AFMC WHO Textbook Community Medicine

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2. Section 4 : Social, Behavioral and Communication Sciences
113 Principles of Sociology in Health Care S S L Parashar 608
114 Family Health History & Individual Medico - Social History - Taking RajVir Bhalwar, SSL Parashar 613
115 Health Education SSL Parashar 619
Planning, Implementation and Evaluation
116 RajVir Bhalwar 624
of Health Education Programmes

3. living and socializes man. A culture denotes total way of life.
Principles of Sociology in Health
113 Care
It is recognized that cultural factors are deeply involved in all
the affairs of man including health and sickness. The cultural
factors such as customs, beliefs, values and religious taboos
S S L Parashar create an environment that helps in the spread or control
of certain diseases and affect health of the community. The
cultural factors are deeply involved in matters of personal
Social, cultural, psychological and behavioural factors are
hygiene, nutritional and breast feeding habits, weaning and
important variables in the etiology, prevalence and distribution
rearing practices, family planning, immunization and seeking
of disease. The way the people live, their habits, beliefs, values
early medical care.
and customs are significant determinants of individual and
collective health. The behavioural sciences (sociology, social Family : “The Family is a group defined by a sex relationship
psychology, cultural anthropology) have made significant role precise and enduring to provide for the procreation and
in developing better understanding about the social etiology of upbringing of children” (MacIver). The family is a primary
health problems. It is recognized that causation and spread of a unit of all societies. As a cultural unit, the family reflects the
disease does not depend entirely upon biological organism. The culture of wider society of which it forms a part and determines
cultural and social factors which govern human behaviour also the behaviour and attitudes of its members. The family is an
have dominant role to play in the disease process. Any behaviour epidemiological unit, and a unit for providing social services as
is determined by a combination of cultural, psychological, well as comprehensive medical care.
social and economical variables. Hence the study of health Family life cycle stages : A family passes through the following
embraces the totality of life and ways of living. stages in its evolution :
Sociology : Sociology is the science concerned with the ●● Married couple - beginning of family
organization of structure of social groups. It studies the kinds ●● Child bearing family
and cause of variation in social structure, and the processes by ●● Family with pre- school children
which intactness of social structure is maintained. Sociology ●● Family with school age children
deals with the study of society. Society is a group of individuals ●● Family with teenage children
who have organized themselves and follow a given way of life. ●● Middle age
The behaviour of man depends very much upon his relationship ●● Aging family members/ retirement
with other fellow beings. Man is a subunit of a small group; Role of Family in Health and Disease
the family, while the family is the basic unit of society. Man’s Family is the reproductive nucleus of society, a fundamental
behaviour is affected not only by his physical and biological and social institution whose primary and essential task is to
environment but also, to a larger extent by social environments socialize the new born so that they may be placed in life as
represented by his family. mature and independent. From the time the child is born, the
Community : In the simplest terms, a community can be defined course of his physical and mental development is determined
as a group of people who have some common characteristics by his initial experiences with the family. Every society from
and are bound together by “WE” feeling. This sense of ‘we’ nomads to city- dwellers has its institution of marriage and
feeling (i.e., shared togetherness) may be due to a place where stable family life. Through the family, human beings maintain
they all stay or due to some other common interest. physical continuity by reproduction, maintain social and
Accordingly, communities can be either “structural” or else, cultural continuity through training and education.
“functional” communities. Functional communities are non- The health of the child is bound up with the family’s internal
geographical aggregates which are bound together by some and external environment even before it is born, and the
common factor other than geographical place of residence or foetus in the womb can be harmed by the health, nutrition
work; e.g., religion (as, Hindu community), occupation (as and behaviour of the mother. Undernutrition of mother can
medical community), special interest (as cricket lovers) or need give rise to infants born prematurely and of low birth weight
(as socially backward communities). Structural communities with attendant high risks of mortality or damage to the
are organised by geographical or political boundaries. It could nervous system. Her unborn child can be damaged by familial
be as small as an “indoor patient’s community in a hospital” infections like rubella and syphilis. Subsequent experiences in
or increasingly larger, according to a “Mohalla”, village, slum, infancy, in the quality of feeding and method of training for
city, district, state or even a nation. Community affiliations instance may further influence development, physique, stature
often provide a source of support for individuals and group. The and personality.
sense of group identity eases the growth of motivation. For this The members of family share a pool of genes and a common
reason the community is ideal for focal point of programme. environment as well as common modes of thoughts and
Culture : Culture is defined as learned behaviour which has behaviour and family material and social environment which
been socially acquired. Culture includes all that man acquired includes housing, sanitation and diet. A damp overcrowded
in the mental and intellectual sphere of his individual and house encourages streptococcal infections (Rheumatic fever and
social life. It is a product of human societies. nephritis). Tuberculosis flourishes in poor and over crowded
Culture is necessary for human being; it makes life worth homes. It is not only infective agents that pass between the
members of a family; parents may transmit distorted cultural
• 608 •

4. perceptions & behavioural norms to their children; thus creating the parents. The capacity of an individual to withstand
deviant behaviour and failures of adaptation among them. stress and strain and the way in which he interacts with
Familial beliefs and attitudes go a long way in shaping the other people is to a large extent determined by his early
reasons for health and disease. The various causes for sickness, experience on the family. The families acts as a placenta
as understood, may be classified in two categories : Supernatural excluding various influences, modifying others and pass
causes and Physical causes. Supernatural causes include through it and contributes some of its own in laying
diseases caused by (a) breach of taboos e.g. leprosy, sexually foundation of physical, mental and social health of the
transmitted diseases; (b) wrath of god and goddesses e.g. small child.
pox & chicken pox; (c) spirit intrusion, ghost intrusion and evil ●● Care during sickness : The family is expected to provide
eye. The physical causes include excessive heat or cold, wrong care during sickness and injury of adults and dependents
combination of foods and impurity of blood etc. Prevention of from the public health point of view. Care of women during
disease and bringing improvements in the health conditions in pregnancy and childbirth is an important function of the
any society is dependent upon our ability to understand and family. The joint family provides support, security and
improve the social or environmental factors. encouragement to the aged and handicapped.
●● Family as strength in crisis : The family is understood
As families enter each new developmental stage, transition
as shock absorber. The family is an important source of
occurs. Events such as marriage, childbirth, releasing members
support. During times of illness and crisis the family is
as adolescents and young adults, and continuing as a couple
there for the individual. The family provides an opportunity,
or single person and aging years move families through new
both for adults and children, for release of tension so that
stages. Each new developmental stage requires adaptation and
the individual can attain mental equilibrium and strive
new responsibilities. Each new stage presents opportunities for
to maintain a stable relationship with other people. The
health promotion and intervention. There are certain functions
family has an important function in stabilization of the
which are relevant to health behaviour, and are important from
personality of both adults and children, and in meeting
the medical sociology point of view.
their emotional needs.
