I. S. Sokolov (Moscow)

Health Education as Part of Anti-Epidemic Measures²

From the Central Institute of Health Education

The tremendous achievements of socialist construction have ensured the growth and strengthening of Soviet health care, creating all the prerequisites for the eradication of epidemic diseases.

Nevertheless, our achievements in overcoming epidemics still fall short of what is actually possible. Enemies of the people sought to do everything they could to disrupt anti-epidemic measures and, in particular, to discredit health education. Improvement

² Considering the strengthening and improvement of the quality of mass health education as part of anti-epidemic measures to be a highly pressing task, we invite local workers to share their experience in this field in the pages of our journal. — Ed.

…of health education will increase the effectiveness of epidemic-control measures.

The principal shortcoming of health education is its separation from day-to-day epidemic-control practice; moreover, health publicity is often sporadic and campaign-driven.

Health education aimed at combating epidemic diseases usually proceeds on its own, while practical epidemic-control measures proceed separately. Yet some physicians—including epidemiologists and sanitary physicians—successfully use health education as a routine method in their work. Unfortunately, such examples are few.

In this article, drawing on local practice and, in part, our own experience, we attempt to outline forms of health education directly linked to practical epidemic-control measures. This, of course, in no way eliminates the need for general health education on epidemic-control topics, through lectures, the wide distribution of popular literature, and so forth.

Health publicity yields the best results when its content, forms, and methods follow directly from the tasks and nature of the work of a given medical worker or institution.

From this perspective, for example, the explanatory and publicity work carried out by a state sanitary inspector in connection with the issuance of mandatory regulations to combat epidemic diseases can play an important role.

Thus, in Kaluga, the local State Sanitary Inspectorate carried out extensive and noteworthy publicity work timed to coincide with the city council’s issuance of a mandatory regulation on measures to combat gastrointestinal diseases. Before the regulation was published, the local newspaper carried popular-science articles on the prevention of gastrointestinal diseases, which helped focus public attention on the issue. Subsequently, the local radio station broadcast special information about the regulation several times, with commentary on individual provisions. Instructional meetings were held with members of the health section, street committee members, and volunteer sanitary representatives, at which the regulation was discussed. In this way, the public learned about the principal sanitary measures in this field. In such a case, health education is especially effective not only because it is concrete and timely, but also because it rests on the authority of the local council.

It is equally essential for the sanitary inspector to conduct publicity work in connection with the imposition of fines. A short newspaper item reporting a fine imposed on the management of an enterprise or institution often has a much stronger effect than the fine itself, exerting a “preventive” influence on the management of other institutions and enterprises.

We have repeatedly seen that the sanitary inspectorate was able to secure the correction of deficiencies it had identified only after the relevant material had been published in the press.

The educational measures accompanying an administrative penalty can take many different forms. In Ryazan, for example, the local sanitary inspectorate for a time used the following exceptionally simple method: notices were posted in the windows of a food store it had closed, reading: “Closed because of unsanitary con-

…condition. State Sanitary Inspectorate of the city of Ryazan.” This simple method had a considerable educational effect.

It is even better to accompany such notices with a brief explanation acquainting the public with the specific requirements of sanitary inspection.

We offer these examples merely as individual illustrations.

Drawing on concrete facts and materials, local newspapers, radio, and various meetings should be widely used in day-to-day work to publicize anti-epidemic measures and provide the public with appropriate health education.

Unfortunately, sanitary and epidemiological institutions rather seldom carry out educational work as part of their routine daily activities. At best, their staff give lectures on anti-epidemic subjects at the behest of health education centers or health education bases. Yet sanitary-bacteriological laboratories, vaccination stations, disinfection stations, sanitary inspection and disinfection facilities, and the like deal with living people and need to publicize their activities widely. Without claiming to be exhaustive, we shall use selected examples to show the need for and value of incorporating anti-epidemic education into the work of sanitary institutions in keeping with their tasks and areas of specialization. Thus, all sections of sanitary-bacteriological laboratories can and should carry out lively and engaging health education.

Usually, when the food section of such a laboratory detects bacterial contamination in a product, it confines itself to drawing up a report and forwarding it to the “appropriate authorities.” Yet consider the great educational value of a popular science talk given to workers at the food-processing enterprise from which the contaminated product came, accompanied by a demonstration of bacterial cultures grown from the defective products. This form of education would be far more persuasive and effective than abstract lectures on the need to maintain cleanliness, comply with various sanitary inspection measures, and so forth.

