Regaining the preventive medicine edge: training for 2000 and beyond.

We review the state of preventive medicine in the context of four factors that have eroded the influence and effectiveness of the specialty: (1) historical; (2) cultural; (3) political-economic; and (4) changing epidemiological and demographic factors. We address the implications for public and medical peer recognition of preventive medicine, for funding of residency programs, and for recruitment of medical students. We outline five objectives for preventive medicine training as steps to improve the response of the specialty to the above factors and to regain its edge. Also, we propose two specific innovative training programs to partially meet these objectives: a cross-cultural public health exchange and a preventive medicine fellowship in policy and public administration. We discuss the pertinence of these programs in terms of reversing preventive medicine's growing obsolescence.

Factors associated with success among southern Cheyenne and Arapaho Indians.

Researchers in applied social science are seeking ways of approaching the facilitation of community-based development at the grass-roots level. Much research to date has focused on negative social aspects in communities, such as substance abuse and high numbers of school drop-outs. An innovative approach was developed that involved looking instead at successful individuals in communities. Individuals identified as successful were interviewed about the factors they associated with their own success. The experience of supportive parenting during their childhoods and moderation in alcohol and other substance use as adults were strongly correlated with success in life. The interview process provided an effective springboard for discussions and the development of intervention strategies at the community level.

Participation in child health and family planning activities in rural southern ghana.

A variety of child health and family planning activities, conducted by the Danfa Project in Ghana, were evaluated from a behavioral standpoint to determine features of programs which encourage participation by village mothers. Interest, intent to participate, and actual participation rates were measured. Contrary to expectations, activities which demand greater participation were more popular than more passive activities which involved lectures. Activities related to child health were better received than family planning activities alone. Barriers to participation which were best predictors of actual participation included "selling goods in town," "cooking," or "busy with housework." That these were ranked by respondents as weak barriers suggests that it didn't take much to dissuade mothers from participation in those activities that they felt had little merit. Study findings suggest a need for greater integration of activities into village schedules, more systematic targetting of activities to high-risk groups, more activities demanding greater participation, and direct promotion of activities through influential individuals (community leaders, traditional healers).

Ethnomedicine and biomedicine linking.

This paper considers the integration of the biomedical establishment with traditional medical care systems given the urgent need for health care services by the underserved masses in developing countries. The difficulties of identifying and categorizing indigenous practitioners are outlined. Several strategies are suggested for standardizing, professionalizing, or otherwise mobilizing traditional healers in the movement of achieve the World Health Organization's goal of "health for all by the year 2000". The potential benefits as well as the constraints related to such efforts are described. As examples of what attempts are being made today a link modern and traditional health care systems, programs in the People's Republic of China, India, Ghana, the Philippines and Indonesia are summarized. The paper concludes with some recommendations as well as some predictions for the next 20 years.

Community Health Education in Rural Ghana: The Danfa Project-an Assessment of Accomplishments.

The Danfa Comprehensive Rural Health and Family Planning Project was a joint effort of the Ghana Medical School, the Ministry of Health, UCLA, and USAID. A health education component was developed as an integral part of program inputs during the initial conceptual phase of the project. As a result non-equivalent experimental and control areas were designated permitting an assessment of program impact during a five-year period (1972-1977) for which baseline and follow-up study data were available. A new cadre of community-based workers (Health Education Assistants) was developed from existing health personnel in the country, and trained in health education and multipurpose health work. Although the HEAs were found to have difficulty in bringing about changes in health practices when other support services were not available, they did have measurable impact on villagers' adoption of family planning methods and a number of specific health practices.

Self-care in rural areas of India and Nepal.

Self-care during illness and pregnancies by individuals and their families is a ubiquitous and integral part of societies throughout the world. This paper reports findings about self-care practices identified during four studies carried out over a ten-year period involving about 14,000 interviews in 7,400 households comprising over 48,000 people in three Indian states and three districts of Nepal. The proportion of ill individuals using self-care over a two-week period in the different study areas ranged from 19 to 42 percent. This involved 5 to 9 percent of the total population in self-care activities during these two weeks. Much larger differences were found between India and Nepal in the use of self-care during pregnancies. Self-care or care by relatives and friends was the predominant source of maternity care in Nepal, including deliveries, while Indian maternal care was dominated by traditional birth attendants. Comparisons also were made between self-care and the use of professional healers or health care services during the same time period. Differences in the use of self-care by age, sex, caste, access to government or special project services, type of illness, and duration and severity of illness have also been shown. The need for similar, better standardized surveys in combination with intensive studies examining the details and rationale behind self-care practices in different societies has been stressed as an essential step in developing programs to expand or modify self-care practices of individuals and their families.

The training of traditional birth attendants in Ghana: experience of the Danfa Rural Health Project.

Three quarters of deliveries in Ghana are still attended by untrained personnel, including traditional birth attendants (TBA's), and maternal mortality remains high. The Ministry of Health is exploring ways of improving this situation. Recently, training traditional birth attendants to improve maternal and child health practices and promote family planning has been considered. Most TBA's in rural Ghana are elderly illiterate farmers. The Danfa Project has identified and trained 57 of these TBA's with the objective of developing a programme that might be replicated elsewhere in the country. This paper describes the design of the programme and problems encountered and makes recommendations to others who may be considering similar programmes in other countries.

