New policies for health education and information in support of health for all by the year 2000

WORLD HEALTH ORGANIZATION

~.

REGIONAL OFFICE FOR.

•

ORGANISATION MONDIALE DE LA SANTE

THE WESTERN PACIFIC

BUREAU R.~GIONAL DU PACIFIQUE OCCIDENTAL

REGIONAL COMMITTEE Thirty-third session Manila 20-24 September 1982

WPR/RC33fTechnical Presentationfl 10 September 1982 ORIGINAL: ENGLISH

NEW POLICIES FOR HEALTH EDUCATION AND INFORMATION IN SUPPORT OF HEALTH FOR ALL BY THE YEAR 2000 Technical Presentation

Health education policies must be based on, and derived from, national health policies, which in turn should be in harmony with the principles embodied in primary health care, particularly the concepts of community involvement, social control, and intersectoral collaboration in the achievement of community self-reliance in health. Primary health care calls for a radical shift from a passive role of compliance on the part of communities to one of active partnership. The challenge in health education and public information thus consists in developing a partnership with communities in health development. Health education policies must therefore focus on developing and strengthening community organization. Efforts must be made to develop local capabilities for organized community action in support of its own health. At the same time, efforts to promote specific health programmes through the spread of health literacy must be continued, with a gradual shift in emphasis, as communicable diseases are brought under control, towards improvements in lifestyle. The community development process can be initiated and strengthened only by involving communities in the decision-making process and in the planning and management of health programmes through an intersectoral approach. Such an approach calls for flexibility in management, decentralization of authority and the existence of a network of active community organizations. A favourable social climate and peer support are essential prerequisites for the acceptance of new ideas and practices by the people. A social climate conducive to action for health could be developed through community level extension work and the use of the mass media in generating popular awareness and political support. In social marketing for health, the health needs of the people must be combined with demands that are popular and attractive.

CONTENTS

1. INTRODUCTION

.............................................. 2 2 3 3 4 5 5

2. PURPOSE OF TECHNICAL PRESENTATION . . . . . . . . . . . . . . . . . . . . . . 3. PAST AND FUTURE: NEW DIRECTIONS IN HEALTH EDUCATION POLICIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Towards partnership with communities . . . . . . . . . . . . . . . . . . . . . . . 3.2 Community organization and health literacy: both are needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Community development: intersectoral approach . . . . . . . . . . . . . . 4. RESOLVE CONTRADICTIONS AND BRIDGE THE GAPS 4.1 Community organization versus problem-specific health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Health services versus health education .. .-. . . . . . . . . . . . . . . . . . . . 4.3 Bottom-up versus centralized planning . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Lay control versus technocratic leadership . . . . . . . . . . . . . . . . . . . . 4.5 Health educators: identification with communities or services ................... ; . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 Education versus marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 Local community action versus mass mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. THEORETICAL BASIS IN HEALTH EDUCATION 5.1 Health behaviour models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Diffusion theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Action based on felt needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 6 6

7 7 7 8

8 10 10 11 11 12 13 16

6. CURRENT STATUS OF HEALTH EDUCATION IN THE REGION

. . .. .

6.1 Infrastructure and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Impact of health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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l.

INTRODUCTION

At its thirty-second session in 1981, the WHO Regional Committee for the Western Pacific resolved that the topic of the Technical Presentation at its thirty-third session should be "New Policies for Health Education and Information in Support of Health for All by The Year 2000". The importance attached by the Regional Committee to health education and community involvement is reflected in the fact that this is the third time in a row that the technical presentation topic has focused on community support and participation in health development. Obviously the Committee strongly feels the need for further collective thinking and action in defining the community's roles and responsibilities and devising policies and programmes for health education and information to implement the strategies for health for all by the year 2000. Community involvement is an accepted principle and a vital element of primary health care. The International Conference on Primary Health Care, held at Alma-A ta in 1978 (1 ), in defining the concept of primary health care, stressed the importance of engaging-all sectors of the population in the development of primary health care. In enunciating its underlying principles, it declared that "the people have the right and duty to participate individually and collectively in the planning and implementation of their health care". The concept of primary health care "requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care ••• and to this end develops through appropriate education the ability of communities to participate". In point of fact, the report of the Conference listed "education concerning prevailing health problems and the methods of control and preventing them •.• " first among the eight essential elements of primary health care. It further emphasized "the importance of full and organized community participation and ultimate self-reliance, with individuals, families and communities assuming more responsibility for their own health". Health services must be socially relevant and respond to the expressed health needs of the community. The Conference also highlighted the importance of intersectoral collaboration in health development, and declared that the attainment of the social goal of health "requires the action of many other social and economic sectors in addition to the health sector". Governments should "promote primary health care and related development activities so as to enhance the capacity and determination of the people to solve their own problems". Health care should be "based on practical, scientifically sound and socially acceptable methods and technology made universally accessible .•• ''. The concepts and principles evolved at the Alma-Ata Conference have since been further elaborated and operationalized in the formulation of national, regional and global strategies for health for all by the year 2000, and emphasis has been placed on the sharing of responsibilities, partnership with communities, intersectoral collaboration and appropriate technology. (2-6)

