Adhyaru Industrial Estate, New
Sun Mill Compound, Lower Parel, Bombay 400013 at Rs. 180
for 500 grams.
2.
Fill up a graduated 1 litre beaker to the 500 ml level with clear
drinking water and add the 40 grams of MacConkey broth powder.
Stir to dissolve.
It is of course possible to make up MacConkey broth from the
. 4 :
E-15
individual constituents. Bl; this is a tedious process and it is not
usually possible to ensure that each batch of medium is identical this can lead to significant errors' in the test results. Dehydrated
media overcome these disadvantages.
3.
When the powder has dissolved, measure 10 ml of MacConkey
broth into each of 50 1 -oz (28 ml) screwcapped bottles (either
’universal containers'or’McCartney bottles'). A 10 ml tilting
pipette is a convenient means of dispensing the solution.
4.
Add to each bottle an inverted Durham tube; this is a small test
tube which is used to detect gas production (see figure 2). Make
sure that the open end of the Durham tube is at the bottom of the
bottle.
■5.
Screw the capr on to the bottles. Do NOT tighten the caps but
leave them loose. Sterilize the bottles as described below.
Sterilization
Before a water sample can be analysed all the bacteria present in the
g? issware and the MacConkey broth must be killed; if they were not,
they would interfere with the test on the sample - we are only interested
in the bacteria in the water sample, not those on the surface of the
glassware or those on your hands, The process of killing bacteria is
called sterilization.
The following items need to be sterilised:
a.
b.
c.
Sampling mottles
Screw-capped bottles containing Durham tubes and
MacConkey broth.
10 ml measuring cylinders and 10 ml beakers - these
are used to transfer 10 ml of the water sample to each
screw-capped bottle (see next section on Test Procedure);
the 10 ml beaker is placed over the open end of the cylinder
in order to.protect the inside of the cylinder from becoming
contaminated after it has been sterilised.
An ordinary domestic pressure cooker is recommended as the sterilizer.
The temperature of the steam inside the pressure c ooker reaches 120°C
which, when maintained for 15 minutes . kills all the bacteria which are
likely to interfere with the tesL.
To use the pressure cooker, follow the manufacturer's instructions.
The items should "cooked" for 15 minutes at 120°C (this temperature
is achieved at a steam pressure of 15 pounds per square inch). Bottle
caps should only be screwed on loosely - otherwise they may explode.
Make sure that the 10 ml cylinders are fitted with 10 ml beakers. When
the bottles have cooled after being sterilised, screw the caps down
tightly.
: 5 :
E-15
General cleanliness
The work area set aside for analysing water samples should always
be. kept very clean. Try to choose an area free from both dust and
draughts. Always wash your own hands before you start to analyse a
sample. Rinseout all glassware with clean water immediately after
use.
- •
Test procedures
There are two tests: The 5 x 10 ml test and the 5 x 1 ml test. They
are very similar - the only difference being the range of counting:
the 5 x 10 ml test can count up to 16 E. coli bacteria per 100 ml
whereas the 5 x 1 ml test can count up to 160 per ml. Always use the
5 x 10 ml test first and only use the 5 x 1 ml on subsequent samples
from the same source if the E. coli count is more than 16 per 100 ml
(see below for further details).
It is not always necessary to do the 5 x 1 ml test and your laboratory
may not have the extra equipment required for it. The 5 x 10 ml
test is the more important one.
The 5 x 10 ml test
1.
Vigorously shake the sampling bottle to mix its contents
thoroughly.
2.
Pour the sample into a sterile 10 ml measuring cylinder to the
10 ml mark. Remember not to touch the top of the sampling
bottle, nor the top of the cylinder.
3.
Add this 10 ml of the sample to a screw-capped bottle which
contains sterile double strength MacConkey broth and an
inverted Durham tube.
4.
Using the same measuring cylinder repeat steps 2 and 3 four
more times . You should now have. 5 screw-capped bottles
each with 10 ml of the sample.
5.
Make sure that the inverted Durham tube is full of liquid. If'
there is any air trapped inside it, tighten the bottle cap and
turn the whole bottle upside down. The air will now rise up
out of the Durham tube; when this happened quickly turn the
bottle upright again.
6.
Place the 5 bottles in a bottle rack (such as the homemade one
shown in Figure 3) and place the rack in a water bath which
has been set at exactly 44cc, The caps on the bottles should
only be screwed on loosely.
7.
After 24 hours remove the rack from the water bath and
: 6 :
E-15
examine each bottle for the production of acid and gas.
Acid production: If acid has been produced the colour of
the MacConkey broth will have changed from red or purple
to yellow.
Gas production: If gas has been produced, some, of it will
have been trapped in the Durham tube where it will be visible
(Figure 2c). If necessary tilt the bottle so that the Durham tube
is next to the bottle wall - this allows you to see the gas more
easily.
8.
Count the number of bottles in which both acid and gas have been
produced. Read off the most likely E.' coli count from the
following table (this count is often called the 'most probable
number' or'MPN' of E. coli in 100 ml of the sample):
Number of positive
bottles (acid and
gas production
)
*
Most likely E. coli count
per 100 ml of the water
sample.
0
:'
2
3
4
5
0
2
s
8
16
**
infinite
* Acid production without gas production is a negative result
** Record the'result as "greater than 16 per 100 ml".
See paragraph 10.
9.
Sterilize all the bottles and their contents before cleaning them.
This is to ensure that large numbers of live bacteria do not
excape into the environment.
10.
If all 5 bottles are positive it is not possible to obtain an E. coli
count. Use the 5x1 ml test for the next sample to be taken
from the same source.
The 5 x 1 ml test
This test is identical to the 5 x 10 ml test except that 1 ml quantities of
the sample are added (by means of sterile 1 ml pipette) to screw-capped
bottles which contain 5 ml of single strength MacConkey broth (the
bottles are also fitted with smaller Durham tubes).
Single strength MacConkey broth is most conveniently obtained by
mixing together equal parts of the double strength broth and water before
sterilization.
E-15
Tie 1 ml pipettes should be individually wrapped in aluminium foil and
placed in the oven of a domestic electric or gas cooker oven for 1
hour at 166cC. If such a cooker is not available, then pre-sterilized
disposable pipettes must be used (Sterilin Ltd, 43 Broad Street,
Teddington, England). When you use the pipette, be careful not to
touch its tip or any part which comes in contact with the water sample.
The test procedure is otherwise the same as that for the 5 x 10 ml test.
The E. coli count is obtained from the following table:
Number of positive bottles
(acid and gas production
)
*
0
1
2
3
4
5
Most likely E.coli count per
100 ml of the water sampl e
0
20
50
90
160
**
Infinite
* Acid production without gas production is a negative result.
** Record the count as "greater than 160 per 100 ml".
Interpretation of Test Results
5 x 10 ml test
Ideally all five bottles should be negative as drinking water should not
contain any E.coli in 100 ml; E. coli count is the standard recommended
by the World Health Organisation (International Standards for Drinking
Water, 3rd edition, 1971). This ideal is not always reached however and
in-practice we often have to be content with a water which contains some
E. coli. It is extremely difficult to set realistic standards for drinking
water quality. -For sophisticated water supply schemes, such as those
found in large cities, it is both financially and technically feasible to
insist on the absence of E.Coli. But in rural areas, villages and small
towns the provision of drinking water with zero E. coli is often impossible,
especially if waters from rivers and lakes are used for the supply.
Standards are a necessary part of water supply engineering; but they are
almost always controversial - for example if it is accepted that the WHO
standard of zero E.coli is unattainable in a particular area,and that
therefore some less stringent standards need to be established, it is
almost impossible to obtain agreement on what the new standard should
be. Ideally each country should establish standards suitable for its own
circumstances. This is however another ideal unlikely to be achieved
in the immediate future and so, as a realistic basis for the preliminary
evaluation of bacteriological water quality, we offer the. following interim
'standards' for use in conjunction with the 5 x 13 ml test:
Unchlorinated supplies
a.
In any twelve month period the average number of positive bottles
. in each test (on samples from the same source) should not be
more than three ; i.e. the average E.. coli count should be less
than 19 per 100 ml.
b.
In not less than eight tenths of the number of tests done over a
twelve month period there should not be more than two positive
bottles in each test; ite, for 80% of the time the E.coL. count should
be less than 5 per 100 ml.
c.
In no test should there be five positive bottles.
Cholorinated supplies (samples taken before entering the distribution
system)
a.
In not less than nine tenths of the number of tests done over a
twelve month period , there should be no positive bottles in each '
test ; i.e. for 99% of the time E. coli should be absent.
b.
hi no test should there be more than one positive bottle, i.e. the
E.coli count should never exceed per 100 ml.
Chlorinated supplies (samples taken from within the distribution system)
a.
In not less than r.i r.e tenths of die number of tests done over a
twelve month period, there should be no positive bottles in each
test; i.e. for 90% of the time E.coli should be absent
b.
In no test should there be more than tw.o positive bottles; i.e.
the E.coli count should never exceed 5 per 100 ml.
The local Water Engineer should be informed about all waters which
consistently fail to satisfy these standards. He will then be able to
investigate the cause of the pollution and thus be in a better position to
improve, the quality of the water in question'.
.5x1 ml test
The very fact that this test has been done on a water means that it is
known to be badly polluted. The actual count obtained will be useful to
the local Water Engineer in helping him assess the extent.p| the pollution
involved.
If all five bottles in this test are positive, the local Medical Officer of
Health should also be informed so that he can , if he so wishes, arrange
for a more detailed bacteriological analysis to be done on the water.
Equipment
The room in which the tests are done must be provided with electricity
(to operate the pressure cooker and .he water bath) . It should also be
: 9 :
provided with a sink and cold water (to wash glassware after use).
equipment required for the tests is listed below.
The
The most important piece of equipment is the water-bath; it is essential
to maintain the incubation temperature to within 1/2° of 44°C. Hie
electric hotplate is not essential; for example a simple charcoal stove
is a perfectly satisfactory alternative.
Costs
The equipment costs are from£' 143 to/ 202 depending whether a balance
is bought and facilities for the 5 xl ml test are provided. The running
costs (MacConkey broth only) are 3.5 pence per test for the 5 x 10 ml
test (UK price in March 1976).
Technical appendix
Method
The 5-tube MPN method is chosen because of its simplicity and low cost.
Membrane filtration is too comp.’bcated a method for a person with no
previous experience in practical bacteriology; moreover its running costs are
much higher (its capital cost being only slightly less)
Medium
MacConkey broth is chosen because of its wide availability and time-ptoven
reliability. Glutamate media (such as Oxoid’s Minerals modified glutamate
medium) require pH checking after sterilization; but facilities for doing
this are unlikely to be available. Medium A-l of Andrews and Presnell
(Applied Microbiology 23(3) 521: 1972) is more satisfactory for direct
E.coli counts at 44°C than other media including Mac Conkey broth, but it
is not available dehydrated.
