WORLD HEALTH ORGANIZATION

ORGANTSATION MONDIALE ISE LA SANE

HEALTH BDVCATIOH IN SELF-CARE POSSIBTLITIES ANQ LfHXTATIOHS Rcpart of r Sc ient i f i c Conaultetion Geneva, 21-25 November 1983

1- L i s t of prrciciptinca

4. State of knovladge regarding self-care behaviour

4.1 self-crre i n health 4.2 Self-care i n illneeb

4.2.L Dacisiane t o do nothing about ayuptomb 4,2,2 Self-treatacnt 4.2.3: Cerc seeking ss rtl f-ereatraenc

4.3 The IasiLy and self-care behaviour

5.1 C~accptual iamuas 5.2 Policy and practice isauca

h. Enhancing effective self-curt behaviour

1 Palicy i n support of self-care

&*l. l legi6 l&t ive p01 i c y 6-1.2 ~ d m i n i s t r a t i v e p ~ l i c y

6.2.1 Ucilizatian of natural tnviroomesta for educrtian regsrdiag sel f -care 6.2.2 H e & l t b e d u c m t i a n d i r a c t e d t a v ~ r d s p a c i f i c p a p u l a t i a n n a r h c a l t h p r o b l e e ~ 6.2.3 Iaforaacion dymrtma ( - d i d

6.3.1 Impscc of praEesatona1 rtcituder end brhrviour 6.3.2 Prefermianal aducation

6.4 Rcasarch haor f o r informed palicy end pragr- devslapmcnt

6 . L . 1 Etaasline data 6.4.2 Analytical studies b . 4 . 3 Evrlurciam etudiea 6.4 .4 Palicy r tud iee

Cs doarrmnt rr, m l t w prw urn rhhliudan. II n6 dait hirr I'obirt d'aumn ecrmm t b d u bll

r h d ni d'wm~ns e i ~ t b r r unr I'mtoriutirrn da I'Chgmlurion mandlllr de lr Smtd. opiniom wrprimdsl 1- Iat wticrtr rignh n'd.ngrgmt qub

Iwr~ rvnun.

SCIEtITIIrXC CONSULTATION OM W T H BDUCATXOH 1H SELF-CARES! POSSIBILLTIES AND LIKITATIONS - 21-25 NOVEMBER 1983

1, L1$T OF PARTICIPANTS

D r H. Adaasonrr , 2 Ch. bs ~ r ~ k t h a ~ ; '- ' '" Is . . . Grand Saconnex 1218 Geneva S * i Ucr land S , . .

,S. . :: .' .

U* EJlwi'. ' - . -. h:: , : - 8 -Q-. . *

Ceatra for: Seei.1 sad Eavirozmmaral Rtaerrch

Uuiverrity of Brain Esnia C i t y N i g e r i a

D r R. barn Inatitutt af S w i r l Hadiein. Unirermity of C~psahrgae 32 Julirac HatFam V s j IlK-1000 Capcnhrpen D e m r k

Dr C. Dcfriemr P i r l e t a r Htrlth !%rmicaa Rerearch Eentmr Univetr it7 vf H ~ r t b Ctrolinm Cbaprl H i l l North C r r a l i n r 27514 United S t r t a r mf krrr fea

Hr E. Drrptr Director Cemerml of trrLth Prcmmtiw H i n l a r r y of I a c i m l Baalth

mad Wtlfara O t t r w r Casrdr

Dr X. Moaref i 57 rue de noilleberu l209 Genrrr . . Sviererlahd

'... . . Dr A. Oatroveka

- rirvtirut4 a € Philoeapby and Social S c i e o c t ~ + . .

Paliah Academy of 8ciaactr ~ ~ s w i a t 7 2 . . Pal ac Warmn Poland

Dr V, Ramnkrirhm Virhvamth6 Rao Road

Hadhava N a ~ a r Bangrlarc 56OOD1 Karn~tmku S t a t r India

Ptofemror M. Sorry. Univtrsicy of Tthtraa Tcbcras Islsaic Republic o f Iran

Pr T. Tulchimkky Haniaery of Health . 20 Kin# bavid Street Jeruarlra. I araa l

Dr. J. Yillimmron General Praecici~ncr 24 Ucatvil~s Rasd Barnslsy South Yorkehir. 575 2TR United Kingdom

Profaraor Pei-ahu Zhmg Diractor China Urlfart Irlneiturc: Intarnat iarul Ferca Iiatarnity and C h i l d Healch Horpicrl

920 Hcn~rhan Road, Shannhai Fcaple'a Republic of Chine

A Ereup of eapcrte in the lLeldr aE. health tducatiaa, sel f -cara rarearch rnd progrmmne davslappent; and h e a l t h asrraican administrat ion war convened in Geneva to a d r i m regarding the role of tducrr im for @elf-rare in the orgmiratian'r global otrategy for Aesleh f a r a l l . The Director-General, Dr H, Mahlcr, i n h i e opening addreee, pointed auc that there Could hardly be a -re resounding juat i f i c s t ian for the Scientific Caarultrtion on t h i n aubjscr Chad 8 statement included id tha uuamipaounly doptrd A l m r A t a Deelarstioa; . .. . ,

.. .ped@li h- tkm - right a d duty Le p.rricipare i d i & i d u ; l l y and' sollactivel;': i n the plrnahg .and i m p l e m m t ~ t i m of chair her l th care (36-1, . . L . ,

. 8 . , ' c . Thafe fl: i n long' rtmdihi interesc i m rh i r rubjscc;. &lehougb; mat lsbslld "ar l f -~rra", . . in

the policy and work of WO, Par e-la, i n 1954, srr expert e o m i t t e c repor t on health sducatiori dincuamcd helping ind3viddsls:

. . .I

. ,r t . : . , , . t o become competeat i d and t o carry out thore activiair* they w e t ..uwlarLaka, far thmm~elvem BB a n d i v i d u 6 1 ~ , o r i n -11 groupa, in order t o rralite f u l l y th t atarc of healeh defined in t h e Can~titution o f the World HcrLth Oreaniration (37).