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In defining health education policies, therefore, the key concepts in the philosopy and approaches of primary health care which must be considered include: community participation, shared responsibility, social control, self-reliance, social relevance, total coverage, intersectoral collaboration, self-care and self-determination, and appropriate technology. 2. PURPOSE OF TECHNICAL PRESENTATION

The topic for the Technical Presentation is timely, for it gives us an opportunity, at this important stage in the development of national health policies, to examine whether these policies are in harmony with the Alma-Ata Declaration and the health for all by the year 2000 strategy. Do they support the principles of health education, community involvement, appropriate technology, intersectoral coordination, and community self-reliance? Do they provide for the required institutional framework, . infrastructure, manpower development, information support and research, and the necessary reallocation of resources to ensure community participation in health development? It is timely also because the emphasis on primary health care and community involvement occurs at a time when a substantial body of scientific knowledge has been acquired in understanding human behaviour and its determinants and when important advances have been made in the development of health education theory and practice. The state-of-the art of health education is such that it can meet with the challenge, though much more research needs to be done to understand why people do what they do and why some people are able to give up certain habits like smoking and others cannot. An attempt is made in this presentation to review some of the above issues, to describe the trends in health education, and to share some reflections on future strategies for strengthening community involvement in health development. 3. PAST AND FUTURE: NEW DIRECTIONS IN HEALTH EDUCATION POLICIES

What were the former policies and why were they inadequate to meet the challenge of health for all through primary health care? What are the features in primary health care and the "health for all" strategy which call for new directions in he9lth education? Do we need new policies and a reorientation of approaches to enlist community support to attain the goal of "health for all"? The answer to this last question is, yes, we do. The scope of health education has evidently widened. More is expected of cqrnrnunities now than ever before. Massive efforts are needed to generate the political will and to create a conducive social climate and a strong determination ampflg people to ensure that local communities are able to organize themselves for he~lth action in partnership with the health services. It is recognized that the health

WPR/RC33/Technical Presentation/ I page 3

sector alone cannot deal adequately with all the health needs of the people. Efforts in the area of health education must therefore be based on community needs, aspirations, and expectations on the one hand and an intersectoral approach on the other hand. Thus, new directions and changes in health education policy and practices are imperative. Some of the distinctive features are highlighted below. 3.1 Towards partnership with communities

With the advent of primary health care, the concept and scope of community participation have changed radically. Passive compliance is no longer enough; the active involvement of communities must now be sought in the decision-making process, in identifying needs and mobilizing community resources, and in planning, managing and monitoring the health services. This marks a distinct shift from a passive role of compliance to one of partnership. The concept of partnership implies the sharing of responsibilities and control in relation to the health services with the communities. In a sense, this means transferring power to the people, together with the shared responsibilities aimed at achieving community self-reliance in health. Responsibility and authority go hand in hand. The failures in past efforts stem from extending responsibility, but not authority, to the communities. Health education policies need to be derived from this distinctive feature of partnership and social control incorporated in health policies based on primary health care. 3.2 Community organization and health literacy: both are needed

