Received date: January 06, 2016; Accepted date: July 25, 2016; Published date: August 08, 2016
Citation: Thakur JS, Jaswal N, Kaur R, et al. Development of Integrated Health Promotion Manual on National Health Programs in India. J Healthc Commun. 2016, 1:4. doi:10.4172/2472-1654.100029
Objectives: There is an enormous capacity gap in health promotion and lack of sufficient resource material in India for effective implementation of National Health Programs. The present paper highlights the process of development of the manual, its objectives and potential future usage.
Methods: The manual on health promotion has been developed, reviewed by experts and key stakeholders and finalized after going through a 6-step wise process such as literature review, extraction, draft preparation, expert review, translation, piloting, and finalization.
Results: The Integrated Health Promotion manual has been prepared with an aim to build the capacity of the health professionals including health workers, counsellors and Accredited Social Health Activists (ASHAs) in creating awareness regarding the risk factors and prevention of Communicable Diseases (CDs), Non- Communicable Diseases (NCDs) and key Reproductive and Child Health (RCH) issues to advance healthy lifestyles. The manual can also be used to train key stakeholders in the community like community leaders, school teachers, and peer educators and to involve other sectors like education, public works department, irrigation, youth and sports, etc.
Conclusion: The manual shall be useful resource in implementing the preventive components of all national health programs under National Health Mission in India.
Integrated; Drug abuse; Manual; Health promotion; Health; Unhealthy diet
The common behavioral risk factors for Communicable Diseases (CDs), Non-communicable Diseases (NCDs), Injuries, Reproductive and Child Health (RCH) issues such as unhealthy diet, physical inactivity, smoking, substance abuse, harmful use of tobacco and alcohol, drug abuse, negligence in road safety, stress, unsafe water and sanitation, lack of personal and oral hygiene, etc. have become the leading determinants of morbidity and mortality worldwide. Today, the call for promoting healthy lifestyle by reducing above mentioned risk factors remains a challenge in both urban and rural sectors, despite of some improvements in the prevalence of risk factors in some areas. During the last twenty five years, much has been learned about the causes of risk factors and many local, regional and national initiatives have been put in place, but, in fact, the challenges remained mainly due to vertical nature, lack of convergence, integration and coordination.
Integrated health promotion focuses on achieving equity in health. A major aspect of the work of integrated health promotion is to provide the opportunities and resources that enable people to increase control over and improve their health. This includes developing appropriate health resources in the community and helping people to increase their health knowledge and skills, to identify the determinants of their own health, to identify actions by themselves and others, including those in power, that could increase health, and to demand and use health resources in the community .
Hence, there is a need to speed up efforts and to strengthen initiatives through integrated focus on these risk factors within the IEC/BCC/health promotion component of existing national health programs which would certainly help in the optimum utilization of the available human, financial and operational resources in India. Efforts have been put to develop a manual on integrated health promotion for capacity building, being implemented in District Ambala of Haryana and District Hoshiarpur of Punjab states. The present paper highlights the process of development of the manual, its objectives and potential usage in future.
The preparation of manual underwent through two stages: review of relevant literature and review of manual draft by the experts.
Review of literature and extraction of relevant material
Project team reviewed the relevant literature from various sources such as existing manuals of different health programs under National Health Mission, journals and related IEC material. Many international as well as National websites were also searched relating to World Health Organization, UNICEF, NIMHANS, Central Health Education Bureau, National Health Mission, Ministry of Health and Family Welfare, etc. Thus, relevant material was extracted and used for the preparation of the draft of the manual.
The manual draft
The draft of the manual was prepared and went through various phases of review. Milestones in the development of manual are shown in Figure 1.
Validation of the manual: The draft of the manual was shared with the health experts from Chandigarh, Punjab and Haryana.
First hand review: The copy of manual was given for review to the stakeholders of three states i.e., Punjab (8), Haryana (10) and Chandigarh (13) and their inputs and valuable opinions were considered for the revision of manual. The stakeholders comprised of Mass Media Officers, Programme Officers of various programmes, faculty from PGIMER, GMCH-32, Punjab University, Fine Arts College who offered their valuables comments. One of the students of Fine Arts College was also engaged for the designing of the manual.
Second hand review: one state level stakeholder’ workshop in Chandigarh and two district level stakeholders’ workshops in District Hoshiarpur and District Ambala were conducted in the year 2015. The manual was reviewed and discussed thoroughly in all the three stakeholders’ workshops. It was further revised standardly at district level training so as to incorporate the inputs of the participants.
