7

CHAPTER 2

Achieving good health

According to the World Health Organization (WHO) good health is not

merely the absence of disease; it is also a reflection of the social and mental
well-being of people in a community. Thus, to achieve the WHO goal of pro-
viding health for all, improvements in a community should aim not simply
to reduce disease, but also to reduce social tensions and mental ill-health to
acceptable levels.

2.1 Factors that influence health

Many factors influence health and some may have both good and bad influ-
ences. For example, surface water bodies can be beneficial as they can supply
water for domestic and agricultural work, may be used for fishing and re-
creation, and can create a pleasant environment. However, they can also be
breeding areas for insects and snails that transmit diseases such as malaria,
dengue fever and schistosomiasis. Pollution of water bodies by humans also
increases the risks to health. Factors that influence health can be grouped as
follows:
• The environment.
• The awareness of individuals and communities about health.
• Personal hygiene.
• Health care.
• Disease.
The linkages between these factors and health are discussed more fully below
(see also Figure 2.1).

2.1.1 Environment
The environment includes both the physical environment we live in and
the social fabric of the community, and both significantly influence health.
The physical environment plays an important role in many ways. A clean
8 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

Figure 2.1 Linkages between factors that affect health

environment helps prevent the spread of disease and may reduce depression.
For example, safe and adequate water supplies, sanitation, drainage and solid
waste disposal all benefit health by removing disease vectors from human
contact. Dirty environments, by contrast, encourage the spread of disease and
may adversely influence the mental and emotional well-being of individuals.
CHAPTER 2. ACHIEVING GOOD HEALTH 9

Industry and traffic also adversely affect health by polluting the air, water
and soil, and by causing accidents.
Equally important are the home and social environments. When the home
environment is dirty, disease may still spread even if the rest of the village is
clean; and where houses are of poor quality, with poor ventilation and light-
ing, other health problems may result, such as premature eyesight failure
or respiratory diseases. The social environment also has a major impact
on health. If people are marginalized because of gender, income status or
ethnic/religious affiliation, they are more likely to be prone to anxiety and
depression and to suffer mental ill-health. In particular, the status of women
in the community is important. In communities where women are discrimi-
nated against, they are more likely to suffer both physical and mental ill-
health. By contrast, in communities that are harmonious, accept differences
and promote resolution of conflict through dialogue, the people are usually
more healthy.

2.1.2 Awareness of health issues

The awareness of individuals about health is fundamental to promoting a
healthier village. If people do not understand the causes of ill-health and how
they can improve their health they cannot make decisions about investing
resources and time to improve their village, or about lobbying for outside
assistance. Such awareness should be developed in all areas that influence
health because the different influences are often interrelated. Unless people
accept that they need an improved environment, better personal hygiene and
better access to adequate health care, investments aimed at improving health
may have only limited impact. It is also essential that community members
are aware that improvements in their environment or hygiene need to be
sustained to achieve long-term improvements in their health. Both com-
munity leaders and governments play important roles in developing this
awareness.

2.1.3 Personal hygiene

Personal hygiene is essential both for improving health and for sustaining
the benefits of interventions. For example, if injuries and minor cuts are
not kept clean, they may become infected and lead to further health prob-
lems. And even though water supplies and sanitation facilities may be
constructed in a community, unless people use these facilities properly and
wash their hands after defecation, store water safely, bathe, and clean clothes
and utensils properly, diseases caused by poor water and sanitation may still
exist.
10 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

2.1.4 Health care

All people suffer from disease at some point in their lives and may need to
seek medical advice and treatment. Small children in particular may be prone
to illnesses that require treatment and there are several infectious diseases for
which immunization is recommended (which should be carried out or super-
vised by trained medical staff). In all cases, the health outcomes are pro-
foundly affected by whether health care facilities are available to the people.
Community leaders should therefore lobby national and regional service
providers to locate health care facilities as close to communities as possible
and preferably within the community itself.

2.1.5 Faecal–oral diseases

Many diseases are caused by food, water and hands that are contaminated
by disease-causing organisms or “pathogens” that come from faeces. The dis-
eases caused by these pathogens are called faecal–oral diseases because faecal
material is ingested. These diseases, which include dysentery, cholera, giar-
diasis, typhoid and intestinal worm infections, are responsible for much sick-
ness and many deaths each year. Many of these illnesses and deaths occur
unnecessarily, since the faecal–oral routes of disease transmission are among
the most easily blocked. There are several faecal–oral routes of transmission
(Figure 2.2). For example, many infectious diseases are spread through poorly
prepared and stored food, and many epidemics start with the consumption
of poor quality food, or from drinking contaminated water. Good quality
drinking-water and good personal hygiene in food preparation and hand-
ling are therefore of utmost importance in preventing the spread of these
diseases.