. .. .. . ' 'i

The gorle o f the Scientific ~onsult~tion add of thf s i tpert , vcre t o provide to WO; , . y ) . -

2) A summdty o f - the- mai lable iafarprti~a. releqant. to .&ha. rubject af self-care, behewiwr; . , , C L '..I .. . C < . ' . ,. - . : . . . I 1

2 ) ' A biscusrion of. the iqartan6 i ~ s u e a and rctias arsm identified during t h i a working cmf crencc;- a d . . . .

' , 1,. - . a . , . ' , 1 - . 1 ~ e e ~ d r ~ i r r ~ r far polity; education; bcrl th rprtcme r a d reucarch.dirretad eaward supporting and enhancing ef fec t ive self-earc bchrviouf i a the member staccs af WO,

,. . " a . ;.. L . .l . . - ... . T%c v i t a l canrrfbutian tbrc barter self-&% behaviour' csa 'b lcc ta the H d e r Scater'

gar'l oi Health fat A I 4 by trHr Year 2000' in b h m bp e h s graving rccapitian of the import~oce of i ad ib idur l bchdv iau~ td health prchaociou, d i a t ~ r t prevtnticm r o d c r r c during illnesn., Tht heal th dtatur of an individual (o r af a populctioo) i r rhe remit .@f mny farcem w i t h i n the individual rod 'the *wtsuundin~ ~ c r e i e t y . Safe air, rater and! f a d aupplism an. well r a rdcqurta mrtritioa and ehcletr. are p r t t t q u i d i t a e , e i t h u u t h i c b ptoplc can d a l i t r l a ta wifiebia their health; Hcrtctitrry factor8 are mLso important detarninantr af .heal th s trtud+ Hawe*'er, given badis prcrequiaicta, rhe major detemParncs af health t t r c u r ate; 1) eslfycsts g a t t e r w o f drily l iv ing; 2 1 t h t capac i ty rnd. oppartunity to contain,strema and erbtaim ~ a e i ~ l Brrpport; 33 t h e a b i l i t y t o identify and cart far h e a l t h problma; and 4 ) tha c a p a c i t y t o obtai,d and i n t e r a c t effectivkly w i t h appropriate p r a f e a e i o o s l asmiear, ,

" 3s ~ p i t c a # c ' h C ' w l w be ai@eriential knorled#c a d rcicntif ic data t o illultrate the- f riti; c a n f l i r t rnd dcbati? o f rcri- surround dlacueafans. of btlf-care,.. It. L1 imporreat ta cmphlri+c that thc part ic ipahca oft c h i r e a t i n g do ant ~6naidtt-~aelS-cara.~ way ta replace d ~ c t o r s , nureer and other worker6 - p v w i d i q - . the w d i e r l scrviccr. ncceerary to eura r i c k people. rri him opening r b d t s r e , the ~ l i r e c t o r - ~ c n s r s l d e f i n e d t h e concept of self-carr uasd aa a h r i r far tht work of the meeting participants;

($elf-care i m J 1 mtaan h e r e b y people take -h grcrttr r e e p n a i b i ~ f t y for their ovn h t s l t h batted m a4 undtrat-mding, i n their awn language, ctf vhac heal th i a rll,about, hbw to pr-tc ir, h a t damagee i t , ha* ta protect it, and *at to da whsn %L daab go wrong.. ,

Parr af the proctse o f self-erre i r kmuing i t a limite and whcn ta get apprbpri t tc proftsaionsl arwfcea. The p a r s l L t l rtnponaibiliry.of harlch prafcsaianala is t o provide an dppropriaec level and mix of services rhith cbhrntt the competence snd canfideoce af aalF-care b&aviimr in t h e populatien. 2ha pri lrciplca are applicable in m 1 1 t o u f i t ~ i ~ ~ , but havr r i d d l y diffsrcnt implicatiomb for pragrrmne dcvaLdpwnt in davaloping countr ies t r campared w i t h the drvrlqsd i a d u s t r i r l i z e d araas. . .

There i s a growing body of evidence t h a t s t r e s s management, eaciaP ima2vement and/ar aoc ia l support p r w i d e pra tee t ion from both mental and physical. i l l n e s s , and i n general , promote health {6, 8, 9, 10, 29). The a b i l i t i e s t o express neads and neek help &an neceesrry a l s o are heal th protect i v t behaviours. Children and e l d e r l y persona a r e soc ia l groups for which thcee heal th protect ive a k i l l e m y b e e spec ia l ly important. Very l i t t l e research has been conducted on t h i s eubject.

A gemerally uarecognixed fom of heal th protect ion i s the use of natura l hea l th resources and technologiee which a r e readily a v r i l a b l e and appropriate t o hea l th needs. Breastfmeding. herbal and other h m c r m a d i t a and et l f -help support groups are oxamplea of such individual end group hea l th protective bchaviourl. I n Rome canes they may even be l i f e aaving. Situations were: reported where people with very l i t t le i n c m b o u ~ h t phermaceut ice1 produc t r t o treat illnersd uhich reduced t h e - amount, of manay avai lable to buy food and other nccesaities. When these prapla learnad t o make hame remedies which were just as useful. ee but cheaper than c m e r c i e l productr, ,both in fan t mortal i ty end m o r b i d i t y dropped due to t h e g r r r t e r i a t a k a o f food which r e ~ u l t e d ,

Amthrr farm of herlth nwinten~hce. is the early detect ion of dieeaee i n order to f a c i l i t a t e cure when -posaib.le, and t o p r w e n t negative. aaque l l a t from nceuring. Thin involveo personal monitoring baeed pa, ep, undererending of major hea l th r ioks and the apprnpriata . uaa of prevent iva hea l th services. . .

.. 6

Thmse various farm. of hea l th prorcecive lifcmryle behaviours depend on rhe availrbliry of eorrsct hcelch ipforrmt5oa to people .a, w e l l a8 rociel and psychological asptctm of che perem' e l i f e eituation, - Bohsv,ioural pat terns , once e r teblimhed, a r e .aftem hard co change. There is evidence t h a t eelf-help groupe can be ea efEective farm of self-care which f a c i l i t e c e s behavioural change ( 1 7 , 20, 263.