●● Upbringing of children : One of the important functions ●● Problems in families : The factors in most problem families
of the family with which medical and health workers are are usually those of personality and of relationship,
concerned, is the physical care of the dependent young backwardness, poverty, illness, mental and emotional
in order that they may be survive to adulthood and instability character defects and marital disharmony. These
perpetuate the family. It is important to note that child care families are recognized as problems in social pathology.
(e.g. feeding, nutrition, hygiene, sleep, clothing, discipline, There is a need to render useful service in rehabilitating
habit training) are passed on from one generation to such families in a community.
another. The ideas people have about nutrition exercise;
The family therefore plays an important part both in health
sleep and clothing have a large social component which
and disease - in prevention and treatment of individual illness,
varies from society to society.
in the care of children and dependent adults, and in the
●● Socialization in the family : By socializing is meant
stabilization of the personality of both adults and children.
teaching the values of society and transmitting information,
culture, beliefs, general codes of conduct, by example and Crowd : In common usage any large number of people gathered
precept, in order to make them fit for membership in the in one place is called a crowd. A crowd is potential medium
wider society of the family is a part. The family plays the for arousing emotion and for encouraging its expression. Large
most dominant role in the individual’s socialization. The gathering people provide congenial conditions for emotional
child finds much to learn in the behaviour of his family contagion. Simulation and suggestions are heightened. The
members, parents, relatives and friends. He imitates them presence of others gives a sense of security and approval and
in their mannerisms, behaviour etc. He tries to avoid such crowds convey a feeling of anonymity. By their very nature
activities which are considered bad in the family. It is the casual crowds and mobs are not part of organised system of
family environment which forms his good habits. It is in social relations.
the family that the child acquires such important qualities Mob : The term refers to one crowd that is fairly unified and
as sincerity, sympathy, self submission and realizing single minded in its aggressive intent. Mob action is not
responsibilities. The child’s first school is his home and usually destructive but tends to be focused on some one target
family. It is the family which imparts practical education or identity. Mob activity is the most goal oriented and the most
to children concerning the customs in society, preservation dependent upon leadership for its direction
of health, love, sympathy, cooperation etc. Learning about Sick role : ‘Being Sick ‘ is not simply a state of fact or condition,
health promotion and disease prevention begins at birth, it is a specifically patterned social role. To be ill is more than a
with the family providing the environment for incorporating medical condition. The patient has a customary part to play in
health in the value system of its members. relation to his doctor and to his family members of his society &
●● Influence of family on personality : The environment of in turn they expect him to behave in certain prescribed ways.
home has a comprehensive influence on the development
of personality. In the family the relation of the child with Rights
the parents is the most intimate. The cultural development ●● The Sick person temporarily is exempt from normal
of the child is very much influenced by the behaviour of social roles. The more severe the sickness, the greater the
exemption.
• 609 •

5. ●● The sick person generally is not held responsible for his Practices : Practices are application to particular and personal
condition. Illness considered beyond individuals control situation. Practices are guided by principles under the light of
therefore not simply curable by willpower. intellect. The individuals modify their behaviour and maintain
●● The sick person has a right to be taken care of. the change for the rest of their life. e.g. the individual stops
Duties / obligations smoking after changing attitude.
The sick person has an obligation to try to get well. In this Community’s social support systems : In medical practice the
context exemption from normal responsibilities is temporary ability of a family to provide social support and material aid
and conditional upon wanting and trying to get better. to dependent members is obvious importance. When patients
who are disabled by sickness are reintroduced to normal social
The sick person has an obligation to seek technically competent
life, for example their family relationships and attitudes help to
help from a suitably qualified professional and to cooperate in
determine the outcome. Support comprises a network of family,
trying to recover.
friends, co-workers and professionals.
Social Pathology : Social pathology is the systematic study
Social assistance implies provision of relief to individuals at
of human disease in relation to social conditions and disease
critical times without having received any contribution from
process outside the human body. The cause is to be found in
them. Social assistance is a non-contributory benefit extended
the society. These include Social Problems ( namely, poverty
to vulnerable groups including women, children and the aged.
and destitution, illiteracy and ignorance, migration, lower
The community’s participation in health programmes and
status of women,, child neglect and child abuse, child labour,
programmes which are developed locally is to be found through
drug abuse, juvenile delinquency); social conditions (as
situational analysis. The programmes such as aid to families
housing, environmental sanitation, crime and corruption,
with dependent children, medical aid, family counseling
stress, suicide) and social circumstances (Viz., stigma, social
services, crisis support (food, shelter, clothing, fuel), referrals
isolation, vulnerable populations). The causes of social
to appropriate medical services, drug de-addiction services,
problems, conditions which affect the health of the people are
treatment services for alcoholics, delinquency prevention,
to be understood and actions are to be taken to prevent such
services for the retarded and emotionally disturbed, income
problems through health education and rehabilitation.
generation, vocational training services are provided by the
Social Diagnosis : This is made by socio- medical surveys and community through appropriate groups, organizations and
by study of domestic and social conditions of individuals. agencies. The philosophy behind tertiary prevention of chronic
Social Therapy : Social therapy offers holistic development diseases is that it is often possible to live with and die with
centered therapeutic and support services. The approach disease rather than dying from the disease. It is possible to
addresses and supports the total social, emotional and prolong time period of optimal physical functioning and social
educational needs of young and the entire family. Clinical activity by providing social support and self management
treatment of any disease with drug should be supplemented services.
with social therapy as far as possible. The Social security Social Environment : The social environment includes all those
measures link between hospital and community, health things which arise out of social relationships such as customs,
education, legislation serve as supportive measures. traditions, institutions social conduct, rituals, diet, way of
Knowledge : Education is a process of learning undergone by life and economic status. Health is profoundly influenced by
individuals for gaining knowledge, developing attitudes and the social environment which acts in many ways to shape the
acquiring skills. Knowledge is the basis of health education contours of disease, in populations as well as individuals. For
where a person gets of information by many modes which promotion and protection of health and prevention and control
become his knowledge. Some apply the term knowledge to what of disease, social environment should be free from harmful
are held to be certainties. Knowledge is intellectual and passive. agents. Important measures for providing healthy social
Awareness can be created through imparting knowledge on environment are :
a particular topic. e.g. receiving information about harmful ●● Social security against fear and want (ESI scheme, old age
effects of smoking. pension, life insurance, provident fund and health and
Attitudes : Attitudes are mental habits acquired from social medical facilities).
experiences that predispose us to react to specific objects, ●● Fair distribution of food and other amenities of life such
persons or situations in a definite way. They are the crystallized as housing
habits of thoughts that we develop relative to social situations ●● Facilities for exercise and leisure
and that set us to respond in a certain manner. An attitude ●● Facilities for education for all
is an enduring system that includes a cognitive component, ●● Propagation of healthy customs, freedom of expression
an emotional (feeling) component and an action tendency. and thought
They are manifested in conscious experience, verbal reports, ●● Protection of property, life and honour
gross behaviour and physiological symptoms. The people are ●● Safe work place which involves establishing a stimulating
motivated to change attitudes to adopt new health behaviour. work environment and making sure that the work place
e.g. the individuals are motivated to stop smoking through creates social contacts which do not interrupt the family
various methods of health education and individuals are ready networks.
to change behaviour.
