An integrated approach to reduce childhood
mortality and morbidity
due to diarrhoea and dehydration; Maharashtra, India
2005 - 2010
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childhood mortality and morbidity due to diarrhoea and dehydration; Maharashtra,
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30 May, 2005
Project Summary
Project Rationale
What problems will the project address?
Health Education to Mothers
Educating Health-care
Providers
Safe Water Management
Targeting the Whole Community
Programmes
Long-term Goals and Conclusion
Lessons drawn on and new approaches
Monitoring and sustainability
Long-term benefits of the HETV network
Conclusion
Section I: Summary
Submitted by: Nand Wadhwani,
Executive Director, Rehydration Project Tel: +852 3482 5121
Prepared by: Nand Wadhwani, Max Pitman and Ami Mody
Name of Project: Health Education to Villages: an integrated approach to
reduce childhood mortality and morbidity due to diarrhoea and dehydration;
Maharashtra, India 2005 - 2010
Region and Country: Maharashtra, India.
Name of Local Partners: Government of Maharashtra - Health Services,
IMR Nutrition Mission, United Nations Children’s Fund (UNICEF) India and Education to Home (ETH)
Research Labs.
This plan of action introduces Health Education to Villages (HETV), a network of
programmes and organisations working in partnership to reduce childhood mortality
and morbidity.
Project Summary
The goal of this five-year project is to better educate the people of
Maharashtra, especially health-care providers, mothers, and children, about
basic health practice, sanitation, and child care, with a primary focus on
diarrhoeal diseases and the use of oral rehydration therapy (ORT)1. The
purpose of this plan of action is to improve the health, and therefore the
quality of life, of all citizens, especially mothers and their children in rural
villages and urban slums.2 More specifically, the purpose of this project is to
decrease the high child mortality rate resulting from dehydration caused by
diarrhoea, and also to decrease the prevalence of diarrhoeal diseases, through
targeted health educational programmes. More generally, this project will
develop an education network to train mothers and health-care providers in
proper health practices, with the aim of expanding this network in the future to
include more regions of India and more areas of health education. This journey is only the
beginning. We hope to build on it and root it into the good health landscape of
Maharashtra. We hope it can serve as a learning experience for other parts of
India.
At present, the people of Maharashtra lack much of the basic information and
resources necessary to improve their health and reduce the incidence of disease
and child mortality. Either they do not have access to accurate information,
especially in rural areas and among those who cannot read or write, or they have
received mixed, inconsistent, or insufficient messages about proper health
practice. In the case of diarrhoeal diseases, for example, the message of
correct management simply has not reached its audience in a consistent and
sufficient way. After 37 years of ORT knowledge and more than 15 years of
promotion of a variety of ORS Programmes, 42% of mothers in Maharashtra still
believe that a child with diarrhoea should receive
less fluid and
less
food than normal.3 This belief is entirely inconsistent with any form of proper
diarrhoea management, and speaks to a deep lack of understanding of dehydration,
the real danger of diarrhoea. Clearly, even when a well-intentioned message like
ORT reaches a fairly large number of people (65% of mothers have at least heard
of ORS), without basic education of the meaning of that message, the message
loses its effect substantially.
The HETV project will expand the education of health-care providers, mothers,
children, and communities in several targeted areas of health, water, hygiene,
and sanitation. The project will use an aggressive, focused, comprehensive
approach to spread consistent health messages, and in a manner and order such
that the goal of these messages - better health for mother and child - will
reach all its audiences.
The activities of the project will enable HETV, through multiple,
on-going, discrete yet integrated programmes, to promote proper health practices
and certain necessary health resources to the mother at the village level.
Health workers and other medical professionals will receive supplemental
education at the same time, so that they may teach and reinforce the information
available to mothers and communities. The programmes are grouped into four
target areas, and address specific problems within these areas: health education
to mothers, knowledge of health-care providers, safe water management, and
targeting the whole community.4
This grouped approach will achieve rapid transfer of knowledge in an organized
and comprehensive manner, so that all target audiences are reached with the
information they need to know. Many of the programmes, such as the Mother Child
Protection Card computer based training (CBT) programme and the Facts for
Life Marathi wall calendar, will incorporate
built-in sustainability and monitoring. In the former, for example, the process
of certification and required yearly recertification will assure both the
supervision and continuation of the programme in the long term, and in the
latter, the prospect of yearly reprinting allows permanent sustainability,
integrated with a continuation of health days and health educational mass media
events scheduled on the calendar. Long-term monitoring in the form of surveys
and success statistics will be conducted by the government of Maharashtra and
the National Family Health Survey (NFHS), and HETV will work closely with the
government to incorporate feedback and revise the programmes for increased
efficiency and efficacy.