The vision of partnership can be realized only if local communities develop the capability to organize themselves to respond to a wide variety of local needs, including those relating to health. Community organization must therefore be the first priority in health education. Communities will not be able to organize themselves until they are given an opportunity to participate in decision-making and management of local health and development programmes, and until they have acquired a sense of responsibility for mobilizing available community resources for health development. The health and development agencies, for their part, will be reluctant to venture into participatory management, fearing that communities are not yet ready for it. There is thus a kind of vicious circle which will have to be broken. This is a complex challenge, and some bold initiatives will have to be taken even at the risk of initial failure. Risk-taking behaviour in any case can hardly be considered one of the characteristics of a bureaucracy, and professionals are usually chary of accepting social control and vigilance by the lay public. The process therefore calls for strong political will and de,termined efforts to persuade both the professionals and the communiti.es. A hglf-hearted approach would be self-defeating.

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There is much evidence to show that communities do succesfully rise to the challenge once thoughtful and sustained efforts are made. There are many, albeit isolated, examples of successful community involvement in participatory management. Community organization efforts are essentially transprogrammatic and intersectoral in nature, and provide a framework to facilitate the extension of individual programmes to the communities. At the same time continuous health education and information efforts are needed to ensure support for specific health programmes (e.g. rural sanitation) through promotion of specific health behaviour (e.g. use of sanitary latrines) in order to attain specific health goals (e.g. reduction in the rate of parasitic infestation). This might be termed promotion of health literacy. It implies, for instance, the integration of health education in the major health programmes and the inclusion of health education in the school system. Efforts in health education should, therefore, be directed towards: (I) community organization to develop local capabilities for organized community

action in support of its own health, and (2) problem-specific health education related to the promotion of selected health programmes. 3.3 Community development: intersectoral approach

In strengthening the community development process, which is a major objective as out lined under 3.1, the developmental efforts must start with the needs as perceived and expressed by the people. Community needs are often diverse, cutting across sectors and agencies, and therefore cannot be satisfied comprehensively by a single programme area or sector. Research findings in the community development and health fields show that approaching a cluster of related problems affords much better rewards or chances of success than dealing with problem-specific vertical programmes in isolation. Moreover, aspects of risk-taking behaviour tend to occur together and to influence each other (for example, tobacco smoking correlates with alcohol and drug abuse, which in turn are associated with risk behaviour such as not using seat belts and contraceptives, drunken driving, etc). They are therefore better dealt with as a package. The health sector alone cannot deal with the varied needs of a community. An intersectoral approach emphasizing the community development process is therefore imperative and must be considered when formulating health education policies and strategies. Furthermore, different communities are likely to have different priorities. How are we to reconcile local priorities with national priorities? How are we to match or synchronize the upward flow of demands from the grassroots and the allocation of national resources? This implies two options: decentralizing the managerial process by strengthening decision-making at provincial, district and community levels, and maintaining flexibility in resource allocation, at the same time strengthening mechanisms for upward and downward flow of information. Health sector policies must therefore aim at facilitating a two-way flow of information and enhancing C()ITlmunity participation in decision-making at various levels.

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The community development and intersectoral approach thus calls for widening the scope of health education to enable it to deal with the diverse needs and health goals of communities. 4. RESOLVE CONTRADICTIONS AND BRIDGE THE GAPS

A variety of issues, contradictions and deficiencies in health and h:a!th education policies will have to be carefully considered and resolved when determmmg priorities and developing strategies for community involvement in actions for health. Some of these issues are briefly discussed below. 4.1 Community organization versus problem-specific health education

Conventionally, health education efforts in most countries have been directed at promoting problem-specific programmes. Media campaigns are launched and programme personnel are activated to facilitate acceptance by the community of selected vertical programmes in isolation from other health and development needs. With few exceptions, only limited efforts have thus far been made to develop activities around diverse community needs through an integrated approach. In primary health care, where the emphasis is on community development, how do we reconcile the two approaches? The answer is that both approaches are necessary. Communities must be organized to respond to their needs and programmes must be promoted to combat specific health problems. Seeking compliance from communities is, however, not the answer. There is much research evidence to show that the existence ofsocial support is a vital _factor in facilitating the adoption of practices advocated under various programmes. (7-9) The necessary social support could be strengthened through community organiZation efforts and mass media support. Educational efforts aimed at promoting specific health programmes and altering the specific health-risk behaviour of individuals are equally important, and the existence of a network of organized community groups will facilitate this process. However, it can be assumed that promoting a package of related programmes, some popular with people and others not so popular, rather than isolated problem-specific programmes, will be more rewarding. 4.2 Health services versus health education