Incubation temperature
Too many saprophytic lactose -fermenting bacteria grow from tropical
water samples if the incubation temperature is 35-37°C. These organisms
have no sanitary significance and to avoid a high incidence of false positive
results an incubation temperature of 44°C is chosen. At this temperature
false positive reactions can occur due to the growth of anaerobic sporeforming bacteria, but the incidence of these false reactions is likely to be
significantly less than those occurring at the lower temperatures. Preiiicubation for 2-6 hours at 30-35°C is not considered necessary for
tropical water samples.
The method, medium and incubation temperature recommended here for
water samples are essentially the same as those used by Quadri, Buckle
and Edwards (Journal of applied Bacteriology 37(1), 7: 1974) for determining
the degree of faecal contamination of oysters.
: 10 :
E-15
List of Equipment required for Bacteriological
Analysis of Drinking Water Samples
Operation
Qty.
Item
Sampling
30
125 ml. glass
bottlesa
Corning^
Sigcol ,
Nutex
Media prepa
ration
1
Balance
3
250 ml. glass
beakers
3
1000 ml glass
beakers
1 gross^
10 ml pipettes
5 ml Pipettes
1 oz McCartney
bottles
1 gross®
Durham tubes
Avery or
Rs. 500.00 approx
Blue Stare
Coming
Rs. 4.35 each
Sigcol
Rs. 3.20 "
Nutex
Rs. 1. 95 "
Corning
Rs 16.30 "
Sigcol
-Rs 10.50 "
Nutex
Rs 5.55 "
Corning
Rs 9*70
" A
Rs 9*25
" •
Corning
Any scientific supply
house.
Rs 1.50 "
Rs 10.00 per gross
1
Pressure cooker Any electrical Rs 185 to Rs 225
(5-6 liter)
Appliance shop
■. Electric Hot Plate
"
Rs 80 to Rs 120
(1000 watt)
Sterilization
1
Inoculation
20
Incubation
20
20
1
3
Source
Cost
Rs 20.85 each
Rs 4.00 "
Rs 1.70 "
10 ml measuring
cylinder
Coming
Rs 11.95 each
10 ml glass beaker
"
Rs 4.65 "
1 ml pipettes
Rs 7.65 "
Water bath with lidScientific
Supply House1
12"xl(»4"
Rs. 300.00
12x12 "x4"
Rs. 350.00
I^'.’xi2"x4|
Rs. 400.00
Thermometers
Rs 6.00 each
a.
Polypropylene products are not yet readily available in India but
they are coming soon.
b.
Borosil Glass Works Ltd, 44 Khanna Construction House,
Khan Abdul Gaffar Khan Road, Worli, Bombay - 400018.
also: Dabriwala House
10 Middleton Row
Calcutta 700071
19/90.Connaught Circus
New Delhi 110001
c.
TheS cientific Indian Glass Co. Ltd., Calcutta
d.
Marketed in India by:
23/24 Second Line
Beach, Madras600001.
The Republic Scientific Supply Co.,
Munshi Niketan, Asaf Ali Road,
New Delhi 1.
: 11
e.
Avery India Ltd
1 Ansari Road
Darya Ganj
Delhi 110006
f.
such as :
Blue Star Ltd
34 Mahatma Gandhi Marg
Lajpat Nagar Part IV
New Delhi 110024
Widsons Scientific Works
10 West Sadar Thana Road
Delhi 6.
Mercantile Engineers
4/5 Jhandewalan Extn.
New Delhi 55.
Scientific Equipment Works,
Nicholson Road,
Delhi 6.
g.
Minimum quantities available (1 gross = 144). These items
could of course be shared between several laboratories.
Acknowledgement
1.
We are grateful for permission to reproduce this article
from Appropriate Technology Vol. 3 no. 3, Nov. 1976,
p. 7-10.
2.
We are grateful to Sr. Barbara Ann, Pathology Department,
Holy Family Hospital for details of local suppliers.
5/77-200
Mg^e J.
VOLUNTARY
C-14,
Community
HEALTH
Centro.
Phone : 652007, 652008
Sofdorjung
ASSOCIATION
OF INDIA
Development Area,
New Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
E-17
LOW COST TUBE WELLS
A, Denis N. Fernando
Senior Deputy Director Planning,
Ministry of Irrigation, Power and-Highways,
Sri Lanka
Synopsis
While I was in India in 1973 as a guest of the Indian National Academy,
I heard of the bamboo tube wells of Bihar, originally frowned upon by
the technical bureaucrats, but which had served to provide water co
the drought-stricken farmer. In this instance he used a drilling machine
to bore the whole and placed it in a cheap bamboo and coir tube instead
of the expensive steel
and PVC (polyvinylchloride) tubing and
filter, and drew the water with the aid of a pump, for the requirements
-of his farm. Details of the bamboo tube well are given in this article.
In Sri Lanka we are not in the happy position of having many drilling
rigs. The few that we have are under the control of the bureaucracy.
Having been trained as a soil surveyor in the early part of my career,
it occurred to me that an alternative solution could be to use a simple
hand auger and bore the hole by manual methods. This was the birth
of the idea of the low cost tube well. Once the hole is dug in the ground
it is necessary to use locally available materials to construct the tube
well to keep the hole from collapsing and enable the farmer to draw
water with a suitable pumping device.
These low cost tube wells can be constructed in soft rock and semi
consolidated formations like alluvium, colluvium, valley fills and
sedimentary rocks, including weathered rocks where the soil can be
excavated with iron implements. In Sri Lanka we have constructed
them in almost all parts of the country and they give about 1, 993
gallons per hour, and can be used to irrigate 1-P-/2 acres (1/2 hectare)
of land. In addition the well is a hygienic source of water for domestic
consumption. Wells can be constructed by the village youth, the local
potter and the village smith, making the village community self-reliant.
Low cost drilling kit for boring holes in sand and soft rock
The method adopted is a simple manual method. The diameter of the
bore hole would naturally depend on the diameter of the tube-well.
In this instance the tube wells have an average internaLdiameter of
3-1/2", while the bore hole is 8" in diameter.
A device called a hand auger (see Fig. 1) is used to remove the soil.
This auger is trapizoidal in section so that when rammed into the ground
it compresses and contains the soil, enabling the soil to be brought to
1
■ ■ ------
: 2 :
the surface. This auger can be extended to any desired length with
the help of threaded connecting stems and sockets. Likewise, if the
soil is hard or the rock weathered, then we use a crowbar threaded
at the top so that it can be attached to connecting rods to break up
the rock or soften the soil. When we reach water the soil is moist
and the auger will not hold the soil. Then we use a gadget like a
flattened fan with the axis vertical, the stem of which if also threaded
so that connectors can be attached. When this is rotated it traps the
moistened soil, which can then be brought to the surface. At this
point if the wall of the cylindrical hole being dug starts to collapse it
is necessary to introduce a cylindrical casing into the hole (see
Fig. 2). The casing is 8" in diameter and is let down by steel cables
or strong rope’attached to the upper end of the casing. The longer the
casing the better, preferably 29 feet, since if shorter casings are
used the subsequent casings to be inserted into the well will have to
be progressively smaller in diameter. Thus the second casing would
have to be 7" and the third casing 6" in diameter. Moreover if we use
more casings, in addition to problems of retrieval, there is also the
problem of water seeping through the joints which makes physical
excavation more difficult. When the casing is introduced, the fan
excavator is generally used first. At this stage a piston and cylinder with
a valve arrangement at the bottom are used to excavate the soil and water.
The piston and cylinder are controlled from the top by an arrangement
of ropes and can be manipulated so that when the piston is raised with
a jerk the mixed soil and water enters through the valve and is trapped.
This operation is continued until the cylinder is reasonably full of soil
and it is then brought to the surface and emptied. At the same time
the casing is progressively pushed down from the top with the help of
connecting rods and by applying pressure to the top of casing. If hard
material is encountered below the water level it is generally not necessary
to have a casing. However, if alternating layers collapse a casing has
to be used. It is sometimes more convenient to have a more solid
cylinder plus the valve arrangement with provision to attach connecting
rods at the top, so that when pushed from the top the moist soil gets
trapped and then brought out to the surface when the cylinder is full.
This has a disadvantage as the connecting rods have to be disconnected
each time the cylinder is emptied. The material in the casing is
removed progressively until a depth of about 20 feet in water is excavated.
At this stage, one of the different types of tube well is positioned in
the hole, the casing gradually removed and coarse gravel inserted
between the tube well and the casing, which is then completely withdrawn.
A suction tube is in serted into the tube well, and the water pumped
out for some time to clear and develop the well . Once this is done
a permanent pump is installed, whether it is a hand pump; electric
pump, fuel pump or windmill pump, with a maximum rating of
1, 990 gallons per hour.
1
: 3 :
Cost of drilling
The cost of fabricating one drilling kit by the village smith is around
Rs 1, 999 and this kit can be used to drill over 59 wells. The depre
ciation works out (including minor repairs) at about Rs 39 per 39 ft. well.
The well can be dug by three able-bodied youths in one or two days
depending on the materials encountered. The cost of labour and
depreciation on the drilling equipment is about Rs 129 for a 39 foot
tube well or about Rs 4 per foot of manual digging.
Materials for low cost tube well
I shall now describe the four types of low cost tube wells that can be
constructed : Bamboo, Hollowed Arecanut Tree Trunk, Terracotta
(clay pipe) and PVC (polyvinylchloride)
Bamboo tube wells
Basically a bamboo tube well is constructed by binding strips of bamboo
around iron rings of specific diameter sufficient to take a suctiontube to
draw the Water out of the well. For the purpose of the bamboo tube well
that we constructed we used 4" iron rings. The bamboo strips are
tied together as close as possible to form a continuous pipe to the length
desired. If it is long it can be constructed as it is being lowered down.
The bottom is sealed unless artesian conditions make it necessary for
it to be open. The bamboo strips .hat have been put together in the
form of cylindrical tube are tied with a layer of coir rope wrapped round
the bamboo strips like string tied round the handle of a cricket bat.
This tube is gradually lowered into the hole that has already been made.
Bamboo tube well cost:
Two 25ft lengths of bamboo Rs 10)
Iron rings
Rs 20) - cost per foot Rs 2
Coir rope
Rs 15)
Labour
Rs 15)
Hollowed Arecanut tree trunk tube well
In this case the Arecanut tree trunk is split hto two parts ahd the pulp
removed from the centre. Cuts are made in the base ends of each half,
and the two halves are put together again and tied with coir rope at
intervals of 1-1/2 ft along the length of the tree trunk. Further cuts
are made in the trun k at intervals and wooden wedges inserted into the
slits to keep them op er. a tenth of an inch. The base of the tree trunk is
sealed, and, the hole: having already been made, the completed tree
trunk tube is lowerec’ into it.
