soleh berusaha

1. Introduction – NGOs, the origins of primary health care and health promotion.

The primary health care movement sprang up in an autonomous manner in different parts of the world, in the 1960s and 1970s. Rooted in the community and voluntary sector, initiatives developed in different social and cultural situations, exhibiting a rich diversity. The movement gained global visibility and legitimacy from national governments through the World Health Assembly in 1977, and the International Conference on Primary Health Care jointly organized by WHO and UNICEF in 1978 in Alma Ata. Ever since then there have been ripple effects and cross currents in the health and health care related sectors. One of the strong positive currents that emerged was that of health promotion. It is important to recall the different collective experiences, forces and perspectives that developed the Health for All goals and strategies. Dr. Mahler, Director General of WHO at the time publicly states that it was the non-governmental organizations (NGOs) who pressed WHO strongly to move beyond a disease focused, expert dependant, techno-managerial approach, based on the dominant system of medicine, to one wherein community participation, inter-sectoral coordination and appropriate technology were important. The key underlying principles of primary health care (PHC) were social justice and equity with a shift beyond doctors, diagnostics and drugs to addressing the conditions for health. An important component was health education, which grew in strength to emerge as health promotion. NGOs, professionals and people across the globe sustained the spirit of primary health care through decades when it met with resistance and neglect. The Ottawa Charter of 1986 introduced a clear focus on fundamental conditions or basic determinants for health such as peace, shelter, education, food, income, ecosystems and resources. Ownership and initiatives by states, international bodies and experts provide a professional strategic approach and increase coverage. However communities and community based organizations (CBOs) may get excluded in decision making, while powerful interests get accommodated. Public health ethics and principles of universal human rights suggest that the challenge before the health promotion community is to build partnerships upholding the public good in health, by addressing health determinants and respecting cultural diversity in a transparent manner. The role of communities, CBOs and NGOs along with the state should be central.

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2. Contextual challenges to global health promotion

In the year 2005, despite increasing knowledge and wealth, health goals remain a distant dream for the social majority globally. Inequalities in wealth and health have grown. Efforts to medicalise health, with professional control over information, are now compounded by commercial and corporate interests in medical and health care and professional education. The stakes of multinationals, producers of pharmaceuticals, medical equipments, and medical insurance companies are at a much higher scale. Globalisation provides for free flow of information and ideas. The use of information and communication technology has benefited many. However, macro-economics, speculative financial flows and global trade policies adversely affect livelihoods, food and human security, the environment, and purchasing capacity of a significant proportion of people. While health status has improved for some, disparities are growing, health gains are being lost and new problems are emerging. Community impacts of corporate led globalization point to increasing denial of health and access to health care. Conflicts of interest that underpin many of these developments need to be clearly addressed by the health promotion community. Strategies need to address health determinants including war and conflict, unhealthy trade practices, environmental injustice, recognizing the complexities involved. Partnerships with affected communities and NGOs are critical. This paper reviews the role of NGOs, The strengths and opportunities of potential and existing partnerships and peoples movements in health promotion and in addressing health determinants.

3. NGO Partnerships for Global Health Promotion

The role of civil society organizations (CSOs) has received increasing importance in public policy and health policy over the past decade. As more financial and other resources were invested in this sector, the profile of its constituent groups changed. Different agencies define CSOs and NGOs differently. There is need for clarity in understanding the heterogeneity of this sector, and to recognize the unique roles of different constituents for global health promotion. NGOs in the 1960s and 1970s were largely not –for – profit voluntary organizations working towards integral development. In health they included medical service through hospitals, health centres, and mobile clinics run by charities, missions and philanthropic organizations. With experience and reflection this group developed a deeper community based understanding of the dynamics of health, health care and development in different socio-cultural situations. They were often able to achieve what governments in resource poor situations could not. With professional and social skills developed through working in difficult circumstances they became alternative experts, and the sector soon became an additional policy option. With growing recognition, money and influence, the profile of NGOs and new entrants to the sector changed . NGOs now include corporate NGOs, with companies setting up Trusts and Societies, building brand images, obtaining tax benefits and blurring the profit and not for profit sector. Government NGOs (GONGOs) and other new entities developed to overcome the bureaucracy of government. Professional associations’ and research bodies with a high degree of knowledge and expertise, such as the International Union for Health Promotion and Education comprise another important section. NGO networks developed at national and global levels with a specific focus on health. During the past decade a global people’s health movement emerged with a strong focus on health determinants and a right’s based approach to health care. The potential for partnerships are thus many. Including those that can impact on health determinants provide a strategic option to global health promotion.

4. Creating enabling environments for NGO coalitions for health promotion

The Millennium Development Goals (MDGs) provide a renewed framework for partnerships between governmental and nongovernmental organizations to create an environment conducive to development and elimination of poverty[1]. Investment in health is critical for development and achievement of the MDGs. Through advocacy for healthy public policy, NGOs increase community health literacy and knowledge. NGOs with diverse structures and functions are the sine quo non in health promotion due to their grass roots presence and closeness with communities, which enables them to respond to people’s health needs, concerns and aspirations.

One of the corner stones of solidarity is sharing and defining common objective, in this case the promotion of health. The objective to be attained should be time bound and measurable. It requires carefully designed strategies with each partner assuming specific roles (Berhane Ras Work, Inter Afrocan Committee)

NGOs understand that health is produced not just by hospitals and health professionals, but by individuals and families in the context of their daily lives and by influencing health determinants. NGOs are a positive force through direct health empowerment and action with people, as well as by working on the deeper issues. They apply the principles of health promotion including capacity development, knowledge transfer, community participation, empowerment, intersectoral collaboration, equity and advocacy for sustainable development.[2]

The agenda for health promotion involves tackling multiple determinants of health. No single governmental or nongovernmental organization can deal with the multiplicity of issues. This is a sound rationale for NGOs to establish networks and alliances between themselves and with academia, governmental and other organizations to maximize their resources and achieve better outcomes. Partnerships provide an opportunity to make best use of the strengths and comparative advantage of each organization. However NGO coalitions do not occur by chance.

To be effective partnerships must be planned, fostered and managed. Partnerships can be focused and time bound to achieve defined outcomes or work through long-term commitments. An example is the Geneva based NGO Ad Hoc Advisory Group on Health Promotion.

NGO Ad Hoc Advisory Group on Health Promotion

Born as an outcome of the WHO 4^th International Conference on Health promotion in Jakarta in 1997, the Group supported implementation of its recommendations, and worked in partnership with others towards the Global Conference on Health Promotion in Mexico City, 2000. The Group comprises several NGOs whose activities include health promotion and education, health co-operatives, nursing, rural women; social welfare, women’s health and those whose main mandate may not be “health”.

Member’s commitment to health promotion helps pool resources and expertise in tackling health determinants. For example, Associated County Women of the World (ACWW) partners with local NGOs, and Governments to provide literacy centers in Mali. ACWW provides partial funding and expertise to help local NGOs achieve their goals with community ownership and ongoing monitoring[3].

The wide diversity of activities, international structures and grass root involvement give the NGO Ad Hoc Group its richness of approach, experience and expertise. Working collectively and individually, and in close partnership with WHO headquarters, the Group has kept the Jakarta and Mexico agendas in the forefront of the NGO community. The Group hosts briefings at the World Health Assembly on NGO and government partnerships in health promotion. This would not have been possible for any single NGO. By their work and commitment, the Ad Hoc Group contributes to the attainment of the Millennium Development Goals.

4.1. Investing in Human Resources and Capacity Building

Human resources are the lynchpin to achieve health and development goals. Distortions in health care priorities hinder progress in health promotion. Major distortions include concentration of health facilities and personnel on urban populations rather than rural, on tertiary care rather than primary, on curative care rather than on promotive and preventative services and on the middle-class and better off rather than on the poor[4].