Section II: Project Rationale
What problems will the project address?
This project addresses the primary health concerns of the 100 million
people in Maharashtra, especially women and children in rural areas and urban
slums, who live in very poor health or die young from the diseases of
sub-standard health, water, hygiene, and sanitation.
40% of both mothers and
children in Maharashtra are chronically undernourished, and under-five mortality
occurs at 58 deaths per 1000 live births, or 1 in every 17 children. A very
large number of these deaths are caused by dehydration from diarrhoea, the most
easily preventable cause of childhood mortality. We recognize that widespread
diarrhoeal diseases, malnutrition, and high child mortality result first and
foremost from poverty, the eradication of which is beyond the scope of this
project. But, in the area of health education, there are many possible
improvements we can address in the short-term, using the resources and
infrastructure already in place. This project will address problems relating to
mother and child health, with a primary focus on diarrhoea, in the following
areas:
1. Health education to mothers
A healthy and educated mother can
dramatically improve the health of her child. Mothers in Maharashtra, however,
currently have little or no access to information or materials relating to
proper child care, and even when information is available, it often does not
target the more than 20 million women in Maharashtra who cannot read or write.
Without sufficient and understandable information, mothers are not properly
equipped to look after the health of their children and themselves in the best
possible practice, given their limited resources. This project will educate
mothers about several key issues which relate immediately to diarrhoeal diseases
but carry over into many other important areas of child health.
Diarrhoea management. If ORT and other sound
diarrhoea management measures were administered early and correctly, mothers
could prevent up to 90% of diarrhoeal deaths.5
Increased fluid intake. As mentioned in
Section I, mothers need much more education about when and how to use
ORT. Only 65% of mothers in Maharashtra have ever heard of ORS, only 50%
use any kind of ORT when a child has diarrhoea, and only 33% use ORS.
And even more grave, of the 50% who do use ORT, only 14% give increased total
fluids. This absolute contradiction of understanding - that a mother
could give a child a solution designed to facilitate the rapid
absorption of fluids by the intestinal lining, and then give this same
child less total fluid than normal - is the most clear indicator
available that the message of ORT simply has not reached mothers in a
way they can understand, and that a new approach is necessary.
Continued feeding. In addition to more
fluid, children with diarrhoea need to receive more food and more
breastmilk than normal, both during and after an episode. There is a
widespread misconception among mothers in Maharashtra, however, that a
child with diarrhoea should be given less food until the episode is
over.
Recognizing signs and degrees of dehydration.
In order to prevent deaths, mothers must also be better educated
about how to recognize signs that a child is in danger. Clearly, mothers
must learn when and why to give more fluids, but they must also learn
when to seek immediate medical care. For example, while
only 41% of
mothers in Maharashtra can correctly identify symptoms suggesting a
child needs medical treatment for dehydration, 77% take a child with
diarrhoea to a health facility. If mothers could recognize and treat
dehydration early on at home, the great majority of these children would
not need additional medical care. In this way, better practice would
save mothers the trouble and expense of travelling to the health centre
(and also prevent them from spending money on unnecessary drugs), and it
would release some of the burden on health facilities.
Zinc supplementation has emerged in recent
studies as an effective method, along with ORT, to prevent deaths from
diarrhoea. According to research conducted by USAID, UNICEF, and WHO,
zinc
supplementation during an episode of diarrhoea, combined with correct
use of ORT, can reduce a child’s chance of death by up to 50%, and it
can decrease the child’s susceptibility to diarrhoea and other diseases
for up to three months after the episode. Since these and other benefits
of zinc are not yet widely known, there is great potential to promote
this supplemental treatment for diarrhoea, which is cheap and easy to
distribute, to mothers throughout Maharashtra.
Diarrhoea prevention. With better education
about prevention, mothers could reduce the prevalence of diarrhoea, and many
other diseases which are caused by similar health conditions.
-
Timing births. Children born to mothers
under the age of 18 are far more susceptible to diarrhoeal diseases, yet
women aged 15-19 account for 26% of all fertility in Maharashtra.
