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

2.1 Factors that influence health

Many factors influence health and some may have both good and bad influences. For example, surface water bodies can be beneficial as they can supply water for domestic and agricultural work, may be used for fishing and recreation, and can create a pleasant environment. However, they can also be breeding areas for insects and snails that transmit diseases such as malaria, dengue fever and schistosomiasis. Pollution of water bodies by humans also increases the risks to health. Factors that influence health can be grouped as follows:

· The environment.
· The awareness of individuals and communities about health.
· Personal hygiene.
· Health care.
· Disease.

The linkages between these factors and health are discussed more fully below (see also Figure 2.1).

Figure 2.1 Linkages between factors that affect health

2.1.1 Environment

The environment includes both the physical environment we live in and the social fabric of the community, and both significantly influence health. The physical environment plays an important role in many ways. A clean environment helps prevent the spread of disease and may reduce depression. For example, safe and adequate water supplies, sanitation, drainage and solid waste disposal all benefit health by removing disease vectors from human contact. Dirty environments, by contrast, encourage the spread of disease and may adversely influence the mental and emotional well-being of individuals. Industry and traffic also adversely affect health by polluting the air, water and soil, and by causing accidents.

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

2.1.2 Awareness of health issues

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

2.1.3 Personal hygiene

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

2.1.4 Health care

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

2.1.5 Faecal-oral diseases

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

2.1.6 Vector-borne diseases

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

2.2 Identifying health problems and establishing priorities

Figure 2.2 Faecal-oral routes of disease transmission

To improve the health of people in a community a number of problems may need to be resolved. While it is better to address these problems in an integrated way, it may be necessary to establish priorities and deal with the most pressing issues immediately. This situation could arise, for example, if communities or service providers have limited resources and can tackle only a few problems at a time. Community members may also have different perceptions of the main problems: people living in low-lying areas prone to flooding may feel that drainage is the major problem to be resolved, whereas those living in higher areas may be more concerned with water supply. If external bodies alone are responsible for prioritizing the issues, the priorities may not reflect community concerns and there may be a more limited sense of community ownership of a project.

Two questionnaires are provided in this guide that allow community members to identify major health issues in their community and establish health priorities. However, to ensure that community priorities are understood and that needs are met, it is essential to involve the different stakeholders in a community. Women and men, rich and poor, children and the elderly, and different ethnic and religious groups may all have different health priorities, and while it may not be possible to accommodate every view, the final list of priorities should reflect what most people believe are important health issues. To identify health problems in a community, community members should try to answer the questions listed below and then discuss the most pressing issues. During the discussion community members can try to list (or rank) the problems identified in order of importance.

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

2.2.1 Assessing community perceptions about health

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

Questionnaires

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

Participatory approaches

Because of the limitations of questionnaires, a number of other techniques have been developed. They are often grouped together and referred to as a participatory rural (or rapid) appraisal. The techniques allow the community itself to develop areas for discussion, rather than using questionnaire responses to define the topics. These techniques are sometimes used with questionnaires: by asking the same question in different ways during community discussions, issues raised by questionnaire respondents can be verified. More information about the techniques can be found in the documents listed in Annex 2. They are briefly discussed below to provide an idea of how such techniques may be used.

Participatory approaches cover a range of techniques, including key informant interviews, group discussions and observations. Although these techniques are often used by trained staff, they can also be used by community leaders to assess the perceptions of community members about health issues. When using these techniques it is important to balance the need to discuss all issues of community concern with the need to remain focused on the principal objective - assessment of community health priorities.

Key informant interviews are discussions with key people within a community who have a special interest in, or responsibility for, improving health. Key informants include women's leaders, youth leaders, religious leaders and health workers. The interviews are usually structured, in that the interviewer has the objective of obtaining information on key health issues. Rather than directly asking prepared questions, however, the interviewer can instead prepare topic guides to ensure that the principal areas of interest are covered during the course of discussions. The objective of each interview should be clearly defined and the community members best placed to provide answers should be identified.

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

A focus group discussion is a technique that brings together groups of people to discuss a particular issue, often in an informal setting as illustrated in Figures 2.3 and 2.4. The role of the group facilitator is to help the group to identify key issues related to the topic under discussion, while allowing sufficient flexibility to cover all aspects of the topic to everyone's satisfaction. To help foster agreement about the key issues, it is better to establish a goal or objective that the whole group agrees with from the outset. For example, the goal may be to decide which problems are most important to resolve. Sometimes people may give responses that are not relevant, or that appear silly or amusing to the other group members. It is important that people do not feel they are being ridiculed for their views. This can be accomplished by saying, for example, "That is a good point, but maybe we need to discuss the relevance of this."

Figure 2.3 Focus group discussions

Figure 2.4 Small community discussions

Problems may arise during group discussions which can lead to biased answers or dissatisfaction among group members. For example, the discussion may be dominated by a few individuals who express their point of view forcefully and prevent others from fully participating. Lack of contribution by some members may also be a problem and it may be necessary to directly ask such individuals what they think about a particular issue. However, care should be taken not to appear too aggressive or insistent since some people find it hard to talk in front of others. One approach that may help everyone to feel comfortable during discussion is to select individuals from specific groups, such as women or young people, rather than include a mix of people in the discussion. To overcome problems in group discussions, it is important to set ground rules at the outset of the discussion which all members agree to abide by. If this is not done, the discussion may become heated, some people may dominate the group and others may feel disappointed with the discussion.

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

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

Key points for collecting information from a community · All sections of the community should have input into the process. Priorities established by only a few people may not cover all needs adequately. · Decide from the start how the information will be used. This should be developed with the whole community. · Make sure the information is reliable.

2.2.2 Identifying causes of health problems

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

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

2.3 Using the information

Whichever techniques are used it is essential that the information obtained reflects broad opinion in the community, is reliable and can be translated into action. Once the major causes of ill-health have been identified by the community and the necessary interventions agreed upon, the resources required must be identified. If the community lacks the necessary resources, representatives of the local government and NGOs can be contacted to discuss how best to carry out the improvements. It may be possible to prepare a proposal that identifies the work the community would like to undertake, how much the improvements would cost and the contributions community members themselves can make.

The time and money required to keep improved facilities working should also be considered, because benefits may be short-lived if the community cannot afford to maintain improvements. It is important therefore to discuss with community members, local governments and NGOs the long-term requirements of improvements and whether they are affordable. This will help community members to select options most suited to community needs and resources.