• 610 •

6. Non-Governmental Organizations (NGOs), Voluntary be correlated with social class.
Organizations : NGOs form a bridge between the government Kuppuswamy’s scale : The socio-economic status scale
and community and provide platform for people participation (urban) developed by Kuppuswamy attempts to measure the
NGOs are many and diverse. Their scale may be large, medium, socio-economic class of family in urban community. It is
and small. Their support may come from external sources, from based on three variables - education, occupation, and income.
their own fund raising or from Government. Their principle A weightage is assigned to each variable according to seven
activity may be direct service to those in need in the community, point predefined scale. The total of three weightages gives the
health education or research. Voluntary organizations could be socio-economic status score which is graded to indicate the five
defined as those organizations which are non- governmental classes, as per details in Table - 1. To get current income group,
and non profit making in character and not fully funded whether a conversion factor based on current All India Consumer Price
directly or indirectly only by government. Most voluntary Index (AICPI) is used, which is given later.
organizations have four primary purposes (i) raise money to
For income, the conversion factor can be obtained by dividing
fund research and programmes (ii) provide education to both
AICPI by 60.04. The income group in the Kuppuswamy’s scale
professional and the public (iii) provide services to individuals
are multiplied with the conversion factor to get the appropriate
and families affected by the disease and health problem (iv)
income group (Indian Journal of Pediatrics, volume 70, March
to advocate for beneficial policies, laws and regulations. (e.g.
2003). Now, since AICPI in June 2008 was approximately 650,
VHAI, Indian Red Cross Society, Hind Kusht Nivaran sangh,
hence 650 divided by 60.04 = 10.83. Thus all the income groups
Tuberculosis Association of India etc. )
in the Kuppuswamy scale in the above table are multiplied
Social Security : Social security means public programmes with the conversion factor to get the appropriate income group.
designed to protect individuals and their families from income Thus, the conversion factor 10.83 is multiplied by Rs. 2000
losses due to unemployment, old age, sickness or death and which comes to Rs 21,660/- and rest income groups would be
to improve their welfare through public services (e.g. medical as given in Table - 2.
care) and economic assistance. The term may include social
insurance programmes, health and welfare services and various Table - 2 : Recalculated family income groups of the
income maintenance programmes. Kuppuswamy’s scale as on June 2008
Social class and Socio-Economic Status : Socio-economic
standard of people is conventionally expressed in terms of Income Modified by using conversion
Score
various social classes in which people are distributed which Original factor (multiplied by 10.83)
are referred to as social stratification. Social stratification is > 2000 >21660 12
a horizontal division of society in to several socio-economic
layers : each layer or social class has a comparable standard of 1000-1999 10830-21659 10
living, status and life style. Social class is determined on the
750-999 8122-10829 6
basis of three parameters of development, namely education,
occupation and income. Education determines the knowledge, 500-749 5415-8121 4
attitude, and value system of individuals and their socio-
economic growth potential. Occupation determines the income 300-499 3249-5414 3
generating capacity of individuals and their status. Income 101-299 1093-3248 2
determines the purchasing power of individuals and their socio-
economic status. On the basis of these parameters populations <100 <1093 1
are divided in to social classes - upper, upper middle, middle,
upper lower and lower. These social class gradients have helped The Total score in Kuppuswamy’s classification is calculated as
to provide a deeper understanding of clinical phenomena. The the sum total of the three scores, i.e., Education (A)+ Occupation
poor had a higher incidence of some diseases, the rich of others. (B)+ Income (C) Depending on the total score so computed, the
Health practices too, like the use of health services, welfare and five socio-economic classes are as given in Table-3.
maternity clinics, and methods of infant feeding were found to
Table 1 : Kuppuswamy’s Socio - Economic Status Scale (Urban)
Education of head of family Score Occupation Score Family Income per month Score
Professional Degree 7 Professional 10 Rs.2000and above 12
Graduate 6 Semi-profession 6 Rs1000-1999 10
Intermediate/Diploma 5 Clerical/shop/farm 5 Rs 750-999 6
High school 4 Skilled worker 4 Rs 500-749 4
Middle school 3 Semiskilled 3 Rs 300-499 3
Primary school 2 Unskilled 2 Rs 101-299 2
Illiterate 1 Unemployed 1 Rs <100 1
• 611 •

7. services as well as comprehensive medical care. The Family has
Table - 3 : Socio-Economic Class
an important role to play in Health and Disease. The health of
Total Score Class Description the child is bound up with the family’s internal and external
26 - 29 I Upper class environment even before it is born. The members of family
share a pool of genes and a common environment as well as
16 - 25 II Upper middle
common modes of thoughts and behaviour and family material
11 - 15 III Lower middle and social environment which includes housing, sanitation
5 - 10 IV Upper lower and diet. For health promotion and intervention, every family
has certain important functions like Upbringing of children;
Below 5 V Lower
Socialization in the family; laying foundation of physical,
mental and social health of the child; Care during sickness
Prasad’s Scale : Dr. B G Prasad’s social classification was
especially pregnant women, children, aged and handicapped;
developed in 1961 and is based on per capita per month income.
providing support in crisis and problems.
There are five classes, as follows Upper class (per capita per
month income Rs 100 and above); Upper middle ( 50-99); Lower Any large number of people gathered in one place is called a
middle ( 30-49); Upper lower ( 15- 29); and Lower (below 15). crowd. A crowd is potential medium for arousing emotion and
The income group can be recalculated by multiplying the above for encouraging its expression. The term mob refers to one crowd
mentioned income as mentioned in Prasad’s classification with that is fairly unified and single minded in its aggressive intent.
P Kumar’s conversion factor i.e. Mob action is not usually destructive but tends to be focused on
some one target or identity. Social Pathology is the systematic
Conversion factor = (Value of CPI X 4.93) ÷ 100
study of human disease in relation to social conditions and
For example, the AICPI for June 2008 was 650. Thus the disease process outside the human body. Social Diagnosis is
conversion factor will be made by socio-medical surveys and by study of domestic and
(4.93 X 650) ÷ 100 = 32.04, or roughly, 32. Thus the ranges social conditions of individuals. Social Therapy offers holistic
of per capita per month income of this classification for 2008 development-centered therapeutic and support services. The
will be >Rs 3200; 1600 - 3199; 960 - 1599; 480 - 959; and, approach addresses and supports the total social, emotional
< 480. and educational needs of young and the entire family.