Though the primary health care strategy promoted by WHO was designed to achieve greater equity and universal coverage, health reform and economically driven models of care reduced public spending on health and social services leading to growing inequities[5].

Besides misallocation and mal-distribution of resources, access to health care is hampered by shortage of competent health professionals capable of providing comprehensive health care. Poor investment in training, recruitment and retention, force health care workers to look for ‘greener pastures’ leading to brain drain. Nurses and physicians trained at public cost migrate from poorer countries to the developed world, leaving health care facilities in a state of collapse.

Nursing staff shortages cause closure of essential health care facilities, including emergency rooms. Serious shortages in all health professional categories in Zimbabwe resulted in closure of health facilities and reduced access to services[6]. The New York Times reported, “the nation is currently engulfed in a huge nursing shortage which is going to get worse”[7]. In the United Kingdom there is concern that: “the National Health Service (NHS) does not have enough pairs of hands to deliver the care that the nation needs… and hospitals are turning abroad to find staff”[8].

Shortages of doctors are reported in several countries including Botswana, Ghana and Guinea Bissau. In some developing countries, shortage of nurses and doctors often results in staffing rural clinics by poorly trained personnel ill-equipped to provide comprehensive services including health promotion. In these circumstances, it is likely that investment in health promotion will continue to be eroded and neglected. NGO coalitions and all stakeholders need to address this issue on priority.

Health promotion strategies draw upon multiple actors and stakeholders including multilateral organizations such as UN agencies; development banks; national and local governments; faith-based groups, citizen’s organizations; international, national and local NGOs; WHO collaborating centres; academic institutions; trade unions; the arts and entertainment industry; the private sector and others. Collaborative efforts by stakeholders who promote the public good in health is crucial for success. For example, the progress made in onchocerciacis control was only possible with committed partnerships. While reducing under-nutrition and universalizing access to water and sanitation attract less attention, regressive policies of some organizations also reverse health gains.

Community Empowerment

Different stakeholders, working with empowered communities can become a powerful voice, lobbying governments to invest in human resources particularly for health promotion training and capacity building. NGO networks have a convening power and a large outreach capacity enabling them to bring about a “paradigm shift” from the curative to the preventive, promotive and social health model.

Training and capacity building by NGOs are characterized by active community participation, empowering individuals and families to increase control over the determinants of their health, and to demand universal access to health care. NGOs and health profession associations should be enabled to become “social health activists”.

4.2. Strengths, weakness, opportunities and threats to coalition building

Strengthening NGO coalitions for health is necessary in the current landscape characterized by declining development resources, increasing privatization of services, and reverse transfer of resources from developing countries[9]. Coalitions need to be built with skill, care and mutual trust using strategies that include identifying opportunities and partners with shared goals; reaching agreements; maintaining and evaluating partnerships [10]. This takes time and resources.

Challenges faced include selecting partners, working with communities, defining partnerships goals, setting time frames, mobilising resources and keeping long term commitments to meet complex evolving needs. Often unequal distribution of power and decision-making within NGO groups or between NGOs and governments can negatively impact outcomes and sustainability of partnerships. Corporate interests working through governments and international bodies can be counterproductive. Lack of trust and suspicion between NGOs and governments is a potential threat.

Coalitions can multiply actions outlined in the Ottawa Charter: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services[11].

Mutual commitments to engagement between governments, civil society and NGOs would help achieve better health. Governments need to see beyond their term in office and to see the long-term role of health promotion. NGOs and civil society need to be rooted in their reality, and to see beyond that reality and their own constituencies to engage with a wider spectrum of stakeholders. Both need to recognize barriers that prevent the realization of health promotion in the community and to undertake cooperative measures to tackle this[12].

As an intergovernmental agency, WHO has a long history of working with NGOs In health promotion WHO – NGO partnership from decision making to evaluation has been fruitful. While partnerships are strong at WHO headquarters, there is scope for improvement at country and regional levels.

5. Global coalition’s promoting health, addressing determinants

Concern about the social determinants of health, and the difficulties faced by governments and international bodies to effectively work on their own towards Health for All goals, resulted in the emergence in the late 1990s of a much broader global coalition, the Peoples Health Movement (PHM). Unlike the 1970s, health groups and NGOs are now joined by women’s movements, the science and literacy movement, the environment movement, trade unions, development groups and many community based organizations, all of whom recognize that better health is a common concern. Collective analysis, planning, action and reflections with affected communities build solidarity. Groups from varied backgrounds and cultures have become connected locally and globally through horizontal and vertical linkages. This awakening culminated in the first Peoples Health Assembly (PHA 1) in December 2000 in Savar, Bangladesh, wherein 1493 persons from 75 countries debated health related issues over five days and adopted the Peoples Charter for Health ¹³. Through thousands of prior community, village and town meetings, the Charter built on perspectives of people, whose voices are rarely heard. It clearly addresses health determinants, namely:

a) economic challenges posed by the global trading system, third world debt, intellectual property laws, speculative international capital flows;

b) social and political challenges, including the right to work and livelihood, gender issues, rights of expression, political participation and religious choice, the weakening of public institutions and services;

c) environmental challenges including water and air pollution, climate change, ozone layer depletion, nuclear energy and waste, toxic chemicals and pesticides, loss of bio- diversity, deforestation and soil erosion ;

d) war, violence, conflict and natural disasters.

Action points concerning these issues, and for developing a people-centered health sector with people’s participation resulted in much follow up.

Spontaneously translated into 50 languages (see www.phmovement.org) the Charter has become one of the largest consensus documents on health providing a framework for action. Since 2000, country, regional and issue based circles evolved leading to specific action such as the right to health care campaign in India; advocacy regarding global public private initiatives; policy dialogue with the WHO; a global campaign on patents; the Peoples Charter on HIV/AIDS and Asian People’s Alliance for Combating HIV/AIDS; the first Global Health Watch report; International Health Forums; state national and UNESCAP health policies; a Tsunami Watch; and most importantly advocacy, street action and community work, including training thousands of community health workers. Media strategies resulted in greater national and local reporting of health issues and controversies, including corruption. In some countries health moved higher on the public and political agenda with commitments to increase budgetary allocations. There has been support for the peace movement in the USA, Europe and Asia, and a PHM response to disasters in Iran, Sri Lanka, and India. The second Peoples Health Assembly in Cuenca, Ecuador in July 2005 raised issues and concerns of the Americas and reviewed progress since PHA I.

These activities took place without centralized funding and through a loose networking structure. Partners from the South played an important role in developing the Charter and strategies for action. The PHM identifies people, particularly those excluded, as its greatest resource and reservoir of talent and energy. Providing space for community voice and agency has brought in dynamism, diversity and focus on priorities. The health movement, along with allied movements, is a force that is part of a globalization of solidarity from below.

6. Conclusion

NGO coalitions with communities, governments and other organisations can mobilise human, political, financial and scientific resources to make health promotion the backbone of health care systems and services. There is a need for the health promotion community to develop and sustain working links with local communities, groups and movements working beyond the traditionally defined health sector in order to influence health determinants. Working for equity in health would involve challenging powerful interests. Public health ethics requires that this be done. The paper provided an overview of NGO coalitions and movements, their strengths, weaknesses, opportunities and threats, suggesting how they make a difference in the health and wellbeing of communities

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[1] General Assembly resolution 55/2, para. 12

[2] Ottawa Charter for Health Promotion, (1986).

[3] Joanna Koch, Associated County Women of the World

[4] Swedish International Development Agency (undated), Health is Wealth.

[5] Braveman, P. & Tarimo, E., Social inequalities in health within countries: not only an issue for affluent nations. Social

Science & Medicine 54 (2002):1621-1635

[6] Mutizawa-Mangiza, D (1998), The impact of health sector reform on public sector health worker motivation in Zimbabwe.

Major applied research, 5, working paper 4. Partnerships for Health Reform, Bethesda.

