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Primary health care in Southeast Asia: Attitudes about community participation in community health programmes
0277-9536/X3 $3.00 + 0 00 PerXamon Press Ltd
.%c. %I. Med. Vol. 17. No. 19, pp. 14X9-1496. 1983 Pnnted in Great Bntain
PRIMARY HEALTH CARE IN SOUTHEAST ASIA: ATTITUDES ABOUT COMMUNITY PARTICIPATION COMMUNITY HEALTH PROGRAMMES
IN
SUSAN B. RIFKIN Center
for Asian
Studies,
University
of Hong
Kong,
Pokfulam
Road,
Hong Kong
Abstract Although community participation in health has become a major plank in WHO’s Primary Health Care platform, comparatively little concrete programme data has been collected which helps to define its potenttals and problems. In an effort to expand knowledge in this area, a study of three Church-related community health programmes in Southeast Asia was undertaken. All three programmes have the stated goal of ‘having the community take responsibility for its own health care’ and as a concrete step in this direction. have developed training programmes for community health workers (CHWs). Starting about the same time, 1973-1975. they provide data for comparative examination of the development of communtty participation. As part of the study. a questionnaire was designed to elicit information from three categories of programmc participants (the medical professionals, the community development workers and the CHWs) in community health programtnes. It sought to discover their attitudes about the objectives of community health programmes: impact and measurements of success of these programmes: the role of health services: the role of medical professionals and community development workers in community health progrwnmes: the role and training of community health workers: and financing community health programmes. The hypothesis of the investigation was that all three categories of programme participants in one programme share attitudes distinct from participants in the other two programmes. Although, due to technical reasons. it was not possible to test this hypotheses, the survey produced other conclustons. One was that the categories of professional people (the medical and community development workers) in all three programmes share attitudes which are distinct from the CHWs in all three programme\. Secondly, participants in the same programme most often exhibit the same attitudes when a programme has initiated an activity which enables the CHW to gain experience in health work.
INTRODUCTION
The author had undertaken a study to establish some of the potentials and problems of community participation in health care. Based on case studies of three Christian Church related programmes in Southeast Asia in Hong Kong, Indonesia and the Philippines, this study attempts to analyse how and why community people get involved in community health programmes [I]. One part of the study seeks to evaluate the attitudes of the three major groups involved in community health programmes toward community participation. This paper is a report of the findings of a survey which sought to elicit these views from medical professionals including nurses: community workers who are also professionals by virtue of their training and paid positions; and community health workers (CHWs) who are laymen engaged in health activities in each of the programmes.
BACKGROl’\D
The three programmes are the following: the Kwun Tong Community Health Project of the United Christian Hospitals in Hong Kong. an urban hospital based programme that began its activities through community health set-vice centres for a population of 600,000 people; the Community Welfare Development Programme, Banjarnegra Regency, PurworejoKlampok District, Central Java. Indonesia, a rural community based programme along some of the lines
of the community development movement of the 1960s; the community health programme of the Rural Missionaries of the Philippines, established to help initiate community based health programmes in all parts of the rural Philippines by building awareness of the causes and cures of ill health and poverty based on the teaching methodology of Paolo Friere and his disciples. These three programmes were chosen firstly because of the author’s familiarity with them [2]. Secondly they were chosen because they presented a diversity of situations which made possible the comparison of a new health concept. They provided comparisons between urban/rural settings, hospital:’ community based programmes. heavy/light outside funding and health services/education oriented approaches. Finally, they were chosen because despite size, area and cultural and political difference, they had sufficient similarities to make a comparison possible. The similarities which the programmes had were some of the following: they all shared the major stated goal of ‘having the community take responsibility for its own health care’. They were all Church-related which meant that firstly, as members of voluntary organisations, they had more flexibility than government to try new experiments. Secondly, they had access to the world-wide funding network available through the Christian Church. Thirdly, they had a group of highly committed, highly motivated plant&g staff who carried out the work with enthusiasm and dedication. They all worked to develop a model of community participation in health care which could be
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SUSAN B. RIFKIN
used on a countrywide scale. They all had a framework which was created through the initial inspiration of medical professionals who worked with community development workers to actively engage the community people in both planning and implementation of programmes. A BRIEF
DESCRIPTION
OF
THE
PROCRAMMES
The following paragraphs describe the programme from its inception to the time of the survey. For Hong Kong the survey date was September 1979; for Indonesia, May 1979; for the Philippines, January 1980. The Kwun Tong Community Heulth Prqject (KTCHP) oj’the United Christian Medical Service, Hong Kong [3] The KTCHP became operational in March 1972 with the opening of the first community health centre in the housing estate of Sau Mau Ping. Its programme activities were geared to cover the health care of 600,000 people in the urban Hong Kong district of Kwun Tong. The staff number grew to about 70 people in 1979. It was a hospital-based programme designed to take pressure loads off hospital beds and staff by creating curative, preventive and promotive health care in the community through the establishment of community health centres and through the development of community participation in the health activities. Essentially service-oriented, the programme established four health maintenance schemes (infant, adult, geriatric and industrial) whereby community members could participate by paying a relatively small fee to receive preventive services, limited curative care and health education. In addition to staff trained to provide medical services, the programme also employed health educators and community development workers whose main task was to educate the community about health problems by running large health education campaigns and enlisting community volunteers to help with these activities. Policy was made by a management committee consisting of the United Christian Hospital’s medical director, nursing director and administrator, the Project administrator and several members of the larger Hong Kong community who ran schools or social service centres in Kwun Tong and/or had a special interest and expertise in the field of community health. The role of the medical professional in the programme was mainly to take responsibility for running the three community health clinics and to treat outpatient cases. The role of the community worker never was clearly delineated [4]. It was an amalgamation of health education, community mobilization and public relations/liaison work. The role of the community health workers (called Health Advocates) focused mainly on health education activities with service extender roles only in the area of first aid [5]. CHW contact with the clinic was mainly through the community workers or clinic staff who taught the CHW’s. CHW’s were volunteers. Training focused on developing some knowledge about disease problems and teaching CHW’s ways of developing the potential of health education and community mobilization to improve bad community health conditions such as poor refuse disposal, and air and noise pollution.