. . :. . I . ... . . '

. '. :. , . , . . . . . , . . .:: ,4.2,, SEW- CARE' IN ' ILLNESS ' . .. - .

Tht corrtlroveay which my..ayrcounb dircure ioaa of oelf-care i a pr.edaaimntIy relarrcd to itm f Ilnese behaviour component k tendency, t o view s c l f-care as behaviaut o p p m i t r t o snd etparate nfrcm profeerional c e r c . h e l contributed t o the teristante t o the concept by both profeesionals and some- ley perrona, This view of self-care hides the f a c t that u h i l e self-care durinx i l l n e n r may be a new and challenging i d e s to heal th p ro fese imnl r , it $5 and always ham bean ths dominant farm of e a r s i n i l l n a s a (12, 22, 23 , 32). This v iew a l so Esile to rccogniw. rhar evaldarim. of. ~ymptmb: and dee i e ione regard i n & reaponers . to eymptomm are the bauis a € a11 conauLtntian behaviour.

4.2.1 Ddtisictna t o dp natbing about eymptoma

Decimicrna tn ha n o t h i v about- syaptclms have r a r e l y been emsidered in invcstigaticna of behavioural rcepanees ea illness. Even though having eympcms r a t h e r than not having them i s the norm end i a regarded ao q u i t e compat ib le with ~ o o d h e a l t h ( M ) , m e t inves t igat ions o f behaviour i n i l l n a a s a r e dcaigntd wich an implicit assumption t h a t aymptnms should be created, mis biae i n crritncetion ptrttiats i n apire of the ee l f - l imi t ing natilrs of moat i l l n ~ s a mpirdae, It a f f e c t s both. tha design af studiea em w e l l as the in te rp re ta t ion of reaultn. . , I

, .

When t h i r var iable was included in an inves t igat ion of behavioural r c a p n a e s ea i l l n e n s in a national p p u l a t i n n , it va* found t h a t a large praportion (37x1 of the eymptom episodes reported by rcepondencs stare not created in any w a y y . Uhilc t h e m candi t iana were more o f t e n minor, i r Utb not only tr iv ia l and r a p i d l y pasaing a y m p c m t h a t were not trested. 113) A ~ i m i l a r f inding haa been reparted from the reau l t a of a t t t a a t t w a other s tud ias of reaction, to i l lnees i n general popul&tian groupe 11, 14).

Uhee ds ta regarding untreated symptoms a r c col lec ted and analyxad, the canclusions generally crcluda the p e s i b i l i t y t h a t t h r pa t i en t evoluetts the sympcams and decider t h a t t h c b t ~ t . response i a t o da nothing. Furthermore, life a i tue t ioaa which may prevent or in te r fa re with the p a t i e n t aeeking treatment ara rarely explored.

Hen!&. I. Page 5

The caneilptions of lay people abouc hea l th , disease and ca re and the var iables which shape t h a i r l i f e n i tuat ion appear t o be the major detarminontm of ael f -care behaviour. Y e t these fac to rs a r e generally ignored i n heal th po l i c i es and pragrrlmpas. During the Cortaultstian's warking sessionm, repeated examples of eelf-care p r a c t i c e s which grow out of thc sick peraonrs, understanding of d i s e a s e , o r that are prevalent i n the socia l e n ~ i r ~ ~ ~ n t , vsre presented. Self-care p t n c t i c e e a lao depend on the reaourcea ava i l ab le for developing 'Lreetauent procqduree, One repor t from a developing country reminded ua chat only the individual knove exactly how heldhe Peels when in good heal th o r a f t e r t h e anaet of i l lneas . When there I s i l l -hea l th , it ie the individual who take8 the f i r r t r e ipons ib i l i ty f o r dacisiane regarding care and dccerminae the kind of care. It ua6 noced'.that people have ~Luaya held h o l i s t i c v i e w about the human being. They therefore get .upant by the tendency 0f mast profeesioanl& to regard the dieeaee as the object of interveneion [care andl0r c u r t ) end not t b , p e r s o o who haa t h e dieesee. I t in imporcant to lieten t o the people about t h a i r eoncsptr ~f h ~ e l t h , disaasm and heal th c a r e .

?. . .: ; 'L . - . a . d.% : - , , :, 1 ,'>

n ~ = t self-car; bchaGiour trket place i n 4 family environment. I t is :iri the fnmijy.;thkt heal th e t t i t u d e a e r e f i r r s aoc ia l i t ed , hea l th pract ices are learned end m a t heal th care i a prwided. (231- ?he faaily is. the bas ic source of aocial support mod contact , bath of which influaner heal th otrtua ad.. henlth behaviour.!. Becauee oelf-cure .takqs place i n families, heal th pol lc iea aad ,prrrgr-@-,to, enhmnca ~ e t f - ~ e r e .<behrviour must be d i rec t+ t w a r d suppar t iag fmnily unit,. Tbe type aid amount' of card provided' i a . a given faajly w i l l be a funcltion of t h e acute'andfor ,chronc morbidity arprrienie -of it 's ,embere, their l i f e e t y l e e , value Byetea, feeling8 of reepone ib i l i ty , f inancihl a i tuae iah and t h e " c o m n i t y puppart: serricea available, I

, , . . I . ' . , < . . . r .., .. ' .'. . . . . . . % . . . . . h a qii;l.i t<& . . . . : tk i f i ~ i y . imiirmiedr' vi i l ' , ;$ihr iu&ir o r rkdu& the , f~rtal+&6.d~,

aclf-c& can ba pr rc t i ced , aafely ,sad e l f s e t i v ~ l y , , , Fqr, e x a w l e , the h&',, thk, phyeical;' ~ i - a c e ia uh ich self-cat&' , ip. . pritct iced ie an ,imp$rtarit ., eisdhPoneat ' 'of .', the: e a v i i 6 k h l . . Adother important influence" ii the family's' educrtionai' eiiri3anmant, t h i acieee ' t o ' i n f 6 m t i d A of family mcabtrs. R , t h i r d important. f s c t o r ,affacclng f a m i l y eelf-care is, the time r v a i l a b l a r o i t s rnambera. . The ' q i i t s t h n , 05 :who functibke ori whose behalf i n t h e , faniily hap ' : idffuen~@ both t h e qua l i ty . , bf c h i family car? pbv ided aqd, equity crl oppo'rtunity, among fhily ukimbcie.. The type an$. amount of tamily , auppart nervicsa avai lable i n the ccnmnunity v i l , l , a f f e c t thim

. . . . . ' I . . . . aituatiariS . . . . . . . . . . . . . . . . . . . . . . : . . . . . r . , , , . . . , - : . - . . . . . . . . .

