Journal of Community Health Vol. 17, No. 2, April 1992
A C O M M U N I T Y HEALTH E D U C A T I O N SYSTEM TO MEET THE HEALTH NEEDS OF INDO-CHINESE WOMEN Ranjit N. Ratnaike, MD, FRACP; Tracy L. Chinner, BA, (Hons)
A B S T R A C T : This p a p e r presents a Community Health Education System which is cost-effective, sustainable, strongly community-based, and directed at improving the health status o f rural women in Indochina (Kampuchea, Laos and Vietnam). T h e system is developed t h r o u g h a series o f steps which are concerned with the education o f C o m m u n i t y Health Education Units (in national ministries o f health) and, at the village level, a m o n g community health workers, women's groups, and other women. T h e ultimate aim is the establishment of a community health education p r o g r a m in Indochinese villages.
War, violence and the subsequent disruption of families and communities, especially in Vietnam and Kampuchea, have been a feature of life in Indochina for many years. T h e pattern of war is such that the brunt of its effects are on the male population, causing death as well as physical and mental disability. Roles that were traditionally "male" now have to be fulfilled by women. Consequently, war in Indochina has recently provided women with the opportunity and urgency for a larger role in community life than previously experienced. An improved health status would enable Indochinese women to u n d e r t a k e this role effectively. Rural women, who comprise over 80 percent of the female population in Indochina, are one of the most disadvantaged groups. ~ T h e information available on the health of women in this region is meagre. T h e average life expectancy of Indochinese women is approximately 55 years, ranging from 46 to 65 years. ~ In Kampuchea, the maternal mortality rate is 500 per 100,000.' Only 50 percent of the rural Kampuchean population have access to health services, 2 whilst in Laos, 89 Ranjit N. Ratnaike is director of international health programs; and Tracy L. Chinner is technical assistant at the Department of Medicine, The University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia, 5011. Requests for reprints should be addressed to: Dr. Ranjit N. Ratnaike, Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, 5011, Australia. © 1992 Human Sciences Press, Inc.
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percent of the rural population do not have adequate sanitary facilities. Further, 63 percent of the Laotian rural population do not have access to a safe water supply. ~ Based on the information available '~':~and the health problems of women in other developing countries, four major health areas need to be addressed in order to improve the health status of women in Indochina: maternal care, improved nutrition, prevention of infectious diseases and screening for breast and cervical cancer. We propose an intervention, in the form of a community health education system, to address these health problems. The success of this intervention depends on a variety of factors: cost-effectiveness, the economic viability of the program after "donor departure," sustainability through continued community interest, and adequate monitoring and evaluative procedures. An important ingredient to success, often overlooked, is community participation. Health programs are often imposed on the national governments of developing countries, who in turn impose the programs on their country. The lack of consultation at various levels (national and local) by external donor agencies, precludes community participation in the development of these programs. Ensuring community participation, even by those committed to its need, is not easy? The lack of community participation is due to a spectrum of reasons, ranging from lack of community awareness or acceptance of the health problem addressed, to more subtle problems like resenting the attitudes of the program implementers: for example, "top-down" messages, authoritarian behavior, and gross cultural insensitivity. Indochina in particular has many unique cultural beliefs concerning medicine and health which must be dealt with sensitively. Vietnamese people tend to consult herb doctors, shamans, astrologers, or chiromancers for the diagnosis of health problems and utilise coin-rubbing, 5 prayers, rituals, herbs and bones in the treatment process. 6 Western medicine coexists with, rather than replaces, the traditional health system. Customary Indochinese birthing practices include: delivery of a child by an unqualified midwife or older woman, the non-administration of pain relief and the burial of the placenta. ~ Post-nataly, a small fire is continually burned under the new mother's wooden bed for three days (to heat the house, warm the infant and to draw blood out of the mother's body) and the new mother is made to rest for seven days. 7 The structure of the Community Health Education System we propose, addresses many of these basic impediments to the success of health programs.