[7] New York Times 12 April 2001

[8] Jeremy Laurence, Health Editor, The Indipendent, 26 November 2002.

[9] United Nations Research Institute for Social Development, States of disarrary; the social effects of globalisation. London,

UNRISD, 1995.

[10] Kickbusch, I, and Quick, J 81998), Partnershps for Health in the 21^st Century. World Health Statistics quarterly, 51, 61-

74.

[11] Ottawa Charter for Health Promotion, 1986

[12] Manoj Kurian, World Council of Churches, E-mail correspondence

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CONTENTS

INTRODUCTION.. 1

LEARNING OBJECTIVES. 1

11.1 What is Counselling and Health Promotion?. 2

11.2 Importance of Counselling. 5

11.3 Qualities of a Good Counsellor 6

11.4 Counselling Skills. 10

11.5 The Counselling Process. 14

11.6 Barriers to Effective Counselling. 16

11.7 IEC Messages on Malaria Prevention and Control 20

CONCLUSION.. 21

Counselling And Health Promotion In Malaria

 

INTRODUCTION

Welcome to Unit 11. In the last unit we looked at the interaction between malaria and HIV/AIDS. In this unit we shall learn about counselling and health promotion in malaria.

As you may already be aware, there are a lot of misconceptions in communities about malaria. For this reason, it is important for you to educate and counsel both the healthy people as well as those suffering from malaria. Education and counselling play a very important role in reducing the high rates of malaria infection.

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As a health worker, you play a key role in health promotion and counselling for Malaria.

LEARNING OBJECTIVES

By the end of this unit you should be able to:

• · Define counselling and health promotion;
• · Explain the importance of counselling in Malaria management;
• · Describe the Qualities of a good counsellor;
• · Explain the counselling skills;
• · Describe the counselling process;
• · Explain barriers to effective counselling;
• · Counsel patients/clients effectively;
• · Identify IEC Messages for specific Malaria prevention and control.

Let us begin our discussion by defining counselling and health education.

11.1 What is Counselling and Health Promotion?

Counselling is the professional advice and guidance given to a person (client) by a trained person (usually counsellor), in order to assist the client to explore, discover and clarify ways of living more positively, satisfactorily and resourcefully in society.

You the health worker, is the trained person (counsellor), the malaria patient or a member of the community you serve is your “client”

Health Promotion is the process of passing information and practical skills with the primary goal of improving people’s health by promoting better health practices.

Health promotion/education usually aims at changing positively the knowledge, attitudes and practices of its recipient.

Before you proceed, do Activity 1 it should take you 5 minutes to complete.

ACTIVITY 1 What general information about malaria would you pass on to the client or community? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

We hope your list included the following important information about malaria, which should be part of your messages to the client or community:

• Malaria is caused by a parasite that infects a person’s blood when he or she is bitten by a mosquito carrying the parasite;
• Malaria can also be transmitted through blood transfusion if the blood contains malaria parasites;
• The other method of transmission is to the unborn baby through the placenta. This is also known as congenital malaria;
• Malaria is not a sexually transmitted infection;
• Malaria is commonly transmitted by a mosquito bite. Transmission by blood transfusion or during pregnancy is very rare;
• The unborn baby is not the cause malaria in the mother;
• If a pregnant mother gets malaria, the parasites live in blood and in the placenta. The parasites in the placenta interfere with the nutrition and oxygen supply of the unborn baby. When this happens, the following may occur:

o Abortion,

o The baby may die before birth. This is called still birth,

o the baby may be born weak, small and sickly;

• Malaria is more dangerous for women when they are pregnant. It weakens them and often causes anaemia;

• Mosquitoes that transmit malaria breed in stagnant water. Draining the stagnant water and building houses at least 2 Km away from water sources, such as rivers and lakes, reduces mosquitoes and their contact with people respectively.

• Malaria is best prevented by sleeping under LLINs every night to avoid mosquito bites.

• Malaria is also prevented by spraying of internal walls of houses with residual insecticides particularly in epidemic prone areas.

• Malaria is treatable and curable by effective antimalarials.

You now know the messages you should pass on to your client and/or the community. Next, let’s turn to the importance of counselling.

11.2 Importance of Counselling

Counselling occurs only when there is a mutual understanding between the health worker and the patient/client which is brought about by information sharing and exchange of ideas.

Figure 11.1: Counselling Patient/Client. (© 2003 Germain Passamang Tabati, Courtesy of Photoshare)

Before you read on do Activity 2, it should take you 5 minutes to complete.

ACTIVITY 2 State three reasons why you think counselling is important in the management of malaria. …………………………………………………………………………….. …………………………………………………………………………….. ……………………………………………………………………………. ……………………………………………………………………………. ……………………..……………………………………………………….

Confirm your answer as you read the following discussion.

Counselling is important for a number of reasons:

• It is a psychological therapy. It enables patients/clients to release their stress and anxieties on malaria;
• Patients/clients are empowered and able to understand and solve their own problems relating to the treatment and prevention of malaria;
• It enables patients/clients to use available resources and experience to develop positive ways of coping with situations/problems;
• It acts as a preventive measure since it encourages adoption of healthy behaviour in combating malaria;
• It ensures that patients/clients are adequately informed about their medication.

Having learnt the importance of counselling, let us now turn to the qualities of a good counsellor.

11.3 Qualities of a Good Counsellor

What qualities or attributes should you possess as a counsellor in Malaria in order to pass on effective messages and communication to your patient/clients?

To be a good counsellor you must possess the following qualities:

· Patience:

You need to be very patient. Go to the next step of explanation only when the patient/client has clearly understood the content of the information you are giving. Have ample time for the patient.

· Good Listening:

You need to be a good listener. Never interrupt what the patient/client has to say. Give your inputs only when the client / patient has finished talking.

· Observant:

You need to be very observant and able to interpret non-verbal communication. If the patient/client looks angry, find out the cause of his/her anger first.

· Warm:

Provide non-possessive warmth in a counselling environment. Smile and show concern and acceptance to the patient/client.

· Knowledgeable:

You should have good knowledge on rational drug use and drug compliance. Some people do not take medication for one reason or the other, while others demand drugs. For example, Muslims do not take oral medication when they are fasting while Jehovah’s witnesses do not take blood transfusion. This interferes with drug compliance. Giving patients/clients drugs on demand can cause drug shortage at the health facility or lead to drug abuse (overdose/under dose).

· Having empathy with the patient/client:

Try to understand the feelings the patient/client is having in the counselling process. In other words put yourself in his/her position.

· Maintaining a therapeutic relationship with a patient:

Give the patient/client the opportunity to make his/her own decision from your message.

· Confidentiality:

Although confidentiality is important in health matters it does not apply very much to malaria. Most people will openly say they have malaria. However, ensure that you maintain confidentiality on what the patient/client tells you. The patient/client would feel greatly offended if you disclose any information about him or her to other people. Counselling must be done individually and privately.

· Personal integrity:

Maintain a high degree of personal integrity, credibility and mutual trust as a counsellor.

Before you read on, do Activity 3, it should take you 5 minutes to complete.

ACTIVITY 3 From the knowledge you have acquired so far in this and previous units, write down the key counselling and health education messages you would pass on to a patient with signs and symptoms of Malaria. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Confirm your answer as you read the following discussion.

The following are the counselling and health promotion messages you should give to a patient with signs and symptoms of malaria:

• A person can have malaria parasites and show no signs of the illness. This is why it is important to take measures to protect oneself from Malaria;
• Fever, however mild, is not a normal sign. Fever is an important symptom of illness and should be treated or investigated;
• Signs of malaria include fever, headache, body aches, chills, rigors, and signs of severe Malaria as discussed earlier;
• Uncomplicated/simple malaria can quickly progress to severe/complicated malaria, which is life threatening and can be fatal if not treated in time.
• Seek medical advice whenever you are sick.
• Explain to the patients’ use of and application of malaria prevention methods such as importance of sleeping under Insecticide Treated Nets (ITNs) or LLINs. These nets not only kill mosquitoes which come into contact with it, but also repel and reduce mosquitoes in the room. They are safe to the user and should be used daily all year round.
• Whenever you have fever visit a health facility immediately for treatment;
• Visit ANC clinic during pregnancy for IPT (SP);

You can identify other relevant messages from the previous units you have studied.

