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Health education in the maternal and child welfare centre
HEALTH EDUCATION IN THE MATERNAL AND CHILD WELFARE CENTRE By H I L D A
M. D A V I S ,
M.D., O.P.H.
Senior Medical Officer, Maternity and Child Welfare, Buckinghamshire A RECENT editorial in the Health Education Journal deplores the fact that although doctors are teachers and that in their work, whether clinical medicine or public health, they are health educators, doctors are not taught how to teach. At a conference this summer W.H.O. has studied the introduction of health education into training of doctors and nurses, and of those taking higher qualifications such as the D.P.H. Hitherto it has been left to individual medical officers to learn the technique of teaching through experience and by attending post-graduate courses. Many of us have been content through the years to confine our teaching methods to the personal interview with mothers in the ante-natal clinic, welfare centre or school. Are we sure that our methods are right ? Do we tell the mother what she wants to know, or what we think she ought to know, and are we sure that she always understands what we tell her ? For many years child welfare centres have worked to a set pattern, originally called for by prevalence of poverty, poor hygiene and ignorance among the mothers who came for help. Now that standards of health and living have improved, mothers are taking an intelligent interest in the upbringing of children and in the mental health of their families. If the child welfare centre is to retain its useful place in the community it must meet the needs of the modern mother. It is time that we took a new and serious interest in teaching because we have a unique opportunity in our personal contacts with mothers to help them to lay firm foundations for family life. Health education calls for team work and the doctor should be the leader. In the past there have been welfare centres where in no sense was there a team at work, but only isolated centres of activity ; the health visitor glued to the scales, voluntary helpers at the register and the " f o o d table," and the doctor known only as a shadowy figure hurrying to and from the inner sanctum where mothers were interviewed. Health visitors in the main are alive to the opportunity ; they are knowledgeable about visual aids and the value of group discussion ; they are in fact fast becoming a body of expert teachers. It is up to medical officers to join them, for here in the M. & C.W. centre are the components of the health education team 9 the mother and her young children, the doctor, midwife and health visitor, the voluntary helper and perhaps the clinic assistant. In the background, often waiting in vain to be included, is the father. Other members of the family are there too, and a host of other health and welfare workers who might be willing participants if only invited and made welcome. 229
230
PUBLIC H E A L T H
VOL. LXXI
NO. 6
To be successful, health education needs a planned programmr suitable materials to support the spoken word and the creation of interest in the participants. Sometimes it is difficult to distinguish between teachers and learners, and one of the joys of group discussion is the amount one can learn from parents who can tell each other, and us, what they have discovered from practical experience. It is salutary to find that some theory one has passed on dogmatically for years doesn't really make sense in practice. A planned programme needs background help and every health department should have a health education section, with one or more organisers who can assist by providing materials, ideas and notes for talks, and suggestions for outside speakers. For the M. & C.W. service it is an advantage if the health education organiser is a health visitor, for she has an intimate knowledge and experience of the subject matter and appreciation of the needs of parents and, which is important, of her busy colleagues in the field. She should have a health teaching qualification and, in view of her added responsibility, have senior rank on salary scale. The health education organiser would be responsible for planning a programme for the whole area, in consultation with other senior staff, according to local needs. This can include a syllabus for antenatal classes, subjects for group discussions, organisation of inter-welfare centre quizzes, exhibitions of handicrafts and materials to illustrate subjects discussed in study groups at welfare centres and mothers' clubs. The health education organiser should be available for consultation to all health visitors and doctors in the area, and to other interested people, for advice regarding subject matter, organisation of meetings and for provision of teaching material. She will also visit welfare centres and give sample talks, or lead discussicm groups until the local staff have overcome their diffidence and are ready to branch out on their own. It is essential to build up a good stock of teaching material, both centrally and in areas, which can be borrowed as required. Materials available should be catalogued and up-to-date lists distributed to all field staff. Filmstrip projectors and screens are primary needs, and when funds permit an epidiascope and film projector can be added. Mothercraft demonstration material and small portable exhibits on various subjects can be loaned out and the staff of the health education section will be responsible for the library of books and pamphlets, filmstrips, flannelgraphs and other teaching material. It is a great advantage if one member has some artistic ability to help in producing posters and other exhibits, but keen health visitors soon learn to devise their own~ and so should the medical officer t To be effective the programme must aim first at creating interest in group teaching among the health visitors and doctors, and then reorganisation of the welfare centre to provide facilities for this. A staff conference could be the first move, at which the health education organiser can explain her ideas
M A T E R N A L A N D CHILD W E L F A R E CENTRE
231
