Public Health Education Needs as seen from the grass root
Item
- Title
- Public Health Education Needs as seen from the grass root
- Creator
- Narendra G
- Date
- 2007
- extracted text
-
l°IZ
Public Health Education Needs as seen from the grass root
Narendra G, Prayas
Public health education is an important element in changing people’s beliefs, mindset
and behaviour to move towards healthy life. Therefore, it is seen as an important aspect
for attaining the objective of health promotion. Globally, a substantial mass of human
resource is created to carry out the work of public health education and various
strategies are adopted to do it effectively depending upon the context. However, most of
the public health education related activities are carried out by the Government system
only.
Undoubtedly, public health is a big challenge for health personnel in India, because a
large number of people especially those residing in rural areas still have deep beliefs in
myths and superstitions. Coupled with this is the dispossession of resources required to
maintain good health viz. full nutrition, clean water, secure dwelling and safe working
conditions. Strong traditional practices also act as block in operationalising public health.
'Health' including public health is a state subject in India, therefore many states have.
different methods of health care systems in terms of infrastructure and personnel.’Health
education in the governmental sector is performed by several categories of functionaries
in our country. Some of the designations for public health personnel' in different
provinces are health education officer, health extension education officer, health
education instructor, extension educator, block extension educator, block -family
extension educator, block family' welfare officer, extension training officer, health
extension education worker, demonstrator, assistant professor, reader, professor,
medical officer, social worker, social welfare officer, public health assistant, nutrition
assistant, sanitary inspector, case worker, district extension educator, district family
welfare officer, district family welfare extension officer, mass education and media
officer, deputy health education officer, media education officer, education and
information officer, education and publicity officer, district health education and
information officer, deputy mass education and information officer, state health education
officer, project leader, and regional health educator. All these categories of people are
placed at different positions. However, amongst these the most important cadre is of the
people engaged straight into primary health care delivery'because most of the time, it is
these who interact and work directly with community on subjects of public health.
Public Health Education in the context of Primary Health : India has a well
conceptualized network of outreach health delivery services with the mandate to make
health care available, accessible and affordable to all citizens irrespective of caste,
religion, gender, income and geographic location. To attain it, primary health care
institutions have been created based on population norms and postings of health
personnel
is
being
done
accordingly.
Health care personnel in primary health care can broadly be categorized into two
sections. One segment is of medical officers and other is of paramedics. Within
paramedics there are many categories viz. female and male multipurpose health workers
and general duty nurses. Medical Officers could be simple graduate or post graduate in
any discipline of medicine. The female and health multipurpose workers undergo one
year training while nurses have at least three years training. Public health is taught in all
health courses, but not taken earnestly and taught in very indifferent manner. In fact this
is the biggest weakness as far as public health teaching is concerned. Though there has
been continuous change in public health teaching. There, is an attempt to make it more
1
interactive, experiential and challenging but in the absence of supportive milieu, these
remain only paper dreams.
One and rather important activity of the personnel in primary health care is to render
preventive services which are essentially non-clinical. These include health & nutrition
education, disease surveillance, disinfection of drinking water sources and issues
relating to maternal, reproductive and child health. Most of the preventive health
activities require sound knowledge about the public health principles & issues, skills to
use the knowledge in the local context and above all a sensitivity and attitude to do it in
effective manner. Knowledge source to health workers are basically their training
schools and later continuing education is possible through in service training, workshops
and literature. However, if the knowledge, skills and attitude about public health amongst
health care providers in primary health care system is examined, we find that it is
invariably incomplete and full of several gaps. These gaps are perhaps for the reasons
public health is taught in the medical and nursing schools to doctors and paramedical
staff.’Some of the glaring gaps in public health education amongst male health workers
and also the doctors engaged in.delivery_o_f .primary health care .from.the way.they,
function as providers are discussed below:
,
Knowledge: Prevention of any disease can be advocated or operationalised only if there
is clear grasp of facts of the distribution and determinants of causation of disease in a
particular area. But often it is seen that peripheral health workers posted in community
'settings have imperfect• clarity abQut-these~aspects~of_tne~“hea1th—arid~_diseases^
■ Therefore, mostly they'look for to receive instructions and their actions are mostly limited
to carrying out ihe’messages and directions received from their higher offices and senior
persons. On many occasions, these instructions and messages are ambiguous and in
the absence of any sound public health knowledge, activities are conducted in
perfunctory manner. A very important aspect of public health education is connected to
knowledge about collection of accurate health information especially of the vital events
like births, deaths and' morbidity through setting up appropriate surveillance system.
Sound knowledge is also required to collect information on prevalence of various
diseases, their periodicity, case fatality and the treatment seeking behaviour of the
community for these diseases within different social segments. Curriculum of the nursing
and medical schools do show that these aspects of health are taught to students but the
approach of teaching remains very technical and deprived of any social context. As a
consequence, health personnel pass out from schools with flawed knowledge on health
issues. This gets further perpetuated by the system of unethical clinical practice with
over emphasis on clinical activity. In the words of a Chief Medical Officer of one district in
Rajasthan “My surveillance system operates through newspapers...the first thing in
morning I do is, open newspapers and look for any epidemics or outbreaks reported
within district and based on it, I plan my activity." This kind of statement clearly reflects
that there is hardly any surveillance system and emphasis is on containment after an
outbreak rather than on prevention.