Arecanut tree trunk tube well cost:
30 ft Areca nut tree
Coir rope
Cleaning and
preparation
Rs 10)
Rs 5)
Rs 15)
,
- cost per foot Rs 1
: 4 :
Terracotta (clay pipe) tube well
In this case perforated clay pipes have to be specially made by the village
potter. They should be 3-1/2" in diameter and 1-1/2 feet in length, with
alternating longitudinal slits 4" long and up to 1/19" wide, spaced evenly
round the circumference of the pipe. The pipes are made with a socket
and joint arrangement for one pipe to fit into the next, and the inside
surface should be straight and smooth. The clay pipes are then sun dried
and fired. Blank clay pipes without perforations are also necessary for
the upper end of the tube well.
When the whole has been made to the desired depth, the introduction of
the pipes is a simple operation using a tripod arrangement above the
hole. The bottom of the first pipe is closed with a piece of hard wood,
and the pipe placed vertically above the hole. It is kept vertical with
the aid of three ropes and coir cord attached round the pipe. The second
pipe is placed on the first and lowered, the third placed on top and the
process continued until all the pipes are one above the other in the hole.
It is not necessary to use perforated pipes for the upper encl of the well,
and in feet it is best to use unperforated pipes above water level so that
seepage of unhygienic water from the surface into the pipes is..prevented.
In practice , we use five unperforated pipes at the top of the column.
Clay pipe tube well cost:
1-1/2 foot pipe i
Rs. 2y50)
Three 30 foot coir cords Rs. 15.00) - cost per foot.Rs. 2.50
Coir rope for tying
Rs. 5.00)
PVC tube well
In this instance we need the 3" diameter PVC tubing that is normally
used for rainwater gutters in modern houses. This is usually about
.1/1.0" think.. The section of pipe that would be under water is perforated
With a hand saw at an angle of about 45° ( a vertical slit is better., if
possible). The slits should be about .3/4" apart. The lower end of the
pipe is plugged either with wood or a PVC cap and inserted into the hole.
Cost:
PVC per foot
Cost of perforation of
the tube well
Rs. 15)
) - cost per foot Rs 16
Rs. 19)
Coarse gravel
Coarse gravel is required to fill the gap between the excavated hole
and the low cost tube well. It is preferable that well-graded rounded
gravel about 2/10" - 3/10" in diameter (about three times the width of
the slit ) be used. About 10 cubic feet of this material is required. If
rounded gravel is not available then metal or rock of the same size can
be used . If this material is also not available , then baked clay could
: 5 :
be broken up into small pieces of this size and used. The cost of
coarse gravel is about Rs 29 for each tube well. Locally excavated
material can be used to fill the space where the unperforated pipes
are used.
Comparative costs of low cost tube well
In the decentralised operation where the local smith, the potter and
the village youth'are mobilised for the construction of low. cost tube
wells, the cost copld be-around Rs 509 per, well inclusive of the hand
pump.
Cost of 30 foot low cost tube wells:
Bamboo
Arecanut Terrap otta
Materials:
a) Tube well
60
b) Coarse sand
20
Drilling
120
Hand pump and suction tube 250
Contingencies
50
Total
3TT
PVC
4
30
20
120
250
50
"TO
75?
20-'
120
250
50
~515
430
_ 20
120
250
50
However since the PVC tube well involves foreign exchange we
discourage its use, in addition it is much more expensive. In
principle any tree trunk where the centre can be dug out could be
used. Since bamboo and Arecanut trunk tube wells decay relatively
quickly we discourage them too. The terracotta tibe well is advocated
as it is permanent and can be constructed and maintained by the village
community. Moreover the hand pump can be fabricated by the village
smith.
The average discharge from each of these tube wells is about 15 gallons
per minute or 1, 000 gallons per hour. This is sufficient to cultivate
3/4 acre of paddy or 1-1/2 acres of subsidiary food crops and is
sufficient for the small farmer..
If hand pumps are used in these tube wells then the discharge is limited
by the pump to about 400 gallons per hour and the cost of lifting 1,000
gallons works out at Rs 2/40 (hiring a man at a rate of Rs 10 for a 6
hour Shift)..
If we use a small electric pump (capital cost about Rs 1,500) the cost of
lifting 1, 000 gallons of water works out at about Rs 4.25.
Whereas if we use a small capacity windmill pump, with hand pump
incorporated (capital cost about Rs 2, 000), the cost of lifting water ■
is nominal, but for practical purposes could be rated as Rs 2.15 for
1, 000 gallons.
: 6 :
The use of petrol and fossil fuel pumps are discouraged as the capital
cost and maintenance is prohibitive.
It is clear that when the tube well is deeper than 28 feet it would be
necessaryto have medium deep well pump, whether hand-, electric-,
or wind-powered. The cost of which would be approximately in
proportion to its depth. This type of tube well has been designed to
go down to about 75 feet.
The cost is also doubled when we have a centralised tube well construc
tion programme, as much money is spent on men for idle time and the
cost of transport of men and materials is exhorbitant. The decentralised
operation brings technology to the people who are in a position to
construct and maintain these wells with local resources, mobilising the
local skills of the smith and the potter.
Ac know ledge ment
We are grateful for permission to reproduce this article from
Appropriate Technology 2_, 4 p. 15-16 1976.
(For Figure 1, 2 & 3 see next page)
AUCER
CROW bar
fan
CROSS SECTION
DRILLED
WELL
CONNECTING PISTON ANt>
CYLINDER
STEM ANO
WITH VZi.VE
SOCKET
CYUNC Jf,
WITH l/ALVE
Ano SOCKET
-At
VOLUNTARY
C-14,
HEALTH
Commuinty Centre,
Of /ND/A
ASSOC/AT/ON
Safdarjung
Phone : 652007, 652008
Development Area,
New
Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
VHAI - 222.
PREVENTION OF TETANUS IN THE NEWBORN BY A
STERILE DELIVERY PA'CIG
~
Helen Gideon & Murray Laugesen.
How common is tetanus of the newborn?
Tetanus is commoner in rural areas, in- male babies and in certain States.
In Punjab it kills about one baby per 1000 population per year. In the
Khanna Study in that State about one quarter of the first month deaths were
due to tetanus.
Most women get neither hospital delivery nor tetanus toxoid. If the dai
uses a dirty or unflamed knife to cut the cord, tetanus may occur. If the
dai puts ashes or cowdung on the cut end of the cord, the baby may get
tetanus.
Tetanus almost never occurs in hospital deliveries. Of all women given
antenatal care only a third may deliver in hospital. Some antenatal women
get at least two tetanus toxoid injections and so their newborn is protected
from tetanus even if they deliver at home.
Tetanus usually starts between the 6th and 12th day of life; village people
are aware of the disease and have their own name for it, e.g. it is known as
"the jaw disease" (jabrae ki bimari) in Hindi, as a skin infection (alti) in
Oriya, as "tanakvar" in Punjabi, as "the bowstring disease" (opisthotones)
in Rajasthani dialect.
Packs prepared for use at delivery are useful in preventing tetanus. These
are simple to make and can be used by attendant at delivery.
Preparing the Packs .
1.
2.
Use the sample
*
supplied as a guide.
(a)
Take a piece of string and razor blade and wrap in clean cloth
. and autoclave.
(b)
Put some aqueous iodine 1% solution into a boiled or autoclaved
empty penicillin bottle, and seal with candle-wax.
(c)
Put (a) and (b) intp a plastic bag and seal the bag with the flame
of a candle (or with electric sealing machine
).
**
Write the instructions for the use of the pack in the local language;
The following can be a guide:
(a) Wash hands properly with soap.
(b) Deliver the baby on to a clean sheet, towel or cloth.
(c) Wash hands again and open the pack.
common rTY health cell
oorlSt- Marks Road
47/1, (First Fl
This reprint comes to you from the
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14 Community Centre. SDA, New Delhi 110 016.
Phone : 652007, 652008
GramsVolhealth
For a detailed catalogue please write to the Publications Officer.
Code H-20
How to Scientifically Prepare own
Flashcard Sets
Health
education
begins
w',itti local
beliefs.
1.
Choose an important local health problem (for which no
visual aids already exist).
2.
Collect local beliefs 'and practice about this problem.
Write out these questions in the local language.
What are all the focal words and names used to des
cribe this disease ? List them all. Find out what each
word means.
What do they think causes it ?
What do people usually do when this disease comes ?
i
What do people think usually makes it get better ?
What do people usually think makes it get worse ?
Is anything forbidden as part of the treatment?
Write the answer exactly as said in the local language,
or use a casette tape recorder to note all their answers.
In interviewing village women especially.
If there are tribals interview some of them also.
Try and get the ideas of at least 20 women.
Collect all the answers together.
summmarise.
3.
Do not interpret or
Write down which of these beliefs and practices are
harmful, harmless or helpful.
Write down what minimum essential changes are needed
to replace the harmful practices. These changes become
our teaching objectives.
4.
Write a flashcard story that teaches these points. To do
this, we start with their existing beliefs which are harm
less or helpful. For example:
Present helpful belief :
tuberculosis spreads from person to person.
(flashcard story begins with this)
(1)
Present harmful practice
they spit on the ground
Teaching objectives:
that they will know that spit
ting spreads tuberculosis.
(flashcard story gose on to
teach this. Some may know
this already).
•
(2)
Teaching objectives:
that they will spit into a rag
or handkerchief but not on
the ground.
(flashcard story goes on to
teach)
Note: We only mention germs or bacilli if necessary to achieve
our teaching objectives. If we have to mention germs, we do
so after first mentioning their present beliefs.
5.
Describe illustrations needed and numbers these. Div
ide up the story into say 10-15 pictures, and number one
part of the story for each picture.
6.
Sketch and colour the picture, 22x26 cm. will be economy
size.
7.
Next day test the pictures on a group of women.
(a) What dose the story teach them ?
Are these things the same as in (3) above ?
If so the story is clear.
(b) Do the pictures help to tell the same story?
If they say so, then the pictures are helpful. (But
check whether they recognise the different things in
the pictures).
8.
9.
10.
11.
Then if you can afford it, get a good local artist to improve
the pictures.
Write the story you usually tell on the back of each pict
ure in your own language. Number the back of each pict
ure clearly.
Mount the pictures on strong cardboard and cover with
clear X-ray film or plastic to keep dry in the rains. Put
them all in a cardboard box, such as X-rays come in.
Make a copy of the set, and send one set to Voluntary
Health Association of India, C-14 Community Centre,
SDA, New Delhi 110 016, who may be able to get it prin
ted if the idea is good, so that others will benefit.
Reference: H-16 Health Education - the missing link Christine
Mathews, J. of Christ. Med. Ass. of India, July
1974.
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14 Community Centre, SDA, New Delhi 110 016.
Phone : 652007, 652008
Grams : Volhealth
For a detailed catalogue please write to the Publications Officer.
Code H-43
Fifty Universal Health Messages
Murray Laugesen
These are universal messages because they apply to most
parts of India and nearby countries.
These are health messages because if they are adopted
they will result in control of diseases and improvement in
health.
These messages, like telegrams, say the most important
things in as few words as possible. But like telegrams their
meaning may not be clear to the receiver. So each message
has to be translated into commonly used village words and
communicated slightly differently for each area, using diffe
rent arguments, stories and jokes to suit people of that area.
