Counselling improves the quality of service and builds up the confidence of patients, which in turn increases motivation in the community to receive eye care services and to accept IOL surgery. Certainly pseudophakic patients are much more satisfied customers than aphakics. This helps the organisation to attain both the trust of the community and financial viability.
Community participation: 'putting the Community into community eye Health'
John Hubley BSc PhD
Health Promotion Consultant
21 Arncliffe Road
Leeds LS16 5AP
UK The challenge of promoting eye health and prevention of blindness can only be met through a change of emphasis towards active involvement of communities in order that:
Persons with early symptoms are ncouraged by their family to attend health 5ervices when their conditions are still treatable.
Patients follow treatment procedures to ensure a full recovery.
Families adopt changes in lifestyle that encourage eye health and prevent eye disease.
Communities take action to improve their environment to reduce risk of transmission of eye diseases and promote eye health.
The community demands that policymakers give priority to improving eye care services.
A community participation strategy should take into account the many factors that can influence community actions. These include ommunity beliefsÄ perceptions and values concerning the cause, prevention and treatment of the different forms of blindness. Of basic importance are the felt needs and understandings and values that the community place on health in general and eye health in particular. A community-based approach should also consider the pattern of influences and decision-making in the family and community including family members, elders, local leaders and traditional healers. These influences are often rooted in local culture and traditional health practices.
Effective action therefore involves moving from a patient-centred approach to one which involves the family and community in making decisions and taking action. Communication and health education are at the heart of this community-based approach which was first outlined in the concept of primary health care that emerged in the Alma Ata Declaration in 1978. The development of community-based eye health promotion can benefit from the successes and failures over the last twenty years of many programmes on other health topics. These have explored a wide range of relevant strategies including: developing village health workers, working with traditional healers, using folk media and drama, social mobilisation and advocacy, self help groups, social marketing and improved patient education.1 Of particular interest are developments in participatory learning and rapid appraisal methods.2-4 These new approaches respect and build on community values and culture and use methods aimed at promoting decision-making skills and community empowerment.
There is an overwhelming need for a community-based approach to eye health "romotion. Most of the methods needed have already been developed for other health topics. The challenge is to apply them to the most important goal of all - the prevention of blindness.
Hubley J. Communicating health: an action guide to health education and health promotion. Basingstoke and London: Macmillan, 1993.
Keehn M. Bridging the gap: a participatory approach to health and nutrition education. 54 Wilton Road, Westport, Connecticut 06880, USA: Save the Children, 1982.
Welbourn A. RRA notes 16: Special issue on applications for health. n: International Institute for Environment and Development, 1992; 1-115.
Pretty JN, Gujit I, Thompson J and Scoones I. Participatory learning and action. London: International Institute for Environment and Development, 1995; 1-265.
Brendan Dineen BA BSc MPH
Senior Research Fellow
International Centre for Eye Health
Institute of Ophthalmology
University College London
11-43 Bath Street
London EC1V 9EL
'Never underestimate the power of individuals to change the world - indeed that is the only way it happens' Margaret Mead In 1986, an international conference was held in Canada that reunited government health representatives from nearly all the world's countries. This event signalled the formal recognition of the concept of 'health promotion' as expressed in the unanimously agreed 'Ottawa Charter for Health Promotion'.1 Following the 5eclaration on primary health care of Alma Ata in 1978, the Ottawa Charter signalled a Áecognition of the many aspects and influences concerning health and illness, not only as applied to industrialised but also, importantly, in the so-called 'developing countries' of the world.
The Ottawa Charter and Health Promotion
The Ottawa Charter, as a strategic document, outlined the five key practical elements that are included in health promotion (See Table):
Healthy Public Policy.
Personal Skills Development.
Healthy and Supportive Environments.
Re-organisation of Health Services.
Community Participation and Eye Care Programmes
This article focuses on the role of active public participation in community eye care programmes, particularly in developing countries. It should be pointed out, however, that the potential success of health promotion in practice is closely associated with a comprehensive approach that integrates as many of the five components of health promotion as possible.
As described in the Ottawa Charter, 'community participation' is relevant in the process of empowerment and increased involvement of the members of communities. This relates to problem identification and decision-making, collaboration in lanning for health care delivery and, inally, active participation in the implementation of health care programmes - essentially local control of services to improve the health of individuals and of communities.
While it may be generally understood what 'community participation' refers to, in practice it is important to recognise that community involvement invariably differs from one setting to another. The reasons for this are many but principal amongst them are the socio-cultural, economic, geographic, educational and gender differences which exist across specific settings. More importantly, with reference to eye care issues, the nature and types of the eye diseases from one area to another influence the type and degree of local involvement in eye care services. Two particular, though differing case studies of effective community participation in eye care, are reported from Uganda and India. The western Uganda ivermectin distribution Erogramme involved community members in the control of onchocerciasis2 and, in India, the incorporation of community members in rural appraisal surveys identified factors concerning barriers to and up-take of eye services in rural communities.3 The benefits of community participation from these two examples have been demonstrated - in Uganda, by decreased per-person treat-ment costs, increased ivermectin coverage, increased collaborative integration between health authorities and community structures and, in India, by increased understanding of the barriers to up-take of services, "specially for cataract surgery.
Additional benefits of community participation in health-related issues cited in relevant literature include:
the increased sense of responsibility and control over individual health and that of the community.
impowerment of individuals through increased knowledge, awareness and the development of new skills through participation.
greater understanding of local conditions.
the appropriate and effective incorporation of traditional, indigenous experience in eye care service delivery.4
Finally, the increased accessibility and up-take of eye care services can be positively affected through increased community involvement, particularly relevant in the desirable reduction of preventable blinding conditions such as cataract.