C activities have been redefined and a change of the terminology to Health Promotion was adopted. This change in terminology was adopted to avoid misunderstanding and confusion with the activities of communication department but also to fall within the framework of our medical activities. This policy paper is written in order to explain why MSF is involved in Health Promotion and to set a framework for the Health Promotion activities; it’s not a guide on the implementation of the activities. It will continuously evolve with the experiences gained over time. 2. Some Health Promotion definitions . 1 From WHO Health promotion is the process of enabling people to increase control over, and to improve 2 their health. Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Participation is essential to sustain health promotion action. - The Ottawa Charter identifies three basic strategies for health promotion.
These are: - advocacy for health to create the essential conditions for health indicated above; - enabling all people to achieve their full health potential; - and mediating between the different interests in society in the pursuit of health. These strategies are supported by five priority action areas: - Build healthy public policy, - Create supportive environments for health - Strengthen community action for health, - Develop personal skills - and Re-orient health services 1 2 For more information see report on the IEC workshop 2006- Genevieve Loots & Ann Wouters Reference: Ottawa Charter for Health Promotion.
WHO, Geneva, 1986 3 2. 2 From John Hubley, "Communicating Health" John Hubley is presenting the HESIAD model which involves 3 different components into health promotion ? “Health promotion component is being used to draw attention to the need for educational & political action to improve health” 3 Health promotion Health education: Communication directed at individuals, families and communities to influence: Awareness/knowledge, decision making, beliefs/attitude/empowerment of individual and community action/behaviour change community participation
Service improvement : improvement: Improvement in quality & quantity of services: services Accessibility Case management Drug supply Counselling Staff attitudes Outreach Social marketing Advocacy: Agenda setting and advocay for healthy public policy Policies for health Income generation Removal of obstacles, discrimination, inequalities, gender barriers Fig. Components of health promotion (HESIAD)4 3 4 J. Hubley, Communicating health- An action guide to health education and health promotion- p. 2 J. Hubley, Communicating Health- An action guide to health education and health promotion-p. 15 4 3. 3. 1 Health Promotion within the OCB Definition As an emergency medical humanitarian organisation, the definition of health promotion, as state by WHO (process of enabling people to take control over their health ) is too wide for MSF actions. It involves a lot of development ideas for example poverty elimination, literacy and general education, social programs, income generating activities, etc.
Therefore, within OCB, we are limiting Health Promotion as a set of activities of health education and health services improvement5 that are intending to develop better the use of health care services (patients & population). The population HP approach is focusing on communities to promote our health structures and to control the epidemics in the population. The patient HP approach is focusing on patient and on the adaptation of the health care to the cultural behaviours and practices of the population where we are working. Example of health promotion activities: 1.
HP activities for population - Investigate health-seeking behaviour Promotion of available health services Create health-risk awareness about cholera, ebola for example Assure user friendliness clinic Patient education on HIV & TB to improve adherence (= treatment literacy) Providing patient-adjusted information on health-issues Stimulate self-management of chronic patients (empowerment) 2. HP activities for patients In most of the old “IEC called” project, the Health Promotion component should be re-orientated towards a support of patients (instead of community) n order to help them to reinforce or adapt a set of behaviour to get better & get more adapted care. In different organisation as well as in MSF sections you will easily hear different names for the Health Promotion activities such I. E. C (Information, education & communication), B. C. C (behaviour change communication), health communication, health education, patient education, etc. But they all aim at reinforcing knowledge and skills related to health (disease, treatment & prevention) in order to allow the patient to take decisions & actions towards his health.
Health Promotion encourages comprehensive interventions that combine approaches such as anthropology, sociology, education, training and communication for healthy behaviour adaptation; for more information on Behaviour change model, please refer to M. Varasso “Behaviour Change towards HIV/AIDS” and the Health belief Model6. 5 Services improvement could be: - Improvement in the content of the services: e. g improvement of the patient education - Improvement in the accessibility of the service: e. g timing, location & introduction of home & community visits - Improvements in the acceptability of services: e. enforcement of confidentiality, use of women field staff, use of lay field staff, involvement of persons from the target community John Hubley - Communicating Health- An action guide to health education and health promotion- p. 15 6 Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals 5 3. 2 Key principles for Health Promotion 1. Health Promotion activities should always be integrated and serving the medical objective of the project.