and all can contribute theirs to the discussion. After this a s h o r t course can be arranged for inservice training in the technique of teaching and group discussion methods, and the preparation and use of visual aids. For this our friends at the Central Council for Health Education are invaluable, and the first lesson they would teach us is that we must give our audience what they want and let them participate. In the M. & C.W. centre we are fortunate in having interest already created for us in our audience, that of the mother in her own baby and family, but we must be sure that we make the best use of the opportunities presented. It is rare for a mother to lack interest in her baby, though at first it may not be obvious on the surface, but it is her own baby and family, and what affects them that is the centre of her interest not just theoretical ideas about children in general. This is the basis of the personal interview which must continue to be the main function of the welfare centre, but the modern mother readily accepts the wider value of group teaching. She is used to group techniques on r a d i o and television; the brains trust, quiz and " any questions" are familiar to her and she is willing to contribute to a group discussion once the ice is broken. A mother is most receptive to knowledge during pregnancy and this is the most rewarding time for health education. Especially when it is her first baby is she eager to hear about herself and the coming baby ; she needs someone to allay her fears and anxieties, and she looks for reassurance on her ability as a wife and mother at this time when her mental health may be in the balance. To-day when it seems probable that clinical ante-natal care will pass gradually from the local authority to the general practitioner and hospital, the medical officer should take an active part in classes for preparation for childbirth and mothercraft, and not leave this field entirely in the able hands of the midwife and health visitor. Although ante-natal exercises have passed from favour, there are no doubts about the value to the woman in labour o f having learnt how to relax and breathe correctly, and in knowing what to expect during the different stages of her confinement. It is proper that her midwife should be the teacher for this practical instruction, but the doctor can lead discussions on ante-natal care and the value of breast-feeding, and j o i n in answering the many questions which come forth at any ante-natal group. At the end of each series of ante-natal classes an evening meeting when husbands are invited too has proved beneficial. The showing of a filmstrip on normal labour promotes keen discussion, and the presence of the doctor is invaluable. Such a meeting has led to the formation of parents' groups, a t which talks and discussions on aspects of child care and family life have been chosen by the parents themselves and in which they display active interest. In the child welfare centre there has been much controversy about the use of attempting health education other than by personal interview. Agreed
232
PUBLIC H E A L T H
VOL. LXXI
NO. 6
that it is not easy to give group talks against the noise of crying babies and active toddlers, nor can the mothers give undivided attention to the speaker, but there are a few ideas that have proved practicable. The subject must be topical and of immediate interest. A small exhibit or even a poster can be set up, perhaps on measles during an epidemic, food storage in hot weather or accident prevention before Christmas. M a n y health visitors keep a small table in their centre on which a new exhibit is placed each w e e k , may be it is fitting shoes for the toddler, suitable toys or a sample meal. At intervals during the session a few mothers can be gathered round for a brief discussion. Sometimes one of the voluntary helpers has special knowledge and will be glad to help with this form of teaching, or someone from outside may be invited to demonstrate. Suggestions can be obtained from the mothers about subjects of interest to them and they may contribute materials or pictures for the exhibits. Those centres which are fortunate in having a separate r o o m can have a filmstrip shown, and with a daylight screen this can be done even in the corner of a hall. A short film can be used to support a campaign for smallpox vaccination or to illustrate a subject previously demonstrated, such as foot health, accident prevention or clean food handling. Voluntary helpers are often willing to care for the children during part of a session and a box of occupational toys is an enormous help in obtaining a peaceful interlude during a group talk or film. The doctor can share in many of these group activities by sparing a short interval for them from personal interviews with mothers, or by discussing a common problem with a small group of mothers who a r e faced with the same difficulties such as weaning or babies who won't go to sleep or who are having temper tantrums. This form of group therapy has great possibilities and leadership by the doctor will draw out observations from mothers which may be of help to each other and to the doctor who is advising. To make room for a health education programme in a child welfare session some rearrangement of the normal routine is necessary. Less emphasis need be attached to weighing after the first months, and a voluntary helper can be trained to do it, thus leaving the health visitor free to move around and talk to individual mothers or to small groups on some point of common interest. An appointment system for mothers to see the doctor will ensure regular check-ups, especially for older children, and gaps can be left to see new babies and for emergencies. A separate toddlers' session is valuable to ensure continued attendance of older children and group discussions will sustain the mother's interest. Voluntary helpers can be drawn into the team by asking them to supervise a small library of books on child care for the mothers, to look after the toddlers' play corner and to help with exhibits. Toddlers' play can in itself be a scene for observation and discussion.