In some areas, special messages for that area will have to be
added. Some examples are given.
These universal health messages are mant to clarify what
needs to be taught, to state in simple words and ideas what
people in villages need to know for their own good health.
They will be found useful as check lists for all health
workers, teachers and extension workers and those writing
training manuals and teaching materials.
The people who finally hear these messages are not just
the women and children of the villages, the people in power.
What changes are they willing for? For each message taught,
resources shoud be available. If we recommend immunization,
we must have sufficient vaccine, transport and staff to immu
nise whole villages.
FOR A HEALTHIER VILLAGE — WHAT THE PEOPLE
CAN DO FOR THEMSELVES.
WHAT FAMILIES CAN DO
1. Dig a pit for rubbish. Compost this rubbish into valuable
manure.
2. Grow a vegetable garden, using the manure from the rub
bish pit, and the waste water from the house.
3. Make a better latrine that the people will like to use, es
pecially in all new houses.
WHAT THE VILLAGE CAN DO TOGETHER
4.
By group discussion, get group decision for group health
actions (to begin with, choose a problem where success is
assured).
5. Clean village wells and keep them clean. Protect them
by building up their sides.
6. Control the worst of the village pests - snakes, stray dogs,
lice, flies, bed bugs, scabies, mosquitoes, rats.
7. Make family planning methods known and available out
side of clinics and health workers.
8. Plan now to feed the very thinnest of the toddler children
with extra food per day during the leanest months of the
year.
9. Arrange with the nearest health centre to immunise all
the children.
10. Get someone in the village trained in simple health care,
and get her supervised regularly. Get at least one village
dai trained also.
CHILD CARE
11.
12.
13.
14.
15.
16.
Breast feed as long as possible.
Introduce semi-solid food from five to six months.
Feed young children five or six times a day.
Continue giving food in illness.
Use the health service available.
Get children immunized.
17.
18.
19.
20.
Keep yourself and your surroundings clean.
Drink clean water.
Have no more than two or three children.
Have children two or three years apart.
CARE OF MOTHERS
21.
22.
23.
24.
25.
A woman who is pregnant or breast feeding, should eat
more food than she normally eats. And she should eat
some green leafy vegetables daily.
A woman who is pregnant or breast feeding needs at
least one iron tablet daily, especially if she is tired or pale.
Pregnant women and women with young babies need spe
cial care. They shoud visit a trained health worker each
month.
A pregnant woman should have the delivery of her baby
done by a trained health worker. A trained health wor
ker washes her hands frequently. This protects the mother
from fever afterwards.
Cut the cord of the newborn baby with a clean knife first
held in the flame. This will protect the baby from tetanus.
CARE OF THE EYES
For healthy eyes, eat green vegetables, and plant a kit
chen garden.
Stop infection spreading from eye to eye. (Trachoma and
pus spreads from one eye to the next by mother’s sari,
common towel, kajal or surma).
28. See a trained health worker if a person
26.
27.
- cannot see clearly in both eyes
- cannot see at night
- has pain in one or both eyes.
If something has got into the eye, or if it is sticky, wash
out the eye immediately with plenty of water. Then
show to a trained health worker.
30. Cataract is curable if operation is done early enough. Get
operations done only by eye doctors from well known
hospitals.
29.
TUBERCULOSIS
31.
Tuberculosis is a dangerous disease if it is not treated
properly.
32.
33.
34.
35.
36.
37.
38.
39.
40.
Proper treatment for tuberculosis means treatment for
at least a year.
If the patient stops treatment as soon as he feels better,
the disease will surely return. This time cure will be diffi
cult and very expensive.
Take treatment only from trained health workers.
Special foods are not necessary, but regular treatment \s
essential.
Regular treatment soon makes the person non-infectk/us.
Tuberculosis is a disease which is spread by sputum and
cough.
Stop the disease from spreading.
Cover the mouth when coughing. Do not spit on the
floor. Keep a special container for sputum, and burn it
in the fire.
If there is cough with sputum lasting more than. 2 weeks,
it might be tuberculosis. Get the sputum tested at the
nearest health centre. Show any thin child with cough
to the health worker; it might be tuberculosis.
Protect all children from tuberculosis by BCG injection.
LEPROSY
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Leprosy is not hereditary. It is a disease, and not a curse
from God. It is not a venereal disease.
Do not be afraid of people with deformity. Usually they
do not have infectious leprosy.
Leprosy can be cured with regular treatement.
Take treatment only from trained heath workers.
Start treatment as soon as possible.
Patients on treatment soon become non-infectious.
Stay on regular treatment.
Start treatment early before deformity or ulcer occurs.
Deformity can often be cured with surgery.
Inspect unfeeling hands and feet each day for injury or
burns; wear shoes to prevent injury to the feet.
SPECIAL MESSAGES FOR CERTAIN AREAS
Here are some examples of extra message for certain areas
and local problems. Each person knows his own area best •
the message has to be short and clear.
Western Orissa where
violent massage is
practised.
Many rural areas where
tetanus is common
despite branding of the
skin.
Areas where goitre is
common as in hill areas
of Assam & Bhutan
In Rajasthan where
water is scarce
In Assam where wood
is plentiful
Do not message the baby’s abdo
men after birth. This is harmful
to the baby.
Do not brand the baby’s abdo
men after birth. Instead brand
the end of the cord and prevent
tetanus.
Iodised salt prevents goitre (If
iodised salt is available)
Purify wells weekly with bleach
ing powder.
Boil all drinking water.
A CKNO WLEDGEMENT
For a healthier village is radically adapted from Nine do-it-yourself
health actions by Dr. Sam Street WHO, Ethiopia in UNICEF News
87/1976/1.
Child care—is from Child Care Education—basic universal messages
by Dr. Peter Greaves FAO/UNICEF Regional Adviser in Nutrition, card
published by UNICEF Information Service, New Delhi.
We are indebted to Dr. Greaves for the concept of Universal Health
Messages.
Care of mothers is adapted from Simple Nutrition Messages by VHAI.
Care of Eyes, tuberculosis and leprosy sections are adapted from the
relevant patient retained health records published by VHAI, and from.
pamphlets on leprosy published by Dr. R. Thangaraj, Leprosy Hospital,
Salur, A.P.
HEALTH EDUCATION AND
COMMUNITY HEALTH^’1'
BEHAVIOUR
By
D. BANERJI
Chairman & Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru University
New Delhi - 110057
VOLUNTARY
HEALTH
ASSOCIATION
OF
INDIA
C-14, Community Centre, Safdarjung Development Area, N. Delhi-16
Phones : 652007, 652008
Telegrams : VOLHEALTH New Delhi-16
Theory and Practice of Health Education
findlmp^n^rf-s hav®1taken 9reat Pains in asserting that health education is
do not rnnc' 7
from propaganda or high pressure salesmanship; they also
° iip°sJd?u lf to be synonymous with mass communication. Health education,
hif^u"^ , heT’ seeks to bring about changes within a person in relation to
his individual and community health goals.
Every community, responding to the health problems faced by it, formulates its
own heaIth goals which determine the pattern of its health behaviour. Changes
in the health goals of a community and of individuals are required when there is
a gap between the pre-existing health goals and the goals they ought to have in
the context of the current knowledge concerning the health problems and the
accessibility and availability to the community of services that are based on
such knowledge.
Three considerations emerge from the above approach to health education :
Firstly, as it involves persuading individuals and communities to shift from
some of the pre-existing health goals to newer health goals that the health
educators consider to be more desirable for them, it involves value consi
derations. There is thus always a danger of health educators becoming,
unwittingly or otherwise, instrumental in imposing certain preconceived
values which may not necessarily be in the best interests of the individuals
or of the community.
Secondly, as there are almost constant changes in the nature of health
problems, changes in the body of the knowledge for dealing with them and
changes in the services that are made accessible and available to the
people, health education has to be a continuous process.
Thirdly, as almost all health practices have been developed in the cultural,
social, political and economic settings of western countries, which are often
diametrically opposite of what are prevailing in a developing country like
India, health educators in such countries have to take an extra precaution
of ensuring that the natural science essentials of health practices are
separated from what are called the social, cultural and political overcoatings
which these practices have acquired in the course of their development in
the western countries. It is the responsibility of the healh 'educators to
ensure that the natural science essentials of the health practices are in
serted into a new "envelope” or “coating” that will harmonise better with
the social, cultural and economic environment of India.
Because of the above considerations, a sound understanding of the response of
communities to their health problems and their response to the various services
that are made available to them is of crucial importance for formulating a strategy
of health education. Unfortunately, this cardinal principle—the principle of basing
health education strategy on community diagnosis—has not received due
attention in the actual practice of health education in India.
For instance, health educators in India very willingly and actively participated on
a massive scale in “selling” family planning to the masses—to a hungry and
oovertv stricken population with very poor health status (particularly of mothers
and children) and with extensive unemployment, social exploitation and illiteracy1.
Neither the health educators in India nor the numerous health education con
sultants from abroad made any significant efforts to base the family planning
health education strategy on sound community diagnosis. Again, in the case of
practice of health education in the Indian tuberculosis programme, instead of
(
2
)
making community diagnosis, health educators chose the easier and much more
"rewarding” path of imitating their western counterparts and kept on the refrain
of "educating the ignorant, superstitious and illiterate" public of India about tube
rculosis. Later on, a community diagnosis, which was made for some other
purpose, revealed that because of weaknesses in the services, a very large number
of tuberculosis cases, who were actively seeking help, were not even being dia
gnosed as cases of tuberculosis and are being turned back with a bottle of useless
cough mixture2. These findings indicated that much more than the tuberculosis
patients, it was the organisers of tuberculosis services who ought to have been
"educated”. Similarly, studies of treatment default in tuberculosis programmes
indicated that organisational, managerial and technological lapses, rather than
lapses on the part of patients account for the bulk of the problem. Yet health
educators kept the focus only on the lapses of the patients and were thus instru
mental in diverting attention from the far more serious lapses in the services.
Health educators in India have a tendency of imitating the approaches that have
been developed in western countries and of almost blindly rushing in to take upon
themselves the task of rectifying the "faults” of the community, without fully
questioning the adequacy of the services that are being provided. In considering
health services to be something sacred, something which is to be accepted without
question, health educators in India have taken a very untenable value position.
Findings from a recent study of health behaviour of rural populations in India3
appear to be very relevant in the context of the present crisis in the practice of
health education in India. This effective study has provided data for developing
a more effective framework for the practice of health education in India.
Health Behaviour of Rural Populations in India
Considering the activities of a primary health centre as a purposive intervention to
change for the better some aspects of the pre-existing health culture of the
community served by it, a research study was designed to examine the current
status and the nature of this interaction between the health services that are in
troduced through the PHCs and the pre-existing culture of rural population in
India. A report on this study has been published elsewhere3. Only a broad out
line of the study design and the principal findings are being summarised here.
in order to get data on health behaviour of rural populations under relatively more
favourable conditions, a deliberate effort was made to select, in the first instance,
primary health centres and villages which are much above the average. The study
has been completed in 19 villages, 11 of which also serve as the headquarter
village of a Primary Health Centre. These primary health centres are from seven
states of the country which belong to the different regions.