2.1.6 Vector-borne diseases

Diseases transmitted by vectors such as mosquitoes (malaria) and sandflies
(leishmaniasis) and those with intermediate hosts in fresh water such as snails
(schistosomiasis) place a heavy burden on rural communities in the tropics
and subtropics. They are closely linked to the characteristics of the local
ecology (e.g. standing water or irrigation systems), human behaviour (water
contact patterns) and socioeconomic status (capacity to maintain a clean envi-
ronment). Since the flight range of most disease-carrying insects is relatively
limited and the transmission of schistosomiasis is restricted to water contact
points, communities can make substantial contributions towards making
villages healthier by managing their environment; by using simple vector
control procedures; and by cleaning the village and its surroundings. In many
CHAPTER 2. ACHIEVING GOOD HEALTH 11

Figure 2.2 Faecal–oral routes of disease transmission

instances these procedures can be incorporated into daily village routines, for
example by modifying agricultural practices.

2.2 Identifying health problems and establishing priorities

To improve the health of people in a community a number of problems may
need to be resolved. While it is better to address these problems in an inte-
grated way, it may be necessary to establish priorities and deal with the most
pressing issues immediately. This situation could arise, for example, if com-
munities or service providers have limited resources and can tackle only a
few problems at a time. Community members may also have different per-
ceptions of the main problems: people living in low-lying areas prone to
flooding may feel that drainage is the major problem to be resolved, whereas
those living in higher areas may be more concerned with water supply. If
external bodies alone are responsible for prioritizing the issues, the priorities
may not reflect community concerns and there may be a more limited sense
of community ownership of a project.
Two questionnaires are provided in this guide that allow community
members to identify major health issues in their community and establish
12 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

health priorities. However, to ensure that community priorities are under-

stood and that needs are met, it is essential to involve the different stake-
holders in a community. Women and men, rich and poor, children and the
elderly, and different ethnic and religious groups may all have different
health priorities, and while it may not be possible to accommodate every
view, the final list of priorities should reflect what most people believe are
important health issues. To identify health problems in a community, com-
munity members should try to answer the questions listed below and then
discuss the most pressing issues. During the discussion community members
can try to list (or rank) the problems identified in order of importance.

Identifying community health issues

• Is diarrhoea common among children?
• Are worm infections common?
• Are respiratory (breathing) problems common?
• Are eyesight problems common, particularly among women?
• Are malaria or other vector-borne diseases common?
• Do many people have fevers?
• Have there been recent outbreaks of disease that affected many people in your
community?
• Are children undernourished? Do they look thin or lack energy?
• Are there health workers or facilities (clinics or health centres) in the community?
• Do any children or adults have a mental health problem (e.g. psychosis)?
• What are the major health problems identified by community members? List them
in order of importance.

2.2.1 Assessing community perceptions about health

To help identify the most important health problems in a community,
the perceptions of community members about health should be assessed.
It is important that all sections of the community are involved in these
assessments. Different methods for achieving this goal are discussed
below.

Questionnaires
One way to find out what people think is to use a community questionnaire.
Because questionnaires may be answered by many people (sometimes, every
CHAPTER 2. ACHIEVING GOOD HEALTH 13

household in the community) they can provide good information about the
perceptions of community members towards health problems and health
priorities. However, questionnaires have limitations. Frequently, it may be
difficult for community members to devise their own questionnaires and the
information collected may require sophisticated analysis. As a result, it is
likely that nongovernmental organizations (NGOs) or local government
staff will administer the questionnaires, rather than community members.
Nevertheless, the community should always ask for feedback on the findings.
Because the questions must be defined before the information is collected,
the information will be limited to these issues. Questionnaires may not
therefore be flexible enough to include other issues of importance to the
community.

Participatory approaches
Because of the limitations of questionnaires, a number of other techniques
have been developed. They are often grouped together and referred to as a
participatory rural (or rapid) appraisal. The techniques allow the community
itself to develop areas for discussion, rather than using questionnaire
responses to define the topics. These techniques are sometimes used with
questionnaires: by asking the same question in different ways during com-
munity discussions, issues raised by questionnaire respondents can be
verified. More information about the techniques can be found in the docu-
ments listed in Annex 2. They are briefly discussed below to provide an idea
of how such techniques may be used.
Participatory approaches cover a range of techniques, including key infor-
mant interviews, group discussions and observations. Although these tech-
niques are often used by trained staff, they can also be used by community
leaders to assess the perceptions of community members about health issues.
When using these techniques it is important to balance the need to discuss
all issues of community concern with the need to remain focused on the prin-
cipal objective—assessment of community health priorities.
Key informant interviews are discussions with key people within a com-
munity who have a special interest in, or responsibility for, improving health.
Key informants include women’s leaders, youth leaders, religious leaders and
health workers. The interviews are usually structured, in that the interviewer
has the objective of obtaining information on key health issues. Rather
than directly asking prepared questions, however, the interviewer can instead
prepare topic guides to ensure that the principal areas of interest are covered
during the course of discussions. The objective of each interview should be
clearly defined and the community members best placed to provide answers
should be identified.
14 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

Example topic guide

Uganda: focus group discussion on water usage
Goal:
To determine which sources of water are used for consumption.
Topics:
• What water sources are available to the community?
• Which local water sources do people commonly use?
• What are the water sources used for?
• What influences decisions to use the sources?

