Author: Aibinuomo, F O
Date published: March 1, 2011
Journal code: FPSY
Primary health care was ratified as the health policy of the World Health organization (WHO) member states in 1978 Alma-Ata, community participation in health care was a key strategy. The Alma Ata declaration stressed health as a fundamental human right and stated that health care must be accessible, affordable and socially relevant to meet the needs of the people. The concept of PHC is based on four major pillars, namely, political commitment; intersectoral cooperation; Community participation; and use of appropriate technology (Olise, 2007). However, the use of the term PHC was reported to be used initially to describe the first care given to a person in poor health, irrespective of where the care was given.
Findings of the needs assessment survey conducted on the eight States under the UNICEF ?' Field Office (Delta, Edo, Ekiti, Lagos, Ogun, Ondo, Osun, and Oyo) revealed the status of PHC in Nigeria as 70% of wards having at least one Primary Health Care centres but most of these states did not have a medical officer in any Local Government Area; Midwives are particularly in short supply at the LGA level and below (grassroots). Only 2.5% of facilities surveyed had more than 75% of standard equipment package; Drug supply situation was especially poor; and nearly half of the health facilities did not receive any drug supplies in the last 2yrs.
Based on the above revelations, it is pertinent that the community needs basic health information to keep them physically, morally, and socially fit. Health communication for positive change involves delivering messages, information, or ideas that can be understood, to clients /care-givers. This, in a nutshell could be termed as 'Community Education' Community Education cannot be defined in isolation, this necessitates a review of the words 'community' and 'education' which makes up the term. Community, from its sociological approach is viewed as a feeling rather than a geographical expression. This is because it is through the interrelationships in a community that community education realizes its power (Anyanwu, 1992). Community here refers to a local situation implying closeness and which may be characterized by a neighbourhood. At the same time, it implies people who have common challenge and common goals. Health workers' are hereby classified as a community by the virtue of the pressing issues they have in common which is, attainment of the MDGs.
Community therefore involves reaching consensus in the recognition of the common end and the regulation of activity in view of it. Wells (1929) as cited in Anyanwu (1992) in his analysis explained education as "the preparation of the individual for the community" while Dewey (1963) reviews education as "the reconstruction or reorganization of experience which adds to the meaning of experience, and which increases ability to direct the course of subsequent experience". These views was corroborated by Anyanwu, Aibinuomo and Anyanwu (2003) who asserted that the fact that education is to teach care-givers to think and take appropriate steps towards living a healthful behaviour within communities has a lot to do with the provider being properly informed about what to do. We can therefore appreciate what community education is all about if community is understood as a feeling rather than a geographical boundary and education as a means of teaching us to think and reason, in order to improve our material prospects, add to our poise and deportment, and develop our judgement
Community education is a process of facilitating and enabling people to acquire skills, knowledge and confidence to make responsible choices and implement them; it helps create settings that facilitate autonomous functioning. This also refers to the educational and empowering process in which the health personnel, in partnership with those able to help them identify problems and needs (community) and increasingly assume responsibility for planning, managing, controlling and assessing the collective action that needs to be taken. Community education engages local people in creative problem solving and provides opportunities for a new form of self-expression. By involving participants in a variety of a new way of learning, learners discover talents and abilities they never knew they had. The discovery increase participation and improves the quality of both participation and learning. Community education also engenders ownership which enhances direct involvement and commitment of local individuals, communities and institutions to the point where they (and not external groups) become the driving force for change.
Community education therefore, is a new basic education for life in society rather than education merely for livelihood. It calls for adjustments and the acquisition of new habits, attitudes and values on issues that concern their health - 'no longer easy live happily in ignorance'. This paper will now deal with the "new methodology and strategies" most of which professionally, has been the practices but unatended to, that's why it's termed "NEW" - rebranded!