Pareek’s Scale : The Socio-Economic Scale (rural) developed Education is a process of learning undergone by individuals for
by Pareek attempts to measure socio-economic status of a gaining knowledge, developing attitudes and acquiring skills.
rural family. It is based on the nine items as follows : Caste; Attitudes are mental habits acquired from social experiences
Occupation of head of family; Education; Levels of social that predispose us to react to specific objects, persons or
participation; Land holding; Farm power (prestige animals); situations in a definite way. Practices are application to
Housing; Material possessions; and, Family type. The combined particular and personal situation. Community’s Social Support
score for the nine items is graded to indicate socio-economic Systems comprise a network of family, friends, co-workers
class categories. and professionals. Social Assistance implies provision of relief
to individuals at critical times without having received any
Summary contribution from them. Social Environment includes all those
Sociology deals with the study of society. Society is a group of things which arise out of social relationships such as customs,
individuals who have organized themselves and follow a given traditions, institutions, social conduct, rituals, diet, way of life
way of life. Man is a subunit of a small group; the family, while and economic status. Health is profoundly influenced by the
the family is the basic unit of society. Man’s behaviour is affected social environment. Important measures for providing healthy
not only by his physical and biological environment but also, to social environment are : Social Security against fear and
a larger extent by social environments represented by his family. want, Good Housing with all important facilities, Protection of
A community can be defined as a group of people who have property, life and honour and Safe work place. Social Security
some common characteristics and are bound together by “WE” : Social security means public programmes designed to protect
feeling. This sense of ‘we’ feeling (i.e., shared togetherness) individuals and their families from income losses due to
may be due to a place where they all stay or due to some other unemployment, old age, sickness or death. Social stratification
common interest. Accordingly, communities can be either is a horizontal division of society in to several socio-economic
“structural” or else, “functional” communities. Community layers : Each layer or social class has a comparable standard
affiliations often provide a source of support for individuals of living, status and life style. Social class is determined on the
and groups. Culture is defined as learned behaviour which has basis of various scales like Kuppuswamy’s scale for Urban and
been socially acquired. The cultural factors such as customs, Prasad’s scale and Pareek’s scale for Rural.
beliefs, values and religious taboos create an environment
that helps in the spread or control of certain diseases and Study Exercises
affect health of the community. The Family is a group defined Long Questions : (1) Describe the role of Family in Health and
by a sex relationship precise and enduring to provide for the Disease. (2) Describe the role of Cultural factors in Health and
procreation and upbringing of children. The family is a cultural Disease. (3) What is Social environment? How does it affect
unit, an epidemiological unit, and a unit for providing social the health and disease? Enumerate important measures for
providing healthy social environment.
• 612 •

8. Short Notes : (1) Social pathology (2) Social Security measures lower class is (a) 11-15 (b) 16-25 (c) 26-29 (d) 5-10
(3) Kuppuswamy’s scale. 4. The Socio-Economic Scale developed for rural setup is
MCQs : (a) Kuppuswamy (b) Pareek (c) Prasad (d) None of the
1. Kuppuswamy’s scale is based on the following variables above
except (a) Education (b) Occupation (c) Income 5. The following are Social security measures against fear
(d) Housing and want except (a) ESI scheme (b) Old age pension
2. According to Kuppuswamy’s scale, total score for upper (c) Housing (d) Life insurance
middle class is (a) 11-15 (b) 16-25 (c) 26-29 (d) 29-31 Answers : (1) d; (2) b; (3) d; (4) b; (5) c.
3. According to Kuppuswamy’s scale, total score for upper
that the family has on the health and disease of individual
Family Health History & members of the family.
114 Individual Medico - Social In fact, it would be highly desirable that every Public Health
History - Taking Programme Manager and Medical Officers in-charge of a Primary
Health Centre (PHC) / Community Health Centre (CHC) should
RajVir Bhalwar & SSL Parashar develop “Family Health Folders” for each and every family in
his / her area of health care, on the same lines as Departments
of Community Medicine in Medical Colleges; maintain and
It is abundantly clear by now that every disease has a
regularly update such folders in their respective Rural Health
tremendous social component. The various components of
Training Centres (RHTCs) and Urban Health Centres (UHCs). The
sociology, as described in previous chapter, decide whether
contents of these family folders should be regularly updated by
a given human being will be exposed to the disease process
regular visits to the households by medical / paramedical staff,
or not; if exposed, whether disease process will perpetuate
preferably once in six months and definitely once in a year. It
or not; and finally, what will be the outcome of the disease
would be a further good work if the contents of these folders
process. It is therefore extremely important that every Doctor
be entered into a computer database, so as to help in quick
should work up the psycho-social and behavioural components
retrieval and analysis of data, which would greatly assist in
of a patient and not simply the clinical findings / laboratory
planning and evaluation of public health programmes.
investigative results, to effectively treat the patient and to
prevent recurrence of the disease. For example, going simply by In the present chapter, we shall be dealing with the details
the clinical picture, we may treat a child with dehydration, with of firstly, the ‘family health folder” and secondly, regarding
i.v. fluids and supportive therapy, and discharge her after a few medico-social history taking and how to draw conclusions
days as “cured”. However, if we did not work up the details from such history.
of environmental sanitation and water supply at the child’s The Family Health Folder & Family Health
house, the knowledge attitudes and health related practices of
the mother, the family size, and so on, for certain the child Records
will keep coming to us. Thus, for having a totalistic or holistic As said above, it should be an endeavour of all health care
overview of our patient and to really treat the disease effectively, providers to ensure that they have a detailed family health
“from the root causes”, we must take a proper medico-social folder for each and every family in their area of health
history, work out the various sociological parameters and treat, care jurisdiction, and these folders should be updated very
not only the clinical disease, but also the social causes. regularly.
Medico-social history taking is, therefore, also an essential General description : The family health folder should be
requirement at the undergraduate and postgraduate level generally 12 inches X 10 inches and preferably having a hard
of medical curriculum, with a view to prepare the general cover to ensure durability. It should have a system so that
and specialist Doctors to function effectively as Community various cards / papers can be filed in the folder. Having a
physicians. “multiple leaflet” folder may be even better as it will assist in
In addition to recording a detailed medico-social history from filing various records separately, for various members of the
an individual patient, it is also very important for the public family, within the same folder.
health manager to consider the “family” as a unit of action The cover of the folder should be printed with the name of
for her various health care activities. In the previous chapter, the PHC / CHC or any other health care providing unit who
we have already emphasized regarding the tremendous impact is responsible for health care of that family, and the address
• 613 •

9. and telephone number of the health care unit. In addition, the (as one of the sons who may be working in a town and coming
following details should be printed on the cover : to stay only during festivals) should be indicated accordingly.
●● The “Family Registration Number”. This is a unique number In column (8), if the person is known to be having any disease,
which is allocated to a particular family and acts as a the details should be entered; this should also include entries
unique identifier for the family, especially when computer regarding current pregnancy. The remarks column should
based records have been made. The number is unique in include any relevant which is considered to be important for
that no two families should have the same number. The the health care provider to know, at the first glance.
number may be allocated based on some registration Sheet for Socio-Demographic Details
given by the local self governmental body as panchayat,
The next sheet in the family health folder should be for the
or may be developed by the health care providing unit.
socio-demographic details of the family, recording the following
What is more important is that whatever system has been
details :
developed should be enforced, ultimately taking care that
every family under health care has a registration number ●● Total number of members in the family
which is unique for that family. Secondly, every family head ●● Distribution according to age and sex
should be communicated about the number (preferably,
Age groups Males Females Total
given a laminated card having the number printed on it)
and they should be advised to bring the laminated card Upto 1 year
whenever they come to the health centre. 1 to 5 years
●● The name, father’s / husband’s name and date of birth of
6 to 14 years
the head of the family.