Ranjit N. Ratnaikeand Tracy L. Chinner
Diagrammatic representation of the proposed Community Health Education System
[ Advisory Team 1 assists, monitors and evaluates
Community Health Education Unit
~ Women's Groups : -•
I & trains establishes] L~ C~mmmunityHealth ,/ Workers
~ establishes I Community Health L Education Programs educates
Village Women With regard to cost-effectiveness, the relatively small overall cost of the system is initially borne by an external agency and decreases considerably over the years. Kampuchea, Laos and Vietnam are developing countries with faltering economies and may be unable or unwilling to independently outlay funds for a health program. Vietnam is one of the 20 poorest nations in the world, 8 while Laos' per capita income has been estimated at only US $120. ~ Therefore, during the maintenance phase of the system, the major cost commitment by the national governments will be to salaries alone. Sustainability, through community participation and cultural sensitivity, is addressed by the minimal involvement of non-national health professionals (numbering three: who will receive considerable in-
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formation on Indochinese traditions) and the extensive utilization of local people at government and village level. Sustainability of the community health education system is further ensured by establishing women's gloups consisting of village women. Through these groups it is anticipated that the villagers will perceive "ownership" of the program and have a vested interest in sustaining it. The community health education system incorporates an inbuilt, on-going mechanism for monitoring and evaluation (rather than evaluation "after the event").
The Community Health Education System The Community Health Education System consists of: • Step 1. Establishing and educating key systemic bodies • Step 2. Implementing the Community Health Education Programs • Step 3. Monitoring and evaluation (Fig.l).
Establishing and Educating Systemic Bodies The setting up and education of key systemic bodies is an interlinked process, since the educational process occurs soon after the developmental process (Fig.2). The four systemic bodies that will be established are: a. b. c. d.
The The The The
advisory team community health education unit community health workers women's groups.
The first systemic body, the advisory team, is responsible for implementing the community health education system. The team consists of a team leader, project officer and health educator, and is funded externally. The second systemic body, the community health education unit, is set up by the advisory team in collaboration with the government of each Indochinese country. Thus a community health education unit with a minimum of four female health professionals, who are interested in health education and promotion, will be established in Laos, Kampuchea and Vietnam. The third systemic body, the community health workers in the
Ranjit N. Ratnaike and Tracy L. Chinner
FIGURE 2 Establishment, education and training of systemic bodies Step 1
I= C.H.E. Unit
Advisory Team ~
C.H.E. Unit ~
C.H. Workers ~
C.H. Workers ~
I= C.H. Workers C.H. Workers
I= Women's Groups Women's Groups
& Village Women
villages of each country, will be organized by the women in each village (who will determine who is best suited for the job), assisted by the community health education unit members. The female community health workers can be either volunteers, as in many programs in other parts of the world, paid a salary, or be subsidized by the national government. The fourth systemic body, the Women's Group, is the most important for the success of the system. The women's group in each village consists of volunteers, and ideally the local midwife, and is established by the female community health workers and the community health education unit. The women's groups will ensure genuine community participation within the community health education system and assist with the implementation of the community health education program. We believe that the success of the program will be largely dependent on the women's group. In association with the establishment of these systemic bodies is a program of education (Fig.2). The community health education unit is trained by the advisory team. The health educator, will be assisted by the team leader and invited consultants.
The Teaching Program
T h e teaching program consists of a series of eight learning modules, within which workshops are conducted. T h e workshop format is preferred since it provides a setting for maximum participation and interaction. Module 1 This learning module covers the medical content of the program: i. Maternal care a. Pregnancy and antenatal care '° b. Postnatal c a r e 'l'l'2 ii. Proper nutrition '° iii. Prevention of infectious diseases a. Germ theory 13'~4 b. Immunization ~° c. Personal hygienC 5'~6 d. Domestic hygiene 17 e. Environmental hygiene l* f. Preventing sexually transmitted diseases ~9 iiii. Screening for breast and cervical cancer TM Module 2 Information on effective teaching methods is given; essentially on how to teach adult learners, such as the Community Health Workers. Module 3 T h e unit members learn to develop and utilize teaching aids, such as posters, slides, audio-cassettes, quizzes, drama. T h e use of local resources is emphasized. Module 4 T h e members of the community health education unit revise modules 1-3. Module 5 A training program is developed for the female community health workers. This is based on modules 1-3. A basic training manual is produced. Module 6 T h e objective of this module is for the Unit members to learn video production techniques: to design and produce a video promoting women's health. A similar health education "package" is developed as a teaching cassette. These are used for training the community health workers and for the community health workers to use in the villages. T h e availability of very light-weight, portable battery-powered video monitors makes the widespread use of teaching-videos a feasible proposition.