The Hong Kong programme was funded mainly through fees for service at the clinics and the government school medical services scheme which paid small amounts for each child to be examined by a doctor. The non-income generating parts of the programme. particularly staff (health educators and community workers) for establishing the health maintenance schemes, received support from the German Protestant General Agency (EZE) for approx. USS500,OOO for a 3 year period. The grant was given with the view of both the donor and recipient that the entire programme could be self-supporting after that period as it was believed that the community would support the project. As a condition of this grant, an outside evaluation was required. The evaluation was done by a two-person team in 1979 and was instrumental to the planners in viewing past mistakes and creating future programme direction [6]. The Community Welfare Development Programme (Klampok) Banjarnegra Regency, Purworejo-Klampok District, Central Java, Indonesia [7] The Klampok programme began in 1973 in a rural area using principles of community development which regard health as only one component of village improvement and the experience of Dr Gunawan Nugroho in the internationally acclaimed Solo programme [8]. Its initial coverage was for the village of Klampok which contained about 5000 people. Unique in the way which it had close integration with and support of the Regency government, it was later extended to serve the entire Purworejo-Klampok subdistrict which had about 32,000 people. Later still, the model was extended to cover the entire Regency. Its staff was about 20 people. The programme was community based emphasizing health as only one aspect of village improvement which also included agriculture, communications, nutrition and education. The health component was service oriented providing both for service extension by the use of CHW’s and health insurance scheme, duna sehef, which provided participants with funds to cover both doctor interviews and medicines. (It did not cover hospital expenses.) Originally the programme was developed by the medical staff in consultation with community workers. However, the programme director, a doctor, dissatisfied with this approach, began to seek ways of gaining greater community participation in the programme. The result was efforts to establish community responsibility for both activities and funds. CHW’s became responsible to a village committee. A health insurance scheme was established by which the village committee collected and administered the surplus funds which were used for building community income generating activities. The role, of the medical professional changed from that of prime planner to that of resource person. The medical people continued to treat patients at the clinic and act as consultants to the community health programme when asked to do so. They also played a role of community development worker. The community development workers advised the medical professional how to develop the programme and train CHW’s. The role of the CHW’s was both that of service-extender and change agent. Volunteers selected by the community committee did first aid work, simple prevention, sanitation and
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Primary health care in Southeast Asia general simple community development work. Their training emphasized both health and disease care as well as organization and communication skills they needed in their community development tasks. Finance for the Klampok programme began with US$25,000 for a rural clinic and provision for a stimulation fund by government of about USS500 per village as well as the same amount for a training fund. The government through a specialized committee also allocated funds as well as provided some health services. Community support for the programme came through the health insurance schemes and CHW work. The Community Health Pro,gramnze sf Missionaries (RM) qf the Philippines [9]
the
Rural
The Rural Missionaries (RM) Programme was founded in 1975 as a programme activity of the Association of Major Religious Superiors Rural Missionary Programme. Devoting themselves to the needs of the poor people, the majority of whom lived in rural and Catholic countryside, a team of 4 women, both medical professionals and community workers, established a programme to teach interested diocese (Catholic Church administrative units) how to create community health programmes. The cornerstone of the programme was CHW training Community based and education oriented, three pilot programmes were set up in the Luzon, the Visayans and Mindanao. Upon these experiences and previous knowledge, a manual was written and seminars were held by which a methodology for programmes was developed. This methodology stressed building awareness of the relationship of health with existing socio-economic conditions through the dialectical teachings popularized by the Catholic educator. Paolo Friere [lo]. The objective was to motivate poor, rural communities to begin to take responsibility for their own health and welfare. The RM financial support for the pilot programmes ended after an initial 3 years. To examine in some detail the development of these community based health programmes, it was decided to investigate one of the pilot areas. The Makapawa (the name means community health programme in Waray. the local language, and literally translated means ‘to give light, enlighten’) of the Diocese of Palo in Leyte, the Visayans was chosen. The population of this island diocese is about 900,000, 78% rural. The staff of the programme varied between 3 and IO. The programme was community based but in the latest period of this study operated from the office of the programme director, a Catholic nun and doctor, in St Paul’s Hospital in Tacloban. The programme staff planned programme functions and activities. The doctor played the role of both clinician and community worker. The community development worker’s main task was to organize community people into units which would choose and support a CHW. The CHW’s were responsible for unit health activities as well as community motivation work. The CHW’s also extended preventive and simple curative services to the unit. Their training focused on learning preventive care and simple medical treatments which included the use of herbs, and on community organization which included conducting Bible studies and building community committees to become responsible for community activities.
Although one of the major objectives of the entire Philippines programme was to mobilize community resources to become financially self-reliant, the programme initially received funding from the Catholic Central Development Agency, Misereor in Germany. From the period 197551978 a total of about US$25,000 was allocated to the RM of which about US$SOOO was given to the Makapawa programme. At the end of the initial grant the RM team asked for each pilot programme to apply separately if it wished the funding to continue, as the RM felt its role as co-ordinator had ended. The Makapawa did so and received money to continue its work. HYPOTHESIS It was hypothesized that because of similar experiences and circumstances based on common views and values, that those in the same programme would share many of the same attitudes and that these attitudes would be distinct from attitudes exhibited by those in the other two programmes.
THE SURVEY
Design
qf questionnaire
To test the hypothesis a questionnaire was used (see Appendix I). It was divided into three parts. The first part was constructed to obtain data about the personal profile of each respondent. This data included age, sex, programme task and length of time engaged in this task in the programme. Section II sought to obtain a general picture about attitudes toward community health programmes. These included three broad questions. The first asked how health of a poor community could be improved. The second asked how the impact of community health programmes could be measured. The third asked about criteria for success of community health programmes. In order to enable the respondent to have a range of choices answers were formulated in the rank in order pattern. The last choice was entitled ‘other’ which allowed the respondent to write down any opinion which was not already articulated. Part III of the questionnaire consisted of 20 statements for which respondents were asked to mark their degree of agreement or disagreement-l was strongly agree, 6 strongly disagree. Their purpose was to gain respondents’ views about community participation vis-h-vis medical services, the role of the medical professional, the role of the community development workers, the role and training of the CHW, and financial support for community health programmes. By using the scale design, it was possible to standardize responses to a degree which negated as much as possible the problems of using four languages. Choice
qf respondents
Respondents consisted of the three groups of programme participants. For the purposes of this survey, the CHW’s were taken as those community members most active in the programme not as representatives of community views. Respondents were chosen randomly with the following qualifications. In the KTCHP programme all 4 clinic doctors and a random selection of community nurses filled out
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questionnaires. All 4 community development workers in the programme participated. Concerning the CHW’s, the choice was random. However, since their training in June 1977, they had not been utilized continually in the programme. They, therefore, had done little in the programme when they were interviewed in Autumn 1979 [I I]. In the Klampok programme, community development workers were no longer actively employed. Those who were interviewed belonged to the training group who developed the programme methodology on which Klampok was founded. All 4 programme doctors were interviewed and a random selection of CHW’s were asked to fill out questionnaires. The RM programme is a special case. Since it is a teaching programme which began its work with three pilot programmes, there were some questions about to whom to give the questionnaire. In the end. medical professionals were chosen from those who were working with the programme in various parts of the Philippines. However. it was decided to chose one of the pilot programmes, that in Leytc, to ask community development workers and CHW’s to participate in the survey. This programmc. the Makapawa discussed above, provided the majority of Philippine rcspondents. A total of II3 people answered the questionnaire. Of these 25 or 22.1”,, were from the KTCHP; 27 or 23.99,, were from Klampok: 61 or 54.0”,, were from the RM programme. In the random sample of respondents, the oldest was 61 years and the youngest was 17 years. Fifty percent were between ages I7 32 years. Thirty-eight or 33”,, were male and 73 or 66”,, were female. Although it is a random sample, these figures appear to be indicative of the proportion of males to females in each programme. Eighteen medical professionals or 15.9”,, of the total respondents answered the questionnaire. Nine were from KTCHP: 4 from Klampok, and 5 from the RM programme. There were I5 community development workers or I3.30/<, of respondents+ 4 from KTCHP; 5 from Klampok and 6 from the RM programme. There were 80 CHW’s or 70.8”;, of all respondents which included I2 from the KTCHP: I8 from Klampok and 50 from the RM programme. The KTCHP had fewer CHW’s than staff involved in the programme. In Klampok and the RM programme, the number of CHW’s great11 exceeds the staff. Also the CHW’s in the KTCHP had not been fully active in over I j years. Of those involved in all programmes 38 or 33.6”,, had been involved in the work for less than I year; I5 or 13.3”,, had been involved l-2 years: 23 or 20.4”,, had been working 2-3 years and 23 or 20.4”,, had been working 3-4 years. A number of respondents, however. answered the question in terms of total years involved in their profession. This fact accounts for the missing percentage. Two-thirds of those ansucring the questionnaire correctly had been involved for more than I year.