●● The detailed address of the household, including the post 15 - 45 years
office and police station. 45 - 64 years
●● Telephone number or any other contact number.
●● The permanent address in case the family is of a “migratory” > = 65 yars
nature or is not a permanent native of that place.
●● Total family income per month (all sources included) Rs.
●● The date on which the folder was opened.
●● Per capita per month family income & Social Class
●● The date on which the folder was last updated as a part of
●● Distribution according to Educational level
the regular survey for updating the family folders.
●● The date on which the folder was updated, since some Educational level Males Females Total
individual member of the family came in contact with the
health care system (e.g., one of the ladies may be seen in Graduate & above
an ante-natal clinic). Matriculate but
The inside surfaces of the folder may be provided with pockets not graduate
made of thick plastic or strong cloth, for keeping important Educated more
slips. than 5th standard
Confidentiality of Information : It should be ensured by the but not literate
health care providers that all information recorded in the folder Educated upto
should be kept strictly confidential, and used for sole purpose 5th standard
of health / medical care, as per the laid down / acceptable codes
of medical ethics. Illiterate
Summary-Sheet : The inside of the front cover should have a Vital Statistics Record Sheet : Information regarding births,
printed table, in which the information should be filled up in deaths, marriages, divorces, in-migration and emigration
pencil (to enable making changes); alternatively, the first sheet should be recorded in this sheet, starting from the day the family
in the folder should have the information as given in Table-1. folder is commissioned for the particular family, recording the
In column (7) of Table - 1, a person who comes to stay temporarily date and details of each such event.
Table - 1
Current Health
Immunisation
Contraceptive
Or Temporary
Date Of Birth
Occupation
Permanent
With Head
Resident
Remarks
Relation
Sl. No.
Status
status
Name
Age
Sex
use
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
• 614 •

10. Sheet for Record of Housing and Environmental Sanitation: as a part of the University curriculum. Similarly, considering
This sheet should record the following information the over-riding importance of the role of family in health and
●● General description of the area, approach, access roads disease, a family is allotted as a project and often during the
●● Evidence of water logging and potential mosquito / housefly examination, to be studied and presented as a “unit”, rather
breeding points than presenting an individual case with a disease.
●● Type of house, condition of roof, floor and walls The details of family-case taking have been already dealt with
●● Total floor area in detail, earlier in this chapter, while discussing the family
●● Total living rooms health folders. The details of medico-social case work up are
●● Total floor area per person and total space (in cubic feet) being discussed herewith in the succeeding paragraphs.
per person Approach to the patient : Introduce yourself with a friendly
●● Any evidence of overcrowding greeting, giving your name and status. Explain the purpose
●● Area of Doors and Windows of your visit, ask for and remember the patient’s name and
●● Ventilation request permission to interview and examine the patient. Some
●● Availability of electricity patients rapidly tire of being questioned or examined, and
●● Details of water supply (source, safety and potability, others may be depressed because they are ill or apprehensive. If
quantity, storage) there are difficulties in establishing a rapport, try to determine
●● Condition of kitchen, eating place and food sanitation the reason; if in doubt, consult the medico-social worker or
practices nursing staff. Show tolerance, particularly with the elderly
●● Details of disposal of night soil and the challenged. Seek first to understand and not judge the
●● Details of disposal of solid wastes patient so that you don’t react to patients with criticism, anger
●● Details of disposal of waste water and storm water or dismissal. Some additional tips for effective medico-social
Individual Health Record Sheets : One health record sheet case taking are :
should be prepared for each individual. It should contain the ●● Maintain good eye contact.
details of the general health check up as well as the records of ●● Listen attentively.
results of investigations and hospitalization, if any. The same ●● Facilitate verbally and non-verbally.
sheet should continue to have entries of treatment given, as ●● Touch patients appropriately.
and when the individual reports sick to the health care facility. ●● Discuss patients’ personal concerns.
The special health cards (as ante-natal card, under-fives health ●● Give the patient your undivided attention
card and child health record card) as applicable should also ●● Keep your notes-taking to a minimum when the patient is
be filed alongwith the general health record card for that talking
individual. ●● Use language which the patient can understand
Special Health Record Sheets : These would include the ante- ●● Let patients tell their own story in their own way
natal and post-natal health care card, the under-fives health ●● Use open questions initially and specific (closed) questions
card and the school-age child health record card. These should later
be prepared for each individual member of the family, as ●● Clarify the meaning of any lay terms which patients use
applicable, as per details given in the relevant chapters in the ●● Remember that the history includes events up to the day
section on maternal and child health care. These special health of interview
record cards should be filed, in the family folder, alongwith the ●● Summarize (reflect back) the story for the patient to check
general health record sheet for that individual. ●● Utilize all available sources of information
Sheets for Record of Special Studies / Surveys : There should The fundamental principles underlying medico-social case
be a separate sheet for recording the findings of special studies work-up : The basic principle which must be kept in mind while
in respect of the family. For example, if a nutritional survey or undertaking a medico-social work-up is that while the patient
a geriatric age group survey and so on have been conducted in is the core issue, his disease is actually a result of complex
that area, the findings of these studies / surveys in respect of psycho social interactions between the patient, his / her family
the concerned family should be recorde on this sheet. members, the environment at the workplace (including school),
the immediate community members comprising of friends
Medico-Social History Taking & Family Case and close associates, the community at large within which
Studies the patient lives, and the larger society which consists of the
As said earlier, every medical, nursing and paramedical person governmental and non-governmental systems. A systematic
should view a given disease in totality, in context of the various assessment of all these factors is therefore necessary to be
socio-cultural, psycho-emotive and economic factors which able to reach the root of the problem and to effectively plan a
initiate and perpetuate the disease process, and not simply holistic therapy, taking care of not only the biological cause of
confine themselves to only the medical aspects of the disease. the disease but also the wider social reasons that lead to the
It is for this reason that undergraduate medical and nursing causation and perpetuation of the disease. The factors to be
students as well as post-graduate students in the specialty of considered at various levels are :
Preventive & Social Medicine (Community Medicine; Public 1. Factors Within the Individual : The following variables
health) are required to be trained and examined in the various should be recorded in detail :
aspects of medico-social case taking and family case studies, ●● Age
• 615 •

11. ●● Education water.
●● Occupation ●● Food hygiene : Methods of cooking, storage of raw and
●● Level of protection against common infectious diseases, by cooked food, food hygienic practices.
way of immunization or previous infection ●● Nutrition : Assessment of intake of overall calories and
●● Lifestyle : details of habitual physical exercise, diet, major macro / micronutrients; deficiency diseases; relative
tobacco, alcohol and substance abuse, sexual promiscuity distribution of food among various members; percentage
●● Knowledge, Attitudes & Practices (KAP) as regards common of monthly income spent on food.
diseases and their prevention ●● Exposure to and protection from insect vectors of
●● Psycho-Emotive state : whether cheerful and optimistic or diseases.
anxious / depressed or concerned. (c) Psycho-Emotive Factors in the Family : These include
●● Separation from family members / near & dear ones. ●● Level of Interactions / Bondages
●● Attitudes towards - Between family members
- Personal protection, as use of helmets, use of mosquito-
- Of family members with the Index Case
nets, etc.