You have come to the end of our discussion on qualities of a good counsellor and the key counselling and health education messages you should give to your clients/patients. Next, let us look the counselling skills you will need.

11.4 Counselling Skills

The qualities of a good counsellor go hand in hand with good counselling skills. In this section you shall learn about some counselling skills.

Before you read on, do Activity 4, it should take you 5 minutes to complete.

ACTIVITY 4 List down five skills you need in counselling (i) ……………………………………………………………………………………… (ii) ………..…………………………………………………………………………… (iii) …………………………………………………………………………………… (iv) ………..………………………………………………………………………… (v) ………..……………………………………………………………………………

The following are some of the skills that you need as a counsellor:

· Active Listening

As a health worker, you should listen to what your patient/client says. Show the patient/client that you are paying attention. For example, rather than looking through papers on your desk as the patient/client is talking to you, you should look at his/her face as you listen.

· Attending Behaviour

You should greet your patient/client politely and make him/her feel comfortable and relaxed. With facial expression, eye contact, gestures, and posture, show him/her that you are interested in what he/she is telling you.

· Interviewing/Asking Questions

As a good counsellor, you should ask open-ended questions as opposed to close-ended questions. You should also ask probing questions.

We have used three expressions i.e. close ended, open-ended and probing questions. Before we proceed to learn about the other skills, let’s explain what they are.

- What is a closed ended question?

A closed ended question is a question that invites a “Yes” or “No” response. For example, “Are you happy with the drug you are taking?” This is a bad question because it does not provide the client with an opportunity to express his or her feelings.

- What is an open-ended question?

An open-ended question is a question that leaves room for a patient/client to give a detailed and complete answer. For example, “tell me about your experience so far with the drug you are taking”.

- What is a probing question?

A probing question is a question that asks for more details for example, “And what else can you tell me?” or “What happened after that?” “Is there anything else you would like to add?” And so on.

You should avoid asking why questions because they may elicit feelings or actions that can be complex and embarrassing.

A good counsellor asks open-ended questions and probing questions because they encourage the patient/client to explore and express his/her feelings. Next time you counsel a patient/client try to use both the open ended and probing questions.

· Reflecting Feelings

By observing and listening, you can imagine how a patient/client feels. You can then tell the patient/client what you think. When a patient/client gives a vague answer, you can point this out by saying “You seem not to be clear on this”. This serves three purposes:

- The patient/client thinks about how he or she feels and why;

- You the health worker can find out whether the patient/client is confused;

- If there is confusion you can clear it up through discussion.

· Praise appropriate practices

You should praise a patient/client for any good practice he/she may mention.

· Giving Information and negotiating changes

After the patient/client has told you his/her problem, you should give her/him relevant information and negotiate changes. You should use words that the patient/client understands. Check whether the patient/client understands you by asking him/her to repeat the information and instructions you have given. If the feedback shows that the patient/client did not understand the information or cannot remember, explain again.

· Use of local language

Whenever possible use a local language that the client understands best. It is important for both you and the patient to understand each other very well.

· Remain neutral and non-Judgemental

Whenever possible give advice but do not judge.

· Be consistent in giving advice

If you are sure of the facts be consistent.

· Summarising and Paraphrasing

By re-stating in your own words what the patient/client says, you show that you are listening and that you have understood what the patient/client has said. For example, “What you are saying is that you have no problem with the drug so far…”

It is important to develop skills in counseling so that you can effectively help your patients/clients.

Having discussed skills in counselling, let us now discuss the counselling process.

11.5 The Counselling Process

When counselling patients/clients, we progress through a series of interconnected and overlapping stages to help patients/clients make informed decisions. Both you and the patients/clients actively participate. You exchange information and discuss the patients’/client’s feelings and attitudes about the disease and drugs. Through this interaction the patient/client makes a decision, acts and evaluates his/her actions.

Before you continue reading, do Activity 5. It should take you 10 minutes to complete.

ACTIVITY 5 The stages of the counselling process can be abbreviated by the word GATHER. Do you know what each letter in the word GATHER stands for? Fill in what each letter stands for. G ………………………………………………………………………………………… A ………………………………………………………………………………………… T ……………………………………………………………………………….………… H …………………………………………………………………………………………. E ………………………………………………………………………………………… R ………………………………………………………………………………………….

Confirm your answer as you read the following discussion.

There are six elements to the counselling process. They are easy to remember with the memory aid GATHER. Each letter in the word GATHER stands for an action or step that a counsellor is expected to take when counselling a patient/client.

What does each letter stand for?

G Greet the patient/client.

A Ask patient/client about herself/himself.

T Tell patient/client about proper use of drugs.

H Help patient/client to understand the instructions

E Explain how to use the drugs.

R Return for follow-up.

In order to have a successful counselling session you must do the following:

• Give the patient/client the right to make his or her own decisions;
• Keep patient’s/client’s problems confidential;
• Be truthful to the patient/client;
• Give correct information;
• Recognise your own limitations in counselling in regard to specific problems.

Remember, self-introduction when you meet the patient/client and the initial questions which address the purpose of the visit or nature of the problem, are useful activities to encourage the patient/client to talk.

This brings us to the end of our discussion on the counselling process. Let us now discuss barriers to effective counselling.

11.6 Barriers to Effective Counselling

To a great extent, the counselling process is concerned with effective communication. Therefore, many of the barriers to effective counselling are those related to communication.

Often barriers interfere with the counselling process. They prevent the patient/client from being able to make free and informed decisions about the course of treatment, how to act on them and to continue using them. When there are barriers the patient/client will not disclose her/his feelings and concerns fully enough for you to be able to give the necessary assistance and guidance.

Before you continue reading this section do Activity 6, it should take you 5 minutes to complete.

ACTIVITY 6 Imagine you receive a patient/client in your Health Unit, what would you consider as barriers to effective counselling of this patient/client. (i)………………………………………………………..……………………………… (ii)………………………………………………………………………………………. (iii)…………………………………………………….….……………………………… (iv)……………………………………………………………………………………….. (v)………………………………………………………..…..…………………………..

We hope the answers you have written include the following barriers to effective counselling:

• · Physical barriers;
• · Differences in social and cultural background and psychological barriers;
• · Inappropriate non-verbal behaviour by you the health worker;
• · Barriers caused by patient/client;
• · Language and level of education.
• Let us now discuss each of these barriers one by one.

· Physical Barriers

Physical barriers refer to environmental factors that prevent or reduce opportunities for the communication process to occur. They include:

- A counselling room which does not offer privacy;

- Poor lighting;

- Dirty and untidy room;

- Distracting noise;

- Extreme temperatures;

- Uncomfortable seating arrangement;

- Distractions in the room such as equipment and visual aids;

- Objects and chemicals which are dangerous to the patient/client.

If the room where you serve patients/clients at your health unit has any of these barriers you should do something to improve it.

· Differences in Social and Cultural background

When a patient/client is from a different nationality, race or ethnic group, it may be difficult for you to know the patient’s/client’s beliefs, taboos and cultural practices. The patient/client may not be able to take action because perhaps the information you give him/her does not tally with his/her beliefs, taboos etc.

As a good counsellor you should endeavour to know a patient’s/clients’ cultural background before you start a counselling session.