In carrying out the survey. it became apparent that the questionnaire had several limitations. The first mentioned above. was that the original had to be translated into three other languages (Chinese. Indonesian and Waray. the dialect of the Philippines
CHW’s). A process was established by which the questionnaire was translated into the appropriate Innguage then re-translated back into English. Despite this precaution, in the Indonesian translation. at least two questions were asked which did not state exactly the intention of the original statement. The language problem was complicated by the fact some of the English terminology did not always convey the precise meaning of the idea when it was translated. For instance. it was not clear as to whether the term ‘volunteer‘ meant a person who willingly agreed to become a CHW or took no payment for the work. One had to make sure that an exact equivalent was found for the translation. Another limitation was that imposed by the design of the questions. One problem was that in Indonesia the question concerning the number of years a respondent had been involved in the programmc was interpreted by many to mean the number of years that the respondent had been involved in his/her occupation or profession. Another problem in all case studies was that some of the questions gave respondents only a limited choice in which to express their views. A third problem was that some questions made assumptions about alternatives which were not articulated. thus possibly confusing the respondent. To solve these problems. an open ended intervieu may have been a better instrument by which to ascertain opinions. However. when an experiment was tried. it w’as found that not only was there an enormous amount of time involved but also there was a great deal of difficulty in overcomin! the barrier of language. A third major limitation of the surve) appeared in interpreting the data. As each programme had only a small number of medical professionals and communit! developmen! workers, the numbers in these tWo catcgories of respondents in each separate programme werenot statistically significant. This meant that unless c//l respondents answered the question, it was not possible to make a general observation about their attitudes. While the aggregate numbers did not present this problem. the lack of numbers in each programme made it impossible to test the hypothesis. It was onI) possible to suggest some trends among the three categories of participants.
Because of misinterpretations of the questions by many Indonesian participants, it was not possible to analyse Part II of the survey. The data in Table I is from Part III. Where the data can be considered statistically significant, the following statements can be made. In seven statements (I, 2. 6, IO. I I, 14, 16) the percentage of CHW’s that strongly or most agreed with the statement was at least twice that of the professionals. Statement I suggests that the major concern of a community health programme is medical services. Statement 2 says that the health committee should be appointed by the medical staff. Statement 6 says that CHW‘s should be primarily responsible to the medical staft: Statement 10 says that community participation means the community carries out activities decided upon by the medical staff. Statement I I says the medical staiT should handle all finances for community health activities. Statement I4 suggests community surveys should be carried out b)
Primary health care in Southeast Asia the professionals. Statement 16 says that community development activities prevents medical staff from doing their work properly. Concerning a concensus of opinion among people in the same programme, the following statements can be made. In Klampok, all respondents strongly or mostly agree with two statements 12, 19). In one statement (18) all the professionals and 94.5% of the CHW’s strongly or mostly agreed with the statement. Statement 12 suggests CHW training should include communication and organization skills. Statement 19 says mothers should help run well baby clinics. Statement I8 says a good community health programme must have community health workers. In Klampok, the conditions described in the statements were in existence. In the KTCHP, all the professionals and 91.6% of the CHW’s strongly or mostly agreed with statement number I2 described above. In the RM programme again all the professionals and 80.9’A of the CHW’s strongly or mostly agreed with this same statement. Also in these two programmes, CHW training included these skills. Concerning the degree of agreement among professionals in the same programme, in Klampok the professionals strongly or mostly agreed with four statements (3, 12, 18, 19). Statement 3 says that a social preparation of community and health staff is necessary before the programme begins. The other statements have already been described. In KTCHP, the professionals all strongly or mostly agreed with only one statement (12). In the RM programme, the professionals strongly and mostly agreed with two statements (9, 12). Statement 9 says that the community should be consulted about what the CHW’s should be taught. Again, the conditions described existed in all programmes as we have seen. The tables which record that data for the individual programmes are not included because the majority of the questions were invalid due to lack of statistical significance.
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SUMMARY
OF FINDINGS
(a) The hypothesis of the study cannot be tested due to the limitations described above. The data however indicates some trends in attitudes among programme participants about community participation. (b) There is a difference between the expectations of the planners (the medical professionals and the community development workers) and the CHW’s in regard to views about community participation in community health programmes. These differences particularly emerge concerning the issues of approaches to community participation and the role of the professional. Planners, true to their ideal view of the community development approach, wish to encourage a greater responsibility for health programmes by community people providing medical services. CHW’s on the other hand, with traditional expectations of health programmes, wish to have professionals make the decisions. We have suggested some reason why these attitudes exist in the conclusions of the larger study [ 121. (c) Areas where planners and CHW’s share similar views about community participation and community health are areas in which planners and CHW’s both have been involved in this activity. Experience apparently convinces both professionals and laymen that laymen have the capacity to perform certain tasks which they heretofore identified only with professionals. In Klampok where CHW’s had learned organization and communication skills. had been brought into the process of identifying needs and had done baby weighing, at least 95”,, of all respondents agreed these activities were an important part of community health programmes. This agreement was found in the other two case studies only in the area of CHW’s learning communication and organizational skills. In the KTCHP CHW’s did neither baby weighing nor needs identification. In the RM programme. only some of the CHW’s had done baby weighing and obstacles had not been overcome concerning com-
Table 1. Percentage of respondents in all countries who strongly/ mostly agreed with the statements according to work in programmes Question No. 2 4 6 8 9 10 II 12 13 14 15 16 17 18 19 20
Medical professionals (N = 18) 44.4 5.6 88.2 22.2 44.4 16.7 27.8 55.5 70.6 16.7 5.6 100.0 88.2 11.8 41.2 0 5.9 80.3 82.3 64.7
Community workers (N = 15) 33.3 6.1 80.0 0
46.6 20.0 40.0 53.3 93.3 13.3 0 100.0 80.0 6.7 13.4 6.7 13.3 80.0 86.6 66.6
Community health workers (N = 80) 84.4 45.0 65.0 12.8 28.7 68.2 17.7 45.0 46.8 59.8 15.6 87.0 69.6 48.7 51.3 19.5 20.5 84.6 78.2 83.6
SUSAN B. RIFKIN
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munity involvement in needs assessment. Additionally, we can note that all planners in Klampok agreed social preparation of a community was necessary. They had all been involved in developing this exercise. In the RM programme, planners all believed the community should be consulted about what the CHW’s should be taught. However, this plan had not yet been implemented very well. (d) In programme plans and activities where planners worked together to develop their ideas, there was a higher degree of agreement about views of community health than in programmes where they did not. As expected, the Klampok programme shows the greatest number of statements with which all planners are in agreement and the KTCHP shows the lowest. However, it is worth noting that even in Klampok, only in l/5 of the questions did this high degree of agreement take place.
