By Lungi Gamede – Graduate Intern RHAP
As a qualified professional nurse who has worked in public primary healthcare in a rural setting, I have come to realize how important the narratives of healthcare users are. Incorporating them into healthcare catalyzes a partnership between the healthcare provider and health user. It creates an environment conducive to patient centered care which is fundamental to Primary Healthcare.
Since joining the Rural Health Advocacy Project (RHAP) I have been able to experience the public health system and the care it promises through the lens of actual health users. Looking at health and healthcare outside the confines of a clinic consultation room has opened my eyes to the challenges communities experience when accessing health services and the role health professionals, like myself have in ensuring the voices of health users are heard and their contributions are used in health decision making.
For the period of my internship, I am primarily involved in RHAP’s Active Citizenry for Health Programme, the aim of which is to build, support and amplify the agency of rural communities and their supporters in advocacy. One of the activities of this campaign is to improve rural communities’ awareness on WASH (water, hygiene and sanitation) in healthcare facilities. Through this project, we are exposing rural communities to the WASH standards they can expect from their clinics, impact of poor WASH services on illness and disease and how they can practically go about advocating for better WASH services at their local health facilities. Inadequate or unsafe sanitation services, water supply and hygiene in South Africa is ranked 11th on the list of risk factors causing deaths. Hand washing with soap alone, among all the WASH interventions shows the greatest reductions in childhood diarrhea morbidity at over 40% and prevents 30 to 47% of childhood diarrhea (Department of Health: Republic of South Africa, 2016-2020).
In the first week of October, we engaged in a four day WASH and Health Advocates workshop. Every day of these four days spent with a different group of health advocates was a reminder of how much health professionals can learn from healthcare users. For example, the notion of the state of health and well-being not having a universal definition came out very strongly amongst the health advocates as we went through what ‘Health’ meant to each and every one of them. The Health Advocates noted how essential spiritual health is to the state of health. However, this is conspicuously missing from the World Health Organization’s definition of health, which only lists physical, mental and social wellbeing as necessary for optimal health. I got to see how understanding a patient’s construct of health helps to shape health outcomes. Understanding this also enables the provision of healthcare to be more inclusive. One other thing that particularly stood out for me each day as we engaged with the health advocates was the role that social determinants of health have in an individual’s experience of health and well-being. I began to realize this through facilitating a root-cause analysis activity commonly known as the ‘but why?’ technique. In this activity, most health advocates identified childhood diarrhea as a common health problem in their community. This was in line with the findings in the District Health Barometer that revealed that 26.3% of children under the age of five died due to diarrhoeal disease between 2011 and 2015 in the OR Tambo District in the Eastern Cape. Social determinants of health such as teenage pregnancy, unemployment and lack of partner support emerged in the causal chains of the health problem. This reveals that so much of the attainment of health lies outside of the formal health system. This exercise enabled me to probe deeper and reveal underlying causes of disease and social problems. It also showed me how different causes are connected. Furthermore, how important it is to not look at disease manifestation with only a biomedical lens because the attainment of health is a broad concept.
Just as there are many connected pathways that lead to disease or illness manifestation, so too can the final diagnosis of a disease or an illness affect multiple facets of a patient’s life. Health professionals should always take this into consideration when planning a patient’s care. A holistic care plan contributes to good health outcomes. The biopsychosocial model of health helps to broaden the view of health. However, the workshop with the health advocates also made me realize that spiritual health should also be incorporated into this model as they mentioned activities such as praying and singing as some things that help them to be healthy. Having a positive attitude was also mentioned in line with this. This is an important area that is often ignored by health professionals and the broader health system.
I have learnt so much from the health advocates. Interacting with them showed me that tapping into existing abilities of individuals, communities, systems and organizations in order to increase ownership of issues and decision-making according to community participation and capacity building principles is a step towards achieving successful health promotion at primary healthcare level. This also helps to dignify communities and show them how capable they are. I noticed how empowered the health advocates were. They were also eager to learn and longed for more knowledge.
If I had been actively exposed to community participation and capacity building projects during my undergraduate nursing degree, I would have definitely made an effort to engage with the members of the community during my community service year as a primary healthcare nurse. I would have had a much better understanding of the socio-economic barriers to healthcare of my patients outside of the pressures and time-constraints that exist within the clinic consultation room. This would have contributed immensely in the assessment aspect of the nursing process specifically of primary healthcare. Thorough assessment assists in better diagnosing, planning, implementing and evaluating for quality patient-centered care outcomes (Thayer & Toney-Butler, 2019).
In conclusion, comprehensive history taking is extremely important in the clinical assessment process, however it is but a glimpse of the full picture of a patient’s health reality and we should strive to see the full picture through community engagement and participation as health professionals. This is because healthcare users are active and integral members of South Africa’s healthcare system. Guarding the gate of Primary Healthcare well means putting healthcare users at the very heart of health services.
Department of Health: Republic of South Africa, 2016-2020. National Hand Hygiene Behaviour Change Strategy, Pretoria: National Department of Health.
Thayer, J. M. & Toney-Butler , T. J., 2019. Nursing Process. StatPearls, pp. 181-188.