STUDY

Health Education in India

Governments, media, academic institutions and NGOs, have to work in close collaboration to give India an effective health education  system, write Dr  B P MAHESH CHANDRA GURU, SAPNA  M S and MADHURA VEENA M L

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Health is everyone's concern.  It is also an important component of human resources development.  Health goes hand in hand with social-economic development.  The Health for All strategy calls for concerted action in all sectors and demands coordinated efforts to enlist active people’s participation in the process of health management.  It is the responsibility of the state to ensure health for all.  Health development is indeed a multi-dimensional activity.

Health education is a fundamental necessity in a welfare state.  People need health education consistently.  Formal programmes in health education did not develop until recent times in India and other developing nations. The International Union for Health Education has stated its position on school health education in a policy paper thus: “Any subject, whether AIDS or tobacco or nutrition is best taught not as a single stand-alone course, but rather within a more comprehensive school health education programme that provides planned sequential education about health at every grade level, that focus on behavioural skills (e.g. decision-making, communication skills, negotiations skills etc.) and that consequently establishes a foundation for understanding relationship between personal behaviour and health” ¹. 

CONCEPT OF HEALTH
The subject of health is widely discussed throughout the world.  Health is not a gift that is bestowed by any supernatural power.  ‘Health’ is an Anglo-Saxon term which means the condition of being safe and sound or whole.  According to Goetz Philip, the term ‘health’ comprises the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity ².  Health is earned by the people through conscious, planned and sustainable efforts all through the life.  Ruslink Doris emphasizes the role of family in health management thus: “The family which regards good health as a precious possession takes precautions to protect it and to avoid those conditions which may jeopardize it.  Such a family safeguards the health of each member in many ways by providing a healthful, happy home environment, a well balanced diet, a good balance of work, rest and recreation, by having periodic health and dental check ups and by taking immunization measures” ³.  The state has an obligation to ensure  enjoyment of the highest attainable standards of health as one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social distinction.

CONCEPT OF HEALTH EDUCATION
Health education is a term commonly used and referred to by health professionals.  Health education is indispensable in achieving individual and collective health.  There is no single acceptable definition of health education which is normally perceived as an instrument of changing attitudes and behavioural patterns of people toward attaining better health status through adoption of health innovations and practices which are tested and tried.

World Health Organization defines it thus: “Health education is the part of health care that is concerned with promoting healthy behaviour” ⁴.  Health education is the translation of what is known about health into desirable individual and community behaviour patterns by means of an educational process ⁵.  John M Last defines health communication as "the process by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance or restoration of health” ⁶.  Green L W observes: “Any combination of learning opportunities and teaching activities designed to facilitate voluntary adaptation of behaviour that are conducive to health” ⁷.  The definition adapted by the National Conference on Preventive Medicine in USA reads: “Health education is a process that informs, motivates and helps people to adopt and maintain healthy practices and lifestyles, advocates environmental changes as needed to facilitate this goal and conducts professional training and research to the same end” ⁸.  Thus, health education encompasses all strategies and activities which are meant of the attainment of better health status of the people. 

FUNDAMENTALS OF HEALTH EDUCATION
Health education is required to increase knowledge and to reinforce desired attitudinal and behavioural patterns concerning health management of individuals as well as communities.  The Alma-Ata Declaration (1978) emphasized the need for individual and community participation in the process of health education.  It has also revolutionized the concepts and aims of health education.  Following the Alma-Ata Declaration the emphasis has shifted from prevention of disease to promotion of healthy life styles; the modification of individual behaviour to modification of ‘social environment’ in which the individual lives; community participation to community involvement; and promotion of individual and community ’self-reliance’.  It also provides a useful basis for formulating the aims and objectives of health education which may be stated as follow:

1. to encourage people to adopt and sustain health promoting life style and practices;

2. to promote the proper use of health services available to them;

3. to arouse interest, provide new knowledge, improve skills and change attitudes in making rational decisions to solve their own problems; and

4. to stimulate individual and community self-reliance and participation to achieve health development through individual and community involvement at every step from identifying problems to solving them. 