CONCLUSION
Community participation has become a key element in Primary Health Care. Its advocates suggest that if health patterns are to change dramatically among the poor and underprivileged, health problems must be seen in a larger socio-economic context and the community must be given responsibility in helping to solve these problems. They tend to assume that if health professionals and community planners can be convinced of the value of these arguments, the community will automatically accept these new, non-traditional ideas. This research, although limited by factors discussed above, suggest that this, in fact, is not the case. Community people who are involved in community health activities tend to see the programmes as extension of medical services and tend to want responsibility to remain in the hands of the medical professional. These findings raise a number of questions which suggest areas for further research. Among them are: (1) what does the community want from a community health programme? (2) how do professionals communicate their objectives to community people? (3) is the field of health care, due to its domination by professionals and its world-wide education network, a field in which community participation is particularly difficult to obtain? (4) are there certain types of activities, methodologies and/or teaching and communication skills which help community people to overcome their reluctance to enter as a full partner in community health? These questions and others are very difficult to answer. It is necessary, however, to begin to examine
them if we are to understand the problems and potentials of community participation in health. REFERENCES
1. This survey is one part of my PhD thesis entitled “Planners’ approaches to community participation in community health programmes: case studies in southeast Asia” submitted to the University of Hong Kong for the degree of Doctor of Philosophy in Social Sciences, July, 1982. I wish to gratefully acknowledge John Anderson, Department of Community Medicine. University of Hong Kong for his assistance with this survey and statistical interpretation. Rifkin S. B. (Ed.) Community Health in Asiu: A Rcporr of Two Workshops, Christian Conference of Asia, Singapore, 1977. Also, the author was a member of the Management Committee of the Kwun Tong Community Health Project in Hong Kong. Paterson E. H. Kwun Tong Community Health Project. Contact 15, June, 1973: Paterson E. H. and Tang R. The Kwun Tong Community Health Project 19722 1976--Progress Report. Conrucr 35, February, 1977; Tang R. C. P. Community efforts in the delivery of health services in Hong Kong. In The Chcmging Rakes and Education of Health Cow Personnel Worldwide in View qf the Increaw of Basic Srrvices (Edited by McNeur R.). Society for Health and Human Values. Pennsylvania, 1978. . 4. Kwun Tong Community Health Project, Management committee notes. I5 June, 1976, unpublished. development in a 5. Lee K. The role of community community health programme. Development Rrsourw Book 1977-1978. Hong Kong Council of Social Service. Hong Kong, 1978. Health Project. Evaluation. 6. Kwun Tong Community Submitted by Dr Stuart Kingma and Dr Emanual de Kadt, May, 1979, unpublished. I. Hendrata L. Community health in rural Java. Con/m/ 31, February, 1976; Johnston M. Development of a community health programme. In Health t/w Hunmn Factor: Readings in Heulrh, Development cmd Conmunity Participctrion (Edited by Rifkin S. B.). Contncr Special Series No. 3, Christian Medical Commission, Geneva, 1980. 8. Nugroho G. A community development approach to raising health standards in central Java, Indonesia. In Health by the People (Edited by Newell K.). World Health Organization, Geneva, 1975. 9. Rural Missionaries of the Philippines. G&e /i>r CornmunirJ, Based Health Programs: -Rural Missionaries of the Philippines, Manila, 1978: Barrion L. The Makapawa-a diocesan community-based health programme on the Island of Leyte, Republic of the Philippines. Conract 56, June 1980. 10. Friere P. Pedagogy of ,the Oppwsx~d. The Seabury Press, New York, 1974. was not main11. The reasons why the CHW programme tained are documented in my thesis cited in Ref. [l]. 12. These reasons are also recorded in my thesis cited in Ref. [I].
APPENDIX Questionnaire on Community
Participation
I in Community
Health Programmes
This questionnaire is designed to help find out different attitudes about community health from different kinds of people. You do not have to give your name. Also, it is not necessary to think very deeply about the questions. It is your reaction to the statements which is required. There is no right or wrong answer to any question in Parts II and III. Many thanks for filling out this form and helping me in this study.
Primary PART 1. 2. 3. 4.
I. PERSONAL
health care in Southeast
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Asia
PROFILE
What is your age’? Sex (cross out as appropriate) What work are you doing now? How long have you been doing this work?
Male/Female
PART II. GENERAL VIEWS ABOUT COMMUNITY HEALTH 1. Please tell me how you think the health of a poor community can be improved. following statements using 1 as the most important. a. b. c. d. e. f. g.
Rank
By having more clinics and more doctors By improving the economic conditions of the people before attacking with the health problems By giving people more information about Western medicine By spending more money on research for cures for common diseases like cancer By having more equal distribution of health care resources By having the community control their own health programmes Other (please be specific)
in order
I
i
( (
) )
( ( (
) ) )
2. Please indicate in what way you think community health programmes can have the greatest on the community. Rank in order the following statements using 1 as the most important. a. b. c. d. e. f. g.
strengthening the co-operation of all organizations working in the community providing more medical services gaining support of the community for health activities helping people to have control over programmes which affect their daily lives helping people realize the link between health and other socio-economic problems improving environmental sanitation other (please be specific) __
3. Please tell me which of the following health programme a. b. c. d. e. f.
PART
criteria
you would use to measure
ABOUT
COMMUNITY
HEALTH
)
(
)
I (
,’ )
1
i
impact
the success of a community
The health centre has an increase in the number of patients People in the community ask for more doctors and more clinics the programme receives more money to increase its activities more people attend health education talks community representatives set up a programme independent of the medical other (please be specific)
III. STATEMENTS
(
the
staff
:
;
I (
i )
(
)
PROGRAMMES
The following are statements about community health programmes. For each statement please put a ring around one of the numbers to indicate the extent of your agreement or disagreement with the statement, Please use the following scale to indicate your response. If If If If If If
you you you you you you
“completely agree” then ring number I “mostly agree” then ring number 2 “slightly agree” then ring number 3 “slightly disagree” then ring number 4 “mostly disagree” then ring number 5 “completely disagree” then ring number 6
1. The major concern of a community health programme should be the delivery of medical services 2. A committee from the community responsible for community health activities should be appointed by the medical staff at the health centre 3. It is necessary to carefully prepare both the health centre staff and the community before starting a community health programme 4. Community participation in health care is a fad which will soon pass 5. Too much money for community health programmes ruins the community initiative 6. Community health workers (people who live in the same community, have another type of employment or tasks but do health work in their spare time) should be primarily responsible to the medical staff at the health centre 7. Community participation should be considered mainly as a means to improve sanitary conditions in poor areas 8. Too much funding from outside the community should be avoided because it creates programmes that cannot be maintained when the money comes to an end 9. The community should be consulted about what community health workers should be taught 10. Community participation in health means the community carries out activities decided upon by the medical staff 11. The medical staff at the health centre should handle all finances for activities for health improvement in which the community participate
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12. Community health worker training should include communtcation and organization skills 13. The most important source of financial support for the programmes comes from the community itself 14. Surveys of the health conditions in the community should be carried out only by professional staff 15. Community participation in health care should be directed mainly to health education activities 16. Community development activities prevent medical professionals from doing their work properly 17. A community health programme needs a great deal of money because it must provide high quality medical services to the community IS. A good community health programme must have community development workers 19. Mothers in the community should help run well baby clinics 20. The best community health workers are those who volunteer for the programme
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.%c. %I. Med. Vol. 17. No. 19, pp. 14X9-1496. 1983 Pnnted in Great Bntain
PRIMARY HEALTH CARE IN SOUTHEAST ASIA: ATTITUDES ABOUT COMMUNITY PARTICIPATION COMMUNITY HEALTH PROGRAMMES
IN
SUSAN B. RIFKIN Center
for Asian
Studies,
University
of Hong
Kong,
Pokfulam
Road,
Hong Kong
Abstract Although community participation in health has become a major plank in WHO’s Primary Health Care platform, comparatively little concrete programme data has been collected which helps to define its potenttals and problems. In an effort to expand knowledge in this area, a study of three Church-related community health programmes in Southeast Asia was undertaken. All three programmes have the stated goal of ‘having the community take responsibility for its own health care’ and as a concrete step in this direction. have developed training programmes for community health workers (CHWs). Starting about the same time, 1973-1975. they provide data for comparative examination of the development of communtty participation. As part of the study. a questionnaire was designed to elicit information from three categories of programmc participants (the medical professionals, the community development workers and the CHWs) in community health programtnes. It sought to discover their attitudes about the objectives of community health programmes: impact and measurements of success of these programmes: the role of health services: the role of medical professionals and community development workers in community health progrwnmes: the role and training of community health workers: and financing community health programmes. The hypothesis of the investigation was that all three categories of programme participants in one programme share attitudes distinct from participants in the other two programmes. Although, due to technical reasons. it was not possible to test this hypotheses, the survey produced other conclustons. One was that the categories of professional people (the medical and community development workers) in all three programmes share attitudes which are distinct from the CHWs in all three programme\. Secondly, participants in the same programme most often exhibit the same attitudes when a programme has initiated an activity which enables the CHW to gain experience in health work.