M A T E R N A L A N D CHILD W E L F A R E CENTRE
233
One method of creating interest among staff and mothers is to hold a quiz, with questions supplied and answered by the mothers on some subject covered previously by talks and discussion. This can be held in the evening when other people and members of the family not needed for baby-sitting can be invited as audience. This has led in some areas to the formation o f mothers' clubs attached to the child welfare centre, but meeting regularly in the evenings with some sessions when fathers are also invited. Once interest in health education is kindled an amazing amount of enthusiasm appears. Mothers' clubs have real value provided the wish to form them comes from the mothers themselves and they are encouraged to choose their own subjects. They should form their own Committee and elect officers, but will require background help from the health visitor and doctor. The main function of such a club is health education, social activities must come second, but a glance at the annual report of one club reveals the broad interests which develop among its members. Speakers, apart from the centre staff, include the schoolmaster, general practitioner, a probation officer and child care visitor and the local butcher who demonstrated the best cuts of meat. That the mothers want information beyond the field of child care is evident from requests received for talks on adolescence, the menopause, marriage guidance and care of the elderly. A mothers' club is an adjunct to the M. & C.W. centre valuable not only as a source of health education but to foster a friendly spirit between staff and mothers and to increase interest in the community. The sharing of interests and learning from one another is beneficial to the whole group. As medical officers in the M. & C.W. service we must face up to our responsibilities as health educators, whether it be to the individual mother or to the group. It is for each one of us to decide how best we can make use of our knowledge and what more we can give to our colleagues, the parents and the community in our area. Opportunities for health education are not far to seek in our sphere of the ante-natal clinic, the child welfare centre and other services for parents and their families. Perhaps we need to get away from a cramping routine and look at our work from a new angle. We may be diffident and need encouragement and practice to gain skill in teaching, but it is up to us to evaluate our own work and prove that it is not true that the day of the medical officer in the M. & C.W. service is drawing to a close and that our work can be done equally well or better by the general practitioner or the paediatrician. Participation in a health education programme can put new life into an M. & C.W. centre by stimulating interest and the desire to share knowledge and experiences. The m e d i c a l officer, by assuming leadership, will find satisfaction in associating with members of the team and in a widened sphere of activities among the mothers and their families.
M. D A V I S ,
M.D., O.P.H.
Senior Medical Officer, Maternity and Child Welfare, Buckinghamshire A RECENT editorial in the Health Education Journal deplores the fact that although doctors are teachers and that in their work, whether clinical medicine or public health, they are health educators, doctors are not taught how to teach. At a conference this summer W.H.O. has studied the introduction of health education into training of doctors and nurses, and of those taking higher qualifications such as the D.P.H. Hitherto it has been left to individual medical officers to learn the technique of teaching through experience and by attending post-graduate courses. Many of us have been content through the years to confine our teaching methods to the personal interview with mothers in the ante-natal clinic, welfare centre or school. Are we sure that our methods are right ? Do we tell the mother what she wants to know, or what we think she ought to know, and are we sure that she always understands what we tell her ? For many years child welfare centres have worked to a set pattern, originally called for by prevalence of poverty, poor hygiene and ignorance among the mothers who came for help. Now that standards of health and living have improved, mothers are taking an intelligent interest in the upbringing of children and in the mental health of their families. If the child welfare centre is to retain its useful place in the community it must meet the needs of the modern mother. It is time that we took a new and serious interest in teaching because we have a unique opportunity in our personal contacts with mothers to help them to lay firm foundations for family life. Health education calls for team work and the doctor should be the leader. In the past there have been welfare centres where in no sense was there a team at work, but only isolated centres of activity ; the health visitor glued to the scales, voluntary helpers at the register and the " f o o d table," and the doctor known only as a shadowy figure hurrying to and from the inner sanctum where mothers were interviewed. Health visitors in the main are alive to the opportunity ; they are knowledgeable about visual aids and the value of group discussion ; they are in fact fast becoming a body of expert teachers. It is up to medical officers to join them, for here in the M. & C.W. centre are the components of the health education team 9 the mother and her young children, the doctor, midwife and health visitor, the voluntary helper and perhaps the clinic assistant. In the background, often waiting in vain to be included, is the father. Other members of the family are there too, and a host of other health and welfare workers who might be willing participants if only invited and made welcome. 229
230
PUBLIC H E A L T H
VOL. LXXI
NO. 6