A focus group discussion is a technique that brings together groups of people

to discuss a particular issue, often in an informal setting as illustrated in
Figures 2.3 and 2.4. The role of the group facilitator is to help the group to
identify key issues related to the topic under discussion, while allowing suf-
ficient flexibility to cover all aspects of the topic to everyone’s satisfaction. To
help foster agreement about the key issues, it is better to establish a goal or
objective that the whole group agrees with from the outset. For example, the
goal may be to decide which problems are most important to resolve. Some-
times people may give responses that are not relevant, or that appear silly or
amusing to the other group members. It is important that people do not feel
they are being ridiculed for their views. This can be accomplished by saying,
for example, “That is a good point, but maybe we need to discuss the rele-
vance of this.”
Problems may arise during group discussions which can lead to biased
answers or dissatisfaction among group members. For example, the discus-
sion may be dominated by a few individuals who express their point of view
forcefully and prevent others from fully participating. Lack of contribution
by some members may also be a problem and it may be necessary to directly
ask such individuals what they think about a particular issue. However, care
should be taken not to appear too aggressive or insistent since some people
find it hard to talk in front of others. One approach that may help everyone
to feel comfortable during discussion is to select individuals from specific
groups, such as women or young people, rather than include a mix of people
in the discussion. To overcome problems in group discussions, it is important
to set ground rules at the outset of the discussion which all members agree
to abide by. If this is not done, the discussion may become heated, some
people may dominate the group and others may feel disappointed with the
discussion.
CHAPTER 2. ACHIEVING GOOD HEALTH 15

Figure 2.3 Focus group discussions

Figure 2.4 Small community discussions

16 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

Ground rules for focus group discussions

• There are no right or wrong answers, just different opinions.
• Everyone has the right to express their opinion and should not be penalized if the
group feels the opinion is not relevant or interesting.
• Only one person at a time should talk; when someone wants to contribute they
should raise their hand.
• No one person should dominate the discussion—all should be allowed to
contribute.

Different sections of the community may have different opinions about which
problems are most important. To reflect this, different groups in the commu-
nity can prepare a map that locates the most important problems. The map
can then be used as a discussion tool with the groups to help community
members decide which activities should be undertaken to improve the health
of the overall community.

Key points for collecting information from a community

• All sections of the community should have input into the process. Priorities estab-
lished by only a few people may not cover all needs adequately.
• Decide from the start how the information will be used. This should be developed
with the whole community.
• Make sure the information is reliable.

2.2.2 Identifying causes of health problems

Once the major health problems in a community have been identified, the
underlying causes need to be examined so that priorities for action can
be ranked. For example, diarrhoea in a community may be caused by
poor-quality water, by unhygienic food, or by a lack of sanitation, and the
type of intervention required will depend on the nature of the underly-
ing cause. To help identify the principal causes of ill-health in a community
and the most important areas to improve, community members can complete
the following questionnaire and discuss the findings with the whole
community.
CHAPTER 2. ACHIEVING GOOD HEALTH 17

Identifying causes of community health problems

• What types of water supply does the community have?
• Is the water source protected and/or treated?
• How much water is collected by households?
• Is the water always available?
• Does everyone have access to water?
• Does the community know the quality of the water?
• Are there special places for bathing and laundry?
• Do households have some form of sanitation?
• What types of sanitation are there?
• Are there separate facilities for women (in areas where mixed facilities are
unacceptable)?
• Is solid waste disposed of, or does waste build up in the village?
• How is solid waste disposed of?
• Are there stagnant or standing bodies of water in the community?
• Is there a system of drainage in homes and for the community?
• Is there a market in the community?
• Is the market area cleaned every day?
• Is the market dirty?
• Is meat sold at the market?
• Is the meat always fresh?
• Are market vendors careful with personal hygiene and do they keep their hands
clean?
• Does the market have water supply and sanitation facilities?
• Are chemicals used or stored in the community?
• How are they stored?
• How are chemicals disposed of?
• Do houses in the community have many windows?
• What cooking fuel is used in the community?
• Where do people cook in the community?
• What materials are used for house construction?
• Are mosquitoes, flies and other insects common in the community?
• Are rats and other vermin common?
• Are cattle or other domestic animals kept close to homes?
• Are the same bodies of water used for washing, laundering and receiving human
and animal wastes?
What are the major problems? List them in order of importance to the community.
18 HEALTHY VILLAGES: A GUIDE FOR COMMUNITIES AND COMMUNITY HEALTH WORKERS

2.3 Using the information

Whichever techniques are used it is essential that the information obtained
reflects broad opinion in the community, is reliable and can be translated into
action. Once the major causes of ill-health have been identified by the com-
munity and the necessary interventions agreed upon, the resources required
must be identified. If the community lacks the necessary resources, repre-
sentatives of the local government and NGOs can be contacted to discuss how
best to carry out the improvements. It may be possible to prepare a proposal
that identifies the work the community would like to undertake, how much
the improvements would cost and the contributions community members
themselves can make.
The time and money required to keep improved facilities working should
also be considered, because benefits may be short-lived if the community
cannot afford to maintain improvements. It is important therefore to discuss
with community members, local governments and NGOs the long-term
requirements of improvements and whether they are affordable. This will
help community members to select options most suited to community needs
and resources.