Health education can only be as effective as the health services are themselves. Studies indicate that satisfaction with the health services, and relative accessibility of svch services are a . major variable in the adoption of a health technology or in influencing modifications in the health behaviour of the people. A positive image of the health services and satisfaction with the health technology not only strengthen the credibility of health workers but also build confidence in the health system. Health

WPR/RC33/Technical Presentation/! page 6

education can only facilitate the process of improving the image of the health services, health workers and health technology. In the final analysis, however, the realities of the health system will speak for themselves. 4.3 Bottom-up versus centralized planning

There is much empirical evidence that people participate more actively if they are involved in setting their own goals and priorities. Programmes imposed from above are often accepted reluctantly and may even be resented. The immediate needs of communities are varied and sometimes not consistent with national priorities or resources allocated to various sectors for local action. For these reasons, the principle of the bottom-up approach is readily accepted by scholars and agencies. Such an approach, if applied, helps to overcome the barriers between sectors and to blur the lines of demarcation between various programmes at community level. However, the process of operationalizing the concept of the bottom-up approach is quite complex. The formulation of national plans with specific goals and targets in relation to various activities is essential for setting directions and ensuring better operational management, resource allocation and monitoring of the programmes. The bottom-up approach, on the other hand, demands that local and national priorities are reconciled, the managerial process for decision-making is decentralized, and more flexibility in management is permitted at lower levels. A combination of the two approaches, bottom-up and centralized planning, is necessary to permit the expression of community needs and to reconcile these with the national planning process. However, the nature and extent of the flexibility and manoeuvreability available to communities in managing resources will have to be defined and well understood. 4.4 Lay control versus technocratic leadership

An important principle of primary health care is that of social relevance and social control of health programmes. But how much social control and vigilance, and in what form, are local communities to be allowed to exercise? Here again, collaboration between communities and health services is called for in managing health care. If this is to be the trend, health education must focus on enhancing problem-solving, decision-making and managerial skills in community organizations. The essential aim of health education will then be, as it should always be, to empower people to protect and promote their own health.

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4.5

Health educators: identification with communities or services

With whom should extension workers and health educators identify? Should they identify with the community and articulate its views, needs and expectations, or should they act as the mouthpiece or agent of the health services in marketing health programmes to the public? This dilemma must be resolved; failing which they could be liable to an identity crisis or schizophrenic split in their sense of loyalty and behaviour. In a community development approach, extension workers and health educators identify with the people and their aspirations, and work with them in identifying problems and defining solutions; they facilitate the process of dialogue between development agencies and communities. However, service realities also demand that they dedicate themselves to the promotion and attainment of the goals and targets set under various programmes. The ideal position appears to be that they should act as links between community and services, harmonizing goals, narrowing gaps and preventing confrontation. They would be failing in their duty as extension workers were they to identify only with the service agencies and function solely as marketing agents. 4.6 Education versus marketing

For sound and understandable reasons, health professionals have been chary of trying the market approach in promoting healthful habits. Marketing models function best when the demand for the goods to be marketed already exists, and when there is a product which is competitive and a network of market outlets. The main concern in marketing is to compete with other brands of the same product. But this is not the case in the field of health, where the main challenge consists in creating a demand for, and satisfaction with, health technology and services. Nonetheless, we are in effect trying to market a healthful lifestyle and promote appropriate use of the health services by the people. Consequently, interest in "social marketing" is beginning to emerge. In social marketing in a community development process, health programmes and healthful habits are promoted concurrently with community involvement in the fulfilment of needs consirlered important by the people. 4.7 Local community action versus mass mobilization

Traditionally, health educators have felt at ease working with small communities through interpersonal communication and small-group discussions, using visual aids to disseminate health messages. The public information specialists, on the other hand, hc:we been more apt at public relations work and the use of mass media (radio and print) for information dissemination; they have been somewhat elitist, with limited contacts at grassroots level and limited direct experience of programme operations at community level. The two groups have functioned largely in isolation.