Considerable care was taken to develop a methodological approach that was speci
ally tailored for studying the health behaviour of villagers (including their behaviour
in relation to the primary health centre services) against the background of the
total village culture. Research investigators lived in these villages for three to five
months. Apart from making special efforts to get themselves accepted by all the
segments of the village community and collecting data through village informants,
the investigators identified informantsand some “ordinary” members from each
segment of the village community and made observations and conducted depth
interviews to understand the health culture of each segment of the village against
the background of its total culture. They also prepared case reports to provide a
deeper insight into the response of the different segments to health problems in
the fields of medical care, family planning, maternal and child health, communi
cable diseases, environmental sanitation, etc. Work instructions, checklistsand
other documents had been prepared to enable all the investigators to cover
uniformly all the major areas in relation to these problems.
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)
The investigators' stay in the village also enabled them to make direct observa
tions, followed by depth interviews, of the actual behaviour of the villagers when
they encountered certain specific health problems. They could also study the
interaction between the primary health centre personnel and the villagers, both
when the former visited the village and when the villagers visited the primary
health centre. Apart from these efforts to ensure that in-depth qualitative data
are obtained from all the segments of the entire village community according'to
well defined work procedures and check lists and that they were, as far as possible,
checked and cross-checked, a quantitative dimension was given to the main
qualitative data by framing an unstructured interview schedule on the basis of
these data and administering it to a twenty percent stratified random sample of
the village households.
As an additional safeguard, after completion of the field work in the villages of a
primary health centre, some of the data concerning the health behaviour of the
community were cross-checked with the personnel of the primary health centre and
the concerned personnel at the level of the corresponding seven state directorates
of health services. An additional four states were added to the original seven to
examine how far the findings from these seven were applicable to the others.
These eleven states covered over 80 percent of the population of the country.
Recognising that the complex nature of the problem for this study calls for a new
and rather exacting methodological approach, an effective monitoring system was
developed by the research director to ensure that the data collected by all the
investigators were of a minimum accepted quality.
Taking into account the social and economic status of the people, the epidemiology
of health problems and the nature of the health services available, it was not
surprising that problems of medical care should be by far the most urgent concern
among the health problems in rural populations. But the surprising finding was
that the response to the major medical care problems was very much in favour of
western (allopathic) system of medicine, irrespective of social, economic, occupatio
nal and regional considerations. Accessibility of such services and capacity of
patients to meet the expenses were the two major constraining factors. These
findings seriously call into question the prevailing views of social scientists and
health educators on this subject.
On the whole, the dispensary of the primary health centre projected a very un
flattering image. Because of this and because of its limited capacity, it was unable
to satisfy a very substantial proportion of the demand of the villagers for medical
care services. This enormous unmet felt need for medical care services has been
the main motive force in the creation of a very large number of the so-called
Registered Medical Practitioners (RMPs) or “quacks”. The RMPs are thus in effect
created as a result of the inability of the physicians of the primary health centre
dispensary of other qualified practitioners of western medicine in the villages to
meet the demands for medical care services in the villages. Without taking these
basic issues into consideration, health educators in India have promptly con
demned the villagers for patronising such “quacks”. It is worth noting that almost
all these RMPs use allopathic medicines rather than aurvedic or unani medicines.
When these RMPs prove ineffective, depending on the economic status of the
individuals and the gravity of his illness, villagers actively sought help from
government and private medical agencies in the adjoining (or even distant)
towns and cities.
There were, however, numerous instances of adoption of healing practices from
qualified or non-qualifled practitioners of the different Indian systems of medicine
1 and homeopathy and from other non-professional healers. This aspect of health
behaviour has received much more than its due share of attention from health
educators and social scientists. In their preoccupation with writing in details
about some of the “exotic” aspects of health behaviour, they seem to have over
(
4
)
looked the fact that among those who suffer from major illnesses, only a very tiny
fraction preferentially adopted these practices, by positively rejecting facilities of
the western system of medicine which are more efficatious and which are easily
accessible and available to them. Usually these practices and home remedies were
adopted : (i) side by side with western medicine; (ii) after western medicine
failed to give relief; (iii) when western medical services were not accessible or
available to them due to various reasons; and, (iv) most frequently, when the
illness was of minor nature.
Another very significant finding of this study is that the family planning programme
had ended up in projecting an image which was just the opposite of what was
actually intended by health educators and social scientists. The image of the
family planning workers in rural areas was that of persons who use coercion and
other kinds of pressure tacticsand who offer bribes to entice people into accepting
vasectomy or tubectomy. Because of this approach to family planning and failure
of family planning workers to develop a rapport with the villagers, sometimes the
villagers were unable to meet their needs for family planning services. There were
several instances of mothers who, failing to get suitable family planning services
from the primary health centre, took recourse to induced abortions to get rid of
unwanted pregnancies. This not only pointed to the failure of the programme to
meet felt need of individuals for family planning services but it also draws atten
tion to the failure of the programme to offer suitable abortion services to mothers
with unwanted pregnancies, despite the passage of the abortion bill. Ironically,
services of health educators and social scientists had been mobilised on a very
large scale to provide “support” for such a family planning programme.
Another significant finding of this study is that there was considerable unmet felt
need for services of the Auxiliary Nurse Midwife (ANM) at the time of child birth.
Villagers were keen to have the ANM's services because they considered her to be
more skilled than the traditional dai. Wherever the ANMs provided the services,
the dai's role had become less significant. However, the overall image of the ANM
in villages, particularly in north India, was that of a person who is distant from
them—meant only for special people or for those who can pay for her services.
She is not for the poor. She can be called only when there are complications and
then also she should be paid. Because of the inability of the ANMs, the majority
of the deliveries even in the villages where the primary health centre is located
were conducted by dais and relatives and neighbours. In villages with no primary
health centre, their sway was almost complete.
As in the case of the Registered Medical Practitioners, confinement by relatives
and friends and by indigenous dais was popular among the villagers not because
of their intrinsic merits but in the absence of suitable services from the ANM/Lady
Doctors, they were compelled to settle for something which they considered to be
inferior but which was all that was accessible to them.
The only two programmes which can be stated to have reached the grass-roots
level in the villages were those concerning malaria and smallpox. Despite several
complaints regarding the sincerity of these workers, there was almost a universal
agreement among the villagers that these workers did pay visits to them. A signi
ficant finding was that these workers did not encounter any major obstacle in getting
participation of the community in these programmes. Except when there were
understandable compulsions, such as prospect of a poverty stricken mother losing
wages for 4-5 days at the peak agricultural season due to the child's vaccination
reactions, and some cases of orthodoxy, their was general acceptance of smallpox
vaccination in village communities. The number of children who were left un- <
vaccinated due to lapses of the parents appear to be a very small fraction of those
who remained unvaccinated due to lapses of the vaccinators and their supervisors.
Patients suffering from tuberculosis, leprosy and trachoma got very little services
from the corresponding national programme. It was remarkable that despite this,
(
5
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these patients actively sought help from elsewhere—from the nearby towns or even
big cities. Such help was not only much more expensive and bothersome but it
was also much less efficacious, both clinically as well as epidemiologically. Other
preventive measures for these diseases, of course, were almost non-existent.
Although, by far the great majority of the villagers still went to the fields for
defecatior; significantly, impelled by sheer felt need, a number of them had in
curred considerable expenditure to get latrines of various types installed in their
homes. They got little encouragement or help in any form from the primary health
centre. This was another instance of the health institutions falling behind even
the already existing felt need for preventive services in the community.
There were no sustained efforts to deal with such diseases as cholera, diphtheria
and guineaworm and bookworm infestations as public health problems. When,
however, epidemics of cholera and diphtheria struck separately three of the study
villages when the field work was going on, the primary health centre and the
district health authorities encountered little difficulty in getting community parti
cipation in the anti-epidemic measures. There were also instances of villagers,
on their own, seeking triple antigen immunization from the primary health centre.
Very often even this need was not met by the primary health centre.
Extensive prevalence of adjectpoverty, as a result of which more than half of the
population was unable to meet even the minimum dietetic calorie needs, and
appalling conditions of sanitation, water supply, housing and education presented
an ecological setting which was conducive to a widespread prevalence to various
types of health problems in the community. These health problems formed only
a component of the overall gloomy picture of the way of life in Indian villages.
Ignorance, superstition, suspicion, apathy and fatalism should thrive in such a
milieu. It is, therefore, a tribute to the strength of the culture of the rural popu
lations in India, that despite these overwhelming odds, their health behaviour has
retained so much of rationality. It is doubly unfortunate that health educators
overlooked these obvious realities and uncritically set out to “educate” the people
of the country at the behest of equally uninformed health administrators.
As in the country as a whole, as indeed in the international fields, in the villages
also, the conditions of acute poverty and helplessness was associated with a
political system which was dominated by a tiny group of highly privileged persons.
This political power, in turn, vested this group with additional power to further
exploit the weaker sections. Over and above, they got support and sustenance
from similar power elites higher up in the hierarchy which extended right into the
international arena. Each one of the villages studied thus presented a picture of
a rather stable equilibrium in which a vast majority of the village population was
kept effectively subdued by a small privileged group which had acquired political
power by controlling land, trade, cooperatives, industry, money lending, education
and the law and order and the judicial systems. Experience had taught the persons
belonging these weaker sections that efforts to stand up to the prevailing order
would invite very deterrent punishment. They had thus learnt to live with the
system, thus giving it the appearance of "stability”. Health Education professio
nals allowed themselves to become an instrument of the power elites for main
taining such an inequitous stability.
Because of their urban orientation, it was observed that workers of rural health
and other developmental agencies generally had a strong distaste for rural life.
This distaste was for the entire way of life and not simply for the very poor
facilities available there. Health workers, including health educators, tended to
keep a distance from the rural population as a whole. However as they were
required to work for rural populations, they took advantage of the village power
structure and confined themselves, as far as possible, to satisfying the privileged
gentry of the village. In doing so they (a) won approbations and rewards from
(
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)
the so-called community leaders who had the. ear of their superior officers and of
the political leaders at the higher scales; (b) dealt with the least disagreeable
segment of the village community; and (c) got a freehand to "tackle” the rest
of the community.
The findings of this study brought out a number of key issues which are of far
reaching significance for the future development of a sound strategy for the
practice of health education in the country :
1.
It brings out clearly that there is no significant cultural resistance to acce
ptance of modern medicine as long as they are efficacious and they are
accessible and available to them. This finding, therefore, seriously calls
into question the belief of a very significant sector of health administra
tors, social scientists and health educators that there is considerable
cultural resistance to the acceptance of modern medical practices in
rural populations in India;
2.
That the existing health services are working at a grossly low level of
efficieancy, which has led to considerable under-utilisation of these ser
vices. Priority should, therefore, be given to ensuring that this problem
is overcome;
3.
