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Indian Journal of Community Medicine

Vol. 26, No. 1 (2001-01 - 2001-03)


Prof. Sunder Lal

Experiences in rural areas:

Promotion of health as a level of prevention is most apt for formative years of life; pre-school and school going children. Value based learning begins in life cycle at early years of life and, thereafter, continues throughout the life cycle with varied degree of acquisition. Health is not valued unless it is lost. Organized value based learning can be acquired much more effectively in schools, homes and families. It would be a real investment in health and development of future citizens. Parents and teachers are best suited to lay foundations and nurture the values of staying healthy. A new push and enthusiasm is called for in the present system directing efforts at community level. To lead a long and healthy life, to avoid preventable morbidity and mortality, to acquire and use knowledge necessitates enhancing children capabilities, which in turn depends first and foremost upon the capabilities of their parents, most of all the mother. Increased acquisition by individuals and families of the knowledge, skills and values required for better living, made available through all educational channels, including the mass media, other forms of modern and traditional communications and social action can be effective in behaviour change. Health and hygiene as a subject cannot be taught, but it can be learnt as a way of life. Foundation of learning and development are laid in the family and neighbourhood. Family plays key role in child development and growth. Parents, family and community occupy the key position in formation of life styles of their children. Empowering parents and families thus becomes a prime concern to achieve healthy life style of the future generation1.

Reaching families and homes in rural areas is a challenge and herculean task. Under the present circumstances the system of health and ICDS holds unique position to ensure regular contacts with parents and families on sustainable basis. In our settings these contacts are happening through regular home visits, friendly visits and event based visits (birth, pregnancy, delivery and services) by health and ICDS workers2. Male health workers contact families and parents during routine surveillance activities, while female health workers contact the families for reproductive and child health services. The major focus of all these activities are "Women" or "Mothers" in reproductive age group. Fathers or men are seldom contacted by health workers female. Most contacts are occurring with elderly ladies and elderly men.

The other opportunity to establish contact with women are, MSS (Mahila Swasthya Sangh) meetings once a month, updating of survey registers once a year, mass awareness and service campaigns such as family health awareness week and pulse polio and intensified pulse polio programme, outreach session of an immunization and clinic visits of mothers at subcentre or at anganwadi. Coverage of young children and women in reproductive age group is the net achievement during home visits. The areas of hygiene and sanitation get partial attention/or else these areas are seldom attended to. However, there are some exceptions to this rule. During the event of outbreak or if the diarrhoeal diseases morbidity and mortality suddenly rises and reported by the media/workers the machinery becomes suddenly active on this front. Outbreak response focuses attention on hygiene and clean water (clean hands, clean food and chlorinated water). Most of the times the chlorination is resorted to only during the outbreaks. Regular chlorination activity is seldom undertaken or valued by the villagers. Insanitary conditions are appalling and there are no easy means to tackle the problem of waste water, garbage, refuse and human excreta. Village panchayats are silent spectators to the scene. Some village panchayats have engaged part time sweepers for cleaning the main streets, but the activity is seldom sustained on regular basis. Problem of flies, mosquitoes, heaps of garbage and refuse around dwelling is a perpetual problem. Animal excreta and human excreta is disposed not very far from the dwellings. Sanitary latrines have been installed by some well to do's in the villages, but in general these are not valued much by the families. Thus whatever is taught in schools gets diminished at the home and in the village as the practice of indiscriminate human excreta disposal is wide spread through open defecation and environments are unfriendly and filthy.

