Health promotion and the prevention of eye injuries
Promoting eye health and preventing eye injuries may be considered the most important aspect of ophthalmic management in the developing world. Where ophthalmologists are limited to 1:1 million population and treatment resources are in short supply, preventive strategies are of great importance. Health promotion was originally described by the World Health Organization in 1984 as ‘the process of enabling people to increase control over and improve their health’.1
Health promotion as a concept is still evolving; however, it is now well established both in practice and theory. Two main views exist; those who argue for a social or system approach, and those who take a more individual (health education) approach.
Health promotion is more than health education
Although the terms are often used interchangeably, health education and health promotion are not the same. Traditionally health education has taken a behavioural approach and considered health problems to be a consequence of individual life-styles. It had little recognition of environmental, political, economic or cultural influences on health. Naidoo and Wills describe health education as an activity aimed at informing people about the prevention of disease and motivating them to change their behaviour.2
Health promotion is a broader concept, which emphasises the responsibility of society, both at governmental and community levels, in the determination of health (in this situation, eye health). Eye-sight is a powerful determinant of health and well-being; hence its preservation is a true health promoting activity. In 1985, Tannahill described health promotion as comprising ‘three overlapping spheres of activity, health education, prevention and health protection’.3 This model most closely represents the author’s beliefs. The principle of empowerment is at the heart of this model; enabling the individual to act in a healthy way. Education interacts with and builds on the foundations of prevention and protection.
Health promotion: eye injuries
There are no reliable data on the incidence of eye injuries in the developing world, and many injuries are not detected or reported. Thylefors, in his review of epidemiological data from developing countries, suggests that ‘up to 5% of all blindness found may be due to trauma’.4 The types and causes of eye injuries in the developing world will vary from region to region but in general there is an increasing number of road accidents.4 Eye injuries resulting from agricultural work, warfare, industrial accidents, children’s ‘games’, e.g., fighting with sticks, and sport-related injuries are reported. Health promotion offers a framework for legislative, professional and community resources to reduce eye injuries. One example of effective health promotion through legislation is the introduction of seat-belt legislation in the UK in 1983. This led to a dramatic decrease (73%) in perforating eye injuries within a short period of time.3 Further education coupled with stricter law enforcement might expect to achieve similar results in the developing world.
Another example of eye health promotion in action is described by Courtright (1996).6 He reports a collaborative eye care programme which was set up in rural Malawi and involved a series of four 1 day training sessions for traditional healers. The training included recognition and treatment of the red eye. Following the programme, the ‘post-intervention’ patients, still treated by the traditional healers, had less unilateral blindness, reduced from 44.3% to 21.4% and less bilateral corneal disease in patients using traditional eye medicines (TEM), reduced from 31% to 10%. Prior to the programme, blindness was three times more common in patients using TEM. Attendance at traditional healers was not discouraged but direct application of substances to the eye was. This type of close working relationship at community level enables a shift in control from professional dominance to more control by the community, as envisaged by the WHO. There are many traditional healers and they have the advantage of being located within the community where they are trusted by the people. Due to distance, transportation difficulties and lack of trust in Western medicine, the traditional healer is often the first practitioner visited. Training traditional healers to make prompt and appropriate referrals would improve the present situation of late treatment of potentially blinding eye injuries.
Raising awareness of eye injuries is an important aspect of health promotion. This can be brought about through carefully planned health education programmes, mass media campaigns and by targeting key groups at risk of eye injuries. The most important setting for health promotion activity is within primary health care. In the developing world primary health care workers are strategically located in the front line of health care promotion and provision, but lack eye health education and eye care management in their training. Prevention of eye injuries and basic ophthalmology should be included in all curricula for nurses, primary health care workers and medical staff. Health promotion can be conveyed to schools, industry, rural health centres, hospital outpatient departments, where long waiting times make an ideal opportunity for health promotion. Sensitivity to culture and health beliefs is an important aspect of eye health promotion in the developing world. Without this approach any health promotion programme is unlikely to succeed.
Promoting eye health requires all sectors of society to work together. Preventing eye injuries is an important aspect of this. Health professionals need to work closely with communities to identify eye health needs, set goals, assist in delivering relevant health education and encourage early referral and appropriate treatment. Governments need to play their part by implementing protective health legislation. Such a health promotion approach could play a highly significant part in reducing the number of preventable eye injuries.
1 World Health Organization. Health Promotion: a discussion document on concepts and principles, Geneva, WHO, 1984
2 Naidoo J, Wills J. Health Promotion: Foundations for Practice. Bailliere Tindall, 1994.
3 Tannahill A. “What is health promotion?” Health Education Journal 1985; 44(4):167-8
4 Thylefors B. Epidemiological patterns of ocular trauma. Aust NZ J Ophthalmol 1992; 20: 95-8
5 Hall N F, Denning A M, Elkington A R, Cooper P T. The eye and the seat-belt in Wessex. Br J Ophthalmol 1985; 69: 317-9
6 Courtright P, Lewallen S, Kanjoloti S. Changing patterns of corneal disease and associated vision loss at a rural African hospital following a training programme for traditional healers. Br J Ophthalmol 1996; 80: 694-7