Children born less than 24 months after a previous birth are also far
more susceptible to these diseases, and 31% of all births in Maharashtra
occur less than two years apart. Compounding these dangerous factors,
statistics show that mothers
aged 15-19 are the most likely to give birth within two years of a
previous birth, and that young mothers are
also the least likely to know about proper diarrhoea management.
-
Breastfeeding and child feeding practices.
Two thirds of all child deaths annually are associated with
inappropriate feeding practices, mostly in the first year of life. The
Indian National Guidelines on Infant and Young Child Feeding quite
clearly recommend exclusive breastfeeding for a child’s first six
months, with complementary feeding for up to two years, as well as
feeding the child colostrum (first breast milk) within the first half
hour after birth.6 Yet only one third of all mothers in Maharashtra feed
their newborns colostrum, which contains antibodies necessary to fight
disease, and only 16% practice the early initiation of breastfeeding.
Also, only 55% of children in Maharashtra receive exclusive
breastfeeding in their first three months, and even less for the full
recommended six months. After six months, only 34% of mothers begin
suitable complementary feeding of nutrient-rich foods, which is
recommended for all children at six months, and which is necessary for
making children less susceptible to diarrhoea, which is most likely to
occur between 6 and 11 months of age.
-
Measles immunization. Immunizing a child
against measles is one of the most important measures a mother can take
in preventing diarrhoea. While 84% of children in Maharashtra do receive
a measles vaccination, that number is still far from the goal of 100%
coverage. Also, only 68% of children receive this vaccination in the
first year of life, the year in which most deaths from diarrhoeal
diseases occur.
2. Knowledge of health-care providers ― improving and
monitoring the education of health workers is a necessary step in ensuring
better health for mothers and children, and in preventing and managing
diarrhoeal diseases. With so many mothers who cannot read or have limited
education, and without any widespread structure of adult education, health
workers provide the means to bring correct health information and materials to
mothers. Health workers are also the first line of defence for a child who is
ill enough to require treatment, and the actions of the health worker are
crucial to the survival of the child. According to NFHS 2, “[diarrhoea
management] figures indicate poor knowledge about proper treatment of diarrhoea
not only among mothers but also among health-care providers. The results
underscore the need for informational programmes for mothers and supplemental
training for health-care providers that emphasizes the importance of ORT,
increased fluid intake, and continued feeding, and discourages the use of drugs
to treat childhood diarrhoea.” Information by itself is
not enough. It has to be communicated. It has to be received. It has to be
understood. It has to be used to make the desired change. This plan addresses this need
for supplemental training in several areas.
Training process for the Mother Child Protection
Card. The Indian government has standardized the health information a
mother receives upon the birth of a child in the form of the Mother Child
Protection Card. The benefits received from this card are greatly dependent
upon the training of health-care providers, who must teach and reinforce its
messages, and instruct mothers on how to use the card. The current process
of classroom trainings, however, will take several years for health workers
to have learned the programme, and these trainings do not include a
certification process to ensure the quality of knowledge a health worker has
acquired.
Correcting dehydration. As noted above,
health-care providers, like mothers, need further training on recognizing
symptoms of dehydration and properly managing diarrhoea, and on promoting
these practices to mothers. It is usually diarrhoea which first brings
babies into contact with doctors and the health system, and therefore,
diarrhoea provides the first opportunity for health workers to educate
mothers early on about proper child care practices. For many mothers,
however, this first educational opportunity too often provides them with
incomplete or unclear messages.
Increased fluids.
Of the 77% of children
with diarrhoea in Maharashtra who are brought to a health facility, only
9% receive increased fluids, all of which is administered in the form of
an IV, and the number of children who receive any form of ORT is
negligible. Using IV is expensive for both the health facility and the
family, and in cases when it is not entirely necessary (most cases), it
can do more harm than good in the long term by setting a poor example to
the mother and not promoting the use of ORT in the home.
Preparation of home-made and packaged solutions.
Studies have shown that in the case of both ORS and home solutions,
health-care providers at several levels often themselves cannot
correctly measure one litre of water. And in the specific case of home
solutions, there are further confusions among measurements of sugar and
salt, such as variations in size of pinches, spoons, and water vessels,
which all make the task of measuring such solutions far more difficult.