Translation of the manual
The manual was translated both in Hindi and Punjabi languages. The translated versions of the manual were further reviewed during the Training of Trainers (TOT) workshops in the district Ambala and Hoshiarpur for making the contents of the manual comprehensive.
Piloting of the manual
Since the manual is meant to train the health workers and counselors, so focus group discussions (FGDs) were carried out with the health workers (LHVs/ANMs) in Ambala and Hoshiarpur districts. Their feedback about the contents of the manual and suggestions for improvement were received. The comments collected during the FGDs regarding the contents and topics of the manual were incorporated properly and the manual was revised accordingly.
Finalization and printing of the manual
The suggestions of the reviewers, key stakeholders and health workers from the districts were incorporated in the manual and manual was finally printed.
Based on the review of relevant literature and suggestions made by the reviewers, the manual was classified into 7 sections. 12 common risk factors for communicable diseases, non-communicable diseases and RCH issues were selected and finalized after extensive discussion with the experts.
The manual covers the aims and objectives of the manual, information about the type of participants, outcomes of the training and the manual usage methods are given in Section-I. Section-II includes the details of communication and counseling skills. The importance of communication and counseling process, its types, skills, barriers has also been discussed in this section. The micro skills of counseling and GATHER approach of counseling are discussed in detail. Common behavioral risk factors/determinants of health are covered in Section-III. It involves introduction, burden of lifestyle diseases in global and Indian context, risk factors, and about the determinants of health. Section IV contains the twelve risk factors as discussed below:
• Healthy diet: The chapter highlights the effects of malnutrition and unhealthy diet including fad diet. The importance and need of balanced diet i.e., composition of carbohydrates, proteins, vitamins, minerals and fats in the diet have been emphasized. Some healthy dietary tips are given for pregnant woman and children
• Physical activity: Physical activity is one of the important determinants for the prevention and control of noncommunicable diseases. This chapter covers the forms of physical activity which could be carried out in routine daily life. The recommended levels of physical activity for children, adults and elderly persons have also been described in this chapter.
• Alcohol use: The chapter highlights the consequences of harmful use of alcohol in terms of health, social, occupational effects. It also includes method for prevention and getting rid of alcohol while including the role of family.
• Tobacco use: This chapter comprises of the information about the different forms of tobacco (both smoke and smokeless tobacco) used in India. Health problems for tobacco users have been indicated. Emphasis has also been given on the effect of second-hand smoking and use of tobacco by pregnant women. The “5A’s” to intervene in the tobacco usage: Ask, Advise, Assess, Assist and Arrange have been discussed in addition to the steps for quitting the tobacco. A case study of Tobacco Control in India with a focus on National Tobacco Control Programme has also been included.
• Substance abuse: The chapter presents the national burden of substance abuse in India, Classification of drugs in the form of stimulants, depressants, anti-psychotics, anti-depressants, cannabis and inhalants in addition to the commonly used drugs in India have been discussed in the chapter. Physical, social, and legal consequences of substance abuse have been elaborated. Emphasis has been given on the prevention and control of substance abuse including evidence-based interventions. The key note of the chapter is the ‘District level plan for prevention and control of drug abuse’ which could be adopted by the districts as per their requirements.
• Coping with stress: The pressure of the studies, broken relationships, burden of responsibilities and workload in office which causes stress have been discussed followed by physical, behavioural and emotional symptoms of stress. Managing stress has been emphasized including body relaxation exercises, i.e., yoga, meditation or morning walk, prayer, etc.
• Safe sex: Describing about the types of sex, this chapter focuses on the safe sex and its benefits. Various forms of family planning methods, such as barrier methods, hormonal methods, IUDs, natural methods and permanent methods have been tipped. Pictorial condom demonstration has been given in addition to some ‘Safe Sex’ tips.
• Road safety: Road safety chapter highlights the factors which increase the risk of road accidents. Preventive measures for road accidents and golden rules for road safety have been flagged along with the rules and regulations under Motor Vehicles Act, 1988 of India.
• Personal hygiene: Importance of maintaining hygiene of various body organs or parts has been highlighted in the chapter. Hand washing techniques (pictorial) have also been demonstrated. In addition to the other parts of body, need for maintaining urinary as well as sexual hygiene has also been described.
• Safe water and sanitation: It includes introduction on safe and potable water and sanitation. Dehydration, prevention and treatment of diarrhea including use of ORS and some pictorial measures to keep water safe have been given. Management and maintenance of sanitation and also initiative by Indian government on Swachh Bharat Mission have also been mentioned.