System of ICDS empowers mothers and families and the most discernible activity has been inculation of habit of hand washing, eating clean food and wearing clean cloths in pre-school children and acquisition of value based skills through non-formal education activities and environmental stimuli. Adolescent girls out of school come to anganwadi and get exposure to family life education apart from functional literacy skills, primarily home based skills. Primarily the system of anganwadis lays down physical, mental and social foundations in young children and supports the parents and families for total development and optimal growth. Anganwadi workers have been promoting the enrolment for elementary education of children completing six years and they maintain complete and accurate information of eligible children which is being used by the school teachers in a big way. Under the National Population Policy the endeavour of ICDS is being expanded to cover children of age bracket 6-9 years to maintain continuity as also to promote universal elementary education programme in the rural settings particularly for girls. Value based skills and habits formed at anganwadi and home continue with children in school and even thereafter and become life long practices, embodied in their life styles.

The primary school education imparts a broad set of values that transcend and specific knowledge acquired during the time at school will determine what kind of a person that child will become; however, the ground situation of primary schools in rural settings is quite distressing. Though the system of education is near universal the physical conditions in schools are quite deplorable. In the absence of furniture and suitable accommodation young children have to sit on floor and bring their own gunny bags/polythene sheets for sitting to avoid moisture and dust of ground. Drinking water facilities are inadequate and sanitary latrines almost non-existent. To promote personal hygiene practices and inculcation of sound practices becomes major challenge indeed for school teachers and parents. Teachers must practise what they teach in school. Most of the times the messages conveyed by the teachers are in conflict with the actual practice or situation. Teaching cleanliness in dirty school or class room is demotivating. Quit smoking makes a little impact if teachers themselves continue smoking. Teachers must practise the values before the taughts, who will emulate their respective teachers in later life.

The system of community health centres, primary health centres and subcentres makes some efforts for school health activities and most visible actions are immunization against tetanus toxoid, diphtheria and tetanus toxoid, occasional health talks, health check-ups, detection of refractive errors, demonstrations, mass deworming, iron and folic acid prophylaxis etc3. These efforts have not yielded much results in terms of health promotion and sanitation and acquisition of good health habits. School health services are in disarray, disorganized and have never taken off.

Our experience of organizing School Health Activities: We focused on primary school children in rural areas of 10 remote villages of Beri block. Three days teachers training and orientation was organized at school level covering the priority areas of personal hygiene, sanitation, nutrition and immunization. 73 teachers participated in the training programme. Learning resources material to each school was provided in local language on the subject of personal hygiene, safe water, nutrition and immunization. The material was collected from the state health and district health education bureau and shortlisted appropriately. Following responsibilities were taken by school teachers voluntarily:-

  1. Chlorination of drinking water.
  2. Personal hygiene check-up once a week (nail-cutting, washing of hands and brushing teeth).
  3. Messages on health and hygiene for better ways of life and healthful living.
  4. Health messages to home and community through school children.
  5. Referral of children to subcentre and PHC and CHC.
  6. Maintenance of record of health activities undertaken by them in a diary.

After the intensive training of school teachers the area health workers and medical interns provided support for continuing education to teachers in school besides material help (bleaching powder, halogen tablets, orthotolidine solution and some medicines as also education material). Teachers continued the assigned activities with varied degree of enthusiasm and interest. After a period of one year the rapid evaluation was undertaken by the investigator. The learning experiences are summed up hereunder:

There was tremendous zeal of learning amongst the younger students, they learned through demonstration and doing things themselves. Demonstration on brushing teeth, hand washing and drinking chlorinated water left an indelible impression on the minds of children once this was done by the teachers themselves the children followed and continued this activity in their daily life and even carried this message to their parents and families. This made perceptible change in the attitude of parents and families, who acknowledged these good habits when our teams contacted them at home to ascertain their views. In our situation well water was the preferred source of drinking water, piped water supply has been made available but it is accepted by 30% of the people only. Routine chlorination of stored water in tank/pitcher or well, to begin with was undertaken by teachers themselves and later on this activity was delegated to children, who picked up the art and practice after learning. Testing water with orthotolidine solution was a fun with children. To begin with, the community resented drinking of chlorinated water as they were not used to it, but the school children, who adapted the taste carried this practice home and convinced their parents to add chlorine tablets in the pitcher (home chlorination). Several obstacles came in the way of promoting piped water supply. People perceived that raw canal water was quite dirty, muddy and unfit for drinking. They commonly saw people using raw canal water channel for ablution purposes after defecation. "How can I drink someone else's foecal matter, which I see with my own eyes", was a common objection. Similarly, many other polluting things were seen by the students and villagers in raw canal water. Most believed that raw water comes to them as such through pipes and is unfit for drinking. We took the students, teachers, women and men to nearby rural water works and demonstrated the process of treatment of raw canal water and, thereafter, they became much wiser and changed their perception altogether and communicated this message to others in the home and village. They understood the value of drinking clean water.