. - , ' S& familica can ,

be, 'iUii=, . ' f lexibse. ' ~i eh'' the ' help'" of 'ftienda':'.and iithck non-praftaaionals i n t h e i r ' social nctmrk, chey a n a g e extremily 'dell'. Many 'athet' f a m i l i e s with P f r a g i l e , member b c e o r s o e i a l l p f r a g i l e familica, uho8e c a h c ~ i a n ,and e f f i t i a n c y - braak d m ; ' 6 r t h . c r limiting t h e i r pbssibiTit ien. Uhethar the oriaei, of i l i n c a s at'.icijury i e .,duddan or g r ~ d u s l , m a y affact. th,a"family'a capakit) ' t o adapt, i n d mbbilika ren&urCcs and ,m+thad~ . to cope w i t h chc eirueci@n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " . . ' .

. , since the i i n &ing r o l e i n f a m i l i e s cbat inurs rb be f.ulA11ed by the r ifej=oLber,

women' m a t be involved i n the dwalopmaac of primsr)bhcalth care eysrems. AB p r w i d t r d and ustrs, they can inerrie that neu approacheo addteas impartant canearns i n a may t h a t a s i u r r s acceptance and par t ic ipat ion. Another important reaaan for a#ausing the invalvamnf of m e n in programt deuelapment ie t h a t they ore not only key providere of heal th care i n f smil iee , but a160 i n cmm.mity. ,hcalth c a r t f a c i l i t i e s . Anather reanon i n related ta the prablaa mentioned 'above of equity of r a o p m o i b i l i t i ce within f milirk. .

When-rrma combine the caring r o l e of the vifeiwrther with employmat, they a r e o h e n subjectad to burdenactme routinea. Studies i n one country revealed that employed #men have on the average only two houre and f i f t y minutea of free t i m e a d a y , T h h t timra ,more ,women than men reported having a l m 6 t no f r e e time. Similar f indinga regarding ckt burdens of double work have been reparted f rom invcat igs t iona i n athar cauntrias,

Generally, it m y be concluded t h a t frmifieo fa ted w i t h tokinE car= of a dependent kr dirsbleb member, or depending on a m d i c a l o r eoeia l insc icucion bceauec i t i a e a s i e r , m u s t enter , a proceas of negotiat ion regarding the responrribil i t iee to be shared by t h e dependent mcber , a thc r family membesn and other group8 o r ins t i tu t iona , When the d i ~ t r i b u t i a n of caring funcrione is uneven and burdenerne, the self-care o f both the care g iver and the rec ipient of ca re w i l k br negatively af fected.

r e ~ v l c e e . The ieeue a € cquitsble acceaa hr . been roised by pctaonr concrroed that the concept o f a r l F c e r t will be ueed a3 an excure for denying or reducing h e a l t h and social ~ c r r i c e a CO cerca in groups of people i n need. The concern is t h a t self-care w u l d betwe part OF s pr~ceea of "blaming the v i c t i m " in order for &QVorIment~ to rvoid public raspansibility.

The prrticular concern. f a that poor hcalch would be ascribed t o peopl t ' ignorance, poar vmtivstioa, and uher l thy lifeatylea so t h a t they, eapecirlly the poor, rauld b e bl-d far KheIr o m p 6 r h e a l t h and he ld reuponsiblr for i e r improvcm?at. Aay such use of the cmcept of erlf-care i r s oieuec and abuse of the eoneept, and i r a l i e n t o the parmpectivar an aele4sr.e d.ircusrrd; in r h i n report,

5.2. POLICY PRACTICE '188UBS -

l%* p o l i t y isrue uhich i r aoee relevant eo tanaider sc th ia t i e i'a the dubjact o f barrisru'which inhibit affactira relfieare. Thena barriara map, be; L) l ega l ; 2 ) da faeta adminiatrat ivc8 o r . preft6nianal- practices; or 3 ) ubinrsndad effect@ of profearionai treaemntuc Erraplmr. of , l e g a l barrier. which prohibit persons i t a m practfciag. or abtsising the t y w of c r t e they wimh ham barn dacumtntsd in relation to chjldbirth, tcrrpinal i l l t ~ a s , the r ight ca die, -and equicablc &CCcB# to elrcrn*tive treatment or pr actitioner e ' ratvicr8. ,

. . .' * _ . . I n uuoy.~iastmncdu vbttc .there ate oe:,sctual legal barriers, d; facco prdce,icce e i ther

dirdct ly . inbibit or - reri6url.y interfere with ef f ee t i ve rrlf-care bahruiaur. One. asampie i a p t ~ f e ~ r i o r c l acrituder that inhibit dirclorurt of heal th c q r ~ iolarmatioo t o l a y people or l i m i r health cart mkil lr in order to saiotain profess ional control and Isy d e p m d e a ~ y . . . ., . .

A t h i r d typi of barriar oeeutm fra.unirrtcnded effcctr a€ profermianal treatment. For a x v l a , umtcanarry t raa tmbtr and medicines often mra prsacribed when advice,. cwfcrrt and seabible h- r-ciiea-. m i g h t b e e q u a l l y or more effeecivc. Health p r o f e r s i o a r l a w e d to raaPixs thrc .the m n t . f d l i e r apsnd a m vitamin tonics, cough medicines,, cold fdraulmr, diarrhoea-l dmgm, nccdlcss irtjettfans and frequent tripe eo healch c e n t r e 8 f o r prohlcma- chay cauLd ummga themnelvcm. ac tua l l y , m y u ta l r~b the herlch 61 lamilp members by ]Leaving Learn w n e p t a spead on food, aoeie l rupport end r~laxs~ion.

