Health has long been defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity ’. This clearly implies the need for promoting ‘holistic’ well-being and comprehensive healthcare that enables people to increase control over improving their own health. This process entails raising health awareness, enabling informed choice, disease prevention and control. Action in health promotion requires that efforts move beyond the boundaries of an absolute biomedical approach, towards one that takes into account the wider determinants of health including social, economic, political, cultural and ecological factors.
Incorporating health promotion mechanisms at every level of our health system is essential. In this blog, I share a few reflections derived from my experiences with health promotion and disease control activity.
HEALTH PROMOTION AND DISEASE CONTROL
I have in the past, had the opportunity to closely observe and be a part of health promotion programmes dealing with cancer awareness, prevention and care. While I had the opportunity to work within the Cancer Screening Programmes in the UK, it was clear that the programmes had been carefully designed, strategized, piloted and rolled out in an evidence-based manner. Understanding the disease, its anatomical symptoms and more so its aetiology at a molecular level, and the social factors influencing its development, held centre focus in the design and implementation of the population-wide disease control programmes. In Bangalore, I had the opportunity to set up a hospital-based cancer registry programmeas part of the wider national programme. Being hospital- based, it was the first time that the ‘patient’ was brought into focus in my work with cancer, and in the process; the seriousness, complexity and reality of the disease with its wider issues governing all aspects of disease awareness, prevention or cure became more apparent and significant.
Simultaneously, my background in Immunology began to re-iterate the significant role our human immune system plays in linking the impacts of our environment with our health outcomes. The Government of India has made efforts to incorporate health promotion into the health system through various intervention-based disease control programmes. Such programmes are important in the short term; however their predominant vertical, biomedical (drug-based) approach is futile for sustained disease control. They fail to consider the wider social determinants of health (SDH) that govern individual and population immunity. One such vertical intervention is the DOTS–TB Control.
Programme introduced under the NRHM.
Tuberculosis (TB) remains a major national and global health problem and is no longer only a disease of the poor; but rather a disease of compromised immunity. Various factors like financial poverty, undernourishment, small, overcrowded and unhygienic living conditions, lack of health awareness and poor health / medical practices; all culminate, to directly or indirectly impact on human immunity and influence susceptibility to TB. The evolution of multidrug-resistant TB strains greatly challenges the efficacy of anti-TB drugs. Furthermore, Directly Observed Treatment, Short Course (DOTS) despite its advantages, fails to address the basic principles of autonomy, appropriateness, accessibility and acceptability; essential for successful adherence and compliance to such a disease control strategy. Responsibility to one’s own health and the sense of personal agency is crucial in positively influencing the SDH and thereby health outcomes.
Recent media campaigns promote the importance of TB diagnosis and uninterrupted treatment via the DOTS programme. While this is a powerful effort in health promotion, it fails to convey the very significance of nutrition and a healthy immunity in TB prevention and control.
HEALTH PROMOTION AND THE INDIAN HEALTH SYSTEM
Health promotion is complex and requires adequate reflection, effort and resources. We are fortunate as a country to have the aptitude and the means to build a massive and effective health promotion campaign as a part of our existing public health system. A successful example of disease control through health promotion activities (education and prevention strategies) and multi-sectoral efforts (including The Ministry of Rural Development, Govt. of India, State Public Health Engineering Departments, and the Rajiv Gandhi National Drinking Water Mission (Rural Water Supply) in India; is the Guinea Worm Eradication Programme. Health promotion has the potential to move beyond the NRHM’s vertical interventions through cross sectoral engagement (sectors that influence the daily lives of the public and their health). Addressing the SDH through such an approach would ensure that important disease–contributing factors like micronutrient deficiencies are addressed even via the food industry, for example.
Health protection through immunity building and addressing the SDH from within the Public Health system and across sectors, to introduce well-planned horizontal efforts together with vertical interventions is a way forward.
Disclaimer:IPH blogs provide a platform for e-PHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.
The World Health Organization (WHO) estimates that 1.24 million road traffic deaths occur every year globally. Of those, the majority (80%) of deaths occur only in middle income countries.Road traffic injuries are never considered a public health issue in India, rather reported as just any other event. India leads the world in terms of mortality from road traffic injuries.In India, road traffic injuries pose a significant public health challenge to the already overburdened health system, and hamper the economic development of the country.Three Es are important in preventing lots of death from road traffic injuries. Education in increasing awareness on road safety measures and behavior change among general public is important. Establishing and designing proper roads is more important. Most important is political will in stricter Enforcement of road safety laws.
Link to Manoj Pati’s blog in BMJ can be found from here.
The institute has been providing an online platform for learning for the past two years. We introduced the online course on public health management for professionals and beginners across the country to gain an understanding of how to be good public health managers. So far, in the past two years we have successfully managed three batches and now have opened enrolments for the forth batch. Here we give you a snippet of what a classroom from the course looks like. This classroom focuses on introducing the students to health financing.
