Community-Based Healthcare in Swaziland: Power to the People by Elizabeth T. Mndzebele Photo credit:  http://www.min-tour.gov.sz/culturalvillage/index.html

The Rural Health Motivators (RHM) Programme in Swaziland was initiated by the Ministry of Health in 1976 to address the health needs of the Swazi people who lacked access to health resources. The Programme emphasizes provision of preventive, promotive, curative and rehabilitative health services via community-based health care. Currently, Swaziland is home to 966,462 people, with an average of one qualified physician per 7,971 citizens. Overall life expectancy at birth is 38.53 years.

The premise of the Programme is that local people are the best motivators for health behavior change in a community. Registered nurses (RNs) are trained in each of Swaziland's 40 administrative centers. The RNs, in turn, train people in the community in disease prevention via reducing poor sanitation and unclean water, the incidence of communicable diseases, and poor nutrition. These newly-trained RHMs then train others to take care of their own health. Each RHM is assigned to 40 homesteads, which they visit monthly. Since the Programme's inception, nearly 3,000 RHMs have been trained and over 80,000 homesteads receive care from an RHM.

The Programme began under the direction of its founder, Dr. Zibuse Michael Dlamini, a former director of the Ministry of Health and member of various WHO committees and was initially funded by UNICEF. Participants were selected by the bandlancane (the Chief's Council) and the bandlakhulu (community members) on criteria devised by the Ministry of Health in conjunction with the community members. Initially, communities received RHM training based on their morbidity and mortality rates. Later on, communities requested to participate.

RHMs in Action

RHMs have nearly unlimited duties, as their activities are dictated by the community's needs. During their monthly visits to the homesteads, RHMs identify health needs, such as maternal and child health, nutrition, sanitation and mental illnesses. They also promote community participation and adult literacy; the current literacy rate is 76%.

RHMs also provide first aid services, and refer people to other health resources and facilities that they might require. RHMs are not completely able to provide proper counseling services and monitoring and evaluation. Many clinics and outreach posts have been set up for such referral.

Improvements and Achievements

As a result of the RHM program, more and more people recognize the need to immunize their infants. They also are better able to treat their children for diarrheal diseases with oral rehydration solutions. Over 95% of pregnant women receive prenatal care, and 56% give birth in a health facility. RHMs assist in emergency deliveries at the homesteads. Thus, the infant mortality rate has decreased from 156 deaths/1,000 live births in 1976, to 103.37 deaths/1,000 live births in 1998.

RHMs are significant sources of knowledge for the community. They serve as an information source for a variety of community health issues. Construction and use of washrooms and latrines has increased. Nutrition information and health education is on the rise as well.

Successful From the Start

The Swazi people are most receptive when a program is from the King. Because the RHM Programme began as a government program, and was nationwide so that all would benefit, it has enjoyed great success. It began as a part of the MOH's existing structure, which helped it with its funding and organization. Community involvement made it more acceptable to the people, and empowered them to develop their communities and nation. Now, health has been promoted to the point that the MOH alone can no longer meet the demand. Thus, the RHMs continue to be a necessary and vital program in ensuring the health of Swaziland.

"Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change." (American Journal of Health Promotion, 1989, 3, 3, 5.)

Ecuador: Student Brigades of Health Promotion by Dr. Amparo Herrera

Schoolchildren in Ecuador have high rates of communicable diseases and injuries, such as falls and interpersonal violence. To combat these problems and address school health as a whole, Ecuador has implemented its "Healthy Schools Program" in cooperation with UNICEF and the Ministries of Public Health and Education. This program is compatible with the interests of both the Ministry of Health and the schools' objectives. Using a series of activities, the program positively influences the health habits of children.

The region-wide program encompasses: policies to advocate for and implement health promotion in schools; coordination between health and education; health education in school curriculum; conditions of the physical and psychosocial environment in schools; and access to health and nutrition services and programs.

Schools that decide to participate in this program need to reach a minimum 75% of the objectives for this year. Teachers receive guides and educational materials to help them reach this goal. A national team coordinates the program. Animation and control teams on the provincial level, and an execution team on the local levels, have been established.