A' rclrtrd . i a s w cmiesrnr : t h r rights of. individual, to grretise rf Lcctivc erl£-care trraapcc t i v e d I : the ccouotic.- idtertsts o f orhere. or che intrrescr of particular raci sl graupm. mum, concernr regarding pradut t i v i t y or pub1 i c npending ohauld not p ~ e v e ~ t people f r w he righc and ccaaoaic recuticy CO itaria or: hoee and csre for chtmaelvea during i l l n t s a . He1 thar s h w l d t h e iatcrsmt o f varioua grafamaianal graupa or organirsd raligiaum bodied inh ib i t b t r rcrn ca he meens neccaaory for effective self-cure. The Iatccr p a i n c iacluder the r i g h ~ of sccesb t o appropriate ~echnologieb i n cht home for a c l f sad. family car t , including childbirtbi.

6. E ~ L H G . - s r ~ e c ~ r n SELF-cnat BEHAV~ OUR

The discurmSsn and xccmendrt iorra were orgenired. around four aubjeca srcss; 1) pai ic7 in ruppnrt a € arlf-crrr; 2 ) t h e role of educwtiotr; 3 ) the imprct of proEeseiahs1 care; and a ) a reeesrch babe for isffirml pol icy sad programat development.

Public p o l i c i t r in eupport of eelf-care auat functian to demyaei€y hwalth cars, creating a m b l i n g anvirnnmcntr in which people eelr more: readily promote their health end care for chrrsselvcs during ill~18a [2%1. Thia wane f i r e t arid foremost, chat the distribution of resaurces t o h e a l t h care Bystrme m e t be altered from exces8ivt t u n ~ c n t ~ a c ~ a h on diacsme-arisntcd praE~wsionr1 approached to hmalch c a r t , to systems which provide w r c infmmatien and tranafer o f trchniesl skills CO the lay papulrcian, provide relevant aupporc s e m i e t a for fnmily care and viably i n t e g f a t e lay and professional care.

Rsalch enhancin~ policy, palicy which enables pcaplr to take greatcr. rtsponribilicy for chr i r o m health, f i r a r recognizes t h e c m t r i b u t l o n end patcntiak of elf-care, The palicy must be raatcd in chu lay population, which mean9 thet t h e people'$ preferences, p t i o r i t i c e and solution rtrrtegie9 musr be in tegrated into the decision-arking pracasa Farming a basia

HRDl84*1 Page L1

and t o t a b action rb changa. thase fac tore . A self-care educeeion prograarmt thus might contain content . to help people:

' I I

l , Regain ~pprac ia t ioa , for thoac home remedie8 and preventive tradition; that are e f f e c t i v e end iocxpcnsiye c Foi example:

- . , - . > A , , p . ... .'.!'* 8 . . - herbal' rnil-.atfkr t&&ir ibn6.r re&d:te . 7 . - ? : : ? , L P . ! . , l ! , . . . ; . . - . a - -. . . . - . . . . h-dq.cr,utche,a~ and- artif ica l liPde.' . . - . . “ . . . . . , , .

. . r . . .......: .; . . . . . . . . . . . , % S , , , .;,. .

. . 24 ' . ~ i a d , $ q # . , CO, ,4.pyaa aid' . hi14 ui& ef t ~ t i i k . trad,iriod& ion. ' of heal i*g'. and .' pr~vrpt.iop, ,eepqcially . . . w h e r e repouccea and hem l t h asrvicse b ~ . e sgrertiy, l imi ted . .

, . . . . . . . . . . . -..,I -, " . . . . . . . "' -.< ,.,: i . ,- .*: . # ! .. . . . . . . . 31, . . _ . , ~y?p , popla,.l~em.~ro.rripk]=iskm and, e i i t i a r i ibe t , bei;.rjri +d undkrtaiid'ihd: ring. a f oprionr avrilabl. r& them. , . . . . . . . . . .

. I

4): . U ~ e a ~ n ~ z t . thuif a y , c a p a c i t i ~ e b a+ Limitations, knwing,.. wbq:t -and how t0,: seek aasibtanqa a f f ~ e t % y e l y , ~ -:'.. .i .,,.l ,L . .%., .: . . - . , . . , . . .. . . . , '

. . . . . . . , ' I . . . . . . . . . . . . m : 7 . - . . . . ,>-. . . . - : : - c . ..., q < 4 , ' .>-,:.-:;. ,,,,,. ?: ..; ;, , : . . - . . . , . ' ' ,. .- ,, L, ? ,

.I:5?rl'bai+.~ch,ai cg+da.eP. u s d o ~ e i r a d i a ~ . and ~ o l l t ~ t i v ~ ~ ~ , ' . ~ ~ i e l y t h . , , t.q , i : 'i<+ $. . iqoti lu~icrrr~, d ~ & . o ~ s , , , h ~ l t ~ ~ . r c r r k e i , an$: t + d i t ional . haalarr ' the. r i f c r r a l rerv,ic~m~!~lie'y

. . .... ne.aS; ,end ~ o . ohta+r); che i o f q d t b n , auppl iea an t - euppart they . need , far more, e f f,ett.ive I : .

. . . . . a 1 e r . . . ...*........ 1 . ::*, ,, , . . . , . . . , . . - . . . , . .+, ', ,. , c , : L , .

61 Obtain rrsd make good uoe of available =erource;'and information 'frw v ~ r b ; i Ad non-verbal teaching material. or from coumiunity h e a l t h workera skilled i n informal. education mathodr. Information ahould be made avai lable or;:. . . . . ? .~ , . / J ; : ~ v , ~ . : ? , , ( , : y . $ : rt,.:> ..*> . . . . . . . . . . . . . . . . , . .. . . L . ..; ! . . . S , . . . . . . . .,.. .. -. - t ~ ~ . h ~ ~ ~ . ~ ~ , ~ l f o ~ i aalypinp~ s i t u m t i a n ~ ' and. s01riu.g~ rob , - :;: -!. .: : .