Health education includes the regulatory approach, service approach, health education approach and primary health care approach.  The regulatory approach involves governmental intervention designed to alter human behaviour through regulations ranging from prohibition to imprisonment.  This approach seeks change in health behaviour and improvement in health through a variety of external controls or legislations.  The service approach involves providing necessary health services needed by the people as and when required through the spirit of volunteerism or social obligation.  The health education approach involves changing the behavioural patterns of the people through planned learning experiences without conflicting with the masses.  The primary health care approach involves enabling individuals to become self-reliant in matters of health.

The scope of health education covers every aspect of individual health, family health and community health.  Health communication essentially involves individual approach, group approach and mass approach which are universally witnessed.  The contents of health education include human biology, nutrition, hygiene, family health, disease prevention and control, mental health, prevention of accidents and so on.  The principles of health education include: volunteerism, dedication, determination, drive, comprehension, experimentation, reinforcement, achievement motivation, participatory approaches, leadership development, social activism, persuasive efforts and so on.

Health communication planning involves the various stages such as, 1. identifying the health problems and health needs, 2. understanding the communication resources and requirements in tune with the health project, 3. identification of the priorities, 4. setting communication  goals, 5. assessment of communication resources, 6. mobilization of communication resources, 7. planning communication activities, 8. implementation of communication plans, 9. monitoring and  evaluation of communication programmes and 10. reassessment of the communication programmes. 

HEALTH EDUCATION IN INDIA
Role of Central Government
The Government of India is responsible for providing countrywide education to the people on health care and management.  The Directorate General of Health Services set up Central Health Education Bureau (CHEB) in 1956 to coordinate health education services through various divisions in the country.  The goals and objectives of the division include educating the people about health plans and programmes, training health educators and  workers, supplying health education materials, conducting health research activities, providing technical assistance to government and non-government agencies in the field of health education, developing health education syllabi for different target groups and collaborating with international agencies in promoting health education.  The School Health Education Division of CHEB provides and monitors the centrally sponsored school health service scheme since April 1977 meant for primary school students in rural areas.  CHEB also works with UGC, NCERT, Board of Secondary Education and other agencies in imparting health education by enlisting the participation of universities, colleges and schools.

Role of State Governments, Union Territories
and Local-Self Government Bodies:
School health services are managed by respective State Governments and Union Territories.  The aim of school health programme is to provide comprehensive health care to all school children in both urban and rural areas.  It comprises of medical examination, treatment, preventive medicine, follow-up action, sanitation, hygiene, safe environment and other aspects of health management.  There is a provision for health check-up twice in a year undertaken by government or private agencies under the supervision of a Medical Officer who is in charge of medical inspection.  Medical fee is collected in schools for the purpose of health care which is compulsory.  This arrangement is made with a view to bring about awareness among parents and teachers.  The Primary Health Centers of Karnataka State implement the National School Health Programme.  The local-self government bodies are also involved at the grassroots level health education activities at district, block and village panchayat levels.

Role of Educational Institutions
Health education is indeed an inter-disciplinary  approach which draws contents and initiatives from physical, biological, medical and behavioural sciences.  Health instruction is not considered a part of the total school curriculum.  Health instruction component is missing from primary school to university levels in India.  Formal health education programmes are not designed and implemented in our country.  Significant health aspects such as health care, nutrition, sanitation, hygiene, preventive medicine, community health, environment protection, drug addiction, mental health, prevention of AIDS and so on are not covered systematically by our schools, colleges and universities.  Healthy habits are not cultivated by the students due to lack of health education.  Systematical health instruction is not imparted on mandatory and regular basis.  The students do not get the benefit of incidental teaching on health care resources and methods.  Printed materials, audio-visual programmes, demonstrations, exhibitions, poster campaigns, group discussions, lecture programmes, field trips, health clubs and other health instructional opportunities are not made available to the students at various levels.  Very few health universities and medical colleges are imparting professional health education and training.  Thus, health education in India is not imparted at various levels formally or informally to the best of the satisfaction of students, parents, teachers and other sections of society. 