●● Family Support System : In terms of financial support,
- Personal hygiene, as regular bathing, hand washing, physical support (as readiness to physically assist the
oral care, etc. patient in activities of daily living) and emotional support;
- Health Care System, whether positive and trusts the and, readiness of family members to provide “support”.
health care system or unhappy / skeptical. ●● Understanding, by the family members, of the disease and
- Attitudes as regards the disease from which the patient it’s determinant psycho-social problems that the patient
is suffering, and his / her concerns as regards it’s is facing
perceived future course / management / rehabilitation 3. Factors in the Workplace : (Note that for children, school is
2. Factors in the family : These will include three broad to considered as workplace)
categories of factors, viz., Social Factors, Physical Factors And ●● General description of the workplace or school
Psycho-Emotive Factors. ●● Attitude & Support (Emotional, Physical, Financial) on
(a) Social Factors in the Family part of
●● Type : Whether joint, three generation or nuclear - Employers / Superiors / Teachers
●● Organisation & Composition : Total number of members, - Colleagues / Classmates
head of the family, description of family members by name, - Subordinates / ancillary staff in school
age, sex, and position relative to the head. ●● Availability of facilities, in school / workplace, to cater to
●● Religion and caste special needs of the patient
●● Education : general level of education; attitudes towards 4. Factors in the Immediate Community : (Immediate
formal education; proportion of members who are community consists of the Village / Mohalla in which the
professionally qualified / having degree / educated / patient is living).
illiterate
●● General description (income levels and standards of living
●● Occupational patterns in the family
in general, major occupations, general types of housing,
●● Income : Total family income; income of the index case; Per
educational levels, social aberrations as alcoholism,
capita per month income
delinquency, etc.)
●● Socio Economic Status according to acceptable scales as
●● Community Organisation, strength of “we” feeling,
Kuppuswamy or Prasad scale.
cohesiveness between the families in the community.
●● Knowledge, Attitudes & Practices in the family, in general
●● Interactions, of various community members, with the
towards healthy lifestyle, personal protection and
Index Case and his / her family members
prevention of common diseases.
●● General attitude of community towards disease prevention
●● Health Care services for the family. These should be
& health care
assessed in terms of :
●● Availability of Physical, Financial & Emotional Support
- Availability Systems within the community.
- Accessibility ●● Health care facilities available
- Affordability ●● Availability of School / Special School catering to the
- Quality special needs of the index case.
●● Availability of NGOs / Voluntary Bodies and description of
- Utilisation
their capabilities.
●● Social Aberrations if any in the family, as promiscuity, ●● Availability of organised public health & social services
alcoholism, delinquency as central water supply and it’s purification, disposal of
(b) Physical Factors in the Family : These will include - wastes, transportation and communications.
●● Housing : General description, type of construction, area & ●● Political will of the community as strength of its
space, ventilation, overcrowding, lighting, other comforts. representation in elected bodies
●● Water Supply : Source, hygienicity, adequacy, storage ●● Identification of peers & influential leaders and their
●● Disposal of night soil, solid wastes, animal wastes, waste capabilities.
• 616 •

12. 5. Factors in the Community at Large : This includes the - Prevention of Other Diseases and for leading a healthy
larger social environment as the District / State where the life
patient is living. - Disability Limitation
●● General Attitude - Physical rehabilitation, eg, physical help for activities
- Towards Health maintenance, Disease Prevention & of living, for going till the health care centre, etc.
Rehabilitation - Vocational rehabilitation - training, education, earning
- Towards the disease in question a livelihood, reservation in job and education, etc.
●● Availability of treatment facilities - Emotional Rehabilitation
●● Availability of Rehabilitation facilities
- Social Security
●● Statutory and Administrative provisions to protect /
facilitate the index case. Summary
●● Availability of VHAs / NGOs
It is abundantly clear by now that every disease has a
6. Summarize The Medico-Social Findings tremendous social component. Thus, for having a totalistic
●● What are the “Key Psycho-Social Issues” in the index case, or holistic overview of our patient and to really treat the
his / her family, workplace, immediate community and the disease effectively, “from the root causes”, we must take a
community at large. proper medico-social history, work out the various sociological
●● What is the “Social Pathology”, i.e. the major “weaknesses”; parameters and treat, not only the clinical disease, but also
for example, in a medico-social case of an adolescent polio the social causes. Medico-social history taking is an essential
affected girl child, the major weaknesses and hence the requirement at both under and postgraduate level but other
social pathology operative in that case could be summed than focusing on the individual patient, it is also very important
up as “Alcoholism in the family” with “Poor purchasing for the public health manager to consider the “family” as a unit
power” with “ Adverse attitudes towards the girl child” of action for her various health care activities.
●● What is the “Social Diagnosis” i.e., those adverse psycho-
It is highly desirable that Medical Officers in-charge of a
social effects that the social pathology (major weaknesses)
Primary Health Centre (PHC) / Community Health Centre
would lead to; for example, in the hypothetical example
(CHC) should develop “Family Health Folders” for each and
of the case of polio affected girl child, “ Gross Physical
every family in their area of health care and these should be
handicap with Poor Rehabilitation facilities with Broken
regularly updated. Family folder should be generally 12 inches
family and adversely predisposed community” may be
X 10 inches, with hard cover and having “multiple leaflets”
identified as the social diagnosis, which will result from
so as to record separately, for various members of the family,
the identified social pathology, and will therefore need to
within the same folder. The cover of the folder should be
be “treated”, the way we treat a disease diagnosed by us.
printed with the name, health care providing unit along with
●● What are the “Major Strengths” in our case. This will be
the address and telephone number. In addition on the cover it
worked out by analyzing the support systems - Physical,
should have “Family Registration Number” (unique number for
Social, Vocational, Emotional and Financial, which are
each family), name and date of birth of the head of the family,
available within the family, workplace, and community
detailed address of the household, telephone number, date on
systems, as also the strengths within the index case (as
which folder was opened and date on which folder was last
determination, residual abilities, etc.).
updated. On the inside of the front cover or the first sheet in
7. Write down the Plan of Management & Social therapy the folder should have a printed Summary-Sheet which would
●● Write down in a line each, the following, for the case being have details of all the members of the family. Other details of
worked up : the family would be recorded on Sheet for Socio-Demographic
- The social pathology Details, Vital Statistics Record Sheet, Sheet for record of
- The social diagnosis Housing and environmental sanitation, Individual Health
●● Write down your summarized analysis of the Strengths, Record Sheets, Special Health Record Sheets, Sheets for Record
Weaknesses, Opportunities and Threats (SWOT) in this of Special Studies / Surveys. Finally it should be ensured by the
case. health care providers that all information recorded in the folder
●● Write down what all should be kept strictly confidential.