PIP: 57 traditional birth attendants were identified and trained by the Danfa Project in rural Ghana in an effort to improve maternal and child health practices and promote family planning. A plan was also developed for follow-up and continuing education of these traditional birth attendants (TBAs). The Danfa Comprehensive Rural Health and Family Planning Project is a 9-year research, service, and teaching project undertaken jointly by the University of Ghana Medical School and the University of California at Los Angeles. The following objectives of the TBA training program were defined: 1) to motivate and train the TBAs to monitor women during the antepartum period and to recognize and refer high risk woman or those with serious complications of pregnancy or delivery; 2) to train the TBAs to perform safer deliveries; 3) to train the TBAs in the proper care of the cord; and 4) to enlist the aid of the TBA in the promotion of improved maternal and child health practices and family planning in their villages. The syllabus - outlined here - emphasizes the teaching skills which are needed to meet the stated objectives. The most important aspect of the training program is the continuing support and supervision of the trained TBAs. Problem areas of the program are related to supervision, transportation, non-participation, age of the TBAs, and remuneration. The following were included among the recommendations to those contemplating the training of TBAs in Africa: 1) training should be continuous; 2) emphasis should be on motivating the younger TBAs and those who perform the greatest number of deliveries; and 3) the training program should be simple and emphasize only those basic scientific midwifery skills which would help the TBAs gain self-confidence and make deliveries safer.

The Danfa family planning program in rural Ghana.

PIP: The objectives of the Danfa Family Planning Program in rural Ghana are to provide family planning services to the people in the region and to conduct research into ways of making these services as effective and accessible as possible within given resource limitations. The effort is made to describe the planning and operating experience of the program during its 1st 2 1/2 years. In order to test the hypotheses and satisfy service, research, and teaching objectives, the region in which the project operates was divided into 4 areas with each area receiving different service inputs. This division was related to the following arguments with the 4th area used as a control area to learn how much family planning occurs in the absence of special health, education, and family planning programs: 1) couples will want to limit the number of their children only if they perceive that they need no longer fear that several of them will die before reaching adulthood; 2) the most cost-effective approach is to provide family planning services in conjunction with an intensive educational program promoting good health practices and family planning but without comprehensive health services; and 3) by amking family planning services available without concern for comprehensive health services or a special education program, adequate acceptance of family planning and a favorable fertility change at minimum cost will be achieved. The 4 research areas covering about 200 square miles are located in a rural region 8-50 miles north of Accra, the capital of Ghana, and have a population of 60,000. It was learned that it is easier to operate a family planning program in this region of rural Ghana than had originally been anticipated and that education about the benefits of family planning and the methods available along with accessibility to services are 2 elements that are crucial to the success of a family planning program in this setting.^ieng

Comparison of morbidity interviews with a health examination survey in rural Africa.

This paper describes a study of the Danfa Comprehensive Rural Health and Family Planning Project, Ghana. The report compares information obtained from morbidity interviews with information obtained during subsequent health examinations. One to 4 days prior to examination by a team of physicians, 3,653 rural Ghanaians were interviewed by a team of auxiliary workers. Information obtained from the interview survey was noticeably different from examination diagnoses. Significant health problems such as malaria, intestinal parasites and diarrhea, as well as minor and chronic conditions were seriously under-reported. Interview findings were more accurate for children, women in the reproductive age group, and in cases in which the disease caused considerable discomfort or diability. Although individual examination was eight times as costly as an interview, small scale rural health examination surveys of a representative sample of the population are recommended to provide accurate morbidity information for health planners.

A household morbidity survey in rural Africa.

A household morbidity interview survey with 2,000 randomly selected households (14,729 people) in rural Ghana is reported for a two-week recall period; 20-8 percent of people reported some illness, injury or disability. This prevalence is lower than reported during surveys in Columbia, USA, Britain and Australia. Adults averaged 0-5 days lost from work, which results in an estimated annual work loss of 13-4 days. The reported illness varied markedly with age, with a peak in middle-aged adults and females in their reproductive years. The use of clinic services varied with age (they were sought particularly for pre-school children), type of condition, and accessibility. The use of drug sellers was surprisingly high, about half that of clinic attendance, and increased in those geographical areas where clinics were least accessible.

Health information system installation: principles and problems.

Many studies have been done to identify health problems and practices and to obtain knowledge of the characteristics of the population. Often specific data desired by the investigators are not available at the time of final analysis. This paper emphasizes the importance of planning and designing the system for recording and processing information together with the planning and development of the program or project. Principles that were applied and problems that occurred in demonstration projects in developed and less developed countries are described. Some examples of applications to improve the health services for the rural dewellers in a less developed country are illustrated. The methodology evolved has broad application and may be useful to others who have needs for data on an ambulatory population.

Attitudes and practices of traditional birth attendents in rural Ghana: implications for training in Africa.

PIP: In the Danfa Project area of rural Ghana a survey of the characteristics, attitudes, and practices of traditional birth attendants was conducted. In 1973, 6 months following the start of the family planning program, a questionnaire was administered to a sample of the traditional birth attendants registered. Interviews were carried out in the local language by public health nurses familiar with the area. 82 interviews were completed. Differences in interview responses between areas were negligible and combined results are reported for the 3 areas surveyed. There were 2 types of traditional birth attendants -- herbalists who engaged in midwifery as only part of their medical practice and those who limited their practice to midwifery. The traditional birth attendants usually gave correct or neutral advice and most recognized the benefits of rapid referral to hospitals for seious problems. They were supportive of family planning and very interested in improving their skills. However, a number of factors must be considered in organizing training programs. Special adult educational methods must be used. In order to achieve adequate coverage 1 must train large numbers of traditional birth attendants who perform an average on only 7 deliveries per year and who are widely scattered in remote rural villages. This creates extensive problems, particularly in transportation and follow-up supervision. Combining training of traditional birth attendants with other village health programs or community development projects could be the answer.^ieng