For more sample classrooms click on the link – https://goo.gl/QzYhUL
This article originally appeared on BMJ Blogs on April 24, 2015 under the same title.
This blog is my reflection on regular field visits as part of the urban health action research project that I am currently working on. The field site for the project is a very poor neighbourhood of Bengaluru called K.G.Halli. This neighbourhood has families who earn their living as daily wageworkers to a few upper middle class families.
Let me give a brief overview of the project. It is an action research project which aims to improve access to quality healthcare especially for people with chronic conditions among the urban poor. As a project initiative, we identified three ladies from the same community and trained in providing awareness sessions for chronic conditions. These community health assistants have been working in the neighbourhood since 2009. They go door to door to deliver awareness sessions on diabetes and hypertension, to inform patients what the preventive measures are that the patient and the family can adopt on a daily basis, how diet plays an important role in managing their conditions, and the importance of regular medical check ups. These ladies are an important interface between the community and healthcare providers. Over the years they have become the “go-to” people to seek advice.
Recently I accompanied these ladies for their regular home visits. As they were walking in the lanes, familiar faces greeted them, some asked them to come and join them for a cup of coffee. These were greetings on one end of the spectrum, on the contrary we had to knock on an average of 20- 25 houses and then there would be one patient or a family who would greet us. A few passers by whom we met on the way had curious questionable looks on their faces, and a few even said: “There is no patient in the family.”
Some responses I found were very startling and some of the interesting ones, which did capture my attention, were:
“I already have the disease, how will this awareness bring about a change?”
“ I do not have a ration card, that is more important to me, awareness is not.”
“ Why don’t you give us money?”
“ It is your job as a doctor to find cure and medicines, it is not the responsibility of the patient to make any dietary changes.”
“ Why are you scaring me after me being diagnosed with the disease? I do not need this information.”
“Do you have to meet certain targets? How many houses do you have to visit like these in a day?”
Another experience cited by the health assistants was, “we are educated people, we do not need your information: you would be better off educating the poor people.”
These reactions from the community, which I worked in for almost two years, made me realize that I was wearing blinkers as a young researcher and a medical doctor. It made me realize that the training in research or medical school did not give me any skills to understand these reactions or even think which other strategy I could use to communicate effectively and motivate people.
They sought a completely different path to find out about or understand their disease. Most of the patients that we visited asked us “why aren’t you carrying a glucometer to let me know if my blood sugar levels are under control.” The patients just wanted a figurative number, which is simpler for them to understand and to reassure them that their disease is under control. They would rather not listen to the “science” but to an immediate solution to their problem.
Their voices echoed completely different priorities, such as ration cards, cheaper sources of medicines, or jobs. Another question which came to my mind was whether my chosen strategy of conducting door-to-door awareness sessions was indeed the best strategy for the community or for the researcher?
The comfort of science and research were no longer my allies in solving my dilemma, reiterating the steps to actually listen to the community and understand their priorities better than going with my priorities as a researcher. How can a young researcher like me help them in securing a ration card of any other welfare schemes? Maybe there were unexplored pathways to find a common ground which has a possibility to solve some demands of the community as well as bring in about motivation in the community for adopting a healthier lifestyle.
Written by – Mrunalini Gowda, Research Officer at the Institute of Public Health, Bengaluru.
KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen and build national capacity in HPSR.
KEYSTONE was convened by the Public Health Foundation of India as Nodal Institute for the Alliance for Health Policy and Systems Research (AHPSR).
The Inaugural course which was held in New Deli from 23rd February to March 5th 2015 had twenty fellows from various disciplines participating in this course from across the country.
Institute of public health, Bengaluru also was one of the members for this intiative. Dr. Devadasan was on the core selection committee, Dr. Prashanth N.S was one amongst the facilitators who helped developing the curriculum of the course and also taught the lens of realist evaluation. Dr. Mrunalini Gowda, was selected as a fellow to partcipate in this course. This two week intensive course covered different lenses of health policy and systems research and the to bring about a learning platform for the fellows and the facilitators to share learning material and also establish a active discussion forum. Learning management system called MOODLE which is managed by IPH was used throughout the course . The learning management system was appreciated by all the members of KEYSTONE initiative.
The World Health Organization , Government of India (GoI) and other technical and donor partners undertook a Joint Monitoring Mission (JMM) to review the India’s Revised National TB Control Programme (RNTCP) from 10-23 April 2015. The last JMM was undertaken in August 2012.
The objectives of the JMM are to:
Review India’s progress in implementation of the National Strategic Plan and follow-up on the recommendations of JMM 2012.
Review the country’s progress as per the National Strategic Plan 2012-1, towards universal access to TB care and to advise GoI and partners on the pathway towards strategies in line with End TB Strategy.
The JMM constituted 100 national and 50 international experts partnering with the RNTCP. Dr.Vijayashree Yellappa, faculty and PhD fellow at IPH participated in the JMM (Private sector engagement). She was deployed in Mehsana district of Gujarat to observe the private sector engagement in RNTCP.