Role of Mass Media
Mass media like newspapers, magazines, film, radio and television are diffusing health information throughout the country in their own way.  Attainment of health and family welfare needs the presence of informed, active and alive citizenry.   Mass media can play a complementary role in facilitating health for all.  In reality, mass media in India have not accorded a place of pride to health education.

Press 
The print media have played a limited role in promoting health consciousness among the people.  Once in a while reports, articles, features, profiles and other health-centered contents appear in the press.  Occasionally some investigative reports about mismanagement of health sector also appear in the print media.  Health centered advertisements appear in the press regularly because of the economics of advertising.  Some professional journals carry serious write-ups on health management.  Medium and small newspapers and magazines predominantly contain health-centered advertisements.  They hardly provide any worthy writings pertaining to health management.  Thus, print media have not contributed adequate writings in the field of health education mainly due to lack of will, commitment and seriousness.

Film
Film is a powerful medium of communication.  India produces largest feature films, newsreels and documentaries in the world.  Feature films which focus on health management are hardly produced in this country.  The Films Division produces newsreels and documentaries which focus the attention of the audience on health, nutrition, family welfare and environment protection.  These newsreels and documentaries are screened in cinema theatres and non-theatrical channels which include community halls, educational institutions, industrial houses, cultural organizations etc.  These newsreels and documentaries are not regularly screened and discussed in the countryside.  Therefore, newsreels and documentaries mainly cater to the informational needs of the audiences.  They have a limited impact on society from the point of view of health education.

Radio
All India Radio is well known in the world as the largest radio network.  Radio is the only mass medium which is accessible to both rural and urban audiences in plenty.  Radio also provides series of special audiences programmes on variety of subjects including health management.  In the age of television revolution, radio listening habits have reduced to a considerable extent.  Talks, plays, quizzes, question and answer programmes are popularly used in health broadcasting programmes.  Women and children welfare programmes are also broadcast to some extent with a focus on health care.  However, radio programmes too have increased awareness among the listeners on health management.  The time, duration, coverage and quality of health education programmes are not appreciated by the people in large number. 

Television
Television has become the massest of all mass media in India and everywhere.  Doordarshan which is managed by the Prasar Bharathi Corporation provides Information, Education and Communication (IEC) support to Health and Family Welfare through telecasts during different time slots allover the country.  The regional centers telecast video spots and quickies on various aspects of health management.  Special programmes are also broadcast on the eve of women’s day, children’s day, worker’s day, world population day, world health day, no tobacco day, world AIDS day and so on.  Discussions, interviews, quickies, quizzes, special chunks, spots, jingles etc., are broadcast by Doordarshan Kendras with a focus on burning health issues of our times.  The Satellite Instructional Television Experiment (SITE) mainly focused on education, agriculture, health and family welfare, national integration and so on.  Cable TV channels provide programmes and commercials which have limited focus on health education.  TV has not emerged over the years as a prominent medium of health education.  

Role of New Communication Technologies
Telecommunication channels, satellite communication channels and computer communication channels predominantly constitute new communication technologies in the present times.  These technologies have given rise to telemedicine, video conferencing and other latest tools of health communication.  Telemedicine application requires information which include images, voice and digital data created by instruments like electrocardiograph, electroencephalograph, image scanner etc., about the patient which is necessary for diagnosis and treatment.  This information is transported to long-distant places through satellite links, optical fiber links, cables or the Internet.  Doctors can also discuss medical diagnosis and prescriptions with experts in India and abroad through video conferencing which has become an important sector in health communication.  These advantages have enriched the process of health communication in India and elsewhere.  However, these new media have not become true instruments of formal and informal health education in India due to policy constraints.  

Role of NGOs
There are many NGOs operating in urban and rural areas.  They are providing education, training and guidance to the people on various developmental themes including health management.  They are also using multi-media for the purpose of health education.  They include: posters, wall writings, tin plates, lectures, group discussions, seminars, workshops, photo exhibitions, demonstrations and so on.  NGOs are playing an active role in promoting health education in urban and rural areas even under certain constraints and limitations.