There is also considerable scope for bringing about qualitative improve
ments in the existing health services and bringing it more in tune with the
social and cultural setting of the village communities; and
4.
Finally, after ensuring a reasonable level of utilisation of the existing
capacities and after bringing about the required qualitative changes, there
is a case for making quantitative expansion of the health services to meet
the requirements of rural populations. This will imply rectification of the
existing imbalance in allocation of resources : this will imply a shift in
providing services from the privileged to the underprivileged.
Basis for an Alternate Approach to Health Education
The findings from this study raise a number of issues which should have important
bearing on the entire field of health education in India—on education, training,
practice and research : in Health Education in India.
1.
There is clear evidence that individuals and groups belonging to all the
segments of rural populations from the different regions of the country
have, on their own, brought about significant changes in their health
behaviour in curative, preventive as well as promotive fields when the
health services that were available to them had fallen far short of the
requirements.
2.
These remarkable shifts in health goals of the community and of indivi
duals had been brought about without any intervention of health educators.
If anything, health educators have to take the blame for being instrumental
in diverting attention away from the central issues of community diagnosis
by raising issues which are peripheral, if not blatantly counter-productive
and irrelevant.
3.
The most urgent task before health educators in India wilt, therefore, be
to "catch up" with the already accepted individual and community health
goals by emphasising that the needed services be made available to them. e
4.
As more effective health services are made available on a larger scale,
health educators will be called upon to motivate people to make more
effective use of these services. Motivating patients of tuberculosis and
leprosy to take the medicines regularly, dispelling rumours concerning
alleged illeffects of contraceptives and ensuring adequate coverage of the
different immunisation programmes, are instances of such fields of action.
5.
As additional resources are made available to the people, health educators
will be required to promote more effective participation in the more
extensive programmes that are developed in such fields as maternal and
child health services, environmental sanitation and control of communi
cable diseases.
6.
These changes in the role of health educators will require fundamental
changes in the entire field of health education in India—in developing the
content of health education and in the fields of education, training and
research. Practice of health education will no longer be confined merely
to implementing “Instructions" that are handed down by programme
administrators, as has generally been the case thus far. Health education
will be an integral part of an elaborate interdisciplinary effort for formula
ting and implementing effective community health services for the country
and for evaluating them. Acting as a “spokesman" for the community,
practitioners of health education will be called upon to marshal the rele
vant social science data and fit them into the bigger process of pro
gramme formulation so that it is possible to promote participation of the
community in these programmes.
References
1.
Banerji, D. (1971) : Family Planning in India : A Critique and a Perspective, New
Delhi, Peoples' Publishing House, pp. 31-35.
2.
Banerji, D. (1971) : Tuberculosis : A Problem of Social Planning in Developing
Countries, NIHAE Bulletin, Vol. 4, No. 1, pp. 9-25.
3.
Banerji, D. (1974) : Health Behaviour of Rural Populations in India : Impact
of the Primary Health Centres, Economic and Political Weekly, Vol. XIII,
pp. 2261-2263.
Acknowledgement
Permission from Dr. Banerji to reproduce this article is gratefully acknowledged.
q.|G
VOLUNTARY HEALTH ASSOCIATION OF INIIA
C-45 South Extension Part II
New Delhi - 110049.
-"-.SELECTION OF VILLAGE HEALTH WORKERS
1
,Who selects the VHW ?
THE VILLAGE HEALTH WORKER IS CHOSEN BY THE PEOPLE OF Hki
NEIGHBOURHOOD
I
________________________________________________________________________J
This is only right and proper, if we wish the village to suppor.. the
worker. The village people can make a good choice, if they kr- /■; ’..hat
kind of person to select.
.2
What kind of VHW is needed ?
The most suitable person is usually a woman who is active and . .1
respected in the community. She is the sort of person ’•■■horn vt .
yi
like to talk to, and the person they would turn to for help i .Loe of
trouble. She is often illiterate, and though this is
e ha
_.p,
literacy is not the most important quality needed. The most important
thing is that she is well-trusted and respected person, and one who will
work intelligently and energetically. In villages where often only 10%
of the women have learnt to read, there are many intelligent, hard
working women among the illiterates. Many of these women have good
memory^ are good at conversation and good-listeners.
Women are best for this work:, as -most illness and unnecessary deaths occur
among small children and women. It is easier for women workers to reach
the women, and give them advice and'teaching. "They have access to the
kitchen where the traditional policy of nutrition and -child rearing of
the family are determined by the dominating grandmother or mother-inlaw". They are able to talk to women in their own terms.
For most village women already understand from experience about married
life, children, the necessity for family limitation, childbirth, death,
the dangers of tetanus, measles and other serious diseases.
Most married women thus have many advantages over a single, shy and
lonely young auxiliary nurse, on her first assignment in a strange
village, with no husband or brothers to help her and guard her.reputation.
Single village girls who have left school and are awaiting marriage are
also not ideal, because they find it difficult to advise older women
about family planning and children with any authority. Sometimes a
younger married woman is chosen by the village because of her personal
qualities. Usually it is an active but mature woman. Sometimes it will
be a widow in need of the salary. Women with children growing up,naturally have more time for part-time work. Health workers may be of
various castes, but in villages where is purdah, or strong caste res
triction, the dais or their daughters, having freedom of movement that
other women do not hate, should be considered for this work.
In remote areas where travel is hazardous for women, men may be employed
for this work in the beginning.
3.
How to select the VHW.
It is not enough to just ask the Sarpanch, Pradhan or headman. He
usually represents the leading caste or community. Minority groups
must be consulted, not forgetting the women.. We then tell them what
type of woman is needed- for this work. All this is best done by house
calls, on say every fcenth house, not forgetting the minority groups
living on the edge of the village. We ask them, which woman would they
consult if they felt ill or depressed. Usually the same names will be
suggested by many people. This information is then given to the village
council for decision. If the VHW chosen proves unsuitable, this can be
discussed again, and another appointed by thv village council.
* Extracted from "Village Health Workers foi- Basic Health Care"
published by Voluntary Health Association of India, VHAI-125
Dec. 1975 p. 18 •*
,.
■
’
TRAINING VILLAGE HEALTH WORKERS
Who can train village health workers ?
Health professionals as trainers.
Health professionals at present training village health workers in India
include public health specialists, MBBS doctors, public health nurses,
registered and auxiliary nurses and social workers. Training of VHWs is
best shared between doctors and nurses, so that, the training does not
collapse, should the only trainer go on leave. Also pharmacists ..nd
laboratory technicians can participate in training the workers, while
the best artist for preparing visual aids for ?their training may be
unemployed and uneducated, living in a nearby village. Village doctors
will prefer an experienced doctor as trainer.
2,
VHWs learn from each other.
Village health workers learn most of
all from each other, according to 17
village health workers interviewed at
Jamkhed. The village health workers
.
said that most of their learning was
"
informally, from more experienced village
health workers. Between them these women
were in weekly contact with the deaths,
births and diseases of some 20,000
village people. So, over a few years,
if they keep sharing their experiences,
they can obviously learn much from each
other.
Training the trainers.
Orientation - Seeing is believing.
Orientation is best done by a visit to scheme successfully using village
health workers. An experienced doctor or nurse may grasp it all in a
few days; some might need several weeks or months.
Revision of attitudes.
Most trainers need correct attitudes and training in how to communicate.
Professional superiority complex can prevent many doctors and nurses
from receiving vital feedback about the villages and the programme.
Can the supervisor respectfully listen to and accept the felt health
needs of the village as expressed by illiterate village leaders ? Will
the trainer listen to the village health workers suggestions on what
they need to learn next ?
Is the trainer committed to excellence in medical care at any price at a price few can pay ? Or does he need to recommit himself to some
basic health care for all the people ?
Does the trainer have enough sympathy for village people, or does he
privately look down on them, for being tribals, low caste or not from
from his own State ? Would he blame the patients for coming late in
the illness, or blame himself for not having organised some health
education earlier ?
Foremost doctors and nurses, village health is so different from hospital
medicine, that years of self orientation are needed. But this can be
much speeded up by in-depth orientation seminars, conducted periodically
by State Voluntary Health Associations and others on community health
and social justice themes.
change has to begin with us and not with them
3•
How much training is needed
Initial training period.
* If we insist on regular weekly training, it is not as important
to have a long initial training period to start with.
* It is often more useful to spread the initial training in the form
of weekly training sessions, rather than a concentrated training
period.
* Married women, dais,^indigenous practitioners and school-teachers
are groups that usually prefer to be trained in groups separate from
each other. .
* An oral exafliination can be held at the end of the initial training.
Village Women Health Workers
For most village women we need to arrange training when they are not busy
in the fields. This may be for 2 weeks (Palghar) or upto 5 weeks
(Kathmandu). This may however be impossible unless the women can bring
their young children with them.
Village teachers may agree to come for 1 month in their annual vacation.
Where bus services are good or the villages close by, workers can attend
the course daily.
Village indigenous medical practitioners may'hot wish to lost income and
thus may prefer a shorter intensive course.
Village midwives also may not be ready to be long away from their patients.
Thus a 4-day course for medical workers may be all that is possible.
Many institutions will want to provide free food and shelter for the
trainees, though we may also give the villagers the chance to pay for
this. They could being grain or produce as 'fee*1 and should cook for
themselves as a group. There may be a school hostel building unused for
many weeks of the year.
Two training centres in easter India have taken village people out of the
village to a training centre with hostel for one year's thorough training.
This made them thoroughly accustomed to the comforts of hostel life, and
they did not wish to return to village life.
I
HEALTH WORKER SHOULD NOT BE OVER TRAINED SO- THAT
I
SHE LEAVES THE AREA WHERE SHE IS MOST
J
NEEDED
I
I_____________________________________________ L
-13th axiom of Maurice King, adapted
Regular on-going training at the health centre
*
This is a key feature for the success of non-professional workers.
Non-professionals can be put to work with little initial training1,'
but they do require years of in-service training.
*
The amount of in-service training suggested is -
or
or
one day per week
two days per fortnight
four days per month, where distances are great, or roads
few as in mountainous areas.
This may be reinforced by training camps in villages in the slack agri
cultural season.
I
VILLAGE HEALTH WORKERS NEED REGULAR
.
I
j
INSERVICE TRAINING
i
1_________________________________________________
*
Regular examinations every 3 months are useful in encouraging interest
in on-going training from trainer and trainees.
The weekly training session at the health centre is, for village
women health workers, the social event of the week,. They come dressed
in their best. This was observed in Maharashtra and in Orssa where
the VHWs, though illiterate, are treated with respect by the doctor
and nurse trainers.
Training the VHW in the village
Training the VHW is repeated whenever the supervisor-trainer visits her
in the village. The more regular the supervisors visits, the more
regular the training.
*
In the village the trainer can give individual attention to the VHW,
for the problems she is facing in that village.
*
Encouragement should be specific and with feeling, such as, "I liked
the way you talked sympathetically to that worried mother".