Concurrently, the adult education instructors and organized women groups in the same village built the capacity of women and parents. The school children had an additive effect and reinforced the messages on chlorination of wells and pots. In essence the school health activities were linked and co-ordinated with home and village community. Over 73% of students acquired the habit of brushing teeth while the practice of hand washing became near universal. Close to 20% of homes now have ladles to draw water from pitcher. Habit of drinking water in Haryana is peculiar. Cupping of one or two hands for drinking water and seldom using a glass for drinking, hence all the more reasons for cleaning hands. This point was well taken and practice of hand washing has been internalized by children. Over 52% of homes started drinking chlorinated water and 85% of children cut their nails regularly. Teachers in three out of ten schools have constituted functional parent teachers association, which met once a month to discuss the problems and undertake appropriate actions. The school teachers who did the things differently within the same resources and carried out innovations shared their experiences with other school teachers. These activities were sustained till such time the visits of the team and support was regular on continuous basis. With the passage of time and when the support was withdrawn these activities diminished. Some school teachers who got motivated enough sustained these health activities on their own. Supply system of bleaching powder at time broke down and people had to resort to drinking unchlorinated water. Enough demand for chlorine tablets and bleaching powder was created, but this could not be met by the system and no alternative source was created in the village. Health education material was much in demand in schools and in the community but this always ran short with us, however, the effort of education was supplemented by adult education instructors (AEIs) and organized radio listening groups, which also built favourable climate and generated enthusiasm amongst students and community. Health workers and supervisors were involved in the process right from the day zero, but they were seldom motivated and no worthwhile initiative came from them, but for one out of ten workers. Health workers work schedule does not focus on school health on regular basis and school activities are ad-hoc and persued to complete the target of immunization (DT and TT) as also to complete and comply with some ritual activities like observance of population day in July, literacy day in September and women literacy in March and so on.

Though the diaries were given to school teachers to maintain the record of routine health activities undertaken but they were reluctant to record health activities undertaken by them and we could not learn many lessons because of poor records and feed back. Invariably the teachers demanded medicines for common ailments but the supply was always short and teachers had no funds to maintain First Aid Kit. Local health staff did help but it was inadequate. The feedback and the experiences were shared with health and education authorities, but we could not see many activities in schools relevant to health, hygiene and environment, subsequently. Tree plantation is a ritual and it has come up in almost all schools but it is quite inadequate. Sanitary latrines installation in schools have not met with much success. Block development and panchayat officer and education department did make several efforts to install symbolic latrines, which were never used by children. Health department continues to beat the old track. Recently in the year 1996 (July) a nationwide massive school health check-up activity by paramedical staff was undertaken and a week long time was exclusively devoted for this prime activity, the result and impact was negligible as neither the parents were involved nor a proper follow-up ensured. More or less it was an activity on paper, did not inspire or created awareness and much less built confidence of teachers, parents and students. On the contrary it generated a negative feeling.