INTRODUCTION
The author had undertaken a study to establish some of the potentials and problems of community participation in health care. Based on case studies of three Christian Church related programmes in Southeast Asia in Hong Kong, Indonesia and the Philippines, this study attempts to analyse how and why community people get involved in community health programmes [I]. One part of the study seeks to evaluate the attitudes of the three major groups involved in community health programmes toward community participation. This paper is a report of the findings of a survey which sought to elicit these views from medical professionals including nurses: community workers who are also professionals by virtue of their training and paid positions; and community health workers (CHWs) who are laymen engaged in health activities in each of the programmes.
BACKGROl’\D
The three programmes are the following: the Kwun Tong Community Health Project of the United Christian Hospitals in Hong Kong. an urban hospital based programme that began its activities through community health set-vice centres for a population of 600,000 people; the Community Welfare Development Programme, Banjarnegra Regency, PurworejoKlampok District, Central Java. Indonesia, a rural community based programme along some of the lines
of the community development movement of the 1960s; the community health programme of the Rural Missionaries of the Philippines, established to help initiate community based health programmes in all parts of the rural Philippines by building awareness of the causes and cures of ill health and poverty based on the teaching methodology of Paolo Friere and his disciples. These three programmes were chosen firstly because of the author’s familiarity with them [2]. Secondly they were chosen because they presented a diversity of situations which made possible the comparison of a new health concept. They provided comparisons between urban/rural settings, hospital:’ community based programmes. heavy/light outside funding and health services/education oriented approaches. Finally, they were chosen because despite size, area and cultural and political difference, they had sufficient similarities to make a comparison possible. The similarities which the programmes had were some of the following: they all shared the major stated goal of ‘having the community take responsibility for its own health care’. They were all Church-related which meant that firstly, as members of voluntary organisations, they had more flexibility than government to try new experiments. Secondly, they had access to the world-wide funding network available through the Christian Church. Thirdly, they had a group of highly committed, highly motivated plant&g staff who carried out the work with enthusiasm and dedication. They all worked to develop a model of community participation in health care which could be
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SUSAN B. RIFKIN
used on a countrywide scale. They all had a framework which was created through the initial inspiration of medical professionals who worked with community development workers to actively engage the community people in both planning and implementation of programmes. A BRIEF
DESCRIPTION
OF
THE
PROCRAMMES
The following paragraphs describe the programme from its inception to the time of the survey. For Hong Kong the survey date was September 1979; for Indonesia, May 1979; for the Philippines, January 1980. The Kwun Tong Community Heulth Prqject (KTCHP) oj’the United Christian Medical Service, Hong Kong [3] The KTCHP became operational in March 1972 with the opening of the first community health centre in the housing estate of Sau Mau Ping. Its programme activities were geared to cover the health care of 600,000 people in the urban Hong Kong district of Kwun Tong. The staff number grew to about 70 people in 1979. It was a hospital-based programme designed to take pressure loads off hospital beds and staff by creating curative, preventive and promotive health care in the community through the establishment of community health centres and through the development of community participation in the health activities. Essentially service-oriented, the programme established four health maintenance schemes (infant, adult, geriatric and industrial) whereby community members could participate by paying a relatively small fee to receive preventive services, limited curative care and health education. In addition to staff trained to provide medical services, the programme also employed health educators and community development workers whose main task was to educate the community about health problems by running large health education campaigns and enlisting community volunteers to help with these activities. Policy was made by a management committee consisting of the United Christian Hospital’s medical director, nursing director and administrator, the Project administrator and several members of the larger Hong Kong community who ran schools or social service centres in Kwun Tong and/or had a special interest and expertise in the field of community health. The role of the medical professional in the programme was mainly to take responsibility for running the three community health clinics and to treat outpatient cases. The role of the community worker never was clearly delineated [4]. It was an amalgamation of health education, community mobilization and public relations/liaison work. The role of the community health workers (called Health Advocates) focused mainly on health education activities with service extender roles only in the area of first aid [5]. CHW contact with the clinic was mainly through the community workers or clinic staff who taught the CHW’s. CHW’s were volunteers. Training focused on developing some knowledge about disease problems and teaching CHW’s ways of developing the potential of health education and community mobilization to improve bad community health conditions such as poor refuse disposal, and air and noise pollution.