Anti-diarrhoeal drugs are widely known to be
ineffective and often harmful in the treatment of severe diarrhoea. They
are a distraction from dehydration, which is the real danger. They are
capable of further dehydrating the child, and they are an unnecessary
expense for the mother. In Maharashtra, however,
of the 77% of all
children who are brought to a medical facility when ill with diarrhoea,
78% receive some form of anti-diarrhoeal drug (pill, syrup, or
injection). In many of these cases, health workers not only endanger the
health of the child, but they also set a poor example for the mother,
making it much less likely that she will understand the danger of
dehydration or manage diarrhoea properly at home in the future.
3. Safe water management ― unclean water is the number one
cause of diarrhoea and many other diseases, and in Maharashtra, there is great
room for improvement in the areas of access to clean water and knowledge of
water disinfection, harvesting and storage.
Water disinfection can be quite effective in
managing soiled water and preventing the spread of disease. In Maharashtra,
however, 44% of all households do not attempt to purify water at all, and of
those that do, the most common method by far is to strain water through a
cloth, which offers little or no disinfection of disease-causing agents.
Only 18% of households (13% rural) boil or filter their water, and
predictably, diarrhoea occurs much less frequently among these households
than in those that do not boil or filter water.
4. Targeting the whole community ― Diarrhoeal diseases
will be eradicated in Maharashtra only with a much wider effort involving
high-level political leadership, social mobilization, engagement of the private
sector, and partnerships between the health community and variety of other
industries, especially in the areas of electronic and print media. These efforts
are necessary to achieve a high level of awareness in the cultural
consciousness about diarrhoea or any other health concern.
Young female education. In Maharashtra, 96% of
villages have a primary school, while only 41% have a secondary school.
Female school attendance remains high (90%) until age ten, but drops to 54%
from ages 15-17, the time when reproductive rates begin to soar (women aged
15-19 account for 26% of total fertility). These numbers speak to a great
need for partnerships between primary school education and health education.
If female children were educated about basic health and sanitation early on,
they would have a much better foundation of knowledge both to pass along to
the mother and family, and perhaps more importantly for the long term, to
use when they themselves become mothers. Within the existing structure of
society, it is much easier to educate a child than a mother (especially if
the mother cannot read), so educational programmes must target the female
while she is still in school.
Toilets and latrines.
In Maharashtra, 85% of
rural households and 54% of all households have no access at all to a toilet
facility. While the Indian government is making great strides in the
availability of toilets, increased advocacy and education will be necessary
to convince people to use the toilets, to create separate male and female
toilets in schools, and to promote proper practices of hand washing with
soap and water after using the toilet.
Social mobilisation of Boy Scouts. The scout
movement and other youth organisations provide a potential army of
infrastructure and willingness to do good works, already in place, that
could be used to further the messages of rehydration and health education.
Promoting health education to the Boy Scouts, specifically relating to
family and child care, could address at an early age the need for men to
take greater responsibility for caring for their children and families.
Mass media.
70% of all women in Maharashtra are
regularly exposed to some form of mass media, and growing numbers of
villagers are gaining access to television and radio. If all the available
media were employed to spread timed, consistent health and diarrhoea
management messages, a wider general health consciousness could be achieved
in a very short amount of time. With regular television and radio
broadcasts, Internet and satellite technology, posters, printed material,
and community events all moving at the same time, Maharashtra could move
much more quickly towards its health educational goals.
Section III: Programmes
Health Education to Mothers:
No claim for originality of the programmes is made by HETV.
We acknowledge our gratitude to the many people and sources whose work has been
drawn freely upon. We thank them all.
Programmes will be supplemented and supported by booklets,
leaflets, posters and informational guides in Marathi and English, and made
freely available at health worker stations, hospitals, schools, and more.
Nurturing newborns and their mothers ― Skilled attendance during pregnancy,
childbirth and the immediate postpartum period. Mothers will be provided with
training for breastfeeding from the nurse or midwife, encouraged
about the importance of providing colostrum within the first half hour after
birth, and advised about other questions they may have about their newborn
or postpartum period.
Diarrhoea Management ― Intended to target mothers’ confusion and lack of
understanding about how to recognize, assess the degree of, and treat diarrhoeal
dehydration. Mothers will be taught the crucial need for immediate fluid
replacement, increased fluids and food, how to correctly prepare
home-made and packaged ORS, cereal-based ORS, when and why to use it, and
continuous feeding, including breastfeeding.