This program's objectives are to create stimulating and healthy environments for health promotion, and to facilitate knowledge on how to care for one's health. The ultimate objective is to extend these health promotion messages to parents and community members through the children.

Student Brigades of Health Promoters

Parents and community members integrally participate in the program. They get involved in and support school activities. As part of the provincial team, teachers receive instructions on implementing the program and achieving its goals and, at the same time, become leaders of the student "brigades" of health promoters.

Course materials for science classes are supplemented with materials that focus on health. Brigades of health are established so that teachers can educate the students on how to change bad health habits and become health promoters for the community. Older students act as mentors for younger students, thus reinforcing their own knowledge and practices.

One grade each month is in charge of arranging small health projects. This allows direct participation of the schools in the scientific process of investigation. To individualize the program's goals, the students learn how to do these things for themselves. The areas that the projects cover include: planting vegetable gardens, preventing household accidents, cleaning up neighborhoods, purifying water, teaching the importance of dental hygiene and immunization, preventing malaria, saying "no" to drugs and tobacco, and being responsible parents. The results of these monthly projects are displayed to the public to allow for the expansion of the health promotion messages to the rest of the community.

A tri-monthly evaluation is organized, which is effective both internally and externally. An Open House ensures changes and observation about the program and affords the opportunity to inform the community of the program's progress.

Nutrition Programs

Participating schools integrate other programs to achieve their health goals and set guidelines for proper nutrition. The project, titled "Targeted School Feeding in Deprived and Indigenous Areas," targets food aid to 500,000 of the poorest schoolchildren. It addresses the short-term hunger of the pupils, with the aim also of improving the learning capacity of the children. Partnerships between participants of the Program of School Coalitions are arranged with support from the United Nations Development Program (UNDP) and the World Program of Food.

This complementary project to the other programs gives the children between 25% and 50% of their daily required micronutrients. The students and their families are instructed about the proper selection of nutrients. In terms of community involvement, they plant the seeds of change needed to improve the health of families.

Medical Services in School

Students and teachers have access to medical and dental care twice a year. The Health Centers visit the schools twice a year to increase the teachers' knowledge of basic preventive care. During these visits, they also revise their files on each individual student's health and record each student's growth, give immunizations, provide screenings and other necessary health services.

Although all schools have physical education on their curriculum, the majority of sports and activities are aimed at boys. Furthermore, the boys tend to act violently during the sports. Measures to address both of these problems will be taken as the program continues to develop.

In Chile, promoting health in schools is just starting at the end of the 20th century. Most recently, the National Conference of School Aides and Scholarships (Junta Nacional de Auxilio Escholar y Becas) has directed the implementation of the School Health Program (1990 to present), which is part of a project by the Ministry of Health.

Like other Latin American countries, and in coordination with UNICEF and PAHO, Chile’s school health program involves: policies to advocate for and implement health promotion in schools; coordination between health and education; health education in school curriculum; conditions of the physical and psychosocial environment in schools; and access to health and nutrition services and programs.

The overall goal of the program is to make equal opportunity a reality and not just a dream. The principal objective is to form and use human resources for the country. The program tries to involve the participation of key leaders in the communities, the professors in charge of health in schools, health professionals, parents, and school directors. The program is tailored to the needs of each community, which can be accomplished with the assistance of charities, state institutions and private citizens.

Three Stages to Success

The Healthy Schools Program is implemented in three stages. The first is the evaluation of the student. In order to effectively realize the medical evaluation, the teachers attend workshops on nutrition and school health. These workshops seek to arm the teachers with knowledge to identify health problems and, at the same time, strengthen the retention of health education lessons.

The second stage is intervention. Once the teachers have identified the students who have a nutritional, mental, emotional or physical deficiency, they refer them to primary healthcare consultants. The health professional diagnoses the student and determines the necessary intervention for the specialists.

The third stage is the evaluation of the process and the system. Teachers are integral to this stage, as schools provide a nearly 100% surveillance of school-aged children, and teachers can evaluate students on an ongoing basis. The results are used to reassess and redefine the program as needed. Reevaluation of the goals at the beginning of the school year, in light of the defined objectives for each region, is also accomplished.