The Hong Kong programme was funded mainly through fees for service at the clinics and the government school medical services scheme which paid small amounts for each child to be examined by a doctor. The non-income generating parts of the programme. particularly staff (health educators and community workers) for establishing the health maintenance schemes, received support from the German Protestant General Agency (EZE) for approx. USS500,OOO for a 3 year period. The grant was given with the view of both the donor and recipient that the entire programme could be self-supporting after that period as it was believed that the community would support the project. As a condition of this grant, an outside evaluation was required. The evaluation was done by a two-person team in 1979 and was instrumental to the planners in viewing past mistakes and creating future programme direction [6]. The Community Welfare Development Programme (Klampok) Banjarnegra Regency, Purworejo-Klampok District, Central Java, Indonesia [7] The Klampok programme began in 1973 in a rural area using principles of community development which regard health as only one component of village improvement and the experience of Dr Gunawan Nugroho in the internationally acclaimed Solo programme [8]. Its initial coverage was for the village of Klampok which contained about 5000 people. Unique in the way which it had close integration with and support of the Regency government, it was later extended to serve the entire Purworejo-Klampok subdistrict which had about 32,000 people. Later still, the model was extended to cover the entire Regency. Its staff was about 20 people. The programme was community based emphasizing health as only one aspect of village improvement which also included agriculture, communications, nutrition and education. The health component was service oriented providing both for service extension by the use of CHW’s and health insurance scheme, duna sehef, which provided participants with funds to cover both doctor interviews and medicines. (It did not cover hospital expenses.) Originally the programme was developed by the medical staff in consultation with community workers. However, the programme director, a doctor, dissatisfied with this approach, began to seek ways of gaining greater community participation in the programme. The result was efforts to establish community responsibility for both activities and funds. CHW’s became responsible to a village committee. A health insurance scheme was established by which the village committee collected and administered the surplus funds which were used for building community income generating activities. The role, of the medical professional changed from that of prime planner to that of resource person. The medical people continued to treat patients at the clinic and act as consultants to the community health programme when asked to do so. They also played a role of community development worker. The community development workers advised the medical professional how to develop the programme and train CHW’s. The role of the CHW’s was both that of service-extender and change agent. Volunteers selected by the community committee did first aid work, simple prevention, sanitation and
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Primary health care in Southeast Asia general simple community development work. Their training emphasized both health and disease care as well as organization and communication skills they needed in their community development tasks. Finance for the Klampok programme began with US$25,000 for a rural clinic and provision for a stimulation fund by government of about USS500 per village as well as the same amount for a training fund. The government through a specialized committee also allocated funds as well as provided some health services. Community support for the programme came through the health insurance schemes and CHW work. The Community Health Pro,gramnze sf Missionaries (RM) qf the Philippines [9]
the
Rural
The Rural Missionaries (RM) Programme was founded in 1975 as a programme activity of the Association of Major Religious Superiors Rural Missionary Programme. Devoting themselves to the needs of the poor people, the majority of whom lived in rural and Catholic countryside, a team of 4 women, both medical professionals and community workers, established a programme to teach interested diocese (Catholic Church administrative units) how to create community health programmes. The cornerstone of the programme was CHW training Community based and education oriented, three pilot programmes were set up in the Luzon, the Visayans and Mindanao. Upon these experiences and previous knowledge, a manual was written and seminars were held by which a methodology for programmes was developed. This methodology stressed building awareness of the relationship of health with existing socio-economic conditions through the dialectical teachings popularized by the Catholic educator. Paolo Friere [lo]. The objective was to motivate poor, rural communities to begin to take responsibility for their own health and welfare. The RM financial support for the pilot programmes ended after an initial 3 years. To examine in some detail the development of these community based health programmes, it was decided to investigate one of the pilot areas. The Makapawa (the name means community health programme in Waray. the local language, and literally translated means ‘to give light, enlighten’) of the Diocese of Palo in Leyte, the Visayans was chosen. The population of this island diocese is about 900,000, 78% rural. The staff of the programme varied between 3 and IO. The programme was community based but in the latest period of this study operated from the office of the programme director, a Catholic nun and doctor, in St Paul’s Hospital in Tacloban. The programme staff planned programme functions and activities. The doctor played the role of both clinician and community worker. The community development worker’s main task was to organize community people into units which would choose and support a CHW. The CHW’s were responsible for unit health activities as well as community motivation work. The CHW’s also extended preventive and simple curative services to the unit. Their training focused on learning preventive care and simple medical treatments which included the use of herbs, and on community organization which included conducting Bible studies and building community committees to become responsible for community activities.
Although one of the major objectives of the entire Philippines programme was to mobilize community resources to become financially self-reliant, the programme initially received funding from the Catholic Central Development Agency, Misereor in Germany. From the period 197551978 a total of about US$25,000 was allocated to the RM of which about US$SOOO was given to the Makapawa programme. At the end of the initial grant the RM team asked for each pilot programme to apply separately if it wished the funding to continue, as the RM felt its role as co-ordinator had ended. The Makapawa did so and received money to continue its work. HYPOTHESIS It was hypothesized that because of similar experiences and circumstances based on common views and values, that those in the same programme would share many of the same attitudes and that these attitudes would be distinct from attitudes exhibited by those in the other two programmes.
THE SURVEY
Design
qf questionnaire
To test the hypothesis a questionnaire was used (see Appendix I). It was divided into three parts. The first part was constructed to obtain data about the personal profile of each respondent. This data included age, sex, programme task and length of time engaged in this task in the programme. Section II sought to obtain a general picture about attitudes toward community health programmes. These included three broad questions. The first asked how health of a poor community could be improved. The second asked how the impact of community health programmes could be measured. The third asked about criteria for success of community health programmes. In order to enable the respondent to have a range of choices answers were formulated in the rank in order pattern. The last choice was entitled ‘other’ which allowed the respondent to write down any opinion which was not already articulated. Part III of the questionnaire consisted of 20 statements for which respondents were asked to mark their degree of agreement or disagreement-l was strongly agree, 6 strongly disagree. Their purpose was to gain respondents’ views about community participation vis-h-vis medical services, the role of the medical professional, the role of the community development workers, the role and training of the CHW, and financial support for community health programmes. By using the scale design, it was possible to standardize responses to a degree which negated as much as possible the problems of using four languages. Choice
qf respondents
Respondents consisted of the three groups of programme participants. For the purposes of this survey, the CHW’s were taken as those community members most active in the programme not as representatives of community views. Respondents were chosen randomly with the following qualifications. In the KTCHP programme all 4 clinic doctors and a random selection of community nurses filled out
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questionnaires. All 4 community development workers in the programme participated. Concerning the CHW’s, the choice was random. However, since their training in June 1977, they had not been utilized continually in the programme. They, therefore, had done little in the programme when they were interviewed in Autumn 1979 [I I]. In the Klampok programme, community development workers were no longer actively employed. Those who were interviewed belonged to the training group who developed the programme methodology on which Klampok was founded. All 4 programme doctors were interviewed and a random selection of CHW’s were asked to fill out questionnaires. The RM programme is a special case. Since it is a teaching programme which began its work with three pilot programmes, there were some questions about to whom to give the questionnaire. In the end. medical professionals were chosen from those who were working with the programme in various parts of the Philippines. However. it was decided to chose one of the pilot programmes, that in Leytc, to ask community development workers and CHW’s to participate in the survey. This programmc. the Makapawa discussed above, provided the majority of Philippine rcspondents. A total of II3 people answered the questionnaire. Of these 25 or 22.1”,, were from the KTCHP; 27 or 23.99,, were from Klampok: 61 or 54.0”,, were from the RM programme. In the random sample of respondents, the oldest was 61 years and the youngest was 17 years. Fifty percent were between ages I7 32 years. Thirty-eight or 33”,, were male and 73 or 66”,, were female. Although it is a random sample, these figures appear to be indicative of the proportion of males to females in each programme. Eighteen medical professionals or 15.9”,, of the total respondents answered the questionnaire. Nine were from KTCHP: 4 from Klampok, and 5 from the RM programme. There were I5 community development workers or I3.30/<, of respondents+ 4 from KTCHP; 5 from Klampok and 6 from the RM programme. There were 80 CHW’s or 70.8”;, of all respondents which included I2 from the KTCHP: I8 from Klampok and 50 from the RM programme. The KTCHP had fewer CHW’s than staff involved in the programme. In Klampok and the RM programme, the number of CHW’s great11 exceeds the staff. Also the CHW’s in the KTCHP had not been fully active in over I j years. Of those involved in all programmes 38 or 33.6”,, had been involved in the work for less than I year; I5 or 13.3”,, had been involved l-2 years: 23 or 20.4”,, had been working 2-3 years and 23 or 20.4”,, had been working 3-4 years. A number of respondents, however. answered the question in terms of total years involved in their profession. This fact accounts for the missing percentage. Two-thirds of those ansucring the questionnaire correctly had been involved for more than I year.