At the same time, staff in this same food section can obtain excellent illustrative material for educational work by arranging for control cultures to be taken from the hands of food-industry workers. This was done for a time at the Moscow meat-processing plant. These control cultures provide highly illustrative documentary material suitable for demonstration and far more convincing to an audience than many of our posters, pictures, and the like.

The water section of a sanitary-bacteriological laboratory is constantly engaged in analyzing water from various sources of supply. There is no doubt that the quality of water-treatment operations depends to some extent on the sanitary knowledge of the operating staff. The water section therefore has a vital interest in ensuring that health education and instruction are provided to these workers, both through courses—by arrangement with the local municipal services department—and on an occasional basis, especially when waterborne infections threaten.

The bacteriology section of a sanitary-bacteriological laboratory can and should conduct particularly intensive health education, primarily among the bacillus carriers identified by the laboratory. For this purpose, it should take advantage of occasions when a carrier is called to the laboratory for a checkup or when a specimen is taken for analysis. In practice, bacillus carriers are all too often extremely poorly informed about the harm that…

he can bring. But in that case, one can hardly expect him to take a conscientious approach to his own behavior.

Health education at vaccination centers is very important, especially when organizing vaccinations for children. The most appropriate forms of such outreach might include talks with mothers who come to the vaccination center about the importance of returning promptly for repeat vaccinations, explanations of the importance of these vaccinations, and so forth. Nurses who visit homes to register children due for vaccination should be provided with specially prepared leaflets to distribute to the public and talking points (outlines) for brief discussions.

An effective form of outreach is for vaccination centers to send out special letters, postcards, and appeals.

Measles prevention centers are also obliged to carry out similar work. These institutions have an interest in obtaining, on a voluntary basis, a sufficient quantity of serum from the public for measles immunization. Their outreach should therefore focus on donation (which is also important for national defense) and on the proper understanding of measles as a disease, particularly the indications and conditions for measles immunization.

Many such examples could be given of health education work closely integrated with the activities of the epidemic-control institution concerned.

Let us consider just one institution that usually serves groups for whom health education on epidemic prevention is especially important. We have in mind sanitary processing stations. In addition to the usual forms of outreach (talks, displays in designated “corners,” posters, and the like), we encountered in one district a rather interesting method specific to this type of institution.

Some members of the public still regard disinfection chambers with skepticism.

Staff at the station in question conducted a convincing demonstration that clearly showed the effectiveness of disinfestation: in front of the audience, they placed a test tube containing live lice in a pocket of a garment being sent into the chamber. After the garment had been treated, the contents of the test tube were examined in the presence of witnesses from the audience. This experiment, which usually aroused the spectators’ interest, readily led to a lively and engaging discussion of typhus and its prevention.

Health education must be an essential component of every epidemic-control measure.

Besides the fact that these measures cannot be effective without the public’s conscientious cooperation, we must also remember that in such cases we are dealing with a family distressed by a dangerous illness and sometimes by the death of a loved one. Medical personnel must show great sensitivity and tact. By conducting health education skillfully and tactfully during epidemic-control measures, we not only explain the purpose of our requirements and actions but also prevent possible misunderstandings between the public and medical personnel.

The importance of promptly detecting a new case of an acutely contagious disease scarcely needs to be emphasized. The assistance of the public itself plays a significant role in this regard. Health education in this area should take the following forms:

1. Publicizing regulations requiring health authorities to be notified of certain diseases.

1. Group instruction for workers who can help identify cases of infectious disease (building managers, hostel and hotel managers, teachers, collective-farm brigade leaders, volunteer sanitary representatives, holders of GSO badges, insurance delegates, etc.).

2. Talks on the importance of identifying every case of an acute infectious disease among the population at the establishments where it has occurred.

Health education during an epidemiological investigation is no less important. In essence, every physician who takes epidemiological investigation seriously conducts such education in one form or another. A shortage of time usually forces the investigating physician to confine himself to a few brief, disjointed phrases that do not adequately explain the matter. In this regard, printed leaflets that the physician could leave with the patient’s family may be of considerable value. Three separate short leaflets should be available: 1) a leaflet explaining the nature of the disease, 2) rules for disinfection, and 3) instructions for caring for the patient at home (if the patient is permitted to remain at home). The following leaflet, prepared by the Moscow Regional Institute of Sanitary Culture, can serve as a model for leaflets addressed to parents whose sick children have remained at home and to households from which a child with diphtheria or scarlet fever has been hospitalized.

MOSCOW REGIONAL INSTITUTE OF SANITARY CULTURE

Parents!

A child with scarlet fever should be admitted to hospital. There the child will receive continuous medical supervision and the necessary treatment and care.