It must be considered as a transversal approach integrated in the different activities of the project; it is not a project in itself. In a logical framework of a project document it should be situated at the level of activities, expected results and indicators. 2. As a particularity, Health Promotion focuses on the health communication with individuals (it's not a health problem in itself). That is why it applies to different: - diseases (HIV, TB-treatment, malaria, etc), - subgroups (children, young women, patient HIV+), - attitudes/habits that we want to influence (access to services & care, promotion of healthy behaviour, etc) 3.
The MSF's understanding of the population, perception of the illness 7 and the health seeking behaviour are essential in order to offer and to improve the development of our health services. It’s an essential step to start any kind of Health Promotion activities, it's necessary to understand how the population is functioning before defining health messages adapted to the culture of the population and patients. 4. The activities of Health Promotion will vary from one project to another and will always need to be adapted to the context. 5.
The Health Promotion/education activities should be done in priority within our health structures addressing patients & care takers in groups or individually 6. Health Promotion activities can also be done at the communities’ level with specific objectives: To promote our services: attract people in our structures and explain our services to communities (promotion of the services for victims of sexual violence in the community, promotion of our vaccination sites, etc) To prevent epidemics spreading: when there is an outbreak of cholera, hemorrhagic fever, malaria, measles, etc. e should inform the communities at risk how the disease is transmitted, how to prevent getting the disease and what to do in case of the contraction of the symptoms To monitor a health situation: in some context it can help the project to develop a component of community health worker or home visitor network to collect health surveillance information (mortality, morbidity, MUAC, vaccination, etc) To ensure access of the vulnerable group to our structures: when a population/village/specific group identified is not coming to our structure and they are at high risk of specific health problem 7 DISEASE is the definition of a health problem by a medical expert, ILLNESS refers to the experience of the problem by the patient; and SICKNESS is the social role attached to a health problem by the society at large. 6 3. 3 Roles and profiles: Ideally, we should send different profiles to be in charge of the HP activities; the first phase should have in priority an anthropologist or sociologist who will analyse the cultural behaviour of the population; followed by a social communicator person who will design a health communication strategy.
However, this rarely happen and one person is usually in charge of the different steps of the HP activities. 3. 3. 1 Anthropologist's role in a project: To understand the risky practices of the target group linked to the transmission of a illness, for example: to collect information on the behaviour and the cultural practices of the pop. linked to the spread of HIV/AIDS; to get information on cultural burial procedure-linked to Ebola; etc To determine the health seeking behaviour of a target population ? Why are the pop not coming to our health services?
Where do they go for care? Linking with Traditional healer? Sorcery, Witchcraft? To get a better analyse of cultural barriers in the population: perception of a health problem by the target group, organisation of the society, power, decision maker, etc. To analyse the knowledge, attitude and practices on a disease or health problem (KAP survey) To analyse and understand how MSF is perceived in the population But also at the level of the service provider, to analyse and understand the staff attitude towards patients/diseases To study the conception of illness Etc. ? He/she will then apply findings into practical recommendations for the project but also for the development of health messages. The anthropologist is NOT going to solve all your problems in the project; he needs to have a clear job description. The field needs to identify what they want to analyse and understand and how it will improve their medical activities. It’s essential to be specific. He is part of the medical team and need constant discussion with the medical team/field coordinator.
It’s possible to require specifically an anthropologist for several months to undertake a qualitative survey. But often, the expatriate health promoter will also have a degree in Anthropology or Sociology (or Social Sciences); it’s more likely to have one expatriate in charge of everything. Rem: For the moment MSF is sending anthropologist too late in the stage of the project design; it would be useful to use the anthropologist’s competences at some early phase of the project (explo mission or starting of a new project).
