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Memórias do Instituto Oswaldo Cruz
Fundação Oswaldo Cruz, Fiocruz
ISSN: 1678-8060 EISSN: 1678-8060
Vol. 90, Num. 2, 1995, pp. 229-234
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Memorias Instituto Oswaldo Cruz, Vol. 90(2):229-234
mar./apr. 1995
Health Education, Public Information and Communication in
Schistosomiasis Control in Brazil: a Brief Retrospective and
Perspectives
Virginia T Schall
Laboratorio de Educac o Ambiental e em Saude, Departamento de
Biologia, Instituto Oswaldo Cruz, Av. Brasil 4365, 21045-900
Rio de Janeiro, RJ, Brasil
Code Number: OC95046
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In recent years, the strategy for the control of
schistosomiasis has placed increased emphasis on the role of
health education, public information, and communication. This
should, not only bring about specific changes in behavior
aiming at disease prevention, but also stimulate participation
of the community in health programs. Beyond this, it is
desirable that both community members and researchers should
seek better life conditions through a transformative social
action. The present paper adresses these concerns; first, by
critically reviewing some health education programs that were
developed in Brazil, and, secondly, by analyzing and
suggesting ways to improve this area.
Key words: schistosomiasis - health education - information -
communication
As schistosomiasis control strategies presently emphasize man
in lieu of other elements of the transmission chain, the
importance of information to populations in endemic areas must
never be underestimated, paying attention to a progressive
point of view.
Since 1984 morbidity control has been receiving greater
emphasis by the WHO (Technical Report Series 1985, 1993),
which should stimulate primary health care programs. These
programs "has placed increased emphasis on the role of health
education and safe and adequate domestic watter supplies, as
well as sanitation, in the maintenance of control of
schistosomiasis"(WHO 1993), which all require the
participation of the population and the essential circulation
of information.
Schistosomiasis, which is generally restricted to populations
of the less affluent classes, is related to poor life
conditions, to areas lacking basic services, and to lack of
information and instruction. In these conditions people
become infected through water-linked activities, such as work,
personal hygiene, laundry, fishing and recreation. The
scarcity of latrines enhances transmission probabilities
through indiscriminate defecation habits, generally carried
out close to water bodies.
Education, information and communication strategies in control
programs should, therefore, not only bring about specific
changes in behavior aiming at disease prevention, but also
stimulate participation of the community in health programs.
This participation should thus promote a wider consciousness
of the biosociocultural factors involved in the transmission
of the disease, which would constitute a transformative social
action searching improvement of life conditions.
TRADITIONAL INFORMATION AND PARTICIPATORY
INFORMATION
Historical background - Historically, the control of
schistosomiasis in Brazil has been largely associated with
chemotherapic measures, either in the treatment of patients or
in the eradication of vector snails of schistosomes. Although
sanitation and sanitary education have always been pointed out
as fundamental prophylactic measures in order to eliminate the
disease (Barbosa 1975), they have actually never been
extensively and continuously carried out.
Since the sixties, control campaigns in Brazil have emphasized
integration of health education with other measures. However,
a great distance remains between planning and the actual
execution, which has been concerned with immediate targets and
which has been vertically carried out through traditional
techniques.
A dearth of publications exists, dealing with educational
actions and information in the control of schistosomiasis.
Among the articles reviewed that of Garcia (1966) stands out
for its modern theoretical approach and for its consciousness
of the limits to the execution of measures, which is hampered
by discontinuous government policies. This author focusses
her attention on the following roles of the educator: as the
investigator of human factors pertinent to schistosomiasis
epidemiology; as coordinator of the planning, production and
evaluation of educational material through the lens of current
communication theories; as evaluator of working procedures,
including creation of comparative pilot projects and control
of intervening variables; as evaluator of methods for training
auxiliary personnel in schistosomiasis campaigns and
technicians in the area of education and communication.