In carrying out the survey. it became apparent that the questionnaire had several limitations. The first mentioned above. was that the original had to be translated into three other languages (Chinese. Indonesian and Waray. the dialect of the Philippines
CHW’s). A process was established by which the questionnaire was translated into the appropriate Innguage then re-translated back into English. Despite this precaution, in the Indonesian translation. at least two questions were asked which did not state exactly the intention of the original statement. The language problem was complicated by the fact some of the English terminology did not always convey the precise meaning of the idea when it was translated. For instance. it was not clear as to whether the term ‘volunteer‘ meant a person who willingly agreed to become a CHW or took no payment for the work. One had to make sure that an exact equivalent was found for the translation. Another limitation was that imposed by the design of the questions. One problem was that in Indonesia the question concerning the number of years a respondent had been involved in the programmc was interpreted by many to mean the number of years that the respondent had been involved in his/her occupation or profession. Another problem in all case studies was that some of the questions gave respondents only a limited choice in which to express their views. A third problem was that some questions made assumptions about alternatives which were not articulated. thus possibly confusing the respondent. To solve these problems. an open ended intervieu may have been a better instrument by which to ascertain opinions. However. when an experiment was tried. it w’as found that not only was there an enormous amount of time involved but also there was a great deal of difficulty in overcomin! the barrier of language. A third major limitation of the surve) appeared in interpreting the data. As each programme had only a small number of medical professionals and communit! developmen! workers, the numbers in these tWo catcgories of respondents in each separate programme werenot statistically significant. This meant that unless c//l respondents answered the question, it was not possible to make a general observation about their attitudes. While the aggregate numbers did not present this problem. the lack of numbers in each programme made it impossible to test the hypothesis. It was onI) possible to suggest some trends among the three categories of participants.
Because of misinterpretations of the questions by many Indonesian participants, it was not possible to analyse Part II of the survey. The data in Table I is from Part III. Where the data can be considered statistically significant, the following statements can be made. In seven statements (I, 2. 6, IO. I I, 14, 16) the percentage of CHW’s that strongly or most agreed with the statement was at least twice that of the professionals. Statement I suggests that the major concern of a community health programme is medical services. Statement 2 says that the health committee should be appointed by the medical staff. Statement 6 says that CHW‘s should be primarily responsible to the medical staft: Statement 10 says that community participation means the community carries out activities decided upon by the medical staff. Statement I I says the medical staiT should handle all finances for community health activities. Statement I4 suggests community surveys should be carried out b)
Primary health care in Southeast Asia the professionals. Statement 16 says that community development activities prevents medical staff from doing their work properly. Concerning a concensus of opinion among people in the same programme, the following statements can be made. In Klampok, all respondents strongly or mostly agree with two statements 12, 19). In one statement (18) all the professionals and 94.5% of the CHW’s strongly or mostly agreed with the statement. Statement 12 suggests CHW training should include communication and organization skills. Statement 19 says mothers should help run well baby clinics. Statement I8 says a good community health programme must have community health workers. In Klampok, the conditions described in the statements were in existence. In the KTCHP, all the professionals and 91.6% of the CHW’s strongly or mostly agreed with statement number I2 described above. In the RM programme again all the professionals and 80.9’A of the CHW’s strongly or mostly agreed with this same statement. Also in these two programmes, CHW training included these skills. Concerning the degree of agreement among professionals in the same programme, in Klampok the professionals strongly or mostly agreed with four statements (3, 12, 18, 19). Statement 3 says that a social preparation of community and health staff is necessary before the programme begins. The other statements have already been described. In KTCHP, the professionals all strongly or mostly agreed with only one statement (12). In the RM programme, the professionals strongly and mostly agreed with two statements (9, 12). Statement 9 says that the community should be consulted about what the CHW’s should be taught. Again, the conditions described existed in all programmes as we have seen. The tables which record that data for the individual programmes are not included because the majority of the questions were invalid due to lack of statistical significance.
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SUMMARY
OF FINDINGS
(a) The hypothesis of the study cannot be tested due to the limitations described above. The data however indicates some trends in attitudes among programme participants about community participation. (b) There is a difference between the expectations of the planners (the medical professionals and the community development workers) and the CHW’s in regard to views about community participation in community health programmes. These differences particularly emerge concerning the issues of approaches to community participation and the role of the professional. Planners, true to their ideal view of the community development approach, wish to encourage a greater responsibility for health programmes by community people providing medical services. CHW’s on the other hand, with traditional expectations of health programmes, wish to have professionals make the decisions. We have suggested some reason why these attitudes exist in the conclusions of the larger study [ 121. (c) Areas where planners and CHW’s share similar views about community participation and community health are areas in which planners and CHW’s both have been involved in this activity. Experience apparently convinces both professionals and laymen that laymen have the capacity to perform certain tasks which they heretofore identified only with professionals. In Klampok where CHW’s had learned organization and communication skills. had been brought into the process of identifying needs and had done baby weighing, at least 95”,, of all respondents agreed these activities were an important part of community health programmes. This agreement was found in the other two case studies only in the area of CHW’s learning communication and organizational skills. In the KTCHP CHW’s did neither baby weighing nor needs identification. In the RM programme. only some of the CHW’s had done baby weighing and obstacles had not been overcome concerning com-
Table 1. Percentage of respondents in all countries who strongly/ mostly agreed with the statements according to work in programmes Question No. 2 4 6 8 9 10 II 12 13 14 15 16 17 18 19 20
Medical professionals (N = 18) 44.4 5.6 88.2 22.2 44.4 16.7 27.8 55.5 70.6 16.7 5.6 100.0 88.2 11.8 41.2 0 5.9 80.3 82.3 64.7
Community workers (N = 15) 33.3 6.1 80.0 0
46.6 20.0 40.0 53.3 93.3 13.3 0 100.0 80.0 6.7 13.4 6.7 13.3 80.0 86.6 66.6
Community health workers (N = 80) 84.4 45.0 65.0 12.8 28.7 68.2 17.7 45.0 46.8 59.8 15.6 87.0 69.6 48.7 51.3 19.5 20.5 84.6 78.2 83.6
SUSAN B. RIFKIN
1494
munity involvement in needs assessment. Additionally, we can note that all planners in Klampok agreed social preparation of a community was necessary. They had all been involved in developing this exercise. In the RM programme, planners all believed the community should be consulted about what the CHW’s should be taught. However, this plan had not yet been implemented very well. (d) In programme plans and activities where planners worked together to develop their ideas, there was a higher degree of agreement about views of community health than in programmes where they did not. As expected, the Klampok programme shows the greatest number of statements with which all planners are in agreement and the KTCHP shows the lowest. However, it is worth noting that even in Klampok, only in l/5 of the questions did this high degree of agreement take place.