In project by choice, the sending of an anthropologist can really provide key information on the context, the population and the link with MSF (in 2008 we have send anthropologist in Niger and Lubutu). 3. 3. 2 Health Promoter's role in a project Your health promoter could have a communication or nursing or educational background depending of what is available and which profile is best suiting the project.
To collect data's about the target population To set up the strategies for the HP activities according to the objectives of the project To recruit (if not yet done) and train/coach a team of national health promoter To define the priorities of the health messages according to the risk practices and the health seeking behaviour analyse To adapt the content of the messages according to the culture & target pop (importance of pre testing the materials) To understand how MSF is perceived in the population 7 - To develop (or re-use) communication materials (educational games, pictures, osters) and to choose appropriate channels of communication To monitor the HP activities (including participation to the Annual Review Operation exercise) To evaluate the understanding of the health messages by the beneficiaries and adapt the content of information He/she is part of the medical team and need constant discussion with the medical team/field. Because the HP activities should be integrated in the project, the expatriate presence on the field should be seen as a temporary phase in order to leave the activities in the hands of national staffs (when available) who usually know better the cultural behaviour of the target pop. nd have easily access to communities. 4. Why is MSF involved in Health Promotion? Health Promotion activities are usually linked to disease preventive 8 activities. To give information and to “coach” or educate persons on different health topic & measures is an essential element to avoid individual getting sick, to recognize earlier symptoms and come to be treated but also to ensure patients following treatment procedures. Health Promotion activities want to ensure preventive behaviour in term of health.
Prevention's level and activities9 It’s important to differentiate 4 levels of prevention where MSF actions put in place will be variable but also where the Health Promotion activities will differ. Primordial prevention: level zero of prevention: Activities aiming at decreasing societal vulnerability, lowering individual risk through contextual interventions. Example of activities= poverty reduction, decreasing stigma & discrimination, HIV awareness for the general public, etc.
So it concerns risk reduction of a health problem at population (societal) level and MSF will never intervene at this level of prevention. Primary prevention: covers all activities designed to reduce the occurrence and the transmission of an illness (disease free). Primary prevention methods are used before the person gets the disease. ? Reduction of the incidence & prevalence of health problem Example of activities done by MSF= immunisation, improve water supply, family planning services, use of condom, prophylaxis during pregnancy, etc.
Secondary prevention: activities aimed at the recognition of early signs of disease and search for treatment before it become serious. Secondary prevention avoids that infection become illness. ? Reducing the morbidity Example of activities = testing of HIV, medical consultations, treatment, vaccination 8 Disease prevention covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established.
Reference: adapted from Glossary of Terms used in Health for All series. WHO, Geneva, 1984 Primary prevention is directed towards preventing the initial occurrence of a disorder. Secondary and tertiary prevention seeks to arrest or retard existing disease and its effects through early detection and appropriate treatment; or to reduce the occurrence of relapses and the establishment of chronic conditions through, for example, effective rehabilitation. Disease prevention is sometimes used as a complementary term alongside health promotion.
Although there is frequent overlap between the content and strategies, disease prevention is defined separately. Disease prevention in this context is considered to be action which usually emanates from the health sector, dealing with individuals and populations identified as exhibiting identifiable risk factors, often associated with different risk behaviours. 9 Disease prevention- definition of WHO For more information on “Prevention and MSF”, please refer to the doc in annex 1. 8 Tertiary prevention: Targets the person who already has symptoms of the isease and it includes behaviours that are involved in treatment & rehabilitation (person is already sick) The goals of tertiary prevention are: - prevent damage and pain from the disease - slow down the disease - prevent the disease from causing other problems - give better care to people with the disease - make people with the disease healthy again and able to do what they used to do Example of activities: treatment, patient education, emotional support etc. ? Reduction of the morbidity, suffering & mortality 9 Risk: Population: General Theoretical risk Healthy population ? ? Specific High Risk ?