An important function of the health personnel engaged in primary health care is to
implement national health programmes of all kinds viz. vector borne control, anti malaria,
tuberculosis control, blindness prevention, reproductive & child health to name a few.
Public health action related aspects to most of these programmes keep changing
regularly and require updating on frequent intervals. Attempts are made to enhance
knowledge and skills through organizing short term training and orientation courses of
field level health functionaries. But most of the time these training programmes are done
2
in very ritualistic manners through one prescribed format that necessarily may not be
relevant in the local context. The trainers themselves many a times are not convinced
with the usefulness of the training. Experience and anecdotal information shows that
most of the workshops and training organized for to upgrade knowledge of the peripheral
health functionaries are not conducted with seriousness. Day long training workshops
are finished in few hours and a lot of time is spent in gossiping. In most training
programmes, the gap between persons nominated to attend and actual attendance is
grossly different. One often cited reason by the nominated persons to not attend the
training/workshops is that they are conducted in boring manner and there is no space for
interaction. However above all the paramount reason for not participating into such
programmes is loss of income that health personnel make through indulging into private
practice. In most states of India including in the state of Rajasthan, health personnel are
allowed to do private practice after duty hours at their homes. The passion to earn
money through private practice is so intense amongst health care providers that it has
led to not only avoiding duty completely or partially but also indulge into unethical or
' irrational therapeutic practice.
Skills: A s-kill can be defined as an ability that is usually learnt and obtained through
training to perform activities to achieve desired outcomes. It implies that skill can be
acquired by practically doing activities. A skill can be best utilized if it is contextualized
especially in instances of social interventions such as public health. However, there is a
universal pattern for public health education in India. With the mushrooming of medical
and nursing schools in private sector^a-lot-of human-resourcermuverrrerTrtakes-place-nT
terms of education. More influx is towards the states where more private institutions are
set up. Since the knowledge of public health imparted in all the institutions is generic,
emphasis is always on teachings theories from text books and with very little practical
work. The application of the knowledge in the local context and above all how should the
local context be analyzed and understood from the point of view of health completely
lacks in the curriculums of public health courses. Therefore, health care providers get
into service without much of skills to work in community setting. As a result there are
ANMs posted in the health sub centres and PHCs whose one important job is to conduct
safe deliveries but they have had no previous experience of doing it. A large number of
health workers would not know, how to estimate haemoglobin, measure foetal growth
and identify at risk factors in pregnant women. Medical Officers also most of their times
are engaged in treating patients and never use principles of public health or for that
matter try to understand the health profile of their area. Though there is scope to
enhance their skills through in service training but these are again conducted without
sincerity and no advancement in skills happen for most of the participants. Most medical
officers are unwilling to carry out public health work. They perceive it as work of an
inferior category and believe that those who can not be good in clinical skills will opt for
public health positions. Therefore public health related skills amongst medical officers
are lowest. Most medical and paramedical health personnel when it comes to getting into
public health related work try to avoid doing it or if compelled then do it very carelessly.
Sensitivity and attitude: Knowledge and skills are important requisite for carrying out
appropriate health activity, but it’s the ‘sensitivity’ which determines whether these will be
applied appropriately amongst those persons who require it. Therefore, sensitivity is a
very important attribute required to deliver health services. Sensitivity is very intimately
linked to ethics. A sensitive person would always try to be ethical and fair in work. There
are different ways by which people become sensitive and motivated. It’s a lot related to
the mindsets which may be influenced by different role models struck to individuals.
Belief in different spiritual, religious and political philosophies also factor in shaping
3
sensitivity of individuals. Sensitivity is the product of socio-economic analysis and vice
versa.
Building of sensitivity and motivation is least looked into public health education. In the
name of sensitivity only lectures are delivered which are mostly alien to the reality. Social
determinants often miss from public health education curriculums. The determinants
include unemployment, unsafe workplaces & housing, urban slums, corporate led market
controlled globalization, gender based discrimination and lack of access to health
systems. Thereby, public health personnel while working with rural and especially the
poor community mostly act in very mechanical way. They rarely look at the socio
cultural, geographical, economic, occupational and gender based segments of them and
in particular how these segments lead to inequities which finally result to act as barrier in
accessing health to certain categories of people. Non-contextualization of the public
health work restrains local people to participate. Insensitive health care provider point
finger towards community for their non-participation and hold people themselves to be
responsible for their poor health. This happens more sb with women especially with
regard to their reproductive and mental health problems. In the absence of gender
sensitization, most health providers accuse women for their problems and owing to non
availability of right information, women get more confused and depressed. Socially
excluded groups such as dalits, adivasis, religious minorities etc. also experience denial
of health care and health education because of insensitive attitude of the providers.
- What is to be done:
The notion that public health is a low skill work in comparison to clinical work has to be
changed and its importance in managing the burgeoning health challenges is required to
be established. While teaching public health, a lot of emphasis is required to be given on
social and economic determinants of health, so that the public health practitioners get
into the causes of causes of ill-health and plan their action to remove fundamental
barriers of health.
Awareness and sensitivity on different patterns of inequities is an equally important
characteristic to be generated among public health practitioners. This will form the basis
of effective, rational and ethical public health approach. Above all, the field level health
personnel are required to be competent enough to analyse the public health issues and
act on them. This can happen only through continuous up gradation in their knowledge
and skills.
Narendra
Prayas,
narendra@prayaschittor.org
G
4
Position: 2683 (3 views)