The program is aimed at elementary school children of the first five grades, and for 1999 will hopefully be aimed at all elementary school children. This program has helped to obtain better results in their programs of immunization, nutrition, and maternal and child health.

Both qualitative and quantitative parameters are used to gauge the results. Qualitative surveys of students’ knowledge, attitudes, and practices of health promotion indicate beliefs and likelihood to change to health behaviors, while quantitative measures such as youth risk behavior surveys are used to look at associations between health and absenteeism and drop-out rates.

The parent-teacher associations are usually active groups, as the program encourages teachers to have seminars, workshops and meetings with parents and community leaders to improve school/community relations and to carry out health promotion activities in the communities in support of the school health promotion activities.

Botswana's healthcare system, arguably one of the best in Africa, is based on the principles of Primary Health Care (PHC) as described in the Alma declaration of 1978. PHC emphasizes community participation, intersectoral collaboration, equity and commitment to social justice. It ensures affordable and accessible healthcare.

The PHC system comprises government, missionary, mine and private-commercial health institutions. The Government's Ministry of Health (MOH) is the main healthcare provider. Botswana has a ratio of 4,130 people to 1 qualified physician, and 404 people to 1 nurse. These numbers are substantially better than the averages for sub-Saharan Africa (18,488 and 6,504 respectively) and all developing countries (5,767 and 4,715). Expansion of infrastructure and human resources is currently underway to make healthcare more accessible.

Health Promotion: An Overview

Health promotion is a major aspect of PHC. It includes health education, environmental sanitation and disease control. Emphasis on health promotion is based on the government concession that Botswana is still at a level of development where the disease pattern is predominantly determined by poverty, malnutrition, poor sanitation and low education levels.

Meanwhile, there is an epidemiological transition characterized by chronic illnesses related to lifestyle changes, particularly in urban areas. These diseases include chronic stress, hypertension, obesity and diabetes. The MOH's Department of Family Health Education works specifically on health promotion of individuals, families, and communities. Community involvement is key to identifying cultural attitudes and practices that impede health promotion programs. Such practices are addressed via cultural brokering and re-patterning.

The Prevalence of Health-Hindering Behavior

Culture plays a large role in attitudes and health behaviors. The Batswana (natives of Botswana; the singular is Motswana) have a low-fat diet high in vegetables. This is partially responsible for Batswana's low blood pressure, though the average Motswana is still obese.

Studies show that Batswana have a low fitness level compared to their international counterparts. There is a saying that in Botswana there is no hurry. This adage, suggesting to not exert oneself, reflects the low fitness level, which is associated with various employers oft-expressed concerns about Batswana's low productivity level. Botswana's labor market was ranked 16th in productivity among the top 20 African nations by the Africa Competitiveness report of 1997. Most government officials and employers blame this on the average Motswana's attitude toward work.

Batswana do not regularly participate in physical exercise, although a relatively small number, mostly males, play sports on Sunday mornings. Corporate fitness programs are almost non-existent, although some private employers provide recreational facilities for their employees use during evenings and weekends. There is no corporate policy encouraging employees to exercise.

In 1996, 11.9% of the 4,507 deaths registered in hospitals were AIDS-related. AIDS is Botswana's leading cause of death. The incidence of HIV/AIDS in Botswana is estimated to be between 25% and 30% of the total population. This is supported by the United Nation's recent submission that AIDS has surpassed malaria as the main killer disease in Africa.

Alcohol consumption is fast becoming a regular cultural celebration every weekend, and is fast degenerating into cases of alcohol abuse and, alcoholism. Alcohol misuse causes many social problems, including drug abuse, early sexual intercourse, burglary, and rape, particularly among youths.

Social problems traced to lack of recreational skills can be linked to the absence of physical education in schools. Although Physical Education has existed in curriculums for the last decade, it is not usually implemented.