Healthy ind. ? Early signs ? Diseases ? Death Infected ind. ? Patients (sick) ? Death/handicap Intervention MSF Never or through partners Polio eradication, HIV awareness, etc Not systematic Prevention activities Vaccination, Vector control, HP, Family Planning, etc. Always Supportive & curative Testing, consultation, treatment, screening, health Education, etc. Always Curative & palliative care Emotional support, treatment, patient education etc. Primordial prevention Primary prevention (Incidence & prevalence) Secondary prevention (Morbidity) Tertiary prevention (Morbidity& mortality) Depending of the project’s objectives, MSF can be involved with variation at the different levels of prevention. 10 5. Health promotion as a transversal axe Health promotion was set up as a transversal axe into the Operational prospect in 2008 and in 2009 Health Promotion is integrated into the “Prevention” transversal axe. It means the HP activities should be considered into the different operational fields of intervention but also in the others transversal axes (Women health, nutrition, etc). 5. 1 Health Promotion activities to consider per health problem Some Health promotion activities to consider . Analyse & understand the risky practices increasing the transmission of HIV/AIDS amongst the population/community & patients 2. Understand the reasons of not coming for testing, for PMTCT (Health seeking behaviour, Stigma) 3. Measure the knowledge, attitude and perception of HIV/AIDS in target group 4. Promote of the services for families members, children and partners 5. Empowerment of patient (patient education on disease & preventive measure, treatment literacy, support group, PLWHA expert, etc) 6. provide support to adherence in health structure and in the community 7.
Ensure HIV services adapted to your target group of patients 8. Collaborate with Traditional healer, TBA, 1. Analyse and understand the disease perception (fears and stigma) & knowledge in the pop. 2. Promotion of services for TB families & care givers 3. Provide patient education & treatment literacy 4. Support to adherence 5. Train health staff on infection control measure 1. Analyse and understanding the disease knowledge and preventive measure 2. Promote the use of the mosquito nets with patients & communities during the season 3. Training on recognition of symptoms 4.
Promotion of the use of our services 5. Develop the component of malaria volunteers 1. Analyse and understand the disease perception and the risky behaviour in the community increasing the transmission 2. Measure the knowledge, perception & attitudes of the pop. towards the disease 3. Disseminate information on the preventive & disease control measures to the general population 4. Collaborate with key leaders of the community ? visit of the isolation unit 5. Educate of the patients and families (and neighbour) in order to decrease fears & stigma of the patients 6.
Participate to burials to ensure the respect of the tradition (orientation of the body, traditional beliefs, etc). 10 Health thematic HIV/AIDS Reference documents/books 1. HIV/AIDS OCB Policy 2008 “chapter on prevention and empowerment & autonomy of PLWH” 2. Patient support in HIV/AIDS – draft MSF OCB 2008 3. DVD Health Promotion communication materials – HIV/AIDS thematic – OCB 2007 4. Patient Support for HIV Infected children- 2008 D. Goetghebuer & K. Bosteels TB 1. Adherence strategy for TB treatment- MSF OCB 2008 2. DVD Health Promotion communication materials – TB thematic – OCB 2007 1.
DVD Health Promotion communication materials – malaria thematic – OCB 2007 Malaria Infectious diseases 1. FVH guideline internationalHealth Promotion & Anthropology chapter 2. Ebola, culture & politics : the Anthropology of an Emerging disease10 3. Cholera Health Promotion technical briefs 4. DVD Health Promotion communication materials – cholera, Ebola, Rift Valley fever, … OCB 2007 Ebola, culture & politics: the Anthropology of an Emerging disease, Barry S Hewlett and BonnieL. Hewlett 11 Some Health promotion activities to consider 1.