*
The VHW must not lose "face" or status in front of the people if the
supervisor wants her to be effective with these people.
Patients
coming for second opinion should be clearly told by the supervisor
that the VHW's advice was correct, or that he will see the patient
again, with the TOW also present.
*
The village is rich in living examples of health problems. For
example, if a child with chickenpox is seen, the rash is compared
with the colour photograph of smallpox to check the diagnosis. If
a child is seen with anaemia, this is demonstrated to all present,
and treated.
PROGRAMME OF WORK FOR THE VILLAGE HEALTH WORKER.
1. Planning the work
Plan ung of the week's work can be done each week or fortnight,
when the supervisor visits the health worker in her village,
For monthly visits , the village can be divided into 4 parts , and
each week a different part of the village is visited for the monthly
Visits-now due.
Special risk patients who are not improving will need weekly visits.
Small work cards, postcards size , are used in the Palghar (6)
to summarise the work to be done each month in each part of the
village health workers area. These cards are taken on house visits
and symbols are used, so that semi-illiterate workers can fill them
in rapidly.'
^Actual size 13"X 20cm'in "regional language)
to illustrate 1.
VHW'S WORK CARD
Village --------------- —
S.No. Name
--------------- Primary Health Centre
Jan. Feb. Mar. Apr. May. June. July.Aug. Sep.Oct. Nov. Dec
SHouse visit
Centre Visit
Immunization
incomplete
Q) Weight increased
Weight decreased
__ T Family Planning
v Advice Needed
[2 Kwashiorkar
complete
(2) House visit )
) At
Centre Visit) Risk
Q>Constant Weight
vt? Family Planning
£>£) Child sick
v advice practised
XZ Did not see on
House visit
. . Did not come to
y\ Centre
2 Food Supplement
[-^Migrated out
Immigrated.
2.
Recording the work done
by literate workers
Work is recorded on work cards (see 1) or in a health workers
note book. Each have similar columns for name, remarks and
, month of the year.
.■
.«:•
by illiterate workers.
In villages where very few women are illiterate,, it will be necessary
to recruit illiterate but intelligent women. ,As part of their training
they will hopefully learn toread, write and count. But until then,
either son , relative, student volunteer must record ,oa work cards,
or supervisor, using an: interview form, must record her x^ork
for her. To make it easier for illiterate workers, it may be necessary
to simplify the methods used, for example, use a bangle for_armr
circumference, instead of tape measure,, or weightgrowth cj^rt,
for toddler malnutrition'7
3.
How many people can a VHW care for?
In one Bangladesh programme, peoples healers each care for the
simplest health needs of 20-40 families.
••
In Manali -jri-'meuntainous Himachal Pradesh each VHW cares for. 250
people or so, so that there is one worker-for each isolated village.
In jamkhed each'\vdrker tares for about 1000 people,------
In Palghar-also in Maharashtra one worker cares for mothers, and
children among 2500 people.
Vfhen more than one worker is employed in the same village it is
'important to define each ones area of responsibility.. |—
If a-workers area is scattered she has more walking to do and can
take care of less people.
EACH WORKER SHOULD KNOW ALL THE PEOPLE SHE SERVES
4.
Work assignments for VHWs.
These are adapted from these in use in the Palghar and Jamkhed
programmes in rural Maharashtra. The assignments are derived
from the health priorities of the programme, which are derived in
turn from the observed and felt health needs of the people of that
area. So, in some areas, village health workers maybe given no
leprosy assignments, but malaria assignments instead. Feeding
programmes are not so necessary after a good monsoon. Smallpox
vaccination should not be necessary by 1977. Thus these assignments
change with place and time.
,
Census
h t. , .v -.
Take census with the help of the supervisor, using the sample house
to house form or using a simplified method for illiterate workers,
using picture drawings and strokes or ticks. This is done at the
beginning of the programme and at the end of it, and possibly each year
as well. If the VHW is illiterate take the help of an educated person.
Vital Statistics.
Record births, deaths, families moving in and out; or notify these orally
to the supervisor, each week , or fortnightly at least. This helps the
census up to date.
5.
VHW's work assignments for Healthier Children
■ Children at risk : identification and home visits.
VHW lists all children at special risk.. S'he .visits them monthly at
least. Indicators of high risk, adapted from (6) are
* Weight below 60% of standard, or bangle of 4 cm diameter
passes above the elbow in child over 1 year old.
* Failure to gain weight in 3 successive months.1
* Loss of weight during 2 successive’’months.
* Birth weight was less than 1.5. kg.
* Recent acute illness such as measles or gastroenteritis.
* Other reasons for special care may include no mother or no father,
congenital abnormality, tuberculosis in the family, recurrent
malaria, severe anaemia, night blindness.
Supervision of growth; •
,• ;
Weigh all preschool children monthly and chart on the growth chart.
Advise mother according to the child's, progress, on how to feed the child.
Or , use a 4 cm diameter bangle for screening all toddler children monthly.
Keep in the feeding programme all these children on whom the bangle goes .
above the elbow.
Anaemia.
VHVZ checks all children every 6 months for pallor of lips and tongue.
This can be aided with the use of colour photographs. VHW motivates all
such to eat green leafy vegetables, and treats all such with oral iron.
Night blindness
VHW'' records all complain ing of night blindness and gives them each
Vitamin A, 200, 000 units six monthly, and starts them on .green leafy
vegetables, daily.
Illness care of pre-school children
Under the supervision of the ANM or supervisor, she examines and treats
children, and this helps her when she has to see and treat children on her
own during the rest of the week.
Referral
VHW refers very sick children to the doctor, and notes whom she has
referred , and discusses these with the supervisor.
6.
VHW's work assignments for healthier mother.
Care of all pregnancies.
Visitall married women every one one to three months fill up their home
based health record, detect early pregnancy, start antenatal care, especially
iron and folic tablets for anaemia and tetanus toxoid. Continue this after
delivery.
Identify 'at risk mothers.
'At risk ' mothers needing special care include previous difficult delivery, or
stillbirth, previous bleeding prior during or after delivery, small pelvis or
height less than 145 cm, weight of mother less than 40 Kg near term, first
baby or fifth baby or more, swelling of hands or face, and pallor. Mothers
with several such factors present, are advised to deliver at the health centre.
Clean deliveries
<
.
To preventtetanus of the new bom and puerperal sepsis of the mother, VIRY,
dai and ANM must all promote clean delivery. VHWs promote clean deliveries by
befriending and persuading untrained dais to
* wash their hands
* use sterile delivery kits supplied by VHWs
* come to training courses.
Where relatives instead of dais conduct the deliveries. VHWs can be trained
to conduct clean deliveries.
Family Planning
The VHw advises parents on family planning and issues pills and condoms.
Condoms can be issued through her brothers or husband. She lists all those
in the village'who have,had sterilisation or who are using loop, pill or condom.
She refers to the health centre all wishing to have loop and sterilisation.
7.
VHWs Work Assignments for a clean village, with control of blindness and
spreading'disease'
'
~
Motivation for mass campai,^ ;s.
Once the village peoples priorities are known the VHW motivates for the next
mass campaign such as immunisation, pest control, village clean-up. She
distributed deworming medicine, Vitamin A, nutrition supplements and other
mass treatments.
Blindness
VHW records all blind people who cat not count fingers at 1 metre. These are
referred to the next mobile eye hospital for possible cure and followed up
after.
’
Tuberculosis
VHW records all with sputum and cough. She gets sputum on to a slide
with a match flame, then sends, it labelled to the laboratory. VHW
suspects other tuberculosis cases such as toddlers from TB families, with
cough, fever or malnutrition. VHW refers such cases and follows up
all patients on treatmen t and especially visits defaulters.
Leprosy.
VHW suspects likely cases with patches and refers them to the supervisor
VHW follows up by visiting homes of those with leprosy each month to ensure
that drugs are taken, families encouraged, anaesthetic hands and feed
protected, and contacts diagnosed at first sight. VHW records suspected
cases and those on treatment and whether they take their drugs each month.
Malaria ,
VHWs can assist Government workers by obtaining blood smears on all fever
cases and starting all positive cases on treatment. Once such positive cases
are reported malaria staff are called to spray insecticides.
8.
VHWs work assignments for care of accidents and illness.
First aid for accidents.
VHW cleans all cuts and injuries immediately, applies antiseptic and bandage.
VHW performs mouth to mouth rescuscitation for drowsing
VHW cools burnt skin immediately with water, apply antiseptic and covers
from flies and dust. She then refers all burns and gaping, crush and deep
wounds to the doctor.
Treatment of simple illness
She treats symptoms with the drugs provided.
Recognition and referral of all serious illness.
Standing instructions are needed for this.
'Aa (1,13
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-45,
SOUTH
EXTENSION
PART-II,
Phone : 616308, 78433
NEW
DELHI-1 10049
Telegrams : -VOLHEALTH New Delhi-49'
-I
VHAI -251
VILLAGE HEALTH WORKERS (VHWs) SCHEME
Ingredients for Success.
DEFINITION
* A village health worker is any health worker who works for the
people of his or her own neighbourhood to improve their health.
* A village health worker is one of the people chosen by the people,
to work for the people, of that neighbourhood.
* A village health worker is regularly guided and supervised to work
with the people of the neighbourhood, and regularly trained by health
professionals.
THE INGREDIENTS OF SUCCESS IN VHW SCHEMES
1.
Involvement of the community. Many people now believe that
community participation is a "must", if the goal is not just health but
total development . Total development cannot happen without
involvement of the people in planning and determining their own destiny.
When the people are fully consulted and involved, only then are their
full energies released.
The projects now using village health workers have all involved some
degree of community participation. But the degree of this community
participation should now be carefully evaluated for each project and
compared with the project outcomes such as extent of change in birth
and death rates.
My own impression is that success is greater where community
involvement has been greater.
2.
Respect for the VHW's as persons. . Widows, Harijans and women
without issue have found fulfilment and work. This has awakened feidden
talents.
Comments from VHW's (at Jamkhed)
"They (the project leaders) believed in us. That was what got
us started. Before I did not have any ideas. Now I have
so many ideas about improving my village that I cannot go
to sleep at night".
These VHW’s like new flowers must not be crushed but allowed to
flower fully.
: 2 :
Psychologically crushing the village volunteers, destroys the scheme.
The Tumkur project near Bangalore used hundreds of volunteer workers
to control T.B. a few years ago. According to a leading person in
National T.B. Programme, this volunteer involvement failed mainly
because the doctors and other professionals were unable to accord
proper respect and unable to listen to any ideas from the volunteers.
There was an authoritarian relationship resented by the volunteers.
3.
Financial plan of support.
" There is no need to form them into a cadre and pay them a
remuneration from public funds. It would be desirable to leave
them to work on a self employment and part time basis"
- -Report of the Group on Medical Education & Support
Manpower, Ministry of Health & Family Planning,
New Delhi April 1975.