· Non-Verbal Communication

Non-verbal communication involves all the little things you do while you talk to a patient/client. It includes:

- Gesturing;

- Frowning;

- Showing signs of boredom or humour;

- Showing signs of disgust;

- Displaying signs of despise towards a client;

- Nodding the head;

- Shaking the head

Some non-verbal communications are negative while others are positive. Nodding the head is a positive non-verbal communication. Gesturing can be both positive and negative non-verbal communication. Therefore, try to make good gestures which will demonstrate your interest, concern and understanding of the patient’s/client’s expressions. These may be a smile or occasional nodding in appreciation of what a patient/client tells you.

· Barriers caused by patient/client

Let us now look at some of the barriers that may be caused by a patient/client. These are:

1. Lack of interest in being counselled;
2. Patient’s/client’s appearance to you (impression);
3. Patient/client’s emotions.

It is important that you motivate your patients/clients and arouse their interest as soon as you start the counselling session. Use of visual aids helps arouse patients’/clients’ interest.

It also stimulates active thinking and learning while providing a shared experience. Lack of interest makes a patient/client inattentive and biased in thinking.

If there is something disturbing a patient/client, such as a family or social problem, you should be able to identify it. If you think the patient/client is so disturbed that they cannot benefit from the session, you should postpone it to another day. If you fail to handle your patient/clients problem they may never come to back to see you again.

We hope you are now well prepared to counsel malaria patients/clients. Next, let us consider the IEC messages you should give on malaria prevention and control.

11.7 IEC Messages on Malaria Prevention and Control

As we mentioned in Unit 8, IEC messages on malaria prevention and control should be given to all your clients/patients.

Before you continue reading this section do Activity 7, it should take you 5 minutes to complete.

ACTIVITY 7 Write down 5 Malaria IEC messages (i)………………………………………………………..……………………… (ii) ……………………………………………………………………………… (iii) …………………………………………………………………………….. (iv) …………………………………………………………………………….. (v) ……………………………………………………………………………..

Confirm your answer as you read the following discussion.

The following are the IEC messages you should give to parents of children under five years and pregnant mothers.

· Malaria In Children Under Five Years

- Every year so many cases of malaria are reported among children under five years of age often leading to deaths;

- Protect your child from malaria;

- Malaria is a dangerous disease and can easily kill your child;

- FEVER is a key sign of malaria especially in children. Other signs are vomiting, diarrhoea, restlessness and loss of appetite;

- Seek early and correct treatment from the nearest health facility;

- Delay may result in dangerous signs like convulsions, difficulty in breathing and anaemia.

- REMEMBER to ensure that your child sleeps under an ITN/LLIN;

· Malaria in Pregnancy in Endemic Areas

- Pregnant women should sleep under ITNs/LLINs;

- Pregnant women should take two doses of SP (IPT);

- Seek early treatment.

In addition, you should be well prepared and knowledgeable about when malaria epidemics occur in your catchment area. What should you do to prepare?

· Epidemic Preparedness and Response

- Set up early warning and detection systems

- Start limited and supervised Indoor Residual Spray (IRS) in epidemic prone areas;

- Set up mobile clinic;

- Ensure that health facilities are stocked with antimalarial drugs;

- Inform communities to seek early treatment.

CONCLUSION

We have come to the end of this unit 11 on Counselling and Health promotion.

In this unit we defined counselling as a face-to-face communication between a counsellor and a patient/client which aims at helping the patient/client understand their problems and make informed decisions for change. We said that counselling is psychological therapy and should be given to all patients suffering from malaria. We also discussed the qualities of a good counsellor and the skills in counselling. Finally, we explained the barriers to effective counselling, which included physical barriers, differences in social and cultural background, non-verbal communication, and barriers caused by patients/clients.

You should now review the learning objectives at the beginning of this unit to check whether you are up-to-date with basic knowledge about counselling and health promotion in Malaria. If you are not sure about any of the objectives go back to the relevant section and read it again. If you feel confident that you have achieved all the objectives, complete the attached Tutor Marked Assignment attached before you proceed to the next unit. Remember to also do the practical assignment given below.

AMREF DIRECTORATE OF LEARNING SYSTEMS

DISTANCE EDUCATION PROGRAMME

Student Name __________________________________

Student Number: _________________________________

Student Postal Address: __________________________

__________________________

DISTANCE LEARNING COURSE ON MALARIA

Tutor Marked Assignment

Unit 11: Counseling and Health Promotion in Malaria

1. a) Define counseling.

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b) What are the aims of Health Promotion/Education?

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2. What Health Promotion/Education messages would you pass on to the individuals, families and communities on prevention of Malaria?

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3. A health worker called Loot investigated a patient and found that he had Malaria. If you were Loot:

a) What steps would you go through in the counseling process of this

Patient?

(i) …………………………………………………………………………….

(ii) …………………………………………………………………………….

(iii) …………………………………………………………………………….

(iv) …………………………………………………………………………….

(v) …………………………………………………………………………….

(vi) …………………………………………………………………………….

(vii) …………………………………………………………………………….

(viii) …………………………………………………………………………….

(ix) …………………………………………………………………………….

(x) …………………………………………………………………………….

b) What skills would you need to be able to provide effective counseling to this patient?

(i) …………………………………………………………………………….

(ii) …………………………………………………………………………….

(iii) …………………………………………………………………………….

(iv) …………………………………………………………………………….

(v) …………………………………………………………………………….

(vi) …………………………………………………………………………….

(vii) …………………………………………………………………………….

(viii) …………………………………………………………………………….

(ix) …………………………………………………………………………….

(x) …………………………………………………………………………….

c) Loot tried to counsel his patient but was not successful. What do you think failed him?

(i) …………………………………………………………………………….

(ii) …………………………………………………………………………….

(iii) …………………………………………………………………………….

(iv) …………………………………………………………………………….

(v) …………………………………………………………………………….

(vi) …………………………………………………………………………….

(vii) …………………………………………………………………………….

(viii) …………………………………………………………………………….

(ix) …………………………………………………………………………….

(x) …………………………………………………………………………….

4. Outline some of the IEC information you should give in the following

Situations:

a) Children under five years old

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b) Pregnant women

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c) Epidemic situation

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Congratulations! You have come to the end of this assignment. If you experienced any difficulties in this unit write to us. Your tutor will be happy to give you relevant responses to enable you cope with the course.

Confirm that you have written your name , student number and address on the assignment. Then post or bring it in person to AMREF.

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This document answers the most frequently asked questions about the 2010 report for the Global Campaign for the Health Millennium Development Goals. The report was officially launched at the Partners’ Forum of The Partnership for Maternal, Newborn & Child Health on 13 November 2010 in New Delhi, India.

What is the Global Campaign and how will it make a difference to women’s and children’s health?

The Global Campaign for the Health MDGs was launched in New York in September 2007 by Prime Minister Jens Stoltenberg of Norway and other global leaders. It aims to increase and sustain political and financial commitment to the health MDGs, particularly those protecting the most vulnerable women and children. MDG 4 sets out to reduce child mortality by two-thirds and MDG 5 aims to reduce maternal mortality by three-quarters and to achieve universal access to reproductive health by 2015.

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The Global Campaign is closely linked to several other important initiatives, such as:

• The Global Strategy for Women’s and Children’s Health launched by UN Secretary-General Ban Ki-moon. This describes progress towards MDGs 4, 5 and 6 and identifies tangible actions to close current gaps.

• The Global Consensus on Maternal, Newborn and Child Health. This aligns momentum in politics, advocacy and finance behind a commonly agreed set of policies and priority interventions aimed at accelerating progress on the ground.

• The High-Level Taskforce on Innovative Financing for Health Systems, chaired by the former UK Prime Minister, Gordon Brown, and the President of the World Bank, Robert B Zoellick. It aimed to identify “innovative financing mechanisms to complement traditional aid and bridge the financing gaps which compromise attainment of the health-related MDGs.”