Analyze and understanding the cultural barriers of the use of the services or understanding the reasons of delivering at home or the KAP on FGM, etc. 2. Promotion of services (ANC, FP, PMTCT, delivery, abortion, sexual violence). 3. Integrated health education for mothers on different reproductive health subject 4. Home visitors to refer ANC visit, follow up of sexual violence 5. Collaboration with TBA – information on dangers of deliveries and referral of complicated cases 6. Collaboration with women groups 1. Analyse of the perception of the malnutrition in the pop 2.
Understanding cultural practices or beliefs increasing malnutrition of children 3. Analyse the cultural factors in a famine context 4. Nutritional education to mothers – develop peer mothers + appetite test 5. Nutritional education to men 6. Defaulter tracing support- community support 1. Analyse of the perception of mental health problem in the community 2. Promotion of mental health services 3. De-stigmatization of mental health problems 1. Analyse and understand the concept of violence in the context (cultural versus contextual violence, definition of violence, cultural profile of victims, etc). . Promotion of the services 3. Working with key actors in the community 1. Understanding of the concept of vaccination, fears & taboos about vaccines. 2. Promotion of importance of the EPI 3. Promotion of day of the vaccination campaign, site of vaccination, type of vaccines, etc Health thematic Women health Reference documents 1. DVD Health Promotion communication materials – Women Health – OCB 2007 Nutrition 1. Anthropological report from Niger- Lieselotte 2008 2. DVD Health Promotion communication materials – OCB 2007 Mental Health Violence 1.
Mental Health Policy OCB 2008 Link with Brazil Medical Unit Vaccination Niger 2008 Tanganika 2008 12 5. 2 Minimum package of Health Promotion activities There are minimum Health Promotion activities to be integrated in all projects: - Analysing of the disease/illness perception and knowledge of the target population - Promotion of MSF health services (usually at the beginning of the project or when new health activities is being developed) - Health education/patient education/treatment literacy in order to ensure that patients understand the symptoms, how to prevent & how to treat his disease . 3 Health Promotion within Operational Field of intervention Field of intervention I: Assistance to population in violent setting Particularities for this operational field of intervention are: The Health Promotion activities are done primary to get closer to the community, to get information on the context, the population but also on their security, on the living condition and on the access to health care. Health Promotion activities in this field are oriented towards collection of information, investigation and promotion of our services.
Several experiences11 have shown good results in developing a home visitor’s network; they seem key persons to get closer to your community and gain trust. Usual HP activities done at the community level with home visitors or community health worker are collection of data (mortality, birth, morbidity, on specific thematic such violence or sexual violence) at household level, defaulter tracing activities (nutritional or others program), promotion of MSF services and health information on a specific disease (ex. malaria explanation because malaria season).
In some context, there is a need to extend these communities activities further and push for a move of the civil society in the non acceptance of the problem (Similela and Seruka- sexual violence projects). HP activities in the medical infrastructure = health education on different health topic done by the medical staff or health educators Field of intervention II: Extreme health gap Particularities for this operational field of intervention are: Health Promotion activities and anthropological components should be more often considered.
In post conflict, under served general pop & exclusion there is space and time to gather key information about the population and their health seeking behaviour and it would help to develop the medical strategy of the project. Key activities to consider: -Analyse of the risky behaviour & needs of population in term of health & analyse of Health Seeking Behaviour -Look for the correlation needs of pop & offering of medical services -Promotion of MSF services -Health education in medical infrastructures -Consider the possibility to develop some HP activities in the communities to increase patient/individual’s empowerment 1 In refugee camps, we often develop network of home visitors. Since 07 In Darfur, we launched several network of HV in city the capitalisation of the network in Kebkabya will be done in 2009. 13 Field of intervention III: Epidemics and endemics See table with health thematic p. 11 & 12 Particularities: Health Promotion activities should be integrated in every disease Field of intervention IV: Assistance for victims of natural catastrophes Particularities are: the Health Promotion activities are usually integrated into Watsan activities (Hygiene promotion) or linked with mental health activities.