FUTURE OF HEALTH EDUCATION IN INDIA
Health education has not been accorded a place of pride in government organizations, non-government agencies, educational institutions and media organizations in India.  The dream of  ‘Health for All By 2000 AD’ has not been translated into a reality mainly due to lack of formal and informal health education in India.  Health education is not managed compulsorily, systematically and meticulously  in India.  The vision ‘Health for All By 2000 AD’ may remain empty and the progress toward that goal tardy if we fail to rejuvenate the health education system throughout the country both formally and informally.  The future agenda for the Central Government, State Governments/Union Territories and Panchayati Raj institutions must deal with the process of people’s participation in health education in which related processes such as evolving a suitable health education policy, developing health curriculum, imparting health education, training health educators, monitoring health education services and achieving the goal of ‘Health for All’ are also addressed at various levels.

Suggestions:  a) A national health education policy is necessary to prepare grounds for nation-wide health education; b) Health education should be accorded a place of pride and treated as an independent subject on par with other subjects; c) Separate communication, training and evaluation division should be created in Health Ministry at National level, state level and grassroots levels; d) Co-ordination committees should be established to implement health education programmes at central, state and grassroots levels; e) There should be region-specific health curricula which fits into ground realities; f) Health educators should be trained and recruited from primary to higher education levels; g) A specialized cadre of health communicators is of utmost importance in mass media organizations; h)  Multi-media campaigns should be envisaged as a holistic approach to health; i) The government media networks should be decentralized with a view to provide sustainable health education services informally;  j) Outdoor media which are more effective channels of health education especially in rural areas should be utilized adequately for health promotion; k) Newspapers and television which are accessible to a majority of people should get government sponsored health advertisement among mass media; l) Health education messages should be formulated by experts in communication.  Using simple language, authentic facts, local idioms and phrases and attention compellers can enhance the quality of health messages; m) Formal evaluation of health education services is required at various to felicitate better modifications; n) Media institutions could be persuaded to provide adequate health education services regularly on a priority basis by increasing time and space; o) NGOs should also actively participate in health campaigns by providing adequate publicity and advertising support; p) Policy makers, health administrators, media professionals and academicians can be involved in directing health communication services. 

CONCLUSION
The policy makers, health administrators, health educationists, media owners and professionals and organizers of NGOs have to accord a place of pride to health education which is a neglected sector.  Health education  must emerge as a critical factor in the process of health development in particular and national development in general.  Compulsory health education will go a long way in improving the health status of people.     So long as health education  remains neglected, the dream of ‘Health for All By 2000 AD’ would remain unfulfilled.   As Michael Traber once observed, people cannot develop or attain their full potential if they are cut off from communication ⁹.  The government, media institutions, academic institutions, NGOs, research and development organizations have to work in close collaboration toward designing an effective health education  system in the country.                                          

REFERENCES:

1. Hygiene; The International Journal of Health Education, 1988.

2. Philip, Goetz (1989); The New World Encyclopedia Britannica Inc., Vol 12, p. 257.

3. Doris, Ruslink (1963); Family Health and Home, Mac Millian Company, New York, p.11.

4. WHO (1988); Education for Health; A Manual on Health Education in Primary Health Care, p. 9.

5. NIHAE; A Guide to Communication System in Hospitals, Technical Report 16, Glossary, p. 33.

6. Last J M Dictionary.

7. Green L W (1979); International Journal of Health Education, 22 pp. 161 – 168.

8. Somers, Anne R (1977); Preventive Medicine 6(3) 406.

9. Villanilam, J V (2002), The Media and the Environment, Journal of Communication Studies, Vol. No. 2 Grishm (Summer) April – June 2002, pp. 91-92.

Dr B P Mahesh Chandra Guru is Professor & Chairman, Department of Communication and Journalism, University of Mysore.  Sapna M S is a lecturer and Madhura Veena M L a UGC Junior Research Fellow in the same department