- Should be done, ideally, in this case All medical professionals should not simply confine themselves
- Can be done in this case (“Do-Ability” analysis), after to only the medical aspects of the disease but view a given
considering the SWOT. disease in totality. This can be achieved by training in the
various aspects of medico-social case taking and family case
●● Write down the overall aim and key objectives for the
studies. The various essential aspect of medico-social case work
medical management part as well as the psycho-social
up are, to start with, initial approach to the patient whereby
management for the case.
you should introduce yourself with a friendly greeting, try
●● Now, write down a detailed plan for each of the following
and remember the patient’s name and request permission to
aspects, indicating “who will do what, how, and in what
interview and examine the patient. Show tolerance, particularly
time-frame”
with the elderly and the challenged. Seek first to understand
- Medical management
• 617 •

13. and not judge the patient so that you don’t react to patients (c) Not discuss patients’ personal concerns (d) Not give
with criticism, anger or dismissal. patient undivided attention.
The basic principle which must be kept in mind while 6) In KAP “P” stands for : (a) Prevention (b) Practice
undertaking a medico-social work-up is that while the patient (c) Psycho-emotive state (d) Physical factor
is the core issue, his disease is actually a result of complex 7) “SWOT” analysis stand for all except : (a) Strength
psycho social interactions and a systematic assessment of all (b) Weakness (c) Opportunities (d) Treatment.
these factors is therefore necessary to be able to reach the root 8) Health Care services for the family should be assessed
of the problem and to effectively plan a holistic therapy. For this in terms of all except : (a) Availability (b) Accessibility
factors need to be considered at various levels, these are Factors (c) Affordability (d) Accountability
within the Individual which would include age, education, 9) Socio Economic Status according to Kuppuswamy or
occupation, lifestyle including consumption of tobacco, alcohol Prasad scale is calculated under which broad heading:
etc, Knowledge, Attitudes & Practices (KAP) as regards common (a) Social Factors in the Family (b) Physical Factors in
diseases, Psycho-Emotive state and attitudes towards personal the Family (c) Psycho-Emotive Factors in the Family
protection, personal hygiene etc. Factors in the family which (d) Factors in the workplace
would involve taking detail history under following headings 10) Physical Factors in the Family include all except : (a) Total
Social Factors in the Family, Physical Factors in the Family, no. of family members (b) Housing (c) Water Supply (d)
Psycho-Emotive Factors in the Family. After family one would Nutrition
like to find out factors in the Workplace, Immediate Community 11) Family Support System includes : (a) Financial support
and Community at Large influencing the individual and the (b) Physical support (c) Emotional support (d) All of the
disease. Now summarize the Medico-Social findings under the above
following heads Key Psycho-Social Issues, Social Pathology, 12) Immediate community consists of : (a) Village (b) District
Social Diagnosis, Major Strengths. Finally write down the (c) State (d) Country
plan of management & social therapy keeping in mind SWOT 13) Factors in the Immediate Community include all except :
analysis (Strengths, Weaknesses, Opportunities and Threats) (a) Community Organisation (b) Strength of “we” feeling
for this case and details indicating “who will do what, how, (c) Interaction between family members (d) Cohesiveness
and in what time-frame”. between the families in the community
14) “Major strengths” of a case can be worked out by
Study Exercises analyzing : (a) Social Diagnosis (b) Social Pathology
Short Notes : (1) Enumerate broad headings under which one (c) Psycho-emotive state (d) support systems
would do medico social case work up (2) SWOT analysis. 15) Plan of Management & Social therapy includes all except:
MCQs & Exercises (a) Medical management (b) Giving money (c) Disability
limitation (d) Emotional support.
1) All are true about “Family Registration Number”
except : (a) This is a unique number (b) no two families Fill in the Blanks
would have the same number (c) may be given by the 1. Public Health manager should consider_______ as a unit.
central government (d) may be developed by the health 2. Family health folder should be updated regularly by visits
care providing unit to household by the paramedics preferably once in ______
2) Following dates should be written on the cover except : _______ and definitely once in ______________.
(a) The date on which one of the family members were 3. Family health folder should of size_____ by _____ inches.
vaccinated (b) The date on which the folder was updated, 4. Factors in the family include three broad categories of
since some individual member of the family came in factors which are ________, _______ and _______ .
contact with the health care system (c) The date on which 5. KAP stands for ____________ , _________ and _________
the folder was last updated as a part of the regular survey Answers : MCQs : (1) c; (2) a; (3) c; (4) d; (5) b; (6) b; (7) d;
(d) The date on which the folder was opened (8) d; (9) a; (10) a; (11) d; (12) a; (13) c; (14) d; (15) b.
3) Immunization status is recorded in : (a) Vital Statistics Fill in the Blanks : (1) Family (2) 6months; one year (3)12; 10
Record Sheet (b) Sheet for Socio-Demographic Details (4) Social factors, Physical factors and Psycho-Emotive factors
(c) Summary-Sheet (d) Sheet for record of Housing and (5) Knowledge, attitudes and practices.
environmental sanitation
4) Special Health Record Sheets include all except (a) Under- Further Suggested Reading
fives health card (b) School-age child health record card (c) 1. Vatsyanan. Principles of Sociology. Publishers : Kedar Nath Ramnath,
Meerut (India).
Post-natal health care card (d) Ration Card 2. Susser MW, Watson W. Sociology in Medicine. Oxford University Press,
5) For effective medico-social case taking one should : (a) Not London 1971.
Maintain good eye contact (b) Touch patients appropriately 3. Mandel E. Health Promotion. Elsevier, USA 2006.
• 618 •

14. Information Education Communication
115 Health Education
(IEC)
IEC is a broad term comprising a range of approaches and
SSL Parashar activities. Visible component of IEC is frequently the material
produced and used. Effective IEC makes use of a full range of
Health education is the application of scientific health knowledge approaches and activities. IEC activities are grounded in the
or translation of what is known about health into desirable concepts of primary health care, concerned with individual
individual and community health behaviour and actions. It behaviour change and changes in social or community
removes ignorance and promotes intelligent understanding norms. IEC can be defined as an approach which attempts to
of individual and community health needs. It helps people to change or reinforce a set of behaviour in a target audience
achieve health by their own actions and efforts. regarding a specific problem in a predefined period of time.
In earlier times, public health dealt with the sanitation of It is multidisciplinary and client centered in its approach
the environment and the control of communicable diseases drawing from the field of diffusion theory, social marketing,
enforced by law, if found necessary. However stimulating and behaviour analysis and anthropology. Embodied in IEC is the
helping people to assume responsibility for themselves needs process of learning that empowers people to make decisions,
understanding people’s behaviours and the factors influencing modify behaviours and change social conditions. Activities are
it. Health education attempts to influence the health related developed based upon needs assessments, sound educational
knowledge, attitudes and behaviours of individuals and principles, and periodic evaluation using a clear set of goals
communities. In fact, in contemporary public health practice, and objectives.
providing health education, with a view to achieve positive Communication
health related attitudes and behaviour form community
A good working definition for effective communication is to
members is the most important requirement, be it prevention
share meaning and understanding between the person sending
and control of HIV / AIDS or lifestyle (non-communicable)
the message and the person receiving the message. The key
diseases or prevention of infectious diseases and so on.
element is “understanding.”