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The emphasis in the past has been on motivational appeals based on self-interest, aimed at stimulating individual action, rather than on social goals and collective gains. The result has been an inadequate build-up of social support and pressure to provoke mass action. There have been exceptions, however, in countries such as China, where self-interest has been combined with ideology and appeals for social progress in building mass movements have met with a considerable degree of success. A balanced mix, combining the community approach, the use of mass media, and the support of a network of mass organizations or community groups, is essential for developing a social climate conducive to the promotion of health programmes and of community involvement in actions for health on a large scale. This is what could be called social marketing, by which popular demands linked with less popular or attractive needs are promoted through a network of community organizations and socially reinforced through the mass media. 5.

THEORETICAL BASIS IN HEALTH EDUCATION

A substantial body of scientific knowledge has evolved in the field of health education during the last two decades. A considerable amount of empirical evidence has been gathered, though much more needs to be done, and a sound theoretical basis and conceptual framework exist for devising guiding principles for the development of health education policies and practices. From a historical perspective, interventions directed towards health promotion and disease prevention have gone through three distinct phases, the type of intervention being dictated by the causal factors operating in the illness process as understood at that time. The earliest phase started with magico-religious interventions, attributing illness to supernatural powers. Subsequently, with advances in microbiology and other medical breakthroughs, a biomedical model was adopted which attributed illness to specific causal agents. The success with the biomedical model in controlling communicable diseases led to the belief that most health problems can be resolved by medical or technological intervention and to the growth of disease-specific vertical programmes. Following the control of communicable diseases, there has been a growing recognition of the psychosocial and behavioural determinants of health. However, the psychosocial model is not advocated to the exclusion of biomedical interventions, even by its strongest proponents. 5.1 Health behaviour models

About 14 empirical models explaining health behaviour interventions have been developed, based on research during the last two decades. All these models attempt to define and test a predictive model of health behaviour from a psychosocial perspective. Though these models include a wide range of variables, there are six sets of factors common in all models. These include: accessibility to health care, attitudes toward health care, subjective threat of illness, knowledge about disease, social norms and interactions, and demographic characteristics.

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Behaviour can be conceptualized as a function of determinants which are internal to the person concerned or intrapsychic (intention to act or motivation, and autonomy or freedom to decide and act) and of determinants in the external micro-environment (accessibility, social support from significant others, such as peer groups, and action situation), which in turn are controlled by the macro-environment (cultural setting and social norms, sociopolitical structures and technological developments). Moreover, there is growing evidence that intention to act, personal autonomy, access to services and social support have direct and additive effects on health behaviour. (.2_) It is a questionable assumption that cognitive factors (intrapsychic: knowledge, attitudes) have a greater influence than environmental determinants, and that the latter affect behaviour only indirectly by influencing the specific action intentions. A cross-cultural study on contraceptive behaviour has, for instance, shown that technology, political environment and social setting (major exogenous variables) significantly influence both programme intensity (accessibility of services) and preventive health behaviour (contraception). (1 0) The health education interventions must therefore focus on influencing both intrapsychic factors (knowledge, attitudes and satisfaction with health services) and environmental factors (accessibility, social support and techno-political systems) in enlisting community support and involvement in health development. Though this is questionable and has yet to be empirically validated, it could be hypothesized that, in most peasant societies where conformity and compliance with social norms are still strong culturally held values, cognitive factors or one's own attitudes have less influence on individual behaviour than in industrialized societies where persons enjoy greater personal freedom and autonomy. If this is the case - and the writer feels this is a reasonable assumption - the implications for health education policies are evident. First, attempts to improve knowledge and attitudes (i.e. health literacy) will not be enough. Second, health education should focus primarily on building social support, creating a. favourable social climate, and improving both accessibility and image of the health services.

However, in countries where communicable diseases are gradually being supplanted by diseases of chronic, degenerative, developmental or psychosocial origin (accidents, drug abuse, etc.) the simple cause and effect relationship between behaviour and health outcomes no longer suffices to explain the multivariate, conditional probabilities in the maintenance and improvement of health. The behaviours of increasing concern will be those which are deeply imbedded in the lifestyle and heavily value-loaded and socially charged. (8) The traditional attention given in health education to cognitive and attitudinal domains of learning will no Jqnger be adequate. Greater attention will have to be paid to factors beyond factual knowledge.