CONCLUSION
Community participation has become a key element in Primary Health Care. Its advocates suggest that if health patterns are to change dramatically among the poor and underprivileged, health problems must be seen in a larger socio-economic context and the community must be given responsibility in helping to solve these problems. They tend to assume that if health professionals and community planners can be convinced of the value of these arguments, the community will automatically accept these new, non-traditional ideas. This research, although limited by factors discussed above, suggest that this, in fact, is not the case. Community people who are involved in community health activities tend to see the programmes as extension of medical services and tend to want responsibility to remain in the hands of the medical professional. These findings raise a number of questions which suggest areas for further research. Among them are: (1) what does the community want from a community health programme? (2) how do professionals communicate their objectives to community people? (3) is the field of health care, due to its domination by professionals and its world-wide education network, a field in which community participation is particularly difficult to obtain? (4) are there certain types of activities, methodologies and/or teaching and communication skills which help community people to overcome their reluctance to enter as a full partner in community health? These questions and others are very difficult to answer. It is necessary, however, to begin to examine
them if we are to understand the problems and potentials of community participation in health. REFERENCES
1. This survey is one part of my PhD thesis entitled “Planners’ approaches to community participation in community health programmes: case studies in southeast Asia” submitted to the University of Hong Kong for the degree of Doctor of Philosophy in Social Sciences, July, 1982. I wish to gratefully acknowledge John Anderson, Department of Community Medicine. University of Hong Kong for his assistance with this survey and statistical interpretation. Rifkin S. B. (Ed.) Community Health in Asiu: A Rcporr of Two Workshops, Christian Conference of Asia, Singapore, 1977. Also, the author was a member of the Management Committee of the Kwun Tong Community Health Project in Hong Kong. Paterson E. H. Kwun Tong Community Health Project. Contact 15, June, 1973: Paterson E. H. and Tang R. The Kwun Tong Community Health Project 19722 1976--Progress Report. Conrucr 35, February, 1977; Tang R. C. P. Community efforts in the delivery of health services in Hong Kong. In The Chcmging Rakes and Education of Health Cow Personnel Worldwide in View qf the Increaw of Basic Srrvices (Edited by McNeur R.). Society for Health and Human Values. Pennsylvania, 1978. . 4. Kwun Tong Community Health Project, Management committee notes. I5 June, 1976, unpublished. development in a 5. Lee K. The role of community community health programme. Development Rrsourw Book 1977-1978. Hong Kong Council of Social Service. Hong Kong, 1978. Health Project. Evaluation. 6. Kwun Tong Community Submitted by Dr Stuart Kingma and Dr Emanual de Kadt, May, 1979, unpublished. I. Hendrata L. Community health in rural Java. Con/m/ 31, February, 1976; Johnston M. Development of a community health programme. In Health t/w Hunmn Factor: Readings in Heulrh, Development cmd Conmunity Participctrion (Edited by Rifkin S. B.). Contncr Special Series No. 3, Christian Medical Commission, Geneva, 1980. 8. Nugroho G. A community development approach to raising health standards in central Java, Indonesia. In Health by the People (Edited by Newell K.). World Health Organization, Geneva, 1975. 9. Rural Missionaries of the Philippines. G&e /i>r CornmunirJ, Based Health Programs: -Rural Missionaries of the Philippines, Manila, 1978: Barrion L. The Makapawa-a diocesan community-based health programme on the Island of Leyte, Republic of the Philippines. Conract 56, June 1980. 10. Friere P. Pedagogy of ,the Oppwsx~d. The Seabury Press, New York, 1974. was not main11. The reasons why the CHW programme tained are documented in my thesis cited in Ref. [l]. 12. These reasons are also recorded in my thesis cited in Ref. [I].
APPENDIX Questionnaire on Community
Participation
I in Community
Health Programmes
This questionnaire is designed to help find out different attitudes about community health from different kinds of people. You do not have to give your name. Also, it is not necessary to think very deeply about the questions. It is your reaction to the statements which is required. There is no right or wrong answer to any question in Parts II and III. Many thanks for filling out this form and helping me in this study.
Primary PART 1. 2. 3. 4.
I. PERSONAL
health care in Southeast
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Asia
PROFILE
What is your age’? Sex (cross out as appropriate) What work are you doing now? How long have you been doing this work?
Male/Female
PART II. GENERAL VIEWS ABOUT COMMUNITY HEALTH 1. Please tell me how you think the health of a poor community can be improved. following statements using 1 as the most important. a. b. c. d. e. f. g.
Rank
By having more clinics and more doctors By improving the economic conditions of the people before attacking with the health problems By giving people more information about Western medicine By spending more money on research for cures for common diseases like cancer By having more equal distribution of health care resources By having the community control their own health programmes Other (please be specific)
in order
I
i
( (
) )
( ( (
) ) )
2. Please indicate in what way you think community health programmes can have the greatest on the community. Rank in order the following statements using 1 as the most important. a. b. c. d. e. f. g.
strengthening the co-operation of all organizations working in the community providing more medical services gaining support of the community for health activities helping people to have control over programmes which affect their daily lives helping people realize the link between health and other socio-economic problems improving environmental sanitation other (please be specific) __
3. Please tell me which of the following health programme a. b. c. d. e. f.
PART
criteria
you would use to measure
ABOUT
COMMUNITY
HEALTH
)
(
)
I (
,’ )
1
i
impact
the success of a community
The health centre has an increase in the number of patients People in the community ask for more doctors and more clinics the programme receives more money to increase its activities more people attend health education talks community representatives set up a programme independent of the medical other (please be specific)
III. STATEMENTS
(
the
staff
:
;
I (
i )
(
)
PROGRAMMES
The following are statements about community health programmes. For each statement please put a ring around one of the numbers to indicate the extent of your agreement or disagreement with the statement, Please use the following scale to indicate your response. If If If If If If
you you you you you you
“completely agree” then ring number I “mostly agree” then ring number 2 “slightly agree” then ring number 3 “slightly disagree” then ring number 4 “mostly disagree” then ring number 5 “completely disagree” then ring number 6
1. The major concern of a community health programme should be the delivery of medical services 2. A committee from the community responsible for community health activities should be appointed by the medical staff at the health centre 3. It is necessary to carefully prepare both the health centre staff and the community before starting a community health programme 4. Community participation in health care is a fad which will soon pass 5. Too much money for community health programmes ruins the community initiative 6. Community health workers (people who live in the same community, have another type of employment or tasks but do health work in their spare time) should be primarily responsible to the medical staff at the health centre 7. Community participation should be considered mainly as a means to improve sanitary conditions in poor areas 8. Too much funding from outside the community should be avoided because it creates programmes that cannot be maintained when the money comes to an end 9. The community should be consulted about what community health workers should be taught 10. Community participation in health means the community carries out activities decided upon by the medical staff 11. The medical staff at the health centre should handle all finances for activities for health improvement in which the community participate
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SUSAN B. RIFKIN
12. Community health worker training should include communtcation and organization skills 13. The most important source of financial support for the programmes comes from the community itself 14. Surveys of the health conditions in the community should be carried out only by professional staff 15. Community participation in health care should be directed mainly to health education activities 16. Community development activities prevent medical professionals from doing their work properly 17. A community health programme needs a great deal of money because it must provide high quality medical services to the community IS. A good community health programme must have community development workers 19. Mothers in the community should help run well baby clinics 20. The best community health workers are those who volunteer for the programme
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