However, only a reduced number of practical educational
actions reflects these intentions so widely and clearly. Such
is the case of the excellent work by Hollanda (1958), which
was carried out in northeast Brazil, and which ranks among the
best ones of its time, according to the WHO. A 1958 report by
Hollanda reveals her wide vision and experience in the
prevention of schistosomiasis. Although her emphasis is laid
on behavior, as recommended by specialized literature, she
also committed herself to social issues and the importance of
participation of the population in control programs. She
further examined the theme of disease, associating it with (1)
patterns of adaptation to the environment; (2) socioeconomic
organization and means of subsistence; (3) conceptions of
reality and the system of knowledge and ideas about nature;
(4) relationship modes between different social groups; (5)
mentality and characteristic attitudes of the dominant
classes.
Quoting her work on communities in endemic areas:
"Restructuring of behavior which conditions schistosomiasis
and other verminous diseases proceeded not only through the
impact of new knowledge and conceptions of nature, but mainly
through psychologically satisfactory participation in socially
prestigious activities, through which the population developed
itself and the community organized itself for the solution of
its basic problems.
Since then the limits of health education work have been
reported, which are imposed by economical circumstances of the
study areas and by structure, resources and orientation of
medical and educational care services in endemic areas."
(Hollanda 1958).
Garcia (1966) refers to economical circumstances of
populations stricken by schistosomiasis and the role of
information to them: "What use would health be to people who
are totally excluded from developing areas in the country; who
are doomed to illiteracy, to famine, to slave work and
unemployment; who can only resort to magical healing practices
in case of disease and who attribute it to supernatural
causes?... Disease may even be an excuse to failure in life
when it is used as a defense mechanism."
Educational actions in the seventies and eighties -
Although, even nowadays, these questions pose an enduring
challenge some successful undertakings are herein reported.
The Project for the Environmental Control of Schistosomaisis
(1970), for example, was carried out in Calciolandia, Arcos,
State of Minas Gerais by a multidisciplinary team of
researchers of the Centro de Pesquisa Rene Rachou (Fundac o
Oswaldo Cruz) and of SUCAM (Superintendncia de Campanhas -
Ministry of Health). After identification of ecological and
behavioral factors linked to disease acquisition, educational
action included an initial identification of knowledge modes
of the population on schistosomiasis. This enabled workers in
the project to (a) help people understand what happened in the
region in terms of intestinal parasitic diseases and other
water-transmitted diseases, able to be controlled by basic
sanitation (adequate water supply and proper sewage
facilities), and (b) develop attitudes involving
responsibility relative to individual and collective health.
Research work was carried out through individual contact and
group meetings, when many resources were utilized, such as
films, slides, display of affected and non-affected mice
livers, live vector snails, discussion and question-answer
practices. Some documents with prevalence rates before and
after the program were also distributed, which should
stimulate maintenance of disease control. An educational staff
bridged contacts between the population and health personnel.
Their action included stimulation of the movement towards
building of the regional leisure center, of a swimming pool
and other facilities for the population.
Of major importance in this experience was the consideration
of knowledge varieties among community members and their
possibilities of transforming reality. This would be possible
through new knowledge about the disease and its association
with environmental changes which would allow confirmation of
acquired behavior patterns.
Although this has been a successful project, with a
significant decrease in prevalence levels, it was only an
isolated experience. Considering the national context, the
Ministry of Health has concluded that up to the mid-seventies
control efforts in Brazil "have failed to stop expansion of
schistosomiasis southwards and to avoid the risks of its
reaching the Amazonian region." (Coutinho & Pimont 1981). This
inspired a new model of fight against the disease, in which
sanitary, as well as medical and educational, actions were
associated, leading to the creation, in 1976, of PECE
(Ministry of Health s Special Program for Schistosomiasis
Control).
Besides traditional control measures (treatment of patients
and control of vector molluscs) the objectives of this program
included improvement of basic sanitation conditions and health
education actions.
The health education program was centered on behavioral
objectives, aiming at a change of habits, as well as on
conceptual objectives, through comprehension of basic notions
about schistosomiasis, aiming at adoption of behavior patterns
relevant to control.