: l ; . c n ,., ?:-:D! i i j .g:fr.q F..,, , .-..:. . :.: % , . . . . : . . . . . . . . . . , . . . , . .,,. > .- !,. . , '.

. - : - . . . . : d i . # g n * l ~ & t j + , , ! ~ e a t ~ ~ p ~ ~ . C a,nd prercn,tloy of. cwmr0.n . h b a l j h , " ~ t i b l e m ~ ~ . . . i -, . . . . . . . . . ; .:. ;

. .'. . . . . . . . . . . . . . . ;.',i,J+L;qrr v / ' . . - . ; , * . . - :.;:, , l . _ , ; . : . . > '

, m - . , : ' r ~ i n ~ . ~ ~ r ~ ~ j x , ; ~ ~ a + ~ ~ 6 1 4 , . . ,Lq,c~l ut;ii;li,' . . ";&hriol&&i , and , pr~st isb. ' ko, <nhiri=6.' . , .

. . . . . . . . . . . . . . ~rot,?qt:,htal 't$, ,,; . : . .. . . . . . . , , . .

. - . . uhat~~,copag$tvt,e,~ . . .. c a r r q c t -urn$, . ,misuat, and overuse, p f mtdicineo, bath trqdit . ianal . , end . . . .. moder&, : ,: ; ::.,, :>. :,.; ..m. .: .,'!. .. . p .. ; . ..'* . . . . . _.I. . . . . I . . . . . , , .' ' , : < . ,

- h# eo avaid being uninformtb, mirled,. ovsrc@orged or.,,over-treated. by health profteaionale, or lay heelere.

. . . ' ' "..,l; ; -, ? . ;,.> 8.. , ; . 7 -, . , , , !. ' : . ' ::. .' . . , . . . . . . . , . . , . . . . . - 9 tha: p t q r ~ m m * . ' ~ f i i ikiaaef ,and. hcml,ch,. the body, aad'hgc' i t .korkr, &l 'the "li i i 'retiana

. . .: I .. .:. . ; :..'!'::+.; . , . . . . 1n a r d k t a f ac i l i t a t e e a r l y ~ocial~rstion i n 'these &opo+tant' se l f -car= s k i l l s , and

pract ices , garrncs and prasptcciva patent& ruer be given the chance to 'Learn b a w t a h'e lp cha ir c h i l d r e n l t s r n s e l f - t e l i r n e e , graup.participation, and 8elf-earil, akillr. . a., , , .

. . . . . , .

Haalrh tducaslon.oftsa h4a referred to courses ar c lassor with s p c c i f i t . heslth content. Bducat;ioq for health pulat &*rend beyond the l i m i t e d t i a and cancent that can be praaented i n 8pecifi.q hmalth, c l a s s ~ a , Hob6 of rhs subjects taught in pehsols sffacc h e a l t h or have health-ralevant aepeccs, .. Health should .not be preaantcd a s o n l y a a p e c i s l nub jack, b u t a l l 0 inrcgra~ed into the 'entire a c h ~ o l curriculum. . .

L . -' C

Health-relevant problem ident i f i ca t ion and probltm' solving skille apply in *many s u b j ~ e t areas . Easmplso related to health can be uard i n training i n ari thmetic skills and l a g i e r l th ink ing . Safety and the importancc of eocial in t tracs ian /euppart #re eub jec ts uhich can b e empheeieed i n mocial atud iea , craf t s , aports , speech and other couraee.

m / w * l Page 13

T h r e e centradie t iono i n t h e o t t i t u d t r and judgcmentr O C profcoslonalb regarding lap and acdlc8l carc mry both mdermiot p e a p l c ' r conf~dcnct in their avn eeif-cure cowpeteace and r l ~ a c r e a t e daubtm rad suspie ionr regarding proferoiod&l care. Thu8, one of ehc b i g g e r tanks i n ehc proctna oE escrbllrhing integrated and effective Iay end profssaionml heelth c a r e r y u t w s T r the nurturing of ac t i tuder v b i c h are r e c e p t i v e t o r r i d tag care and P O ? ~ b d l d h c ~ d and c o n s l a t s a t regarding profcaoioael care.

Praftapimal- &tt%rudrsm, rward health, diacaar rnd care a r t drvelrrpd,rnd aurturtd d u r h g the t r s i n l a g p e i a d . Therefore, a key errsccgy fir rhe ~tr$ahecaent of lay heaLth c ~ a bchna;rviarar i a '*i, alccreh' appqoech t o t h e concept of r e l k c r r r i q kbe tducatioarl p r o g r d d =F herLtB pioferriqnrlr.,' P r n E ~ e a i a o a ~ ,educ,crtion p r d g r w a acn fecuakcb ad c b c , f J c . k ~ t i ? i . t ' drid technics1 infa-t inn relawant t~ the t l t eacen t approachhe a d proct;tei P E thrt: r<a$cdtivc d i r c i p l i n e e . T h i s has resulted ia a medical and prd€cmri~nal aGicniatioi" c 8 iotbctpfi of b e s l t h care. Prmider,r of hnrlth. c a r e thuo have the perception that health c 8 t t , i b cantered I n chc 8ervieee ~hsy~.~r+yjdo, rather rhmn i n chc s e l f - c a r e beh.avia6t.of lay pe.ru+na<

- 7 . . . . I . ' , > ,S. .-%a . . ..., -. *.[ *r ! *

. Om nr, ti 'addrere. r b ~ ~ . ' . p r d ; l a i r t o ,dsfire ntK!ci?.bare';, nGrbid& &k&'.mkd %t&: types ef preEsarianr1, care,' adrcificatly ,in the ' context o f r c l F e a r i , i s iar*icei whkcM oupp'lrrmcat i d i v i d u l l s ' t i ia leh ' p r k e i o a dnd hsa%th carc behaviour : iq ,' <l~etsb, ' F u ~ r h t ~ m x ~ s e , prn!!araieaaf training*. , pragrr-r mist incorporrtc. taaching ' i t r a € a i i & . h i c h rcp'riacit pref e a s i e n r l r e l e a tivard teaching iudcrionr, r e t b i r tbka ' d&na*t eaphihi.6" ? o 'ir'ovid,iag aemicea CO people. Training progr-a deaigned ta he lp prsfcasioaalr vhCI pkav id i r a w i c e * A i r6 facilitate rffec~ivc self-care behaviour muse can~ider; .. ..., ., . ,.:* -