Scarlet fever is a contagious disease. Children contract scarlet fever through contact with the patient or with the patient’s clothing, toys, books, and other belongings. It is therefore especially important to hospitalize the sick child when there are other children in the household who have not had scarlet fever.

Separating children who have been in contact with the sick child from other children is intended to prevent further spread of infection. In the interests of public health, follow the physician’s instructions precisely.

Disinfection of the home and belongings destroys the infection. Assist with the disinfection process. Do not conceal items that have been in contact with the patient: submit all of them for disinfection. Only with the conscientious cooperation and assistance of parents in carrying out preventive measures can we eliminate acute infectious diseases among children.

District physician: ................................................
Office hours: ........ days ........ hours ........................
Outpatient clinic address: .......................................
To the occupants of apartment No. ........ building No. ........ Citizen ........
In view of the occurrence of SCARLET FEVER in your apartment, the children
................................................................
(surnames and given names)
must not attend school, kindergarten, or nursery, and must not have contact with other children until permitted by the physician.

District physician: ................................................

(To be given to the person responsible for the apartment.)

MOSCOW REGIONAL INSTITUTE OF SANITARY CULTURE

Parents!

A child with diphtheria should be admitted to hospital immediately. The sooner the patient receives an injection of diphtheria antitoxin, the greater the chance of saving the child: every hour is precious. In hospital the child will receive continuous medical supervision and the necessary treatment and care.

Diphtheria is a contagious disease. Children contract diphtheria through contact with the patient or with the patient’s clothing, books, and other belongings. Therefore

It is especially important to hospitalize the patient when there are other children in the apartment.

Separating children who have been in contact with patients from other children is intended to prevent the further spread of infection. In the interests of public health, follow the doctor’s instructions.

Before children who have been in contact with patients are allowed to return to school, kindergarten, or nursery, or to mix with other children, their throat mucus must be tested for diphtheria.

Disinfection of the apartment and its contents destroys the infection. Cooperate with the disinfection process. Do not conceal items that have been in contact with patients: submit them all for disinfection.

Only with parents’ informed cooperation in preventive measures can we eliminate acute infectious diseases among children.

District physician: ....................................................
Office hours: ............ days ............ hours ....................
Outpatient clinic address: .............................................
To the residents of apartment No. ............ building No. ............
Citizen: ..............................................................

Because DIPHTHERIA has appeared in your apartment, the children

.......................................................................
(surnames and given names)

must not attend school, kindergarten, or nursery, and must not mix with other children until authorized by a doctor.

District physician: ....................................................

(To be given to the person responsible for the apartment.)

In some places, special notices are posted on the doors of homes where a person with an infectious disease is staying, stating that unnecessary visits to the apartment should be avoided:

A PERSON WITH SCARLET FEVER IS IN THIS APARTMENT

Outsiders, especially children, should not enter this apartment or use items from it, including clothing, books, children’s toys, kitchen utensils, and other household articles.

Observe these instructions until the doctor revokes them. By doing so, you will help prevent the spread of scarlet fever.

State sanitary inspector
.................... 193...

A well-considered and systematic program of health education for families in which a case of typhoid or paratyphoid fever has occurred, and for bacillus carriers, has been developed by the Orekhovo-Zuyevo sanitary station (sanitary physician Pomerantsev). Its principal task is to educate the carrier and those around them in health practices so as to prevent the spread of infection both within the family and, even more importantly, outside it.

Health-education home visits are conducted for 14 days after completion of the final disinfection in a family where a case of typhoid fever has been identified. This period is based on the average duration of the disease’s incubation period. Visits continue beyond the stated period if new cases occur.

Over the 14 days, a sanitary feldsher (the sanitary physician’s assistant) visits the family or group six times. The first visit is made no later than 24 hours after notification of the illness is received; the second is made one day after the first, and all subsequent visits are made at two-day intervals.

During the first visit, all necessary epidemiological data are collected, and a sanitary assessment of the home and family is prepared. These data form the basis of the health education provided.

The time needed to take the temperatures of the family members present is used for a discussion about typhoid fever. This is quite sufficient for a short discussion if several people’s temperatures are taken. During the discussion, advice with explanations is given on maintaining the apartment and toilets, on [[unclear: word continued on the next page]]

…elimination of habits that conflict with hygiene requirements. At the same time, one or two copies of a special information leaflet are handed out.¹

Subsequent visits are used to check whether the advice has been followed. Through health education, we persistently and tenaciously seek to ensure that our recommendations are put into practice.