To be successful, health education needs a planned programmr suitable materials to support the spoken word and the creation of interest in the participants. Sometimes it is difficult to distinguish between teachers and learners, and one of the joys of group discussion is the amount one can learn from parents who can tell each other, and us, what they have discovered from practical experience. It is salutary to find that some theory one has passed on dogmatically for years doesn't really make sense in practice. A planned programme needs background help and every health department should have a health education section, with one or more organisers who can assist by providing materials, ideas and notes for talks, and suggestions for outside speakers. For the M. & C.W. service it is an advantage if the health education organiser is a health visitor, for she has an intimate knowledge and experience of the subject matter and appreciation of the needs of parents and, which is important, of her busy colleagues in the field. She should have a health teaching qualification and, in view of her added responsibility, have senior rank on salary scale. The health education organiser would be responsible for planning a programme for the whole area, in consultation with other senior staff, according to local needs. This can include a syllabus for antenatal classes, subjects for group discussions, organisation of inter-welfare centre quizzes, exhibitions of handicrafts and materials to illustrate subjects discussed in study groups at welfare centres and mothers' clubs. The health education organiser should be available for consultation to all health visitors and doctors in the area, and to other interested people, for advice regarding subject matter, organisation of meetings and for provision of teaching material. She will also visit welfare centres and give sample talks, or lead discussicm groups until the local staff have overcome their diffidence and are ready to branch out on their own. It is essential to build up a good stock of teaching material, both centrally and in areas, which can be borrowed as required. Materials available should be catalogued and up-to-date lists distributed to all field staff. Filmstrip projectors and screens are primary needs, and when funds permit an epidiascope and film projector can be added. Mothercraft demonstration material and small portable exhibits on various subjects can be loaned out and the staff of the health education section will be responsible for the library of books and pamphlets, filmstrips, flannelgraphs and other teaching material. It is a great advantage if one member has some artistic ability to help in producing posters and other exhibits, but keen health visitors soon learn to devise their own~ and so should the medical officer t To be effective the programme must aim first at creating interest in group teaching among the health visitors and doctors, and then reorganisation of the welfare centre to provide facilities for this. A staff conference could be the first move, at which the health education organiser can explain her ideas
M A T E R N A L A N D CHILD W E L F A R E CENTRE
231
and all can contribute theirs to the discussion. After this a s h o r t course can be arranged for inservice training in the technique of teaching and group discussion methods, and the preparation and use of visual aids. For this our friends at the Central Council for Health Education are invaluable, and the first lesson they would teach us is that we must give our audience what they want and let them participate. In the M. & C.W. centre we are fortunate in having interest already created for us in our audience, that of the mother in her own baby and family, but we must be sure that we make the best use of the opportunities presented. It is rare for a mother to lack interest in her baby, though at first it may not be obvious on the surface, but it is her own baby and family, and what affects them that is the centre of her interest not just theoretical ideas about children in general. This is the basis of the personal interview which must continue to be the main function of the welfare centre, but the modern mother readily accepts the wider value of group teaching. She is used to group techniques on r a d i o and television; the brains trust, quiz and " any questions" are familiar to her and she is willing to contribute to a group discussion once the ice is broken. A mother is most receptive to knowledge during pregnancy and this is the most rewarding time for health education. Especially when it is her first baby is she eager to hear about herself and the coming baby ; she needs someone to allay her fears and anxieties, and she looks for reassurance on her ability as a wife and mother at this time when her mental health may be in the balance. To-day when it seems probable that clinical ante-natal care will pass gradually from the local authority to the general practitioner and hospital, the medical officer should take an active part in classes for preparation for childbirth and mothercraft, and not leave this field entirely in the able hands of the midwife and health visitor. Although ante-natal exercises have passed from favour, there are no doubts about the value to the woman in labour o f having learnt how to relax and breathe correctly, and in knowing what to expect during the different stages of her confinement. It is proper that her midwife should be the teacher for this practical instruction, but the doctor can lead discussions on ante-natal care and the value of breast-feeding, and j o i n in answering the many questions which come forth at any ante-natal group. At the end of each series of ante-natal classes an evening meeting when husbands are invited too has proved beneficial. The showing of a filmstrip on normal labour promotes keen discussion, and the presence of the doctor is invaluable. Such a meeting has led to the formation of parents' groups, a t which talks and discussions on aspects of child care and family life have been chosen by the parents themselves and in which they display active interest. In the child welfare centre there has been much controversy about the use of attempting health education other than by personal interview. Agreed
232
PUBLIC H E A L T H
VOL. LXXI
NO. 6