Mid day meal programme is being implemented in different style. At the end of the month all the enrolled children in primary school get three kg. of cereals, what happens to this, no body knows. To some extent it has improved the attendance in schools but it is a ritual and attendance improves only on the day of its distribution4. There are many players in the school health activities but the results are quite dismal or inadequate. New education policy lays great stress on universal elementary education, but the quality of education including learning of hygiene, health and practice thereof in the school tends to be poor. It should be the prime responsibility of teachers and the school system, no one else can substitute teachers. Health education in general and school health education in particular has been a missed opportunity. A comprehensive programme of health education system must be persued at the earliest stage of schooling to cultivate values for healthful living. The core component identified in the National Policy on Education, 1986 includes, the history of India's freedom movement, the constitutional obligations, national integrity, cultural heritage, egalitarianism, democracy and secularism, equality of sexes, protection of the environment, removal of social barriers, observance of small family norm and inculcation of scientific temper5. "Cleanliness is next to Godliness" is a common saying. Mere teaching of cleanliness of body and surroundings is not enough unless it is effectively demonstrated and maintained by the teachers and students themselves, in schools, homes, family and in the community6. Essential and obligatory "Cleans" to be observed by all children include clean hands, clean mouth and teeth, clean food, clean water and clean environment. Basic training orientation and reorientation as also continuing education of teachers can be done by health sector7,8. Contacts with parents and Panchayati Raj Institutions on sustainable basis is absolutely essential and teachers must ensure this and health workers on their home visits should reinforce this activity9-11. Health, hygiene and sanitation goes far beyond the area of teaching as lesson or subject, but the same can be learnt better through activities and demonstrations on health and hygiene by the students themselves in an organized manner12. These learning activities should be on regular basis and be sustained through built in system. Here comes the role of teachers whose primary concern should be to organize school health activities and stimulate experiencial learning as also learning values of health through socially useful and productive work at school, home and in the community13. Linking school health activities with the village and community life and ways of life can usher in better learning, real learning and inculcation of values towards healthful living. This necessitates contact of teachers with homes, village and community on sustainable basis. School hygiene and healthful living and healthy life styles should be high on agenda with health sector and health teams to harness value based learning.


  1. Govt. of India. School Health Committee. New Delhi: Ministry of Health; 1961.
  2. Govt. of India. National Child Survival and Safe Motherhood Programme, Module for Health Workers. New Delhi: Ministry of Health and Family Welfare; 1992.
  3. Govt. of India. Modules for continuing Education of Medical Officer of Family Health Centre. New Delhi: Rural Health Division. Director General of Health Services, Ministry of Health and Family Welfare; 1990.
  4. Govt. of India. National Health Policy. New Delhi: Ministry of Health and Family Welfare; 1983.
  5. Govt. of India. National Policy on Education. New Delhi: Ministry of Human Resource Development; 1986.
  6. Barbara A. Education for all Mother and Children. American Public Health Association. Bulletin on Infant Feeding and Maternal Nutrition. Vol. 9 No. 2, March 1990. Washington DC, USA.
  7. National Council of Educational Research and Training. The Curriculum Guide on Nutrition/Health Education and Environmental Sanitation in Primary Schools. New Delhi: NCERT; 1976.
  8. UNICEF/MNIO. Training Modules on Sanitation. New Delhi: UNICEF/MNIO; 1988.
  9. UNICEF. Rights and Opportunities. The Situation of Children and Women in India. New Delhi: India Country Office; 1998.
  10. Govt. of India. Ninth Five Year Plan (1997-2002). Vol. II Thematic Issues and Sectoral Programmes. New Delhi: Planning Commission.
  11. Population Foundation of India. Training Guide for Representatives of Haryana Panchayati Raj. New Delhi: PFI; 1999.
  12. Anand D. "HUM" Quarterly News Letter. Educational Material Complied by SAKSHI - Centre for Information, Education and Communication under UNICEF Support Parivartan. New Delhi. Vol. III; 1 June-August, 2000.
  13. Ministry of Health and Family Welfare. Intensive Health Education for Primary School Children (Partners in Primary Health Care). Guidelines for Implementation, School Health Education Division. New Delhi: Central Health Education Bureau; 1989.
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