• The International Health Partnership (IHP). This aims to improve co-ordination of support for national health plans, and brings together international health organizations and major donor countries, as well as developing countries.

Who are the Network of Global Leaders and what do they do?

The Network of Global Leaders was formed at the invitation of Prime Minister Jens Stoltenberg of Norway to provide political backing and advocacy at the highest possible level for the Global Campaign for the Health MDGs. Support of this kind will be crucial to the success of the Global Campaign, leading to better health and fewer deaths. The network consists of a small number of international leaders, working alongside Prime Minister Stoltenberg:

• President Armando Guebuza of Mozambique

• President Jakaya Kikwete of Tanzania

• President Luiz Inácio Lula da Silva of Brazil

• President Ellen Johnson Sirleaf of Liberia

• President Abdoulaye Wade of Senegal

• President Susilo Bambang Yudhoyono of Indonesia

• Graça Machel, President and founder of the Foundation for Community Development of Mozambique.

The network does not convene regular meetings or conferences. Instead, the members ensure that their countries’ commitments to the health MDGs (MDGs 4 and 5) is sustained and followed up every day. When participating in summits and other high-level global events, members will push for action to achieve the health MDGs by 2015, maintaining political pressure on behalf of the Global Campaign.

What is the Global Campaign Report?

The Global Campaign published a First Year report in September 2008, which was launched in the UN by Prime Minister Jens Stoltenberg of Norway. Over 50 presidents, prime ministers, global leaders, heads of international organizations and others contributed to the report. The purpose of the Global Campaign Reports is to identify challenges that stand in the way of achieving the health-related MDGs and to galvanize world leaders to take action.

The Global Strategy for Women’s and Children’s Health was launched by the UN Secretary-General in September 2010 and also focuses on women’s and children’s health. How are the two documents related?

The Global Strategy for Women’s and Children’s Health describes current progress towards MDGs 4 and 5 and identifies tangible actions to close current gaps. It also estimates the costs of these actions, and calls for the support of all stakeholders to enhance financing, strengthen policy and improve service delivery for the most vulnerable women and children.

The Global Campaign Report is intended to deepen the commitment to the Global Strategy by asking world leaders to discuss how they will implement their commitments and how they will hold themselves accountable. Please see Frequently Asked Questions for the Global Strategy at: http://www.who.int/pmnch/activities/jointactionplan/20100922_gswch_faq/en/index.html.

What’s new in the 2010 Global Campaign Report?

One of the major differences between the 2010 report and those from previous years is the context in which it is launched. In future, 2010 may be seen as the turning point in efforts to advance the agenda for women’s and children’s health. There is incredible political momentum, and the US$40 billion of funding recently committed is unprecedented. At no other time in recent history has there been so much excitement about, and attention paid to, women’s and children’s health issues. World leaders are emphasizing them at high-level international events such as the World Health Assembly, the African Union, the Pacific Health Summit and the UN General Assembly. They are also being discussed in national parliaments and local councils and across regions, and every stakeholder group is coming forward to offer their skills.

In addition, the 2010 Global Campaign Report contains several new elements intended to maintain the momentum for women’s and children’s health.

1) Plan for developing a robust accountability framework. The Global Strategy identified the need for a clear accountability framework that builds on existing mechanisms. But it did not articulate how this would happen. In the Global Campaign, WHO outlines high-level terms of reference for a Commission on Accountability and Information, and associated working groups that will develop the recommendations.

2) Roadmap for advocacy and political action for 2011. To maintain momentum in 2011, the roadmap outlines a number of key opportunities to deepen partnerships, mobilize further commitments across sectors and renew attention to pledges made.

3) Statements from non-traditional stakeholders. This version of the Global Campaign Report contains statements from a wide variety of stakeholders who will play an important role in implementing the Global Strategy. They include the business community, health-care professionals, faith-based organizations, NGOs and academics and researchers. In the report, these stakeholders outline their commitments and explain the activities they will undertake on behalf of the Global Strategy.

4) Methodology behind the recent US$40 billion commitments. At the MDGs Summit in New York in September 2010, commitments worth approximately US$40 billion were announced. The Global Campaign Report outlines the methodology used to calculate these commitments and lays out next steps for refining the estimates.

Why does the report focus on commitments and accountability?

Following the US$40 billion of commitments pledged at the MDGs Summit in September, the two most important next steps were: 1) to solidify the major commitments made, and 2) to move forward the accountability process to track these commitments and their impact. To achieve this, we asked leaders to comment on how their country or organization will take forward actions to achieve the commitments they made and how they would hold themselves and others accountable.

What are the follow-up steps after the launch of the report?

2011 presents many opportunities to maintain the momentum built by the Global Strategy and the Global Campaign. The last chapter of the Global Campaign is a roadmap that outlines key events at all levels, from national and industry meetings to the UN General Assembly. It clearly states how each event can be used to progress the cause of women’s and children’s health with different constituency groups to ensure that it remains high on international, regional and national agendas

How can this report be used?

The Global Campaign Report is useful on many levels. Firstly, it provides advocates with a tool to hold governments and institutions accountable for their pledges, and the signed statements by leaders can be used to remind those working in government of the strong backing for women’s and children’s health at the highest levels. Secondly, it is a way to share best practice between countries and institutions, helping initiate the dialog between heads of state and between organizations about their initiatives. Thirdly, the report can be used as a call to action for stakeholders who are not currently involved. By seeing the important work of their colleagues, other organizations and governments will be inspired to join the effort.

The Global Strategy for Women’s and Children’s Health

How does the UN Secretary-General’s Global Strategy for Women’s and Children’s Health suggest we make improvements?

It says that partners need to unite and take real action – through enhanced financing, strengthened policy and improved service delivery. The agreed set of action points include:

• Ensuring that political commitment and adequate priority is given to women’s and children’s health in national health plans. We must focus on the needs of poor women and children – who are at the greatest risk of death or injury during childbirth and the first few hours afterwards – and on equity of access and outcomes, making sure we reach those who are especially disadvantaged and marginalized.

• Scaling up packages of essential services, especially in countries experiencing the majority of deaths among under-fives – notably in sub-Saharan Africa and South Asia.

• Strengthening health systems to deliver a package of quality interventions:

1) High-quality skilled care during and after pregnancy and childbirth (routine as well as emergency care);

2) Comprehensive family planning;

3) Safe abortion services (where not prohibited by law);

4) Improved child nutrition, and prevention and treatment of major childhood diseases, including diarrhea and pneumonia;

5) Integrated care for HIV/AIDS (i.e. prevent mother-to-child transmission), malaria and other conditions.

• Developing and scaling up innovative approaches to financing, product development and delivering high-quality services more efficiently. Priority needs to be given to removing financial, social and cultural barriers to access, including providing free essential services to women and children.

• Ensuring better information, which will help leaders decide on the best course of action, and accountability at all levels for credible results.

What outcomes will the Global Strategy help us to achieve?

In the world’s 49 poorest countries, where the need for help is greatest, we can make great progress between 2011 and 2015. We can:

• Prevent the deaths of more than 15 million children under the age of five, including 3 million newborns

• Prevent 33 million unwanted pregnancies

• Prevent 570 000 women dying from complications relating to pregnancy or childbirth, including unsafe abortion

• Protect 88 million children under five from stunting

• Treat 120 million children for pneumonia.

In 2015:

• 43 million more users will have access to comprehensive family planning

• 19 million more women will give birth supported by a skilled health worker, with the necessary infrastructure, drugs, equipment and regulations

• 2 million more neonatal infections will be treated

• 22 million more infants will be exclusively breastfed for the first six months of life

• 15 million more children will be fully immunized in their first year of life

• 117 million more under-fives will receive vitamin A supplements

• 85 000 more quality health facilities will exist and up to 3.5 additional health care workers.

If I want more information about topics discussed in the Global Campaign, whom should I contact?