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Increasing emphasis in health education in these societies will also have to be placed on social reinforcement and on building a supportive social climate, though .the process of health education will have to focus more on interactive communication to clarify values and induce changes in lifestyle (8) and on self-care in health maintenance.(_!_!_) The most important sources of reinforcement, as pointed out by Green (~), are the family, mass media (radio, television and advertising) and peer influences, and to these must be added the broader social setting and the overall social climate. 5.2

Diffusion theories

The adoption of a new practice is not necessarily a product of direct progression from awareness and knowledge to attitude and behaviour change. The diffusion model, pointing to such progression, has in some ways done more harm than good to health education practice. Sometimes behavioural changes precede attitudinal changes. People are drawn into action by the force of social pressure. Moreover, not all people change with equal ease and under the influence of the same set of factors. A few people, the innovators, who are more exposed to modern influences and seek information through the mass media and extension agents, are usually the first to accept new ideas. But the bulk of the people wait and observe, and change behaviour only when they find the climate favourable and the experience of early acceptors with the use of new technology satisfactory. This again points to the need to develop a network of organized community groups, facilitating access to persons in the community with leadership qualities and managerial capabilities, and to use the mass media to soften the climate. Working with organized groups or captive populations such as trade unions and schoolchildren would present similar advantages. 5.3

Action based on felt needs

Communities participate more actively in actions which are related to needs considered important by them. Those engaged in community development recommend that people should identify their own needs and set their own priorities, and that developmental resources should be directed towards meeting those needs and solving such problems as are perceived and identified by the people themselves. The idea is commendable and the argument has its merits. Felt needs do provide an entry point to primary health care. However, in the health field, the emphasis should be on determining linkages so that an activity which is less popular but considered important from the point of view of the community's health status may be packaged with other activities that are attractive to the people. For instance, water is a deeply felt need in most communities and there is a popular demand for activities to meet that need. But programmes to promote the use of sanitary latrines and safe disposal of waste are not so popular with the people; latrines are not part of the tradition and people do not feel the need for them. ( 12) A solution therefore lies in linking water supply with sanitation and other related health promotion programmes.

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The problem is that the health sector does not have a broad enough spectrum of programmes and resources to accommodate fully the philosophy of a need-based community development approach. In the health sector, the most powerful .entry points commonly experienced are community needs for medical care, rural water supply and food supplements• . The community's needs in relation to other sectors often include approach roads and culverts, irrigation, and drainage works, credit and marketing facilities, including storage of agricultural products, insecticides and fertilizers, schools, and community centres and places of worship. These needs will of course present local variations. The creative ability lies in linking these demands to the health needs of the people. The art of social marketing consists in combining needs with demands. 6. 6.1 CURRENT STATUS OF HEALTH EDUCATION IN THE REGION

Infrastructure and activities

With the recognition that the active and dynamic involvement of communities in health development is a vital element in primary health care, health education and public information support to health programmes has received added emphasis in most countries or areas of the Region. Health education units have been established at national level in the ministries of health of practically all Member States, and also at regional or provincial levels in six countries. However, in a number of countries the health education services lack the leadership of professionally qualified health educators while most of them do not have adequate facilities or expertise for media production, training and curriculum development, and behavioural research to strengthen health education practices. The shortage of qualified health educators is gradually being overcome. Institutions for advanced training in health education exist in seven countries, including four where the focus is on training intermediate level health education practitioners. However training programmes need to be more competency-oriented by combining classroom teaching with field training. Some progress has also been made in developing condensed, practical and realistic programmes for the training of peripheral health workers in the community approach and health education. These need to be tested and further developed. This is an area to which much attention and effort will have to be directed in the near future. This also applies to the inclusion of health education in the basic training of various categories of health workers. Although teaching units on health education are generally provided for in these programmes, they are often weak and either too theoretical or focus too much on the use of audiovisual aids. Community diagnosis j$ not given adequate emphasis. In a prescription-oriented health culture, the art of list~ning to and learning from people is most important and should be emphasized in tr!'lining programmes.