Community mobilization is social mobilization at the political Ward and household levels. Social mobilization aims to gain and maintain the involvement of a wide range of stakeholders, networks, groups, sectors within a community for the support of immunization. Community mobilization is a process that uses participatory approaches to motivate groups, institutions, leaders and members at local levels towards shared knowledge, attitude, actions and practices that are collectively beneficial to them. It is a means of encouraging (through proper Interpersonal communication), influencing and arousing the interest of people to make them actively involved in finding solutions to some of their own problems. Community mobilization is useful in achieving effective community participation.
Steps in Community mobilization
1. Know the community (its geography, population, culture, occupations, institutions, and so on)
2. Identify what the community to be mobilized is to do and the expected benefits
3. Plan for other steps in mobilization; use the information gathered from steps 1 and 2 to draw up a modifiable plan. It includes identifying the assignments to be given out, who will do what, how, when, where and with what resources.
4. Identify and meet with relevant community entry points at different levels - local government area (District), wards, and settlements. In agreement with them, plan for more general meetings with other community leaders and focal persons. At this and other meetings;
a. Explain the objectives of the anticipated programme or project and the expected benefits.
b. Establish rapport and obtain their support on all issues as far as possible.
c. Listen to and clarify issues of concern
d. Praise individual and groups' efforts
5. Attend subsequent meetings, broaden support and agree on actions to be carried out towards community participation. Using a participatory approach, assign responsibilities to individuals and groups and set up communities as necessary.
Community Participation, on the other hand, is the process by which individuals and families assume responsibility for their own health and welfare and for those of their community, and develop the capacity to contribute to their and the community's development.
1 . Communication for Development (C4D )
a. Community dialogue and Coalition: Since the onset of immunization programme implementation in 1998, strategies imbibed to encourage community participation has moved from formulation of social mobilization committee at all levels of governance, to the use of data oriented social mobilization, and community mobilization initiative.
b. SWOT analysis of both internal and external working environment
c. Community mobilizers initiative
d. TFD - Theatre for Development.
e. Instituting Community Viewing Centre
f. Community radio: Radio stations within campus es (University of Lagos, Diamond FM in university of Ibadan), private stations, and a host of others.
g. Community involvement Micro planning (CIM) which means the involvement of key community members (community Leaders, Religious and Traditional Leaders and active youths) in the micro planning process to ensure that all settlements are reached;
2. Upstream and downstream approach: This is a two-way intervention (policy makers advocacy and at same time grass root intervention) simultaneously for positive programming.
3. GIVs: Currently, this involves the introduction of new vaccines by the first quarter of year 2010. These vaccines are Pentavalent (DPT+Hib+Hep B) and Pneumoccocal conjugate Vaccine (PCV). GIVs is a framework for protecting children from preventable childhood diseases such as measles, tetanus, and whooping cough. Developed by UNICEF and the World Health Organization (WHO), GIVS calls for raising global immunization coverage for these common diseases to at least 90 per cent in every country over the next five years.
GIVS is the first ever strategic framework for immunization designed to respond to the challenges of a rapidly changing and increasingly interdependent world. It presents a wide range of initiatives which countries can choose from to address their own specific needs. UNICEF and WHO says the objectives outlined in the strategy must be addressed if the world is to achieve the Millennium Development Goal of a two thirds reduction in mortality among children under five by 2015.
4. Appropriate selection of vaccination sites (fixed posts and outreaches) linked with Reaching Every Ward (REW). This is an indication that Community Leaders are well sensitized about immunization activities in their communities.