Mass-media (MM) broadcastings were among the information
activities developed, as well as the use of amplifiers,
distribution of some publications to the general population
and organization of lectures and film projections to
previously constituted groups. Other materials were produced,
such as posters, folders, the documentary film "O Mal do
Caramujo" - The snail and illness - , records and cassettes
for radio and loudspeakers use and slide series. Specific
resources were also distributed in schools, such as "Rules and
instructions for school health agents, small biographies of
great sanitarians, cartoons, album and a reference guide of
instructions to the teacher". (Coutinho & Pimont 1981).
The great effort spent on development and use of various
methods and materials did not prevent the occurrence of
"discrepancy, among population members, of what is known, on
one hand, and what is done, on the other." (Coutinho & Pimont
1981), which was observed in Touros (State of Rio Grande do
Norte), one of the areas under the action of PECE. As the
authors explain, "the transmitted message is of apparently no
use in an environment where it is utopian to expect that
people avoid the same waters upon which they take their
subsistence and where they have their leisure". Environmental
alterations are thus necessary, which are associated to
acquired knowledge and which allow for new alternatives to old
practices. Moreover, educational processes should be cahara-
cterized by participatory communication, in which the teacher-
as-informer is turned into teacher-as-amuser, and the pupil-
who-hears into pupil-who-investigates. This is a shared point
of view among most authors who deal with educational practice,
be it general or specific, as is the case of health
education.
As recommended by Maria do Carmo (1987), it is necessary to
ask and hear what the population has to say in order to
develop joint creative actions. These actions would combine
scientific and technological knowledge with life knowledge of
the population, aiming at more realistic and appropriate
solutions.
As observed by Loureiro (1989) in regard to current trends in
health education, emphasis of the educational process shifted
from a search of change in behavior to conscious participation
of individuals as part of their social group. This has been
demonstrated by that author s practical experience, in which
popular culture is emphasized, to the point of constituting
the axis of the integrated process of education, participation
and organization (Cadernos de Educac o no. 2, 1985).
NEW PERSPECTIVES IN HEALTH EDUCATION - CONSIDERATION OF
POPULAR KNOWLEDGE AND COMMUNITY PARTICIPATION
Progressive awareness of social aspects revealed the
inadequacy of traditional education in relation to (a) its
political character, unconnected to the populations' own
concerns; (b) its technical character, unable to promote
changes in attitude, by resorting only to vertically
transmitted scientific knowledge; (c) historical inertia,
which is reflected in outdated educational practices and
programs.
According to Nascimento and Rezende (1988) "The
inoperativeness of traditional health education methods, which
is reflected in skepticism and passivity demonstrated by the
population in relation to formal orientations, conceals a
resistance to inculcations and to alienating scientism, which
is only able to prescribe purported solutions".
Effective health education requires that a) popular knowledge
and its practices be recognized in order to be used in the
search for solutions to the populations problems; b)
technical and scientific knowledge be updated, and c) emphasis
be given to health promotion and improvement of life
conditions. This calls for critical perception of the
educator, as well as an expertise in the subject area and
inherent motivation for his (her) work.
It is necessary that the educator not indulge him (her) self
on being a mere informer, or helping the needed on a
paternalistic basis. Rezende (1984) urges one to abandon
messianism practiced by angel-like people towards the poor,
which simply reveals a domineering relationship. This tends
to include teaching of health care practices, to underestimate
popular knowledge, and to consider technical knowledge as
inaccessible except to themselves. The educator thus enforces
the great internal contradiction of the system, i.e., by
ignoring knowledge derived from popular practices he also
denies access of the dominated people to technical resources
and to so-called scientific practices.
As regards schistosomiasis, community participation in the
information and communication processes is a priority.
Community participation implies self-responsibility for health
aspects, which is expressed through some activities linked to
improvement of life conditions and to well-being. Tanner et
al. (1986) state that community participation in
schistosomiasis control is only possible either when the
population sees in this disease a health problem, or when it
identifies the influence of the disease on its well-being, for
example, when it affects the population's productivity or
economic and social development. If disease is considered a
priority to the population, then it will turn into a dynamic
question for the development of the community.