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Although audiovisual facilities and resources within the ministries of health are still limited, increasing efforts are being made in a number of countries to involve ministries of information and broadcasting in strengthening media support for health programmes in order to create a well informed public opinion as well as a favourable social climate. Radio programmes on health are, for instance, extensively used in the South Pacific. Media-supported mass campaigns have been launched in some countries (for example, well organized health campaigns have become an annual feature in Singapore for many years), but in most Member States the ministries of health lack the funds and resources required for such campaigns. In order to achieve better coverage of health news in the mass media, the initiative has been taken in some countries to involve and train journalists, radio and television news broadcasters, editors and other media personnel in reporting on health subjects. Two countries are also training health personnel in radio broadcasting. Most countries in the Region have shown keen interest in incorporating or strengthening health education in primary and secondary schools and in teacher training institutions in order to develop desirable health habits and attitudes at an early age among schoolchildren and adolescents. In a few countries, school health education is already well-developed. Other countries and areas, particularly in the South Pacific, are focusing efforts in this area. Health education is being developed as an integral component of the various health programmes. However, transprogrammatic efforts at developing community organizations and organized community groups in support of health development are still limited. This obviously calls for an intersectoral approach and there is now increasing collaboration between those engaged in developmental activities at community level. Health education and information policies are not yet clearly defined and formulated, and the funds allocated are generally not adequate for intensifying health education and public information activities. 6.2 Impact of health education

Assessment of the impact of health education and public information is a complex task. Three sets of indicators will have to be developed for this purpose. These comprise: (1) Social support indicators: Social support is perhaps best reflected in the existence of a network of community organizations at various levels and the nature and extent of their support to health programmes, which will be assessed in terms of their involvement in the decision-making process and participation in health activities. An attempt has been made ih the Regional Office to develop an index taking into account the above factors in order to assess the support extended by organized groups in actions for health. Nonetheless, it should be noted that this index does not adequately take into account a complex mix of variables which determine ''~Qcial support" conducive to behaviour change by individuals.

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(2) Health literacy indicators: Changes in knowledge and attitudes of the people in relation to various health problems and interventions can be assessed only through periodic sample surveys. No routine reporting system can be developed for this purpose. (3) Health behaviour and utilization of health services indicators: This could be assessed in relation to those programmes where changes in behaviour are critical to success, e.g. acceptance of sanitary latrines, immunization, use of contraceptives, road traffic accidents, nutritional status of preschool children and pregnant/lactating mothers, etc.

Indicators in respect of health education inputs or activities are easy to develop, but are generally found to be unsatisfactory. The problem is not one of quantification but of assessing the quality of inputs such as meetings held, materials produced or persons trained. The Sub-Committee of the Regional Committee on the General Programme of Work reviewed activities in relation to health education and community participation in health development in two countries in the Region. The Sub-Committee found that local community organizations and self-help groups were active in varying degrees in extending support to health services and in meeting a wide variety of local needs, including those relating to health. It observed however that the involvement of community groups in the decision-making process was generally still limited, notwithstanding certain striking examples of such participation. It also observed that a multisectoral approach to strengthening community development was gradually beginning to emerge. It can generally be inferred from the report of the Sub-Committee that there is scope for further intensifying health education and public information activities and strengthening resources for the same. The above observations of the Sub-Committee are largely applicable to other countries as well. (_!1) 7. FUTURE DIRECTIONS

Health education and public information policies should be derived from national health policies based on primary health care principles aimed at achieving community self-reliance in health. Once the national health policies have defined the nature and scope of community participation, the role expected of communities and the authority delegated to them, the health education policies should be formulated accordingly to encourage and promote community Involvement in health development. If it is decided to decentralize the managerial process for decision-rnqking in health management and to increasingly delegate authority to communities, then the tocus in health education must be on developing and strengthening community orgf'lnizations. Building social support and ensuring a favourable social climate are particularly important, in developing countries and among peasant cultures, where conformity to social norms is comparatively a stronger value and individual autonomy in decision-making is comparatively limited. Social support will stimulate beha.v~our <;hange, facilitate the adoption of a healthful lifestyle and trigger action by

WPR/RC33/Technical Presentation/! page 14

communities in support of health. When health knowledge is limited, social support becomes all the more important so as to encourage health-promoting action on the part of individuals, families and local communities. In industrialized societies on the other hand, the emphasis will be more on encouraging interactive communication with a view to inducing changes in lifestyle. Efforts at community organization will involved in identifying needs and in developing is tantamount to acceptance of the principle term. Furthermore, we should be willing communities have developed the capability Social control is implicit in such an approach. be successful only if communities are and managing health programmes. This of partnership in the true sense of the to risk a few initial failures until to manage development programmes.