• Vaccination: Information about the role of vaccination in preventing diseases have been furnished in this chapter clearly. Vaccine preventable diseases like tetanus, tuberculosis, dyptheiria, pertusis, etc. have been mentioned followed by the Immunisation schedule.
• Oral health: Importance and effects of oral health on general health, self-examination of mouth, maintaining oral hygiene and techniques of brushing the teeth are covered in the chapter. Tips for keeping healthy teeth and gums are also given.
Section-V relates to the components of implementation of manual at the block and community setting. This chapter discusses the role of stakeholders in the integration of IEC/BCC activities at the district level, role of the district staff in the implementation at Primary health center level and sub-center level.
Section-VI discusses about Supervision, Monitoring and Evaluation. This section includes role of supportive supervision, monitoring and evaluation in the successful implementation of the manual up to the grassroot level, i.e., among the community members.
The present manual has been developed with a aim to build the capacity of the health professionals including health workers, counsellors and ASHAs in generating awareness regarding the risk factors of Communicable Diseases (CDs) and Non-Communicable Diseases (NCDs) among the community members; motivate the community members to promote healthy lifestyles. The module can also be used to train other people in the community such as community leaders, school teachers, and peer educators and involve other sectors such as education, public works department, irrigation, youth and sports, etc.
The English manual has been translated in Hindi and Punjabi languages by experts.
Health Promotion is a key to achieve the objectives under National Health Mission (NHM) but it was observed that it is the weakest area in the situation analysis carried out in 2 districts of Punjab and Haryana state . The manual covers the key preventive aspects of National Health Programs with emphasis on integration, convergence and multi-tasking which will help in the effective implementation of preventive component under the National Health Mission . It was developed to build the capacity and skills of health workers including block extension educators, health inspectors, counsellors, LHVs, ANMs, and ASHAs on common risk factors of CDs, NCDs and key RCH issues during the training. It also serves as a ready reference material that health workers can use and get benefit in the course of their routine work or as a guide in providing community based training or lectures to village level workers and other groups.
This manual is designed for both health and non-health sectors which are key stakeholders for behavior change or lifestyle change. This manual has already been used and practiced in District and Block Level Training of Trainers in District Hoshiarpur and Ambala. In the situational analysis of both the districts it was reported that preventive component is missing and capacity of health workers is poor . This manual would perhaps lead to the increase in the knowledge of risk factors and determinants of the health among staff and improve their skills. Inherent weakness in existing resource material [4,5] in health promotion is that it is programme specific, focus on one or two risk factors but does not provide holistic approach. The health workers have to refer to many documents, so the present manual will serve as ready reckoner.
Another manual developed for Accredited Social Health Activist (ASHAs) ‘Role in Prevention and Control of Non Communicable Diseases’ Book No. 8 "(2009)"  by Ministry of Health and Family Welfare Government of India, National Rural Health Mission contains very less information of one page per topic which is not sufficient for the community to change the lifestyle. It does not include other social determinants i.e, safe water, unsafe sex, immunization, personal hygiene and road safety, which are very important for community to make changes in their lifestyle and for decreasing the burden of NCDs. Whereas the present manual is easy to understand from MO to ASHAs and it has also been translated in the respective state languages and written in simple languages to make it understandable and interesting. There is a flip chart developed by the NHM, Swasthya Jeevan Sarthak Jeevan for Sakshar Mahila Samooh (SMS), implemented in some states, but it does not include physical activity, personal hygiene (only hand wash is covered), prevention of tobacco and alcohol use, safe sexual practices, road safety, water and sanitation. It highlights inadequacy of existing resources.
During the pilot phase, the manual was significantly reviewed and appreciated by the workers which received great demand. It has been found to be feasible for implementation by the health workers. Health Promotion Manual is an integrated holistic approach, covering CDs, NCDs and RCH issues and may lead to strengthening of health promotion component under National Health Mission by promoting convergence and multi-tasking. It may be used in other districts in India. Capacity building for integrated health promotion enhances the potential of the health system to prolong and multiply health effects and to address the underlying social determinants of health.
An integrated health promotion manual with a focus on integration, convergence and multi-tasking was developed and pilot tested at the district setting in Northern part of India. The manual has been found useful and beneficial in increasing the knowledge level of the health workers and community members. It is a vision and mission for making healthy India. Healthy and strong people can only make a country strong and healthy.
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