5. Community Education: information dissemination through education and community-driven, operated programmes for ownership creation. This could be achieved through positive attitudinal change at every aspect of health practice termed
Key Household Practices as stated below:
1) Growth Promotion and Development (6 components)
a. Birth Registration
b. Exclusive breastfeeding for 6months
2) Home Management (3)
a. Continue to feed and offer more food dd fluids when child is sick
3) Disease Prevention (4)
a. Child sleeps under insecticide treated nets
b. Proper disposal of faeces, hand washing, etc
4) Care Seeking and Compliance
a. Sleep under Long Lasting Insecticide Treated Nets (LLIN), every night, to protect from Mosquito bite that causes Malaria. Change your net every four years.
b. Intermittent Preventive Treatment (IPT) of Malaria, using Sulphadoxin Pyrimethamin (SP)
c. Routine immunization: take child to complete full course of immunization before 1 st birthday
i. Measles vaccination; at 9 months
ii. OPV; Birth to 13 days, 6, 10 and 14 weeks
iii. DPT; at 6, 10 and 14 weeks
iv. Tetanus Toxoid; for pregnant mothers and women of child-bearing Age.
d. Active participation of men in childcare and reproductive health activities
Brief on the MDGs
The Millennium Development Goals are time-limited commitments made by governments throughout the world to reduce poverty and promote human development. Adopted in September 2000 by representatives from 189 countries (including 147 heads of state), they include some of the key commitments made at the major UN conferences of the 1990s.
There are eight interrelated goals, each with a number of key measurable targets to be met by 2015. They commit governments to: increase efforts to reduce poverty and hunger (MDGl), improve access to education (MDG2), promote gender equality (MDG3), combat ill health (MDGs 4-6), and ensure environmental sustainability, including access to safe drinking water and sanitation (MDG7). The remaining goal (MDG8) commits governments in developed countries to establish a global partnership for development, intended to support developing countries in their efforts to achieve the MDGs.
Scaling up immunization to meet the Millennium Development Goals (MDGs)
Efforts to scale up immunization coverage in the poorest countries are pivotal to meeting the Millennium Development Goal to reduce child mortality. Of the 10.5 million deaths among children under five in 2003, about one-quarter were attributable to diseases that are already vaccine-preventable (Fact sheet on GAVI, Feb. 2005). Moreover, communication strategy is a combination of methods, messages and approaches by which the immunization manager seeks to achieve the communication objectives. To inform goes beyond just passing out information to the people about health service delivery. It also involves giving detailed health information to the people, for example, making the people to be aware of where health services including immunization could be obtained, for what purpose, at what cost, and the benefits of good health.
Therefore, in order to educate and inform the people, immunization managers must be well educated and fully informed about the health situation of the people, the condition of the environment, as well as the cultural peculiarities of the people, they want to change and/ or modify their behaviour towards desired goals of accepting routine immunization as panacea for good healthful living for a child survival development protection and participation and indeed, polio eradication
Linking Services with the Community
Strengthening the link between community and services can only be achieved through the involvement and effective empowerment of community in the management of the services. This will help create awareness, stimulate demand, help convince those that are hard to reach and lastly encourage community participation. This could only be achieved through activities of the social mobilization committees at all levels; National, State, and LGA (District). Activities at LGA level helps in bridging the gap between the community and policy makers. Identified local associations and organizations will link up with the committees at respective levels to participate in local resource mobilization, plan and implement activities involved in Reaching Every Ward (REW), viz social mapping, mobilization, and defaulter tracking.
Open broadcasting - in this model, there is a lack of infraction between producers and consumers of program before programs are planned produced and broadcasted. This is mainly because of infra- social and knowledge gaps between the usually urbaneducated producers and rural illiterate consumers
Radio Study Group - this is a strategy used in Tanzania to teach practical skills, cooperative and civic responsibility to rural communities. Using the strategy requires much more than mere broadcasting. It requires a structure for organizing, listening and learning practices, support guidance of trained advisers, meet on agreed dates and times that coincides with the radio broadcasts.
Radio Rural Forum - this is the strategy which makes use of radio with discussion and decision for rural groups. The strategy involves the presentation of a regular weekly 15 to 30 minutes magazines programme to rural audiences formed into listening groups. The program usually comprises of rural news answers to listeners questions, family advice, a talk discussion.
