AN EXAMINATION OF THE EFFECT OF COMMUNITY HEALTH EDUCATION ON THE BEHAVIOUR OF PEOPLE (CASE STUDY OF SELECTED RURAL COMMUNITIES IN CENTRAL REGION OF GHANA)

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Rural health improvement is an important area of focus by the government of Ghana in the bid to reduce poverty. This is because ill health, malnutrition and a high birth rate are often reasons for poverty in households. However, poverty itself is also a cause of ill health since inadequate financial resources result in poor access to health care, food, water, and sanitation, which are key inputs to good health (Klugman, 2002). According to Klugman (2002), poor countries and poor people suffer from a multiplicity of deprivations that translate into high levels of ill health that far exceed the population average. He adds that it is not only the lack of income that causes the high level of ill health, but the health facilities serving them are mostly dilapidated, inaccessible, inadequately stocked with basic medicines and run by poorly trained staff. In view of this, health education, particularly preventive health education, is important.

In 1995, the government of Ghana (gog) developed the Vision 2020 strategy for poverty reduction with emphasis on economic growth, integrated rural development, expansion of employment opportunities, and improved access, especially by the rural and urban poor, to basic public services such as education, health care, water and sanitation, and family planning services (world bank, 2003). Within the same period, non-governmental organisations (ngos), perhaps cognisant of these intentions, continued their activities with similar objectives. The most prominent among these were sanitation and health education. The health of Ghanaians is reported to have improved since independence. The infant mortality rate among Ghanaians has been reduced from 133 deaths per 1000 live births in 1957 to 57 deaths per 1000 live births in 1998. While under five, the mortality rate also decreased from 154 deaths per 1000 live births in 1957 to 110 deaths per 1000 live births in 1998 (gss & macro international, 1999). The gdhs of 1988, 1993, 1998 and 2003 for five-year periods preceding the surveys also indicated under-five mortality rates of 155, 119, 108 and 111 respectively. A multiple indicator cluster survey for 2006 by the gss showed under-5 mortality of 111 per 1000 live births.

The ministry of health (moh), considering the rates of decline to be slow, has made several reforms in the health sector. These include a shift from mainly curative care to preventive care, the development of the vision 2020 and the 5-year medium-term health strategy to guide health development in Ghana, the passage of act 525 in 1996 to establish the Ghana Health Service (GHS) as the implementing body for public sector health services, and finally, the establishment of the health insurance scheme, all aimed at improving health care in the country. Currently, the main goal of the health sector is to make health care accessible, acceptable, and affordable for all individuals living in the country.

In Ghana, the majority of the poor are believed to be in the rural areas and are disadvantaged by the lack of knowledge about preventive health and early seeking of health care. Therefore, providing rural communities with access to health information and services has been the main implementation strategy pursued by both governmental organisations and NGOs to achieve good health. A population data analysis report by the Ghana statistical service in 2005 reveals that the formal educational system remains the best means for improving access to information, broadening the horizons of people, preparing them for the life of work and providing the needed tools for all who pass through the system to contribute to the socio-economic development of the country. The report further reveals high illiteracy rates in rural communities, estimated at 55.6 percent compared to 26.9 percent in urban areas. This is attributed to a small number of schools and an inadequate number of teachers.

The 2000 population and housing census of Ghana revealed that the central region, from which the study communities were selected, has an illiteracy level of 42.8 percent, with more illiterate females than males. Also, 33.9 percent of the population has never been to school. Informal education, therefore, appears to be the main way in which awareness is created about various developmental issues. Fortunately, informal education can take place anywhere, unlike formal education, which tends to take place in special institutions like schools. Thus, the uneducated population of the region still has a chance to get education on various issues, including health. In view of this, NGOs and government agencies have instituted some measures, including the use of behaviour change communication strategies through community health education (informal education) to prevent sickness and promote early appropriate health seeking behaviour in communities.

The central region is classified as the fourth poorest in the country, known for its high malnutrition and child health problems, which are some indicators of health. By observation, sanitation is very poor in most communities. From the regional health directorate report in 2005, the unemployment rate was estimated at 8.0 percent. Although this is much lower than the national average of 10.4 percent, it is still considered high. The issue of child labour poses a problem in a number of districts in the region, as 5 percent of children less than 15 years old are engaged in economic activities. Another important factor that may lead to poor health care is poverty, which is believed to be predominant in the region due to the low incomes of the majority of people whose main occupation is agriculture. Agriculture forms 52.3% of economic activities, followed by manufacturing at 10.5%.

The population and housing census (2000) estimated a population of 1,593,823 and an annual population growth rate of 2.1 percent. The region is the second most densely populated in the country (about 162 inhabitants per-square kilometres) and has an average household size of 4.4, with 62.5 percent of the population living in rural areas. The population is made up of 52.3 percent females, and 43.2 percent of children below the age of 15 years, considered as the most vulnerable group to health issues. With such high population density, the implications of inadequate health facilities can not be overlooked.

