Bridging the gap between health care professionals and communities
Bridging the gap between health care professionals and communities is a difficult task. It involves establishing a culture of community participation and improving the process of communication between the two groups. Effective communication between these groups is not easy. The people concerned often speak different languages, have different levels of education and competence, different priorities in life and generally understand things differently. In addition, the greatest proportion of communication is transmitted non-verbally, through gestures, facial expressions and ‘body language’. This is important for two reasons. Firstly, any feelings of pity, superiority, frustration, dismissal or respect, will almost certainly be transmitted through these alternative modes of communication, they carry much more powerful messages than those contained in what is said. Secondly, many of these non-verbal messages, with the major exception of speech intonation, are visual and are therefore missed by people who cannot see well enough to pick them up. This combines to give an effective recipe for communication breakdown.
This article will examine the process of communication in terms of need, opportunity and means. It will also examine the potential benefits of improved communication between health care professionals and community members in terms of what health care professionals might learn from the community. It is important to remember that community members include people with visual impairments and their families.
Effective communication is a two-way, turn taking activity, requiring participation from both parties. It is used to share ideas and knowledge, establish identity, give instructions, ask questions and express feelings. It has three pre-requisites.
Firstly, there must be a need or desire to communicate. The health care worker must want to communicate with community members and the community member must want to listen. For this to happen both parties must feel that they will enjoy and benefit in some way from the exchange. Health care workers sometimes feel that it is only what they say to the community member or patient that is important. They often spend long hours deciding what this should be. The community member might not be ready to listen because of more pressing problems on his/her mind. In either of these situations effective communication is unlikely to occur. The answers to the following questions are required: “Is there the need by both parties to communicate? If not, why not? How can this be resolved?”
The second pre-requisite for effective communication is providing the opportunity. For example, effective communication is unlikely to occur if not enough time is allowed. Is there the opportunity to communicate? Is the health worker too busy? Location is also important, for example, advice concerning private and personal issues given in a frightening environment or a public place, is unlikely to be heard. It must be asked, whether communicating with individuals or groups, is this the best place for this conversation?
The third pre-requisite is the means. This refers to the ability and compatibility of the ‘tools’ of communication, for example, the same language, ability of both parties to listen and or talk, (read or write if this is the means that is being used). The questions that need to be asked are “Do both parties have an effective means of communication? Do they speak the same language, use the same dialect, understand the same terms? If not, how can this be reconciled?”
So what can be leant from community members if effective communication is achieved? The evidence indicates that stakeholders i.e. those involved and affected by ‘visual impairment’ (which, in this article, I use to refer to all degrees of sight limitation from blindness to refractive errors), agree that community members have a potentially positive contribution to make towards improving the quality of life of people with visual impairment. John Hubley1and also Muhammod Sabur2 highlight the importance of community participation in effective eye care. They provide information about what community members can do to improve eye care, such as early identification, prompt action in seeking treatment and adhering to advice. They do not focus in detail on how this can be achieved. The how question is the question that can be answered by listening to perspectives of community members. In other words the health care workers are the ‘experts’ on answers to the what questions, but the communities are the ‘experts’ on answers to the how questions. Obviously it is only by combining this expertise that a true solution can be found, hence the need for community participation in service development. It would seem that if the recommendations of health care professionals are to be put into practice, there is a need to ask, to listen and to act on the expertise of the community members. As a Masai proverb puts it “One head cannot contain all wisdom”.
What can eye care providers learn from communities?
Prevention and cure are only part of the story
Listening to community members tells you that prevention and cure of eye disease is only part of the problem. There is global agreement that up to 80 per cent of eye disease is avoidable, i.e. preventable or curable. For example, a recent study of blindness in children in Bangladesh shows 68 per cent is avoidable (32 per cent preventable, 36 per cent treatable).3 If services concentrate on cure and prevention only, 32 per cent of blind children in Bangladesh are without any support. These children face exclusion from society, health, education and employment and their needs should be addressed alongside any curative programme.
Listening to community members tells you that people with visual impairments are often very brave and strong. It tells you that they are people who have thoughts, feelings, ideas and aspirations, just as any other person. It tells you that they have a lot to offer other people with similar eye diseases in terms of emotional support and understanding. It tells you that their families and their communities sometimes reject them and that they often have little choice or control of their lives. Their lives are hard and challenging. It tells you that many community members do not understand their needs.
The process of increasing awareness is usually a humbling experience for health care workers and serves to motivate them to communicate better and with more respect. They begin to consider their ‘patients’ as whole people and not just walking ‘eyes’! Respecting the people as people will result in them respecting and trusting in return, so the advice given to them e.g. bringing people for treatment early, following treatment procedures, changing life styles, and improving their environment, will be better understood and appreciated.
People with visual impairments have an important role to play in raising the community awareness, in education and advocacy. They are in the unique position of knowing what it is like to be blind and knowing how they themselves have managed to overcome some of the challenges they have faced. Their families too have a great deal to offer each other in terms of support and understanding. Who could be better to explain a treatment procedure to another person than someone who has already experienced it?
The problems faced by people with impairments
The various aspects of disablement that people with visual impairment face are usually similar to those faced by people with other impairments. These include reduced social integration, unequal rights, and lack of access to health, education and employment opportunities. Health care providers can facilitate access to community based rehabilitation programmes where these exist, so that they may be more fully included in society.
In conclusion, health care workers can learn much from community members if they learn to listen. This requires a paradigm shift away from perceiving themselves as the only or most important expert, to recognising the importance of local knowledge and performing the more difficult role of facilitator and supporter. This means recognising people with eye problems and their families as the most important community members. It means working in partnership with them and other community members to achieve maximum prevention and adherence to medical treatment. This process of participation is likely to reveal locally based strategies that can change and improve existing services. It is likely to reveal the tremendous strength, bravery, humility and wisdom of people who have learnt to cope with their lack of sight, or the lack of sight of a loved one. They have leant to come to terms with exclusion from society, discrimination, limited choices, lack of opportunity and independence. They have much to teach us! We need to listen and to learn.
1 Hubley J. Community participation: ‘putting the community into community eye health’. J Comm Eye Health. 1999; Vol.12 Issue 31.
2 Sabur M. Mobilizing resources within the community: ‘mobilising the un-mobilised’. J Comm Eye Health. 1999; Vol.12 Issue 31.
3 Muhit M. Magnitude and causes of childhood blindness in Bangladesh. Childhood Blindness Workshop. Dhaka, Bangladesh, 2004.