Organization and Coordination of Health Promotion Activities

Decentralization allows grass roots action in remote areas to identify a health problem and report it to an immediate governing body, which reports to the district government, which then reports to the central government. Government agencies, like the Botswana National Productivity Center, organize regular workshops for employees and employers to enhance productivity, and annually reserve one week for multi-organizational public awareness activities. Student clubs, like HIV/AIDS awareness clubs, organize cultural activities as forums for spreading health promotion messages. The MOH's Family Health Division plays a leadership and coordinating role. Each year, it collaborates with the WHO to spearhead events like World Health Day. On such days, the National Health Promotion Committee advocates health promotion on a wide scale with multi-organizational activities like cultural shows. Multisectoral collaboration is encouraged by sharing responsibilities with the community, different sectors, and non-governmental organizations.

Health Promotion: The Future

Botswana is clearly on its way to attaining universal health. Its acknowledgment that preventive health is better and cheaper than curative, and its government's demonstrated political will to give its people a good life, means health promotion will soon be a mainstay of the PHC system.

Country Data

Food Guides Around the World

The International Food Information Council (IFIC) Foundation, a non-profit organization located in Washington, DC, recently published an article on effective health communication via food guides around

the world.

Food guides are effective communication tools to relay complex nutrition information to the general public. They aim to depict the optimal diet for overall good health in a clear visual format. Such a tool has been used in the United States since 1916, when the U.S. Government discerned 10 basic food groups. In the 1950s, foods were re-categorized into the present four basic food groups to help people remember them better. Since 1992, these food groups have been depicted in the Food Pyramid.

Other countries use visual aides, such as rainbows, circles, even a chalice, to depict a balanced and varied diet for their native populations. Japan uses a large number 6, to remind people of the six basic food groups it has identified. The Philippines uses a star to show its six basic food groups. Canada utilizes the rainbow, with a food group in each colorful band. Israel uses the chalice, and is one of the few countries emphasizing water as a main part of a balanced diet.

The purpose of IFIC is to provide sound, scientific information on food safety and nutrition to journalists, health professionals, educators, government officials and consumers. The Foundation's mission is to provide a critical link between the scientific community, food manufacturers, health professionals, government officials, and the news media. By disseminating clear and factual information, these diverse groups are able to increase better understanding of nutrition and food safety issues for the benefit of the public.

For more information, contact the IFIC Foundation at: 1100 Connecticut Avenue, NW, Suite 430, Washington, DC 20036. email:foodinfo@ific.health.org Website: http://ificinfo.health.org

National Health and Nutrition Examination Survey (NHANES)

by Kirstin Job

The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations. The NHANES is a major program of the National Center for Health Statistics (NCHS), which is responsible for producing vital and health statistics for the nation. NCHS is a part of the Centers for Disease Control and Prevention (CDC), U.S. Public Health Service.

The NHANES program began in the early 1960s and has been conducted as a series of surveys. Four previous surveys were conducted in 1960-62, 1971-74, 1976-80 and 1988-94. Specialized surveys evaluated the health of children (1963-65), teens (1966-70), and Hispanics living in three geographic areas (1982-84). Each year, the survey examines a nationally representative sample of about 5,000 individuals in 15 counties across the country.

The latest survey began in March 1999 with three sets of four state-of-the-art, medically-equipped semi-trailers. Each set of semi-trailers is staffed by 17 health professionals, including a full-time physician. The NHANES detailed interview includes demographic, socioeconomic, dietary, and health- related questions. The examination component consists of medical and dental examinations, physiological measurements, and laboratory tests administered by highly trained medical personnel.

The 1999 survey includes many new tests for data collection. Equilibrium, cardiovascular fitness, visual acuity, and risk factors for skin cancer will all be tested for the first time. Volunteers recruited for the survey will also be the first to be tested for tuberculosis and mercury exposure. Other health conditions being studied include anemia, hearing loss, kidney disease, obesity, oral health, osteoporosis, diabetes, and lower-extremity disease.

Participants will now also be tested for HIV, chlamydia, gonorrhea and herpes simplex virus 1 and 2. To help determine how many Americans are unfit, and what is needed to improve their fitness, participants aged 12 to 49 are put on a treadmill and then monitored for blood pressure, pulse, and maximum volume oxygen during various stages of exercise. Blood and saliva samples will be taken and stored, with the participants' consent, for future genetics research.