There are 220 health facilities in the region, comprising 108 public, 82 private, 14 mission/quasi and 16 community/ngo clinics. Most of these private institutions are located in the district capitals and other big towns. The distribution of health facilities does not favour the large rural majority. It also includes functional community-based health planning and services (chps) compounds in almost all the districts. In all, there are 1,281 outreach points in the region, recording an increase of 0.9 percent (1,270) over that of 2004 (regional health directorate report, 2005). There are four health training institutions in Winneba, Cape Coast, Ankaful, and Twifo Praso. The service provision assessment survey (spa) by the gss in 2002 reported that there were only 104 doctors and 1427 nurses with a population to doctor ratio of 15,325:1 and a population to nurse ratio of 1117:1 in the central region. However, the senior management report of the Ghana health service in August 2008 gave a worse population to doctor ratio of 26,888:1 and a population to nurse ratio of 3418:1.

The 2003 Ghana demographic and health survey (gdhs) indicates that infant mortality and under-five mortality rates in the central region are 50 and 90 per 1000 live births respectively. Although it is an improvement over 1998 and also places the region among the best in the country, it is still high. A report from the central regional health directorate in 2005 showed a 44 percent incidence of malaria compared to 41.6 percent in 2004. The region also has an average of only 6.3 percent of clinics found within its localities and 34.9 percent within 1-5km of reach, while 1.78 percent of hospitals are found within communities and 16.2 percent within 1-5km (population and housing census, 2000).

From the foregoing, it is evident that health issues are critical to human resource development and poverty reduction, particularly in the central region, for which reason, this study attempts to empirically determine how health education is able to influence preventive health behaviour.

1.2 STATEMENT OF THE PROBLEM

It is a known fact that the doctor-patient ratio is low and there are inadequate health facilities. Therefore, if community health education is profitable, then policy makers can pay much more attention to that, with special emphasis on preventive health care, so that Ghana can achieve its health goals and that of the world at large. However, in spite of the operations of both NGOs (Plan Ghana, World Vision, Hunger Project, and Adventist Development and Relief Association (ADRA/Ghana) and government agencies in the Central Region to reduce poverty, malnutrition, and improve rural health through community health education or sensitization, rural health does not seem to be improving. There does not seem to be any empirical proof that community health education is improving rural health or preventive health behaviour. Literature on the impact of community health education on health or preventive behaviour is sparse or difficult to obtain.

Documentary proof of change is extremely important to justify the continuation of community health education, particularly in rural communities. Indeed, lessons from such studies would serve as input for modification in rural health promotion strategies. If there is minimal or no change in preventive health behaviour or rural health status, then the question that is imperative is; is there any justification for continuing health education in view of the length of time taken and the large amount of money required to train staff, volunteers, and to reach the target population?

What about remote communities?

1.3 OF THE STUDY OBJECTIVE

The overall goal of the research is to:

i.        Determine the percentage of the population of selected beneficiary and non-beneficiary communities with knowledge of the prevention of malaria.

ii.      Examine the importance of health education to communities.

iii.    Identify factors, behind health education, that influence patronage of health care services in the beneficiary and non-beneficiary communities.

1.4 RESEARCH QUESTIONS

The following research questions guide the objective of the study:

i.        What is the percentage of the population of selected beneficiary and non-beneficiary communities with knowledge of the prevention of malaria?

ii.      What are the importance of community health education?

iii.    What are the factors behind health education that influence patronage of health care services in the beneficiary and non-beneficiary communities?

1.5 SIGNIFICANCE OF THE STUDY

This study will aim to investigate the effect of community health education on the behaviour of people, using the rural communities in the central region of Ghana, despite the fact that it will be difficult to analyze due to its sensitive nature.

As a result, in addition to providing some insight into the challenges at hand, the study will also act as a source of literature for future research. The study will be valuable to the Ghana health department. The study would be of benefit to students and other researchers willing to carry out research on similar topics.

1.6 SCOPE OF THE STUDY

The research was conducted over a five-year period. It concentrated on three of the Central Region's coastline areas. Districts in the west. Rural communities with both NGO presence and Ghana Health Service health promotion were chosen for comparison, while rural communities with only Ghana Health Service health education were used. The study included Simbrofo and Mprumem in the Gomoa West District, Etsibeedu and Egyankwa in the Mfantsiman District, and Breman and Eguafo in the KEEA District were all included in the study. The study focused on the most prevalent ailments that were commonly reported in community designated health centers' out-patient departments, which had appropriate and full records that could be analyzed.

1.7 LIMITATION OF STUDY

The study was limited due to the short time frame, budget and the inability to cover all communities because of the selection method.

1.8 DEFINITION OF TERMS

COMMUNITY: A community is a social unit (a group of living things) with commonality such as norms, religion, values, customs, or identity. Communities may share a sense of place situated in a given geographical area (e.g. a country, village, town, or neighbourhood) or in virtual space through communication platforms. 

HEALTH EDUCATION: Health education can be defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of health.

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