Radio schools - this is the most widespread strategy for using radio for rural community education in Latin America. It was originally tried at Sutatenza, Colombia where it has now permeated the life of the rural population. The school are small organized listening/ learning groups meeting in houses or churches under a guide. The audience of these radio schools is primarily illiterate rural adults.
Radio and Animation - The radio, according to Okediran and Momoh (2004), is the commonest, cheapest, and all-purpose means of mass communication. This, amongst numerous reasons is because it overcomes whatever geographical barriers to its reception by listeners. The aim of radio and animation is for promotion of a trained cadre of decision leaders among local communities. This could also be referred to as radio participating group. This strategy is adopted for the training of leaders whose role is to promote, in a non-directive way, a dialogue in which community members participate in defining their development problems, putting them in a wider social context and devising ways to mobilize their people to common action
* Limited availability and poor quality services reducing demand and affecting healthy practices (personal hygiene)
* Increasing household poverty limiting vision to immediate benefits and fuelling new practices
The Appropriate Strategy
In planning and implementing effective social mobilization, it is necessary to take into consideration the following:
i. a decision should be taken on the type of campaign that is to be implemented. Any campaign adopted must result in direct action to improve the lives of the recipient of such campaigns and its objectives should be properly articulated and stated.
ii. Adopt the ABC of behaviour which are;
ANTECEDENTS (A) - Holland and Skinner (1961), noted that antecedents are environmental events that set the stage to trigger behaviour. Many behaviour are automatically triggered by environmental events that we call naturally occurring antecedents, for example, Kano, Kaduna, Sokoto States (Nigeria) initial refusal to allow polio immunization for the children
BEHAVIOUR (B) - Behaviour is simplified as expressed attitude. They argued that the characteristics of behaviour have important implications for communication strategies. They forcefully argued for what they have termed 'Target Behaviour" and concluded that;
i. target behaviour exists but not in sufficient frequency e.g. parent seek some but not all antigen in the immunization series as scheduled.
ii. target behaviour exists but not in sufficient duration e.g. Parents gives chloroquine tablet only until the fever is reduced and not for the number of days required, same thing is applicable in the polio immunization.
They concluded that ...."the relationship between environmental events and the behaviour is often called the 'ABC - chain' i.e Antecedent - Behaviour - Consequence.
In order for health programme providers/ managers to effectively change the people's behaviour, they must also understand the UNICEF invention which is termed the 'ACADA model'
ACADA Model is a communication model which was developed by UNICEF so as to help EPI managers understand fully the basic concepts involved in programme planning, implementation, monitoring and evaluation. In my judgement, ACADA model is a process of scientific enquiry which attempts to influence, change, and modify human behaviour. It is a planning framework for development communication
A - stands for Assessment
In other words, the situation report /assessment which may involve audience assessment channels messages could also be rapid assessment to know current situation
C - Communication Analysis
This will include but not limited to the following
- Problem analysis/ problem statement
- Participation - behaviour pattern
- Media choice, channels
- Communication objectives
D - means the design of the programme under the design of the programme, we expect such items as:
- Strategic plan
- Social mobilization - which is intersectoral participation
- Programme communication: consultation research, K-AB-P, audience segmentation, to mention a few.
A - stands for Action taken or to be taken i.e. implementation, monitoring and supervision, evaluation, and post test.