While the survey sample is selected to be representative of the nation, certain groups, such as teens between 15 and 19, people older than 60, Mexican-Americans, and African-Americans, are oversampled to ensure the accuracy of estimates.

Information from NHANES is published through an extensive series of publications and articles in specific and technical journals. Information is also available on CD-ROMs and diskettes. In the future, data will be widely distributed on the Internet.

The World Bank and Health Promotion

A recent thesis by Adele Beerling, University of London, UK, August 1998, provides an overview of health promotion initiatives of the World Bank in Africa and perspective on what role health promotion plays within this large international organization. The World Bank's involvement in the health sector is fairly recent and it acknowledges its limited experience in health promotion. The Bank is trying to expand its knowledge base by focusing on knowledge management and by drawing on outside expertise from individuals and organizations like the WHO. The primary interest is in improving health to increase productivity. The author of the study acknowledges that tensions between the World Bank mandate and the ultimate goal of health promotion exist, but that higher quality health promotion provides better value for money and can lead to more production in the long run.

Although many projects address one or more determinants of health, health promotion is rarely an explicit or comprehensive strategy. World Bank staff acknowledge a lack of understanding of the full scope of health promotion and of the complexity of behavioral change and identify the lack of resources for health promotion as a key problem. It is increasingly recognized that commitment to health promotion at the policy level is a key determinant for implementation of comprehensive health promotion.

Training Seminar in Brazil

The National Center for Health Fitness at American University and CPH Technologia em Sáude from Sao Paulo, Brazil are hosting a Quality of Life/Health Promotion training seminar from August 9-13 in Sao Paulo. Human resource managers and corporate health professionals from Brazil will attend the seminar to learn about the latest trends and methods dealing with the management of workplace health promotion programs.

IIHP Meeting in Curitiba Update

As a result of the input from IIHP partners and other affiliates during the last year, the following central theme was chosen: "Health Promotion: Policies and Economics." Global Perspectives has covered both topics in previous issues: Volume 1, numbers 4 and 5 (September and November). As many countries are facing the challenge of health care reform and lifestyle-related diseases are on the rise throughout the world, the development of health promotion policies has become a major issue. In a world of fierce competition and maximizing resources, the significance of sustainable financing for, and cost-effectiveness of health promotion programs, will further increase in the next millennium.

The following topics will also be addressed in continuation to previous discussions:

• Training and curriculum development;
• Health communications;
• Testing and database development;
• Research collaboration.

Did you know?
Curitiba provides 52 m2 of green area per inhabitant, including 21 large parks and natural woods, causing it to be called "Brazil's Ecological Capital."

Conference Dates

September 6-12, 1999: Training Course for Fitness Instructors and Coaches (with a health promotion module), in Bistrita, Romania.

September 11-14, 1999: The International Conference on Movement and Health, hosted by the Faculty of Physical Culture, Palacky University in Olomouc, Czech Republic.

October 1-3, 1999: 13th Conference of the European Health Psychology Society: "Psychology and the Renaissance of Health", Florence, Italy.

October 10-13, 1999: The Fourth Annual Meeting of the IIHP, co-hosted by the Brazilian Association for Quality of Life (ABQV) and the Prefeitura Curitiba, in Curitiba, Brazil.

October 13-16, 1999: International ABQV Congress in Curitiba, Brazil.

October 31-November 3, 1999: 2nd International Workshop on Promotion of Health-Enhancing Physical Activity (HEPA).  UKK Institute, Tempere, Finland.   Registration deadline si Spetember 30, 1999.  Contact Ms. Saija Kontulainen, UKK Institute, P.O. Box 30, FIN-33501, Tempere, Finland, Tel +328-3-282-9111, or mailto://losako@uta.fi, http://www.uta.fi/ukki/english.htm.

June 5-9, 2000:  5th Global Conference on Health Promotion:  "Health Promotion - Bridging the Equity Gap", hosted by WHO, PAHO, and the Ministry of Health of Mexico, Mexico City.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe. It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations. More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation. E-mail the IIHP at <iihpaa@american.edu>. The IIHP website is <http://www.healthy.american. edu/iihp.html>

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