Consciousness-raising about the importance of schistosomiasis
may be attained through information and communication
processes. If knowledge is to be conquered by the population,
it is necessary that the latter participates in its diffusion,
in the preparation of materials, or in the use of them. What
counts is the adequacy of the language and the means through
which information is diffused in the sociocultural context of
the chosen population. Also important is that the relationship
between disease and life conditions of the community be
understood, so that scientific as well as popular knowledge
may mingle. It is thus expected that these conditions help
individuals of the population understand disease as an
expression of multiple factors, especially of socioeconomic
and cultural nature. As a result, it is also expected that
the population participates in the organization and
implementation of transformative actions on the adverse
conditions associated to disease.
HEALTH EDUCATION FOR CHILDREN - INFORMATION AND
COMMUNICATION PROCESSES IN SCHOOL
Children and adoles cents represent an important population
sector in transmission and maintenance of schistosomiasis in
endemic areas in Brazil. Epidemiological studies show high
prevalence rates in the 6 to 20 year-old age group (Castro-
Filho & Silveira 1979), as well as higher percentages of
treatment resistance and higher rates of Schistosoma
mansoni egg elimination, when compared to adults (Katz et
al. 1978). Moreover, this population sector is more
frequently exposed to lake, stream and river waters,
especially where no other leisure alternatives exist.
Moreover, this sector does not understand what are the
consequences of indiscriminate defecation habits, which
happens more frequently than among the adult sector of the
population. Physiology and behavior contribute thus to the
active participation of children in the maintenance of the
transmission cycle of schistosomiasis.
A suggested means of reaching a greater number of children is
to include information about the disease in school programs.
The educational process in schools has more chances of
attaining continuity and consistency than information programs
adopted in campaigns. These programs are usually of a
transient nature, employing MM resources in a vertical manner,
having a lower effectivity.
Considering the low instruction levels of the majority of the
Brazilian population and the high levels of school evasion,
the greatest probability of finding a child at school is
restricted to the first grades of elementary school, when
health education is most important.
As demonstrated by Werner and Bower (1985), children act as a
bridging element towards their families and the rest of their
community, to which they retransmit learned knowledge. In
some of these cases effective changes are observed.
In order to be effective, information and communication
processes must take into account the reality of students and
their community, as well as their habits, beliefs, cognitive
characteristics, motivation and concerns. These processes must
also pay attention to children and adolescents development
phase, investigate their intuitive concepts about health and
disease, and their perception of reality, so that no conflict
or inoperativeness of information follows.
Investments on development and training of teachers is also a
priority, in order to attain efficient and lasting educational
actions. These investments would also stimulate the onset of
a critical consciousness. Only the teacher - and not anybody
from outside the community - may deflagrate an informative and
formative process through a politically-oriented work, since
"learning about health is learning about living" (Hollanda
1981).
Experience has demonstrated that training courses which
include both theoretical classes and practical activities are
most effective. Thus, basic contents on disease must be
attached to texts dealing with the relationships between
students and teachers, as well as to educational methods and
to use of artistic and cultural resources. After each unit
teachers should report how to teach on health topics through
the use of different creative activities, such as games,
story-telling, dramatizations, puppet shows, other types of
shows, excursions and handicraft techniques, all of which
related to community health questions, schistosomiasis
included (Schall et al. 1987, 1993).
It is important to stimulate teachers to plan and carry out
practical projects in cooperation with the students, since by
establishing close communication with the community the
information process would be more concrete.
Teachers should yet be warned about the need to amplify
information about health and disease and to orient it towards
the search for collective solutions, if the relationships
between man and nature, and mankind are to be taken into
account.
An amplified health education considers the individual as an
ecosystem, or a microcosm. His (her) body is an environment
where populations of microorganisms live in close
associations, constituting a microbiota. Disease happens
whenever there is a disruption or imbalance of these biota
elements, including the social context.
If one considers an individual as an ecosystem that is
integrated to the total environment, this individual will only
develop values, attitudes and positive actions towards this
environment after he (she) has developed them towards him
(her)self.
It is thus vital to stimulate in children a positive self-
image since early childhood, leading them to value themselves
and to perceive themselves as part of a wider context. They
should also understand that to every action by themselves a
reaction ensues, either from somebody else, or from the
environment.