The concept of home visit is very important to reinforce link with population. 14 6. Some definitions Health education12 comprises consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health. Reference: modified definition- WHO Health education is not only concerned with the communication of information, but also with fostering the motivation, skills and confidence (self-efficacy) necessary to take action to improve health.
Health education includes the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as individual risk factors and risk behaviours, and use of the health care system. Thus, health education may involve the communication of information, and development of skills which demonstrates the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health.
Patient education13 "The patient education is a process, integrated in the process of care, including a series of activities organized awareness, information, learning and psychological and social assistance on the disease, treatment, care, organization and hospital procedures, health behaviours and those associated with the disease, to help the patient (and his family) to understand the disease and treatment, care work, take charge of his state health and foster a return to normal activities"
Patient support 14 The component of Patient Support covers all the activities aiming at supporting the patient in front of his disease and his treatment, beyond the purely medical aspects of care. The patient support is a continuum of progressive, personalised or peer-supported activities addressed to the patient, and going on all along the program. Rem: for the moment within MSF, we are using the component of Patient support for HIV and TB.
Main objectives for all HIV patients are: - To understand and accept his HIV status or disease 12 13 From Health Promotion glossary DECCACHE A. et LAVENDHOMME E. , Information et Education du Patient : des fondements aux methodes, De Boeck Universite, Bruxelles, 1989, p. 45 14 For more info, refer to the draft “Patient Support document for HIV/AIDS“ written by B. Laumont & G. Loots in the OCB. 15 To recognize the consequences of the disease in his everyday life - To adapt his behaviour (way of living) - To be involved in and adhere to his treatment To achieve all these objectives, the patients have to go through 3 complementary processes: 1- Educative process ? Patient Education This is about the patient understanding - the infection and the evolution of the disease - the transmission of the disease - the risky behaviours to avoid - the treatment This includes the following activities: Health Education, Health talks, Treatment Literacy 2- Process of emotional adaptation?
Emotional Support This is about the patient - dealing with the loss of his self-image and the loss of the good health - dealing with the stress caused by the evolution of the disease, the perspective of death, the uncertainty of the future and the reduction of capacities - dealing with the relational changes with his close relationships and occupational environment - dealing with the improvements and the changes brought by the treatment This includes the following activities: counselling (individual & group), support groups 3- Process of adaptation to socio-economic consequences?
Social Support This is about helping the patient to solve his social problems in order to improve his good adherence to treatment - risks of precariousness: financial resources, incapacity, loss of employment - risks of isolation, stigmatisation by family and community This includes the following activities: social consultation, home visits, networking, etc … The Patient Support can be provided through 4 different types of activities: - Individual sessions: individual counselling (pre-test, post-test, follow-up, adherence, etc), social consultation - Group sessions: Health Talks, Educational talks, ART preparation sessions, Support Group, etc - Group activities: expression and creative activities, party, celebration, excursion, etc - Community and Family level actions: Home visits, Home Based Care, Defaulter prevention, Defaulter tracing, Community activities, etc Empowerment for health15 In health promotion, empowerment is a process through which people gain greater control over decisions and actions affecting their health. A distinction is made between individual and community empowerment. Individual empowerment refers primarily to the individuals’ ability to make decisions and have control over their personal life.
Community empowerment involves individuals acting collectively to gain greater influence and control over the determinants of health and the quality of life in their community, and is an important goal in community action for health. 15 From Health Promotion glossary 16 7. - Bibliography « Anthropologues et ONG: des liaisons fructueuses? » ; Humanitaire - Hors Serie; Numero 4Automne/hiver 2007 ; editer par Medecins du Monde « Communicating Health- an action guide to health education and health promotion » John Hubley- 2004 “Applied Health Research, Anthropology P. Boonmongkon, P. Streefland, M. L. Tan, etc. “ Health Promotion glossary” WHO CDC, Prevention “Education pour la sante, concepts, enjeux, planifications”, Jacques A. Bury « Information et education du patient, des fondements aux methodes », A. Deccache et E. Lavendhomme of Health and