. . - --- L

-. 1 the screirl end p b y c h o l o ~ i t a ~ arpeeta of healin8 and eEfcctive de,lf-tart; . - . - .m I

, . - 3 j , the &h; d f iridividumla td fu l l ikfori.ti**$ : &&'~fditxi ' ;he d t o t r of ;khti i-Lli( if i l i , .. . . trert'pcnt'.dpti?rp, and aucccmeb in - relation ta specific diaradah; ' . . _ . . ..;> 'r. 1 ' ,r

h1 . c q t ;irhibihiog, efftete, which profcsrional behaviour eaa OF . l a y .ptoplet~ ~ n w I t d 8 u Of health and i l lnear and. c o ~ f i d r h c t tp act on tbeir:'ovn behi l t -h health . . .. 1 'A; - . , ' , - . l , , . arirtttsra~cr end treatteeet of i l l n ~ d b ; a d ,

. . , m , . 9 # P 7

Studrntr ~ h a u l d tcrvr prolas~ionsl t r a i n i n g progr-ea w i t h an ausrcrieai -th;t mosr patLentb. (&C, ltmt fa prfmfy ear&. p r b c t i c c ~, ituatioam) alreadyL w i l J haveal crrpmded. te t h t i r il'bne+siherlth eoaditionr with. one ar mare etlf-care . a t ra tc~ . re r , " Studantr i h ' t K e , Health profcsrions rhauld acquirs a deep sense O F the ee l f - l imit in& c h a r i k f i r o f ' d G t tCtlhnerdler and che epprapeiatentrs of txc lus ivc ly nelf-care interventions for moat , . ilqnarr,apirodar.

TechaologieaSly oriented medical practice i e a problem of a d i f ~ a r a a g 'mGitudc i n devclaping c ~ u n t r i a r which t r y t o rapl icrte tha madical asrvlcss of tha davelaped r o r l d , It i n imparcane co +leer c h t medical school curricula of thart ebuncries to - re f l ec t the c o u a t r ~ c r ' primary crra need..

fa rddi t ion t o orthodox seieatific medical prsccietr, ~ c u d e n t e o f piofsurioarl training progsommca ehould b e txpoecd t o t r a d i t i o n a l and "mltsrnative" h e a l t h practices. The introduction a€ the concept of u n i f i e d and integrsted herlch ce tc i n training inetitutioar will create awareatss of and -mre goa l t ioe o i t i ~ ~ d e a eslong pro€errion&ll tavardc rrlf-cart.

M l r i l m a g r m t d e a l i r kn- about the valclae.ot ec1f"cdte ptcciices i n vntious nstlondl str rings, very l i r c l e ia known eb09t th'e content and m f f ~ c t i v n a e r r aE sm~€-cirt. S i a i tar lp , knavladgs about tht faetarm uhich determine . the type and excent a £ 'self-car& i8 L T h t cat l sc t ion of valid snd ral ' iable eclf-care d r t r thus should b e e priori ty ut t h i r atagd of t h e duva~mplwat of hsrl th service systcma.

mnr' sa ,3 Page 1 5

A body of v a l i d and reliable aelf-care data can merge only From investigations in which val id and' r e l i a b l e operational meaeures of self-care are ueed t o collect data from probabi l i ty samplaa of general populatiana. Since little i s knou abmt the caneent of naif-car*, qualitative s tud i tp , . ara aeeded ro def ine tbe range of, behaviour i a illnrra. Uniform definit ion. of! self-care variablar must m r g s before factors that determine e l t e r n ~ t i v e ~ forpm,,of ,crqr cam be.e£f~ctively. aaalyzed.

. . ... . . . . . . . . . . . . . . . . . . . . . . , ; f , - : n . . : - ;;: , . . . . . d . .

..l , Eua&par$pqi t+rw~$p, .mp, t h q rubj'eet, of . ,esa-cirq m & i b.: .Anc=rnd --with bath,, eh? c a n t e . ~ t : of thcr'carc and virh the effccta on belf-cake of p i o f e n ~ i o n a l care and 6ubl ic p6licies. Safety i m aa ismur f requent ly raised regarding sel&are. Whrla uc know i i t t l e a b u t t h 8,afecp , - ~ g ~ . , , q q l E , ~ ~ t~#btmn_rss t%(: I M t e d . , avai lable , information . euggerte that . self-care prrcf,rcq,rTs, g~nrcxal, t y safe,! and app+apripte. me . re~~vant, point .1u, that, al, l health ,cam GX~;-$B, eboulp, be.,evaluated, ,&ethet. pract icad by lay. Q%, prqferrfoq.& peesone;,, Evaluation haa r a r e l y crccurrtd in ei ther c a m , even though qu~ntiona of e s f c t y , efficacy, and , cosc effectiven~mrr eanfiot bs a n n w t r e d ~ r i t h w t it.