All queries can be sent to the following email address of The Partnership for Maternal, Newborn & Child Health (PMNCH): pmnch@who.int. The PMNCH will then direct enquiries to the appropriate contributor.

These online resources are also available on related topics:

• Global Campaign website: www.norad.no/globalcampaign

• UN Secretary-General’s Global Strategy website: www.un.org/sg/globalstrategy.shtml

• The Partnership for Maternal, Newborn & Child Health Global Strategy website: www.who.int/pmnch/activities/jointactionplan/en/index.html

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By Grattan Woodson, MD FACP

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A Daily Multiple Vitamin is probably the only way to obtain all the vitamins and micro-nutrients you need over the long run.   While all necessary vitamins and nutrients are found in foods, it is simply impractical to obtain what is needed from what most of us eat every day.  For instance, to obtain the Recommended Daily Allowance (RDA) of the same mix of vitamins and trace minerals found in my preferred brand name multiple vitamin products, Centrum®, would require the daily consumption of an impossible variety and quantity of food.   Even a trained dietician would find it just about impossible to do this.  Study after study now shows the benefit of maintaining an adequate daily intake of these essential nutrients.  No one is too young or too old to benefit either.  For children or adults who can’t swallow large tablets, try chewable Centrum Jr®.  Another way of obtaining a regular daily dose of vitamins, especially for children who won’t take a pill, is by eating a bowel of cold breakfast cereal each day.  Many of these products have been enriched with the equivalent of a multiple vitamin with each serving.  For pre-menopausal women, Centrum A to Zinc® is recommended as it includes iron, an important mineral for menstruating women. For all men and post-menopausal women, Centrum Silver® is the best choice.  It has the same components as Centrum A to Zinc® except iron which is not usually needed for these groups. 

Mega-Doses of Anti-oxidant Vitamins

Mega-doses of anti-oxidant vitamins are no longer recommended.  These new recommendations are for Vitamin C, Vitamin E, and beta-carotene.  Despite the hope that there would be benefit from their use, several very large well designed scientific studies failed to show any cancer or cerebrovascular disease benefit with the use of these vitamins.  Since the best quality long term studies of prevention of chronic degenerative disease with these vitamins failed to show any benefit, routine use of these vitamins in anti-oxidant dose levels can not be advocated. 

Vitamin E
Vitamin E is a fat-soluble vitamin.  It is found naturally in vegetable oils.  The US RDA is 30 iu.  There are anecdotal reports that vitamin E may reduce breast nodules and pain due to fibrocystic breast disease. 

Vitamin C
Vitamin C, ascorbic acid, is a water-soluble vitamin found naturally in fruits and vegetables.  The US RDA is 50 mg.  When used at bedtime, this can lower risk for urinary tract infections in women prone to get them.  Vitamin C is actually ascorbic acid.  Most of the daily dose above 50 mg is passed into the urine.  Ascorbic acid colors the urine yellow and causes it to become acidic which is a difficult environment for bacteria to cause an infection.  Use of more than a 1000 mg of vitamin C per day can lead to kidney stones.  There is no evidence that vitamin C reduces risk or speeds recovery from common colds despite the belief of many. 

Beta-carotene and Vitamin A
Beta-carotene is a chemical precursor of vitamin A.  It is found in yellow and green vegetables like carrots, sweet potatoes, and spinach.  The US RDA for vitamin A is 5000 iu.  The body converts beta-carotene into vitamin A as it is needed for metabolism.  While beta-carotene does not appear to represent any health threats consumption of high quantities vitamin A can cause toxic skin rashes and lead to osteoporosis. 

The Folic Acid Story
For years, nutrition scientists defined the minimum daily requirement for folic acid based upon the amount needed to prevent anemia.  This is because this medical condition was the only one we knew was due to folic acid deficiency and was easy to measure with a simple blood test. In the 1980s scientists and public health officers at the CDC first came to understand that the crippling and sometimes fatal birth defect, spina bifida, was caused by maternal folic acid deficiency. Then came the realization that a low intake of folic acid caused a high serum homocystine level.  Homocystine is a blood substance that damages the artery wall in a way that contributes to the development of cardiovascular disease.   Homocystine levels can be lowered dramatically by folic acid and vitamin B12 supplementation.  When used for this purpose, I recommend supplementation with two 400 mcg tablets daily plus two 100 mcg vitamin B12 tablets daily.  Folic acid deficiency has also been linked to colon cancer.  In the long running Nurses Study, women who had the highest daily intake of folic acid had the lowest risk for colon cancer.  In fact, the risk can be reduced by two thirds after 15 years of use of a daily multiple vitamins.  Unless you have a special need for higher doses, a daily intake of 400 mcg of folic acid appears to be sufficient to obtain the important health benefits of the necessary nutrient.  This is the amount found today in multiple vitamin preparations.  Most diets have some folic acid in them.  Foods especially rich in folic acid include white beans like soy and navy beans.  The US FDA now requires food producers to add folic acid to flour and cereal products so consumption of these complex carbohydrate foods will increase your folic acid intake.

Vitamin D
Vitamin D is a fat soluble vitamin that can be made in the skin when exposed to ultraviolet light.  It is also added to bread and milk products.  Vitamin D is necessary for the proper absorption of calcium from the diet and its lack causes weak fracture prone bones.  A number of studies indicate that vitamin D deficiency is more common in the US than previously thought.  Adults after age 70 are at especially high risk and African Americans have higher rates of vitamin D deficiency than other Americans.  Anyone who consumes a limited diet and doesn’t get out in the sunshine often is at risk.  The US RDA for vitamin D is 400 iu which is the amount contained in all multiple vitamin tablets.  This is fine for young folks but after age 60 studies show that 800 iu is best to prevent osteoporosis.  In fact, some patients with osteoporosis may require even higher doses of this vitamin.  Beware of taking too much vitamin D unless specifically directed to by your doctor as too much can be quite toxic. 

 
Calcium
Calcium is important for preventing osteoporosis, colon polyps and possibly cancer, and may help lower blood pressure.  While all multiple vitamins include some calcium, the amount is much too small to matter much. Pre-menopausal and young adult men need about 1000 mg of elemental calcium daily with postmenopausal women and men over age 50 needing about 1500 mg each day.  Daily calcium requirements are the same whether you are getting your calcium from the diet, a supplement, or a combination of both.  Studies show that except for calcium citrate (Citracal®) there is not much difference in how well these different sources of calcium are absorbed from the intestine.  Calcium carbonate, the most common supplement used, is absorbed into the body better if it is taken with meals or a snack than on an empty stomach.  The reason for this is that acid released from the food during digestion helps break up the calcium carbonate molecule, which is necessary for calcium absorption.  As some people get older their stomachs fail to make as much acid as in the past.  Without acid, the calcium stays in a form that cannot be absorbed.   Citracal® can be absorbed in patients whose stomach lacks acid or who take certain medications (Zantac®, Tagamet®, Pepsid®, Prilosec®, Nexium®, etc.) that reduce stomach acid.  In these patients, Citracal® may be the preferred option.

Recommended Daily Calcium Allowance Infants, Children, & Teens Birth to 6 months = 400mg 6 to 12 months = 600mg 1 to 5 years = 800mg 6 to 12 years = 800mg to 1200mg 12 to 19 years = 200mg to 1500mg Adults 21 to 30 = 1200mg to 1500mg 31 to 50 = 1000mg 50 + = 1500mg Pregnant and lactating women = 1500mg Optimal Calcium Intake. NIH Consensus Statement 1994 Jun 6-8; 12(4): 1-31.

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PHYSICAL DIMENSION

Genetic make-up, age, developmental level, race and sex are all part of an individual’s physical dimension and strongly influence health status and health practices.

EMOTIONAL DIMENSIONS

How the mind and body interact to affect body function and to respond to body conditions also influences health. Long-term stress affects the body systems and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change body responses to illness.