Breastfeeding
― Protect against diseases through the promotion of clear guidelines about
proper feeding practices and the benefits of immunity. Promote the practice of
providing colostrum to the child within the first half hour after birth,
exclusive breastfeeding during the first six months of a child’s life, with
appropriate complementary feeding from six months and continued breastfeeding
for two years or beyond, with supplementation of vitamin A and other
micronutrients as needed.
Timing Births
- Encourage the culture of having children later in life and having a
child at least 24 months after a previous birth. Reduce health risks for
children born to mothers under the age of 18 by educating about the importance
of timing births as it relates to the dangers of diarrhoea.
Measuring Sugar, Salt, and Water ― Correct the confusion created by years of
mixed messages regarding measurement of the ingredients in rehydration
solutions. Mothers will receive a plastic one-litre bottle, with a label about
how to recognize signs and degrees of dehydration, how to prepare home fluids
for rehydration, and how to mix and prepare home-made and packaged ORS.
Additionally, they will receive a 2-sided spoon to correctly measure salt and
sugar.
Zinc Supplementation ― Prevent deaths from diarrhoea and decrease child
susceptibility to diarrhoea after episodes by educating all health-care
providers and mothers about zinc supplementation. Through focused and integrated
campaigns, and through partnerships with local manufacturers, we will increase
availability of zinc supplements.
Facts for Life Wall Calendar ― This 13-month calendar,
corresponding to the 13 Facts for Life messages, makes life-saving
information easily available to everyone. It presents important health
information about an issue or concern that every family has a right to know. The
messages are simple, and people in Maharashtra can act on them. The calendar
will also indicate state health days, and health educational mass media events.
Educating Health-care Providers:
Mother Child Protection Card - Computer Based Training (CBT) ― Provide a
monitored, consistent, and expedited health worker training process, including a
certification program, for the Mother Child Protection Card. The CBT will
accelerate the current pace of training to health workers by using over 1,000
computer literacy centres throughout Maharashtra. This will provide a better
learning experience through interactive computer exercises, and, when necessary,
give the option to complete an individual training module at a modified pace.
Electronic Resources - For those who have access to the internet or a computer,
a comprehensive, up-to-date body of material about diarrhoea, dehydration, oral
rehydration, water systems, hygiene, sanitation, and much more will be
available.
-
Online
Resources ― The portal
hetv.org provides a comprehensive set of resources relating to health
education. Materials can be downloaded for offline research or printed for easy
dissemination.
-
Health Resources CD ― For those without Internet access, all these resources
will be available on a CD which will be freely distributed to health care
providers, educators, reference libraries, doctors, schools, universities, and
hospitals in Maharashtra.
-
HETV Webcast ―
Online health education videos for mothers, health care providers, medical
specialists, doctors, and students. These videos can be easily transferred for
news, TV, or radio broadcast.
Education Satellite ― Enhance the current knowledge of diarrhoea management
by facilitating lectures and training courses which will allow for dialogue and
interaction of hundreds of people simultaneously. Key health issues will be
taught and discussed by doctors, medical specialists, medical students, and
health care providers at the existing 100 virtual learning centres in
Maharashtra with video conferencing facilities linked by satellite.
Cloth Health Guides ― Health workers will inform mothers, especially those
with limited education or who cannot read, using this series of washable, easily
transportable, and simple-to-use health guides. These handkerchiefs with
drawings, diagrams, and graphs, contain useful health information, and will be
distributed to health care providers throughout Maharashtra.
Measles Immunization ― Reduce incidence of diarrhoea by promoting measles
vaccination within the first year of a child’s life. 100% immunization coverage
against measles is the programme goal.
Safe Water Management:
Water Systems ― Water quality interventions that employ simple, inexpensive
and robust technologies appropriate for the developing world. The objective is
to make water safe through disinfection and safe storage at the point of use.
The basis of the intervention is: point-of-use treatment, safe water storage and
behaviour change techniques.
Water Disinfection ― Treat soiled water and prevent the spread of disease by
promoting the practice of boiling water and the usage of chlorine, iodine, or
even household bleach, to conduct home water disinfection. Health workers will
be trained to use these practices, and will convey the techniques to mothers.