Definition : Health education is a process that informs ,
Verbal & Non-verbal Communications : In verbal
motivates and enables people to adopt and maintain healthy
communication, the tone of voice can communicate feelings
practices and lifestyles. It also advocates environmental changes
and emotions that are as significant as the words being spoken.
as needed to facilitate this goal and conduct professional
Accordingly, it is important to choose words that do not offend
training and research to the same end. In other words, Health
in any way and that are easily understood. One should avoid
education may be defined as a process of bringing about change
using trigger words, jargon, medical or other sophisticated terms.
in the individual’s knowledge, attitude and behaviour so as to
The use of particular languages may be important in reaching
enable him to achieve health.
all sections of a community. In non-verbal communication,
Principles of Health Education : body position, gesture and facial expression, often referred to
1. Community involvement in planning health education is as body language, can communicate as much as words. It is
essential. Without community involvement the chances of often through such body language that we express our attitude
any programme succeeding are slim. towards an issue, a person or a person’s behaviour. Service
2. The promotion of self esteem should be an integral provider must become skilled in interpreting the body language
component of all health education programmes. of users as this may assist them understanding users’ needs
3. Voluntarism is ethical principle on which all health and concerns more fully. Service providers must also be aware
education programme should be built without it health of their body language and signals they may be unknowingly
education programmes become propaganda. Health sending to users (e.g. movements or expressions that indicate
education should not seek to coerce but should rather aim fatigue, boredom, fear, frustration, indecision) (women may
to facilitate informed choice. speak fewer languages than men, for example).
4. Health education should respect cultural norms and take Communication Process
account of the economic and environmental constraints
face by people. It should seek positively to enhance respect In health communication we communicate for a special purpose
for all. to promote improvements in health behaviour through the
5. Good human relations are of utmost importance in modification of the human, social and environmental factors
learning. that influence behaviours. It is necessary to understand how
6. Evaluation needs to be an integral part of health communication works. The various components involved in the
education. process of communication are depicted in Fig. - 1.
7. There should be a responsibility for the accuracy of Components of the Communication process : It is
information and the appropriateness of methods used. apparent that several elements are involved in the process of
8. Every health campaign needs reinforcement. Repetition of communication. It will also be appreciated that communication
messages at intervals is useful. is two way process. This implies that just as the sender (source)
is communicating with the receiver; so is also the receiver
communicating with the sender. The components are :
• 619 •

15. spoon-fed and passively acquired. As a mass-communication
Fig. - 1 : Communication process
activity propaganda tends to have short-run situationally-
Communicate or Relays defined aims with an appeal to diverse population on the basis
Sender with message of immediate interest, fears or desires. The objective is to not
feed back
so much influence the individual deeply as to win his support
Decodes or Understands for some immediate issue.
Decodes or Understands
the message. Encodes the The aim of ADVOCACY is to place health problems issues on the
the message
message political agenda and effectively reach the influential group of
policy makers, elected representative, professionals and other
Choose medium and The Receiver receives interest group to formulate and implement policies to create
method the message pressure groups and supportive systems in order to respond
appropriately to the health problems. It helps in identifying
The Sender : Sender is the source of Communication. Sending potential allies and building alliances and relevant policy
the message to the receiver will depend on his personality, and decision making channels. The information concerning
mannerism, conviction conduct etc. The following aspects need position on the issue is collected and provided. A common
to be particularly considered with regards to the sender : understanding among stakeholders concerning issue is created
- His own competence and expertise in the subject. through advocacy and negotiating action on the basis of
- His own convictions about what he speaks. common understanding is taken. Through advocacy reasoning,
- His own mannerism, which include non-verbal influencing, lobbying, pushing and persuading decision makers
communication skills. and other stake holders. The directions of advocacy are;
The Receiver : Also called the audiences who are receiving the (a) Advocacy for policy design (b) Advocacy for decision making
message sent by sender. at various levels (c) Advocacy for implementation .There are two
types of advocacy : Proactive and Reactive advocacy. Proactive
The Message : This refers to the information which desires to advocacy is bringing a particular issue in to public focus and
communicate and must possess the following attributes : providing a definite shape for the audience that is sought to be
●● Message should be precise and to the point influenced and reactive advocacy entails addressing particular
●● The ambiguity in the message may create more harms situation or problem once it has already surfaced in the open.
than good. It involves addressing attitudes and opinions after they have
●● The information should vary from person to person or from been formed in the recent past.
group to group depending upon their background.
●● The message must necessarily contain clear concrete Barriers in Communication
suggestions for action in day to day life of the receiver. Unplanned distortion during the communication resulting in
The Medium (Channel) : The communication channel through the receiver obtaining a different message than that sent by the
which the message moves from the sender to receiver is the sender is referred to as barriers in communication (also called
medium. These include the various methods (as lecture or as “Noise” or “distortions” in communication). These can be :
exhibition) and the “aids” (as slides, slide projector) which are Physiological : Difficulties in hearing, expression.
utilized to communicate the message. Psychological : Emotional disturbances.
Encoding : This process includes the language expression, Environmental : Noise, invisibility, congestion in the
gestures and actions utilized for the purpose of making the classroom, etc.
information intelligible to the receiver. Obviously the receiver
Cultural : Level of knowledge, understanding and receiver’s
must be familiar with the code.
beliefs, etc.
Decoding : The process by which the receiver assigns meaning
All barriers should be identified and removed for achieving
to the symbols transmitted by the sender. In other words, the
effective communication. One of the main challenges in the
process by which the receiver understands or interprets the
design of effective health communication programs is to identify
message is called decoding.
the optimal contexts, channels, content, and reasons that will
Feed back : Feedback is the mirror of communication. Feedback motivate people to pay attention to health information.
is the receiver sending back the message to the sender, the
Communication skills are required to make communication
message as perceived. Without feedback communication is
effective, the following are the skills required at source
one-way. The part of the receiver’s response that the receiver
level. These include greeting skills, speaking skills, listening
communicates back to the sender.
skills, questioning skills, and summarizing skills. In short
Propaganda and Advocacy : Propaganda is merely a communication process would be effective if the communicator
publicity campaign aimed presenting a particular thing or has skills in introduction, skills in presenting and skills in
concept in a favourable light in such a way that public may conclusion. The non-verbal skills play an important role.
accept it without thinking. It is a deliberate attempt planned It affects the communication process. Body language is an
with a view to altering and controlling ideas and values along important constituent of non-verbal communication and
predetermines lines. The widely employed techniques are an consists of gesture, postures facial expressions, eye contact,
appeal to emotions, feelings and sentiments. It prevents or manipulating the eyebrows etc.
discourages thinking by readymade slogans. The knowledge is
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