that it is not easy to give group talks against the noise of crying babies and active toddlers, nor can the mothers give undivided attention to the speaker, but there are a few ideas that have proved practicable. The subject must be topical and of immediate interest. A small exhibit or even a poster can be set up, perhaps on measles during an epidemic, food storage in hot weather or accident prevention before Christmas. M a n y health visitors keep a small table in their centre on which a new exhibit is placed each w e e k , may be it is fitting shoes for the toddler, suitable toys or a sample meal. At intervals during the session a few mothers can be gathered round for a brief discussion. Sometimes one of the voluntary helpers has special knowledge and will be glad to help with this form of teaching, or someone from outside may be invited to demonstrate. Suggestions can be obtained from the mothers about subjects of interest to them and they may contribute materials or pictures for the exhibits. Those centres which are fortunate in having a separate r o o m can have a filmstrip shown, and with a daylight screen this can be done even in the corner of a hall. A short film can be used to support a campaign for smallpox vaccination or to illustrate a subject previously demonstrated, such as foot health, accident prevention or clean food handling. Voluntary helpers are often willing to care for the children during part of a session and a box of occupational toys is an enormous help in obtaining a peaceful interlude during a group talk or film. The doctor can share in many of these group activities by sparing a short interval for them from personal interviews with mothers, or by discussing a common problem with a small group of mothers who a r e faced with the same difficulties such as weaning or babies who won't go to sleep or who are having temper tantrums. This form of group therapy has great possibilities and leadership by the doctor will draw out observations from mothers which may be of help to each other and to the doctor who is advising. To make room for a health education programme in a child welfare session some rearrangement of the normal routine is necessary. Less emphasis need be attached to weighing after the first months, and a voluntary helper can be trained to do it, thus leaving the health visitor free to move around and talk to individual mothers or to small groups on some point of common interest. An appointment system for mothers to see the doctor will ensure regular check-ups, especially for older children, and gaps can be left to see new babies and for emergencies. A separate toddlers' session is valuable to ensure continued attendance of older children and group discussions will sustain the mother's interest. Voluntary helpers can be drawn into the team by asking them to supervise a small library of books on child care for the mothers, to look after the toddlers' play corner and to help with exhibits. Toddlers' play can in itself be a scene for observation and discussion.
M A T E R N A L A N D CHILD W E L F A R E CENTRE
233
One method of creating interest among staff and mothers is to hold a quiz, with questions supplied and answered by the mothers on some subject covered previously by talks and discussion. This can be held in the evening when other people and members of the family not needed for baby-sitting can be invited as audience. This has led in some areas to the formation o f mothers' clubs attached to the child welfare centre, but meeting regularly in the evenings with some sessions when fathers are also invited. Once interest in health education is kindled an amazing amount of enthusiasm appears. Mothers' clubs have real value provided the wish to form them comes from the mothers themselves and they are encouraged to choose their own subjects. They should form their own Committee and elect officers, but will require background help from the health visitor and doctor. The main function of such a club is health education, social activities must come second, but a glance at the annual report of one club reveals the broad interests which develop among its members. Speakers, apart from the centre staff, include the schoolmaster, general practitioner, a probation officer and child care visitor and the local butcher who demonstrated the best cuts of meat. That the mothers want information beyond the field of child care is evident from requests received for talks on adolescence, the menopause, marriage guidance and care of the elderly. A mothers' club is an adjunct to the M. & C.W. centre valuable not only as a source of health education but to foster a friendly spirit between staff and mothers and to increase interest in the community. The sharing of interests and learning from one another is beneficial to the whole group. As medical officers in the M. & C.W. service we must face up to our responsibilities as health educators, whether it be to the individual mother or to the group. It is for each one of us to decide how best we can make use of our knowledge and what more we can give to our colleagues, the parents and the community in our area. Opportunities for health education are not far to seek in our sphere of the ante-natal clinic, the child welfare centre and other services for parents and their families. Perhaps we need to get away from a cramping routine and look at our work from a new angle. We may be diffident and need encouragement and practice to gain skill in teaching, but it is up to us to evaluate our own work and prove that it is not true that the day of the medical officer in the M. & C.W. service is drawing to a close and that our work can be done equally well or better by the general practitioner or the paediatrician. Participation in a health education programme can put new life into an M. & C.W. centre by stimulating interest and the desire to share knowledge and experiences. The m e d i c a l officer, by assuming leadership, will find satisfaction in associating with members of the team and in a widened sphere of activities among the mothers and their families.