Solar Disinfection ― Disinfect soiled water with this free and easy
technique using solar radiation. This simple process of filling transparent
containers with water, and exposing them to full sunlight for about five hours,
destroys pathogens in the water.
Targeting the Whole Community:
Partnership of Health and Education ― Educate all school children,
especially young girls before child-bearing age, about important health
information. A partnership between the Ministries of Health and Education in
Maharashtra will include the teaching of proper health practices within the
curriculum.
Toilet Facilities in all Schools ― Encourage and contribute to developing
the necessary partnership between the state of Maharashtra and the Government of
India’s programmes to establish toilet facilities in all schools. The Indian
government has launched a focused campaign to increase the households in the
country that have toilets by 2010. Additionally, we will target the urgent need
for separate toilets for boys and girls, together with a hand-washing facility
in every school in Maharashtra.
Social Mobilisation of Boy Scouts ― Educate and encourage young boys to be
health conscious members of society, and to convey important health messages to
their families and the community. The Boy Scouts will partner with the
government of Maharashtra, attend school events and public fairs, organize
rallies and fundraisers, create and distribute handouts.
Handwashing with Soap and Water ― Promote the habit of Hand Washing
wth Soap and Water to decrease episodes of diarrhoea. To ensure the sufficient availability
of soap, partnerships with local manufacturers will be used to
promote this practice.
Television Broadcasts ― Educate the entire community about health issues
through documentaries, commercials, news programs, public service announcements,
and other TV programs. The broadcasts, linked to the Facts for Life Calendar,
will advertise health days and other
monthly TV health shows.
Radio
Broadcasts ― Educate the general public and mothers about health issues
through an informal dialogue in various radio formats (interviews,
documentaries, quiz shows). The radio programmes will educate with the same
messages as the TV broadcasts, but will reach a wider audience.
Health Messages on School Notebooks ― Educate school children about health
issues in descriptive messages, cartoons, and animation printed on their
notebooks. Young school-children will see these key health messages almost every
day to encourage them to become health conscious members of society, and to convey
important information to their families and the community.
Section IV: Long-term Goals and Conclusion
Lessons drawn on and new approaches
The lessons of mixed and inconsistent messages
- the HETV programmes draw
their design from areas in which health information has not reached its target
audience, or has reached this audience in an inconsistent and confusing manner.
The two most poignant examples already discussed are those of mothers giving
children with diarrhoea less fluid and food, and of health workers
prescribing anti-diarrhoeal drugs instead of giving increased fluids. Either the
message simply does not reach its audience, or if it does, it is not in a way
which that audience understands. If a mother hears about the benefits of ORT,
for example, and then a health worker gives her child not fluids, but drugs, the
message reaching her is quite inconsistent. Or even when mother hears correctly
about the benefits of ORT, she may lack the tools or instructions to correctly
make the solution, or even to measure one litre of water.
An integrated approach - this project, with the help of partner
organisations, will improve upon the lessons of mixed or inconsistent messages
by providing more information, better targeted to reach specific audiences, and
with the consistency necessary for the information to fully reach these targeted
groups. The new approaches to achieve these improvements will involve the
integration and leveraging of programmes so that messages presented to specific
audiences are connected in a coherent and understandable way. The computer-based
training of the Mother Child Protection Card, for example, is an enhancement and
acceleration of the training of health-care providers tied into an already
existing government programme, so that health workers are taught to reinforce
the messages already being used in the programme, rather than confusing mothers
with a different message. Another highly integrated programme is the Facts
for Life calendar, which uses the very well-established messages of Facts
for Life and reinforces a different message each month. This calendar will
also integrate with HETV mass media events, so that a mother may look at the
calendar to see what day a television programme, radio broadcast, or community
event about health practice will take place, and the information of these mass
media events will in turn be consistent with Facts for Life, the Mother
Child Protection Card, and any other materials or messages of the HETV
programmes in Maharashtra.
Monitoring and sustainability
Several of the proposed HETV programmes incorporate a built-in
sustainability and monitoring structure. Also, the integrated nature of the
programmes assures that the monitoring of one programme can incorporate the
monitoring of a linked programme, which is true for long-term sustainability as
well. For example, the computer-based training of health workers will require a
periodic recertification which will monitor and reinforce the messages being
passed from health worker to mother. The event of each recertification then
provides an opportunity for the health worker to receive new educational
materials, such as the next year of the Facts for Life calendar or the
most up-to-date posters and pamphlets, to distribute at the village level. This
leveraging of programmes assures the sustainability and continued monitoring of
the training of health workers as well as the continual education of best
practice information to the mother.