- Formative research including training, training main, i.e IEC, message design especially putting the language of the local environment into consideration to achieve the desired objective
Behaviour change/ modification is observed from the point of view that 'CHANGE' is a very difficult commodity to sell. Many people are generally reluctant to change their long time behaviour. As health personnel/ communicators, change is just like fertilizer; you know that fertilizer stinks, it smells badly, but when applied to the soil, it gives the soil all nutrients needed to grow and eventually brings out sweet, and desirable product. So human behavioural change may appear difficult to achieve but with more persuasion (good IPC), collective responsibility, strategic communication, it is achievable and also sustainable without prejudice to the prevailing environmental factors and conditions
"As the 2015 deadlines for the Millennium Development Goals draws closer, the challenge for improving materials and newborn health goes beyond meeting the goals, it lies in preventing needless human tragedy. Success will be measured in terms of lives saved and lives improved" - Ann M. Veneman (2009) Executive Director UNICEF
Implication for policy implementation
Since information is power, there is the need for support of the establishment of viewing centres in all communities especially the ones within the rural settings; the existing ones should be resuscitated. This serves as a pice to relax in the evenings after the daily runs and a base where information is shared.
Moreover, the use of information board should be concretized in that this allows for a cursory view of the health status of that community. The board be placed in an agreed location which is accessible to all especially the traditional leadership
In order to have an effective and sustainable community-operated health system in Nigeria, the following recommendations are suggested;
* There should be the involvement of the local (traditional) media in information dissemination within communities.
* The role of Traditional institution in programme planning and implementation should not be overlooked since PHC targeted to the grass root
* Community mobilizers should be resident and nominated by the community themselves for an effective health service defaulter- tracking to be conducted
Anyanwu, CN. (1992). Community Development The Nigerian Perspective. Ibadan. Gabesther Education publishers
Anyanwu, F.C., Aibinuomo, F. O. dd Anyanwu, I.E. 2003. Preferential Utilization of Traditional Birth Attendants (TBAs) by Expectant mothers in Ibadan North-west LGA Oyo State. Magazine of the International council for Health, physical Education, Recreation, Sports and Dance; African Region
Akinwande, J.A. 2003. Media technique in adult education and community development in Education this milleniuminnovations in theory and practice.. Eds. O. AyodeleBamisaiye, L.A. Nwazueke, dd A. Okediran. Lagos: Macmillan Nigeria Publishers Ltd. Chapter 44. 535-539
Alagh B.T., Owoaje T.E. and Omotade O.O. (2003): Routine Immunization Coverage rates. UNICEF ?' zone focus LGAs, Nigeria. 1-2, 34.
Bryant, J.H. and Richmond J.E. Elsevier Press The story of Alma-Ata - past, present, future - in a changing world. In Encyclopedia for public Health.
Declaration of Alma-Ata: international conference on primary health care, Alma-Ata, USSR. http: / /www.who.int/hpr/NPH/docs/declaration almaata.pdf . accessed Julvl 6, 2008
Dewey (1963) in Anyanwu, CN. 1992. Community Development: The Nigerian Perspective. Ibadan. Gabesther Education publishers
FMoH, 2005: Global Immunization Vision and Strategy, 2006-2015. Geneva, Switzerland: www.who.int/vaccines/ /GIVS/ English/ GIVS. Final 17th Oct. 05
Holland and Skinner (1961) in UNICEF, 2001: Communication Handbook for Polio Eradication and Routine EPI. New York: Publishers.
Okediran, A. and Momoh, M. (2004). Introduction tothe Development of Radio Programme guide in Literacy and Non-Formal Education. International Journal of Literacy Education, Gab Publications, Ibadan. Vol INo. 1: pp 28.
Olise, P. (2007). Primary Health care for Sustainable Development. Abuja, Nigeria. Ozege Publications
Park, K. 2007. Park's textbook of Preventive arid social medicine. 19th edition. M/s Banarsidas Bhanot Publishers
UNICEF, 2001: Communication Handbook for Polio Eradication and Routine EPI. New York: Publishers.
Veneman, A. M. (2009) in UNICEF publication of the state of the world children. New York: Publishers.
Walsh, J.A. and Warren, K.S. Selective primary health care: an interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-974. PubMed
Wells (1929) in Anyanwu (1992). Community Development: The Nigerian Perspective. Ibadan. Gabesther Education publishers
AIBINUOMO, F. O
Department of Adult Education
University of Ibadan, Ibadan