Intersectoral and transprogrammatic efforts are essential to sustain the interest of community groups and to keep them functional and active. Activities based on the health sector alone will not suffice. The needs and demands of the people will have to be creatively combined in developmental actions. Less popular health needs will have to be linked with other more attractive health and health-related demands in the social marketing of health promotional programmes. Mechanisms for coordination with other sectors and development agencies, for the articulation of community views andfor community participation in the health management process, will have to be developed at various levels. Such mechanisms will provide the needed support to local community groups in sustaining their interest and in keeping them active and functional. Intensified and sustained media support will be necessary to create a climate conducive to health and developmental actions. This points to the need for developing a balanced and well-integrated approach in health education and public information, combining community organization efforts with the use of mass media, and involving other sectors engaged in community development. The support of journalists and news reporters will be needed to enhance health reporting coverage by the modern media. Training of health and health-related staff in health education and the community approach becomes all the more important if what is envisaged under primary health care is to be put into practice. Efforts must be continued to develop realistic and practical training programmes for peripheral health workers in health education. The curricula for postgraduate training in health also need to be reviewed accordingly. Another important area of emphasis should be the strengthening of health education in schools. Health education should be developed as an integral part of the $chool curricula, particularly in primary schools and teacher training institutions, and there must be a dynamic interaction between schools and communities for health promo~ion.

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The experience gained with community participation should be documented and widely disseminated. Behavioural research on health, health education_ and community participation, which is already beginning to attract attention in some countries of the Region, should be encouraged and supported. Efforts must be continued to develop feasible indicators to monitor trends in community participation and assess the impact of health education.

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Alma-Ata 1978. Primary health care, .Geneva, World Health Organization, 1978 ("Health for AU" Series, No. 1). Global Strate for Health for all by the year 2000. Organization, 1981 "Health for All" Series, No. 3 • Geneva, World Health

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Mahler, H. The · meaning of ''health for all by the year 2000", World Health Forum, ~(1):5-22(1981). Regional Strategy for health for all by the year 2000. Manila, WHO Regional Office for the Western Pacific, 1982. Seventh General Pro amme of Work coverin the eriod · 1984-1989 · inclusive, Geneva, World Health Organization, 1982. "Health for All" Series, No. 8. Analysis of the content of· the eight . · essential elements ·of primary health care. Final report to the Headquarters Programme Committee by the Working Group on Primary Health Care, Geneva, World Health Organization, 1981 (HPC/PHC/REP/81.1 -unpublished document). Cummings, K.M., Becker, M.H., and Maile, M.C., "Bringing the models together: An empirical approach to combining variables used to explain health actions." Journal of behavioral medicine, ~(2):123-145(1980). Green, L. W., "Reconciling policy in health education and primary health care." International ·journal of·health ·educa tlon. X XIV (3 ):supplement ( 19 81 ). Kar, S.B., Psychosocial environment: An empirical model for health promotion policy, research and intervention. Paper presented at the lith International Conference on Health Education, Hobart, Tasmania, Australia, 1982. Kar, S.B., and Talbot, J.M., "Attitudinal and non-attitudinal determinants of contraception: A cross-cultural study," Studies in family planning, 11 (2):51-64-( 1980). Levin, L S., "Self-care: Towards fundamental changes in national strategies". International journal of health education, XXIV(4):219-228(J981). Health education and rural water su"ply and sanitation. Manila, WHO Regional Office for the Western Pacific, 1981 WPR/RC32/TP/0. Report of the Sub~Committee of the Regional Committee on the General Programme of Work, Part I, Manila, ·WHO Regional Committee for the Western Pacific, 1982 (WPR/RC33/7, Annex 2).

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