Ranjit N. Ratnaike and Tracy L. Chinner
FIGURE 3 Development of Community Health Education Program Community Health Education Unit Trains
I= i Community Health WorkersI
Community Health Worker ]
Community Health Education Unit 1
Community Health Education Program content and design Module 7 The unit members and the advisory team develop a national awareness program on women's health to be promoted by the media of each country. Module 8 The unit members learn the need for continuous monitoring and evaluation of the community health worker training program, the community health education program, and the community health education system as a whole. Evaluative techniques and feedback loops will be developed. The unit members will also be given a questionnaire to answer, to evaluate their own teaching program which was conducted by the advisory team.
Implementing the Community Health Education Program The Community Health Workers, once their training is complete, establishes--with the assistance of the community health educa-
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tion unit--the women's groups. The community health workers then teach the women's groups and other village women, through the community health education program, about the four health areas mentioned earlier--with special emphasis on preventive behaviours. The women's groups assist the community health workers with implementing and developing the community health education program (Fig.3), even though they are targeted as pupils of the program. The community health education program of each village will have unique features due to the input of the women's group, who will maximize their resources by using the talents of the local people in their village. After the implementation of the community health education program, four categories of women will have been educated within the community health education system: the members of the community health education units, the community health workers, the women's groups, and the nonparticipatory village women.
Monitoring and evaluating the Community Health Education System The community health education program, as the "end-product" of the community health education system, will be monitored by the
FIGURE 4 Feedback loop
Community Health Education
Community Health Workers
[ OtherVilageWomen] ii l
Ranjit N. Ratnaike and Tracy L. Chinner
community health education unit (and initially the advisory team). Evaluation will be effected through feedback, gathered continually from the community health workers, community health education unit members, and village women. This feedback will also be used to improve and modify, if necessary, the community health education program and the system as a whole (Fig.4). The stabilization of the community health education system and the successful implementation of the community health education programs (determined by monitoring and evaluation) signals the withdrawal of the advisory team from the system. At this point, the external funding body ceases financial support, and it is anticipated that the system will be financed by the Indochinese governments. The community health education unit will then become the supervisory and teaching body, under Indochinese control.
CONCLUSION The community health education system, proposed in this paper, will improve the health status of village women and their families. In addition, significant non-health benefits will accrue: their active involvement in the community health education system will expose rural women to a variety of participatory activities, fostering improved selfesteem and self-confidence so that leadership roles in their families, communities and countries can be assumed.
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10. Winikoff, B, Women's health: an alternative perspective for choosing interventions. Stud Faro Plann 19:197-214, 1988. 11. Ashworth, A, and Feachem, RG, Interventions for the control of diarrhoeal diseases among young children: weaning education. Bull World Health Organ 63:1115-1127, 1985. 12. Feachem, RG, and Koblinsky, MA, Interventions for the control of diarrhoeal diseases in young children: promotion of breastfeeding. Bull World Health Organ 62:271-291, 1984. 13. Escobar, GJ, Salazar, E, and Chuy, M, Beliefs regarding the etiology and treatment of infantile diarrhea in Lima, Peru. Soc Sci Med 17:1257-1269, 1983. 14. Ratnaike, RN, Collings, MT, Ramaike, SK, Brogan, RM, and Gibbs, A, Diarrhoeal disease: knowledge, attitudes and practices in an Aboriginal community. Eur J Epidemiol 4:451-455, 1988. 15. Black, RE, Dykes, AC, Anderson, KE, et al. Hand-washing to prevent diarrhea in day-care centers. AmJ Epidemiol 113:445-451, 1981. 16. Sprunt, K, Redman, W, and Leidy, G, Antibacterial effectiveness of routine hand-washing. Pediatr 52:264-271, 1973. 17. Feachem, RG, Interventions for the control of diarrhoeai diseases among young children: promotion of personal and domestic hygiene. Bull World Health Organ 62:467-476, 1984. 18. Stanton, BF, and Clemens, JD, An educational intervention for altering water sanitation behaviours to reduce childhood diarrhea in urban Bangladesh--II. Am J Epidemiol 125:292-301, 1987. 19. Commonwealth Department of Community Services and Health: National Women's Policy-Advancing Women's Health in Australia, Canberra: Australian Government Publishing Service, 1989. Pp.32-38.