. . . , I . . . T j - j ~5-q ' ,,:;y ? m , <.:, .: a?d,f-h>.,:. . , : . : - , - . : z . : .n .# : , , ,dr ; .,., - :,., .i;,.,; i.. .-:,v T;j+..;,: , . . ; ; F ,,:

. . ., ; . i& - A d i d e t * . e .+ , , ,~pp~g)r ia+. .rqhmloly.,.! ,-=h! imp~i.tnne, .of ,;iyalm~io+, , t o safety.; rliicatg mad. c a s t t f f cc t ivenaan~ is imwd$qf=ly ...G )car,, *tfq, far.. rxamplc,.,,a e u b a t a n t h l interest in mwing e m technology f r m t h e profesairsnal sector t o . t h e l a y sector4.. A . ~ r ~ v i n ~ , ~ ! i ~ u q t r y js converting;.pr~£c8atoonal t q c k p l ? & p : f o r ,Jay.. acceqa,; p p ~ a l s i v e : d e v c l o ~ ~ . . ; ~ . . l q & r . t & & km*- - ' , r a dmu--to enoura .th~t. th& ~ p t . d u c k ~ . and p r u e i d h s ' hi&. are beiag;p?yJu~e$, ,art qFel~cm&:,+f~ec:ive4: Since t h e w + d e y e l o ~ n t e : u&TS,;?e accompanied by ,a c o r n p ~ l < & i ~ s d . ~ : $ r r a ~ ~ ~ ? ~ f , , ~ p n r p q t ~ p ~ ; i ~ a t p ~ e a t r 3 so&: ,of.,.them .c-ercial,, t h e e#tabiishment a f . ; . a , ;g~~~ekteping, ,~p.~,o,c:~~er~ $!3rgla&io~ CO, health, ,care .technology, i a . . necessary: tb protccq, !he .public. . ,

in te ree t . .................... , ' - . . . -..., . . ... . . . . . . . . . . . . ' - . . , . . . . ., .,-, : - . .

;!; ld=atC.~:y~&.4;:rpprw&te:=r-i~.eria..f*r~; w+luoting d i f f e r e a t :health., ectivitiis,.l:eahf $.E. ,, p r . ~ t . i . c ~ & + . , . ~ ,hsrl!q, p r e , . ~ y # t s u , , . y m t . . , preqedm . t h s . des,igs ,. me,. e ~ a l a & j ~ ~ , studian..!; Evaluation should ba a continuoue pr'mees taking. .imq account - both ,, lay:. ,and , pra£ssaiomli mxpectationa arid. p m r f 6 ~ n c & : . : . . . .

1 ... ' ' ? . . . . . . , ' . 0 .' , . .I ; .- . . . . . - 'd i3v 2,:s ~s i f i ; i . s l~ - . ; Is.r~..:...:!! C . . . . . . : . . . . . . . I _

LA$.k:!. & ? & i c ~ , ? 4 d ~ . e q * h,?;* .,fi,,3. .. ? . , X , I, ! , . f < , ... . : , . . , 4 . . 4 . ' ! t , ! - . ; . r , 8 L'+ 1; :< !.. '.. :. . . . . . . . . . . I . . . ,< . , - , ,

Mast- 6 f tha. diaaura'50a had centred on evaluation of apscific practice^, p r ~ e ~ d u r ~ m a r proq?wmtgqcl,,Iq$+,$~.&lp 3e,88eqfial :?.a ,*iacaLn , a ,sacietal perepecti,ve, : in, the process of evaluation. '.mum, Hemb~r State?;, ehpuld, . r n o n i 5 ~ ? ~ ~ ~ t h e i t lawn,,. adminietrat ive ,. procedu~ea, ~roEcas iona l praet i t ta and n i x h£ profeaiional scrvicca ca asetea their impact on -8clf-care pacterns . in: v#&pyar, @ ~ ~ u p + l i l ~mziadic . rsrievy $a. ,aaae&a proprsms i n t e r m : of ~ r l L ~ c r r r anham i r y - p & j c y , + e d p t . i p a am$, prgftseional practice will be , needed,. 8Cudita of the impdc t. of aelf-crra programer an sub-group8 of t h e population such a s dinablecl perranr, a h m l d .ba incorpnratad iato the evaluation proteed t o assure chst needs of particultw grmpe are

. Baa_td, ap. ;: the: . . ; ~ r e ~ ~ q $ a $ ~ o F s , acid, d e l jbarat iog; : of *ia , ~ o n m u l t p t i n ~ , , ' t k ~ pnrtic,ipaar+ devkloped. rec-apaci,?nr,.£q~~~p~nh, o f che four .'?a jor pub jcc t .aress Concerned . w i t h . snha?e ing

. . . . effective. self-care bah&v~hprp.,, !...,., 1

7 , : . '. , '. . . . I . . . . . . . . . 9 . , .: . .

-fw the l&y. c o n y i b u t i a b C O , hea)th ear%,: , , ,: . . . ! . . I . . . . . . . : . . , a ! , .

. . . . . . . 9. , . . . . . . 11 M d e r State* ehould be tntauragcd to recognize t h e role and. importaka oi srl€*=rte'as' a0 easearia1 p,azr(:.pf .B qtratagy.-far reachid& heal th . foq ,a l l . , , . , 7 . . . . . . . . I .

. . . . - .., - - .................... , . . . . . . . . . . ,. . . . . . . I .. ' . . , . . . , .

21 Hembet 3 t a c e r ehauld be encouraged ta review thair exi~ting l a w s a d tokc a c t s = * t & a tO' el iminate, cha- b.;ri~rs: t ~ , . and . , mmcourape, .the acquiait ioh, Q[ sal £-.-care. ,knowledge and skills among the i s . ,citiacne,, .WO :ahauId ,,anacmbla. seprasantativem of. member s t a t e 0 to dimcuoe. three inauen.

, , , . - 8 ' . 3.1 ~ambrr Stater r h i u ~ h be orreoutaged to fac i l i ta te e f f e c t i v e self-cart i n t h e i r , populstions by :

1. Anderron J . , Self-Hcdication. Lanesater, England: m Preae, 11979,

2. Barofsky L., Compliance, adherence and the therapeut ic o l l i ~ a c r : Stepe i n the development of self-care. Soeiol Science and Medicine, 1215A1, 1978.

3, Berry P-, Psxrullo S,, Berry W., De Friese G. et a l . self-care P r o g r a m s ; Their Bolt end Poteatia1, Chepel H i l l : University Norch Carolina, 1979.

4. B e l l o c H., memlw L. ~ a l a t i o n s h i p of physical health s t a t u e a d heal th , practicrr. Preventive Medicine 1, 1932.

5 . Berkma P. Survival and a Hodicum of indulgence i n the s i c k role . ~ e d i c a l ' - Care 13, 85, 1975, , .

. . ; . ; . . . :' .

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