Correctly educating mothers, health workers, and children in the community,
combined with a greater availability of resources like toilets and clean water,
is a form of sustainability itself. As proper knowledge spreads from person to
person into a heightened culture of awareness, capacity-building allows
communities greater control over their health status. Each mother, child, or
health-care provider empowered with better knowledge and the desire to share
that knowledge is an agent of sustainability herself.
Long-term benefits of the HETV network
While diarrhoeal diseases are the primary focus of the HETV programmes in
Maharashtra, the design of the project will allow it to expand into other health
concerns and other regions of the world. This effect will take shape in several
ways:
General disease prevention. The educational
attempts to combat diarrhoeal diseases will necessarily combat other
diseases which are caused by similar health conditions. If mothers become
better educated about timing births, exclusive breastfeeding, and water
disinfection, for example, their children will be much less susceptible to
acute respiratory infections, malaria, and a host of other diseases as well.
Better health education, put simply, will create better health in all areas.
Network expansion. Once the HETV network and
partnerships are in place - with computer-based training available at over a
thousand computer literacy centres in Maharashtra and eventually all over
India, with an education satellite allowing for video-conferenced health
lectures, with health workers using tested materials to teach mothers about
best practice - any message could rapidly travel through this network. With
a new language layer substituted in the CBT programme, or with a new topic
for a series of EDUSAT lectures, these programmes could be quickly adapted
for other regions of India or for any country in the world. If an AIDS
advocacy organisation or a social equity group, for example, wanted to use the HETV model
for a different message and then distribute it to the locations already in
use, the training could be under way in just a few months.
Conclusion
The root cause of many health problems in India is poverty, not diarrhoea,
dirty water, or lack of information. These more direct causes stem always from a
lack of economic resources among disadvantaged populations, and a lack of basic
needs such as toilets, clean water, and sufficient food. Without food and water,
a malnourished population is far more susceptible to disease, which further
cripples the economy, leaving marginalised groups stuck in a cycle of poverty,
malnutrition, and illness. As such, the major killers of children in India can
only be fully eradicated when a more equitable economic and social order is
achieved. However, significant improvements are possible in the meantime, and the
incredible opportunities of our time create the potential for these improvements
to take place far more rapidly than we might have imagined in the past. With
over 500,000 children dying yearly in India from diarrhoea and water-related
diseases, there is no time to wait. It is the moral responsibility of
governments, private organisations, and civilians - of anyone who can help - to
work toward ending the cycle of such preventable diseases.
This HETV plan of action deals with broad programmes involving large numbers of
people, and it often cites statistics to discuss the health concerns of these
people. We wish to remember, then, that every statistic is comprised of a large
number of individuals - individuals loved by their families and communities, and
individuals who work hard to contribute to those communities. Too many of these
individuals die before having a fair chance at life, and many more live, but are
left to lead a life forever handicapped by a childhood of hunger, illness, and
both physical and mental underdevelopment. Behind all our efforts is the sense
that every life has enormous value, and every unnecessary and avoidable death is
a great tragedy. We wish to remember, finally, that health education is at its
core an attempt to value these lives, and that a new order of health can be
achieved to save these lives, which is our true goal and purpose.
1 Throughout
this document, ORT refers to administering by mouth, frequently, small
quantities of fluid, often a solution of sugar, salt and water in order to replace
fluids and electrolytes lost during diarrhoea. ORT includes, but is not
limited to, solutions made from packets of oral rehydration salts (ORS).
2 This plan
often uses language of “village” and “community.” Even when not mentioned
explicitly, these targeted audiences include urban slums as well.
3 National
Family Health Survey, 1998-1999 (NFHS 2), Maharashtra. Unless otherwise
noted, all further statistics in this document come from NFHS 2.
4 See
Section II for an in-depth discussion of the problems addressed in these
areas, and see Section III for discussions of the specific programmes
addressing these problems.
5 UNICEF,
Oral Rehydration Therapy: Elixir of Life, 1997.
6 Government
of India, Department of Women and Child Development, Food and Nutrition
Board, National Guidelines on Infant and Young Child Feeding, 2004.
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