Knowledge of facts and concepts about the environment is an
aid to attain understanding and to develop positive attitudes
in the scope of social consciousness. These attitudes, in
turn, will affect necessary actions of behavior towards the
total environment and towards the disease in question,
accomplishing the educational process.
MASS MEDIA AND OTHER MATERIAL RESOURCES
Besides the fundamental role played by school on health
education, MM have been amply utilized in the global process
of health promotion.
Experiments have demonstrated that some changes in health
attitudes, such as quitting smoking habits, diet alterations,
may be attained through the intervention of MM. This points
to the need of immediate environmental support, i.e., the
environment must offer opportunity and support in order to
effect and sustain behavior transformation. Otherwise, there
will only occur a cognitive change, with no translation of
information into action. In this case the educational
proposal fails in its final objective, and cognitive
dissonance ensues.
Before television is used in informative campaigns an
evaluation should be made, which would take into account the
percentage of the population who has TV sets, as well as the
target age group, hours and days of the week when TV watching
is most frequent, favourite TV programs, traditions and
beliefs, or otherwise stated, popular knowledge which may
interfere in the health education process. In Egypt, several
short (2 min) health education films have been made featuring
well know Egyptian actors. Since these films have been shown
regularly on national television, the number of children being
examinated annually, has doubled (WHO 1993). This was a well
succeded communication strategy that was followed by a
positive change of actitude of the population improving the
disease control.
Besides being carefully planned, the communication process
must be continually evaluated in order to check the effects
and interactions taking place, as well as feedback from the
target population, its acceptance and response to the
introduced program.
Participation of professionals of various areas, such as
scientists, technicians, educators, social workers,
communication specialists and population representatives is
fundamental to preparation of any program, so that information
on health aids in better life conditions. The integration of
different professionals may avoid common distortions, which
occur in programs prepared by scientists who ignore MM
language, or in "translations" of scientific information by
communication technicians who ignore Science's rules.
CHOOSING THE BEST STRATEGY AND FINAL COMMENTS
Since Brazil is a developing country the role of communication
technology is questioned because a great proportion of the
population is not yet ready to fully understand the effects of
this communication. As regards information about
schistosomiasis it remains to be defined the best medium
through which communication may proceed. The following
questions should be addressed, though, in order to establish
the best method: what for?, why?, under what conditions?,
who?, through what means? and what action forms?
Camargo (1985) argues that no previous answers exist, each
case requiring a careful analysis. A diagnosis of the
situation is also required, so that planning alternatives may
be produced and the most appropriate communication strategy be
selected.
As regards schistosomiasis, MM capable of combining
information with entertainment may, in the case of being
adequately carried out, contribute to the development of
attitudes, especially among children, through simultaneously
informative and formative messages. This is the basic trend
of the project "Ciranda da Saude", which employs pleasant
texts and amusing activities in schools, with promising
results (Schall et al. 1987,1993).
Information which stimulates discussion among adults may lead
to alternatives to solution of problems and decision-making
processes, bringing up new elements formerly ignored or
unrelated to disease.
Considering the high percentage of adult illiterates in
endemic areas, some materials have proved to be efficient in
communication processes, as pointed out by Favero (1984).
Among these materials rank (a) posters, considered the best
communication medium in rural areas, and capable of being made
with the participation of population members; (b) display of
photographs showing environments where disease is transmitted,
so that the population may recognize itself; (c) production of
theater plays on the theme; (d) slide series, preferably with
no associated sound, as this may inhibit participation or
create confusion due to technical problems in its transmission
or to speech regionalism.
For each used strategy is very important to maintain a
continuous process of evaluation, paying attention to the
baseline data that have to be collected before the
implementation of the new measures. This evaluation system
contributes to the necessary changes or improvements of the
program in order to reach the planned objectives .
Some suggestion presented above are detailed in a book
published by WHO (1990) in which several practical examples
are given to help the educators on his/her task.This is a
useful guide to develop several educational activities since
the educator consider the reality of the community from which
he/she has to start the program, and with the active
participation of the population, oriented to a transformative
social action and searching best life conditions.
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Copyright 1995 Fundacao Oswaldo Cruz (Fiocruz)
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