Unfortunately, very few villages have been found willing to support
such workers and Panchayats in some States cannot legally use their
funds for such purposes, Thus the project or PHC must pay the VHW,
with all the dangers that the chance for local participation in the
scheme and necessary for consulting the village will disappear.
In another ■ar oa last year a small scheme using VHWs failed
to control TB and other diseases as hoped by the doctor in'charge.
He had excellent rapport with the village people but supervision was
not effective due to lack of community support (Panch was weak) and
project did not pay the health worker . So there was no control
from either village or project over the VHW.
GOOD LEADERSHIP AND ADMINISTRATION - HEALTH PROJECT
MANAGEMENT
There is an old saying that if one wants a new and difficult job done,
one should find an experienced and trained hand for the job.
Frequently a young doctor at age 25 with no previous experience of
administration is placed in charge of 40 staff in a Primary Health
Centre or health project.
If an inexperienced young manager is also expected to start village
health worker schemes, which could add on up to 100 workers per PHC
to supervise, the results will not be good.
Already serious project failures have occurred, traceable to
inexperienced doctors without suitable training.
One project had a doctor who had not learnt to share his medical
knowledge with lay people, and so when a village health worker brought
a patient with TB, he did not tell the patient or the village health worker
about the diagnosis. Consequently they could not cooperate with him in
keeping the patient on treatment.
u , ill
: 3 :
Another project had a doctor, who was not familiar with high risk,
under-fives, third degree malnutrition, tetanus toxoid in pregnancy,
and other community health concepts. He also had difficulties relating
to the nurse, in accepting that a nurse had useful ideas. Such
difficulties are bad enough in a clinic, but in village health worker
schemes,they make for certain failure.
Those projects which have succeeded so far, have succeeded because
top management has been sound, and has personally taken part in training
of the nurses and village health workers.
TRAINING IN HEALTH PROJECT MANAGEMENT.
For expansion of programmes it will be necessary to give wider-and
broader training t'o PHC or health project doctor, or special
administrators from management or social science backgrounds may
.be.recruited .
All project managers will need training, in several areas, beside public
health, so that the necessary knowledge attitudes and skills are acquired.
Some suggested topics Management.
Decision making, problem solving, use of time,
management by objectives, project formulation,, costing, . .
cost and benefit, personnel management, budgeting,
management of physical plant,vehicles and materials,
control, evaluation, organisation structure, leadership
styles, participatory management.
Sociology
Economic causes-of ill health, socio economic analysis
' of a village, village-expectations of outside agencies,
village profiles of land, water, literacy, power, health,
caste, crops and markets, ..food taboos.Local leaders
of various caste or community groups could be asked
to tell about their own villages.
Communication
Art of listening, known village perceptions of health
programmes, exact local meanings of certain words
used for disease, making visual aids locally, transactional
analysis as an aid to better inter personal communication
-in the health team, how to conduct a meeting and elicit
all points of view .
Training.
Writing learning objectives, writing lesson plans,
designing curriculum to suit local conditions and
priorities, teaching methods for training village
health workers.
Public Health
Community diagnosis, survey, selection of priorities,
community participation, census and population projections
for the local area , writing objectives, writing detailed
plans for control of local diseases and pests, organisation
of mass campaigns,, health records, information system
and built in evaluation.
This was a paper presented to the Nov 76 Seminar on "Community Leader
ship - Education of Agents for Health Care" by Dr. Murray Laugesen,
Community Health Consultant at VHAL The Seminar was sponsored Jay the
Indian Association for Advancement of Medical Education, ICSSR.AIIMS & NIHAE
5Q
VHAI
assists
in making
health
a reality
for all
the people
of India
with their
involvement
and
participation
through
the
voluntary
health
sector
'
VHAI is for all of India
VHAI conducts seminars,
workshops, and other education
programmes on community health. VHAI
also assists other associations with
seminars in this field.
It is a federation of fifteen voluntary
health associations in fifteen States/
Regions. These include Andhra Pradesh,
Bihar, Goa, Gujarat, Karnataka, Kerala,
Madhya Pradesh, Maharashtra, Meghalaya,
North-western Region (Punjab, Jammu
and Kashmir, Himachal Pradesh and
Haryana), Orissa, Rajasthan, Tamilnadu,
Uttar Pradesh and West Bengal. Its
services are available also for other
States, not yet officially affiliated.
VHAI is
a non-profit registered society.
Its constitution is SECULAR.
VHAI promotes the education of village
based COMMUNITY HEALTH
^pLUNTEERS.
VHAI helps people to develop or extend
community health services and
programmes.
j Health care
administration
Open to all
Membership in VHAI and opportunity for
its services are in principle open to all
health institutions in the voluntary
non-profit sector of health care irrespective
of religious affiliation.
Community health
is VHAI's main thrust.
|
j
courses are VHAI's way of imparting
managerial skills to hospital and health
centre personnel.
VHAI conducts seminars and workshops
on Hospital Administration, Community
Building, Hospital Finance, Accounting,
Communications, Planned Change in
^^spitals.
VHAI provides a unique fifteen month
VHAI also gives on the job training by a
CORRESPONDENCE COURSE and
Residency programme in Health Care
Administration.
Anaesthesia course
for nurses
VHAI assists nurses
tmailer rural hospitals may have the
to assume new roles in the community.
VHAI is involved in the revision of syllabi
for nursing personnel to include more
community health and the preparing of
teaching aids and materials.
benefit of a qualified nurse anaesthetist.
Our nurse anaesthesia graduates can
also assist in larger hospitals. After the
academic course, there is an additional
year of residency in the nurse's own
hospital, for her to gain facility and greater
confidence.
VHAI shares expertise with schools of
nursing and other organisations in
continuing education, by workshops on
* Nursing management and supervision
• Improving patient care
' Improving written and practical exams
* Health education.
The purpose is to make this medical
cience available at lower levels, so that
Liaison
with Government and other agencies
comes naturally to VHAI.
VHAI’s personnel habitually visit
Government Ministries and offices to get
information for our members, to follow up
their petitions, and promote good health
care legislation.
We keep in contact with numerous
national and international organizations,
and encourage the formation of
associations similar to ours in other
countries.
VHAI collects, sifts, screens and
distributes suitable health learning
materials from all over the world.
VHAI publishes its official magazine,
“Health for the Millions" every two
months. This keeps its people up to date
with what's happening in the field of
^:alth care.
Co-ordinators from VHAI's central office
keep in contact with the State VHA’s and
assist them with their activities.
Health Publications
VHAI puts together its field experiences
in the form of health learning materials.
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VHAI provides
information
to its members. We have a data bank
and personnel to provide members and
interested public with useful facts,
statistics, materials for seminars, and
addresses pertaining to the voluntary
sector of health care.
It all began
Bangalore, in January, 1969, with a
conference of leaders of voluntary
hospitals and health associations. VHAI
was organized on a national basis with its
present name at a meeting in Madras,
September, 1974.
VHAI is governed
VHAI publishes books, pamphlets, flash
cards, flannelgraphs, film strips and slides.
by a General Body in which there are
representatives of the constituent State or
Regional members. There is an Executive
Board which manages affairs between
general body meetings. There is a central
office with staff in Delhi. Supervision of
the central office is in care of an Executive
Director. He is appointed by the Executive
Board.
The Philosophy of VH4I
What is our NEW VISION of health care?
What makes it appealing? All we have
to say is contained in the simple words:
"COMMUNITY HEALTH”. We begin
with the community. Our goal is a healthy
community. Our aim is to maintain the
health of the community.
We promote SOCIAL JUSTICE in the
provision and distribution of health care.
Persons and associations classed as
VOLUNTARY have a great opportunity
to help people see the value of good health.
We help them to want health services.
It is good for us to encourage people
to demand health services as a HUMAN
RIGHT.
^Che health services we speak of are mainly
^Basic or primary. These most commonly
meet the needs of the largest
number of people.
We believe in a REFERRAL SYSTEM.
Primary health care is the base of the
pyramid. This is most important. But it
rises towards hospitals and medical
education.
We believe in PEOPLE. We work with
people. We believe that people grow
better when they are encouraged to do
whatever they can for themselves.
We hope that good health may become
a reality for all the people of India.
We say that TAX MONEY marked for
health must be reasonably shared with
all the people. It is mainly the Government's
duty to provide health services for the
people.
We believe also in RESEARCH, higher
knowledge and the advancement of
health science.
But our first faith is in SHARING.
We emphasize health service for the poor
and neglected. They are in greater need.
We know enough already to provide all
citizens with simple health care. If the
f
poor do not have health, it is not because
we do not have sufficient knowledge. It is
because we as the organized people of
India lack the will. Our OLD HEALTH
SERVICES have been built to favour the
educated, the privileged and the powerful.
Such areas are the practice of virtue, such
as love, friendship, charity, justice, including
social justice, mercy, prudence, courage,
temperance, service of neighbour,
especially of the poor, the deprived, the
weak, decency, humility, personal and
family fidelity, observance of reasonable
laws, repentance and spiritual healing,
.the building of community, reaching out to
'world community.
Our NEW VISION is community and
community health. We wish all goods and
services to be more equally shared
with the whole community.
The world community joins us to proclaim:
HEALTH CARE FOR ALL BY THE
YEAR 20001
The Spiritual Testament^
of VHAI
Can VHAI, due to being open to all, have
NOBLE SPIRITUAL IDEALS? The answer
is a resounding YES. From the beginning
our principle has been to
EMPHASIZE AREAS OF AGREEMENT
and de-emphasize areas of controversy.
People are not merely individuals. All of us
are also social, political, economic and
religious.
Within religion there are areas of
controversy. But there are also large
areas on which virtually ALL GOOD
PEOPLE AGREE.
Even prayer, meditation and contemplation
can be common. Some prayers are
particular to one person or religion, but
tethers can be generally accepted by
^everybody.
If we would try to estimate what is
common to all religions, especially the
larger and more developed ones, we could
surmise that a very high percentage would
be common
It is certain that all the above beautiful
aspirations are agreed upon as part of the
idealism of all religions.
We in VHAI, following our principle of
emphasizing what is common, inspire our
members to the ideals listed above.
Our working together is always religiously
inspiring. We do not compare our
religions. We do not try to prove that one
is better than the other. Each of us,
both singly and in groups, brings the best
of our religious heritage to bear upon the
goals we jointly pursue. Each of us is
free individually and socially to practice
fully and to join with members of his/her
own religion in all religious exercises
of one's choice.
Our way of life is a noble religious
expression. We join hands and hearts
to do all we can together. We encourage
the freedom of each one's personal call.
We are upon to the highest spiritual
accomplishment and commitment.
Interested persons are invited to write for
further information as desired.
You may ask for a syllabus for the
Correspondence Course in Health Care
Administration,
or for the Anaesthesia course for Nurses.
A catalogue of our Publications is availablt
free on request.
You may inquire about
t a particular type of seminar that may
interest you.
Address:
_The Voluntary Health Association of India
C-14, Community Centre, SDA
New Delhi 110016
Phone numbers : 652 007, 652008
Residence of Executive Director 652466
Printed May, 1981
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