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INTELLECTUAL DIMENSION

The intellectual dimension encompasses cognitive abilities, educational background and past experiences. These influence a client’s responses to teaching about health and reactions to health care during illness. They also play a major role in health behaviors.

ENVIRONMENTAL DIMENSION

The environment has many influences on health and illness. Housing, sanitation, climate, and pollution of air, food and water are aspects of environmental dimension.

SOCIOCULTURAL DIMENSION

Health practices and beliefs are strongly influenced by a person’s economic level, life style, family and culture. Low-income groups are less likely to seek health care to prevent or treat illness; high-income groups are more prone to stress-related habits and illness. The family and the culture to which the person belongs determine patterns of living and values about health and illness that are often unalterable.

SPIRITUAL DIMENSION

Spiritual and religious beliefs and values are important components of the way the person behaves in health and illness.

LEVELS OF PREVENTION

PRIMARY PREVENTION

Providing specific protection against disease to prevent its occurrence is the most desirable form of prevention. Primary preventive efforts spare the client the cost, discomfort and the threat to the quality of life that illness poses or at least delay the onset of illness. Preventive measures consist of counseling, education and adoption of specific health practices or changes in life style.

SECONDARY PREVENTION

It consists of organized, direct screening efforts or education of the public to promote early case finding of an individual with disease so that prompt intervention can be instituted to halt pathologic processes and limit disability. Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise result for the individual and the family from advanced illness and its many complications.

TERTIARY PREVENTION

It begins early in the period of recovery from illness and consists of such activities as consistent and appropriate administration of medications to optimize therapeutic effects, moving and positioning to prevent complications of immobility and passive and active exercises to prevent disability. Continuing health supervision during rehabilitation to restore an individual to an optimal level of functioning. Minimizing residual disability and helping the client learn to live productively with limitations are the goals of tertiary prevention (Pender, 1987).

STAGES OF ILLNESS BEHAVIOR

STAGE 1: SYMPTOM EXPERIENCE

The person is aware that "something is wrong". A person usually recognizes a physical sensation or a limitation in functioning but does not suspect a specific diagnosis.

STAGE 2 : ASSUMPTION OF THE SICK ROLE

If symptoms persist and become severe, clients assume the sick role.

STAGE 3: MEDICAL CARE CONTACT

If symptoms persist despite the home remedies, become severe, or require emergency care, the person is motivated to seek professional health services.

STAGE 4 : DEPENDENT CLIENT ROLE

The client depends on health care professionals for the relief of symptoms.

STAGE 5 : RECOVERY AND REHABILITATION

This stage can arrive suddenly, such as when the symptoms appeared.

FACTORS AFFECTING HEALTH AND ILLNESS

PHYSICAL DIMENSION

Genetic make-up, age, developmental level, race and sex are all part of an individual’s physical dimension and strongly influence health status and health practices.

Ex:

1. A toddler just learning to walk is prone to fall and injure himself.

2. A young woman who has a family history of breast cancer and diabetes and therefore is at higher risk to develop these conditions.

EMOTIONAL DIMENSIONS

How the mind and body interact to affect body function and to respond to body conditions also influence health. Long-term stress affects the body systems and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change body responses to illness.

Ex.

a. Prior to a test, a student always has diarrhea.

b. Extremely nervous about a surgery, a man experiences severe pain following his operation.

c. Using relaxation techniques, a young woman reduces her pain during the delivery of her baby.

INTELLECTUAL DIMENSION

The intellectual dimension encompasses cognitive abilities, educational background and past experiences. These influence a client’s responses to teaching about health and reactions to health care during illness. They also play a major role in health behaviors.

Ex.

a. An elderly woman who has only a third-grade education who needs teaching about a complicated diagnostic test.

b. A young college student with diabetes who follows a diabetic diet but continues to drink beer and eat pizza with friends several times a week.

ENVIRONMENTAL DIMENSION

The environment has many influences on health and illness. Housing, sanitation, climate, and pollution of air, food and water are aspects of environmental dimension.

Ex. a. Increased incidence of asthma and respiratory problems in large cities with smog.

SOCIOCULTURAL DIMENSION

Health practices and beliefs are strongly influenced by a person’s economic level, life style, family and culture. Low-income groups are less likely to seek health care to prevent or treat illness; high-income groups are more prone to stress-related habits and illness. The family and the culture to which the person belongs determine patterns of living and values about health and illness that are often unalterable.

Ex.

a. An adolescent who sees nothing wrong with smoking or drinking because his parents smoke and drink.

b. A person of Asian descent who uses herbal remedies and acupunctures to treat an illness.

SPIRITUAL DIMENSION

Spiritual and religious beliefs and values are important components of the way the person behaves in health and illness.

Ex.

a. Roman Catholic requires baptism for both livebirths and stillborn babies.

b. Jehovah's Witnesses are opposed to blood transfusions.

LEVELS OF PREVENTION

PRIMARY PREVENTION

Providing specific protection against disease to prevent its occurrence is the most desirable form of prevention. Primary preventive efforts spare the client the cost, discomfort and the threat to the quality of life that illnesses poses or at least delay the onset of illness. Preventive measures consist of counseling, education and adoption of specific health practices or changes in life style.

Ex:

a. Mandatory immunization of children belonging to the age range of 0-59 months old to control acute infectious diseases.

b. Minimizing contamination of the work or general environment by asbestos dust, silicone dust, smoke, chemical pollutants and excessive noise.

SECONDARY PREVENTION

It consists of organized, direct screening efforts or education of the public to promote early case finding of an individual with disease so that prompt intervention can be instituted to halt pathologic processes and limit disability. Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise result for the individual and the family from advanced illness and its many complications.

Ex.

a. Public education to promote breast self-examination, use of home kits for detection of occult blood in stool specimens and familiarity with the seven cancer danger signals.

b. Screening programs for hypertension, diabetes, uterine cancer (Pap smear), breast cancer (examination and mammography), glaucoma and sexually transmitted diseases (STD's)

TERTIARY PREVENTION

It begins early in the period of recovery from illness and consists of such activities as consistent and appropriate administration of medications to optimize therapeutic effects, moving and positioning to prevent complications of immobility and passive and active exercises to prevent disability. Continuing health supervision during rehabilitation to restore an individual to an optimal level of functioning. Minimizing residual disability and helping the client learn to live productively with limitations are the goals of tertiary prevention (Pender, 1987).

STAGES OF ILLNESS BEHAVIOR

STAGE 1: SYMPTOM EXPERIENCE

The person is aware that "something is wrong". A person usually recognizes a physical sensation or a limitation in functioning but does not suspect a specific diagnosis.

The person's perception of a symptom includes awareness of a physical change such as pain, a rash or a lump; evaluation of this change and a decision that it is a symptom of an illness, and an emotional response.

STAGE 2 : ASSUMPTION OF THE SICK ROLE

If symptoms persist and become severe, clients assume the sick role. At this point the illness becomes a social phenomenon, and sick people seek confirmation from their families and social groups that they are indeed ill and that they be excused from normal duties and role expectations.

STAGE 3: MEDICAL CARE CONTACT

If symptoms persist despite the home remedies, become severe, or require emergency care, the person is motivated to seek professional health services. In this stage the client seeks expert acknowledgement of the illness as well as the treatment.

STAGE 4 : DEPENDENT CLIENT ROLE

The client depends on health care professionals for the relief of symptoms. The client accepts care, sympathy and protection from the demands and stresses of life. A client can adopt the dependent role in a health care institution, at home, or in a community setting. The client must also adjust to the disruption of a daily schedule.

STAGE 5 : RECOVERY AND REHABILITATION

This stage can arrive suddenly, such as when the symptoms appeared. In the case of chronic illness, the final stage may involve in an adjustment to a prolonged reduction in health and functioning.

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