The principal aim of health education for a bacillus carrier is to instill hygienic habits that will make the carrier safe to those around them.

At the first visit to the carrier, which is made by a physician together with a feldsher, the housing and living conditions are examined in detail. This assessment forms the basis for a discussion with the carrier, highlighting all the circumstances that may contribute to the spread of infection: careless storage of drinking water, foodstuffs, and prepared food; dirty lavatories; indiscriminate relieving of bodily needs outdoors; an abundance of flies; unsanitary conditions in the home; unclean hands; long, dirty fingernails; eating from shared dishes; sleeping together; sharing a towel; and so on.

Follow-up visits to the carrier, once every ten days, are made by the sanitary feldsher alone, to check that all the physician’s instructions are being followed and to continue health education persistently. The goal must be to make compliance with hygiene requirements habitual for the carrier.

Another interesting example of work of this kind is the provision of sanitary and cultural home visits in dirty apartments, with an emphasis on combating lice infestation. The experience gained from this work is described in O. Lyutsernova’s article “Methods and Practice of Mass Sanitary and Cultural Work” (published by the House of Sanitary Culture of the Leningrad Health Department).

Unfortunately, in practice, health education very rarely accompanies disinfection measures. Yet it is precisely in this case that such work is especially important and necessary.

People are usually reluctant to agree to disinfection because it causes inconvenience and requires additional, unforeseen housework; fear of damage to belongings and premises also plays a part. All of this must be overcome through explanatory work. Such work is usually hampered by the poor training and inadequate cultural education of ordinary disinfection workers, who deal directly with the public. In our view, the solution is to develop simple forms and means of outreach that the disinfection worker can use independently. Printed information leaflets are also necessary. Distributing them among the people at premises where disinfection is planned could help prepare the ground for it to some extent.

In addition, it is important to instruct those workers who can be enlisted, in an official or voluntary capacity, to supervise the disinfection being carried out. As is well known, the quality of disinfection is often rather low. Such people may include hostel managers, building managers, voluntary sanitary representatives, members of street committees, GSO badge holders, and others.

The simultaneous sanitary treatment of particular population groups also requires substantial health education work.

¹ The Orekhovo-Zuyevo District Sanitary Station developed and published two information leaflets—one for the family and one for the bacillus carrier—and a leaflet entitled “Precautions for a Family in Which a Case of Typhoid Fever Has Been Detected.”

In addition to the general forms of public education that should precede sanitary treatment—for example, in a workers’ dormitory, organizing a talk in advance, using the local wall newspaper, displaying slogans, and so on—special attention must be paid to individuals who avoid treatment.

In such cases, it is very important to establish their reasons for avoiding treatment and to build the campaign in favor of it around explaining why those reasons are unfounded. An important role can be played here by volunteer sanitary representatives who have been properly instructed by a medical worker.

An example of this kind of educational work is the guide for a talk with construction workers prepared by Ya. N. Trakhtman.¹

Very often, only properly conducted health education can prevent conflicts and misunderstandings when patients with acute infectious diseases, especially children, are hospitalized.

We know of an instructive case. In one of the district centers of the Moscow region, the child of a senior district official fell ill with scarlet fever. For epidemiological reasons, the child could not be left at home. Yet no demands from the physician-epidemiologist or the State Sanitary Inspectorate could overcome the resistance of the parents, who did not wish to place the child in a hospital. Once, however, the case was reported in the newspaper, the matter was quickly settled and the child was admitted to hospital.

We have not addressed such important questions as the system—that is, the methods and organization—of health education in an epidemic focus of a given infection, in the work of a mobile bathing and disinfection unit, and so forth, since these require separate discussion.

At least two conditions are necessary for the successful integration of health education into epidemic-control practice.

First of all, we must dispel the harmful misconception that health education is the prerogative of “health education specialists.” This very limited group of specialists has a number of organizational and methodological duties of its own and naturally cannot replace the entire body of medical workers. We must likewise abandon the view that health education is merely an “additional public duty.”

Health education must have its place in the operational plan for combating epidemic diseases of every medical worker and every medical institution.

The institution and its director must be just as accountable for this area as for any other aspect of epidemic control.

The second essential condition is specialized training, however modest in scope, for medical workers in the theory and practice of health education, particularly as it relates to epidemic-control measures. This subject should be included in the curricula for training sanitary physicians and physicians specializing in epidemiology, as well as their assistants, the sanitary feldshers. To some extent, such training should also be provided in courses for disinfection instructors and smallpox vaccinators.

¹ Ya. N. Trakhtman, Two Talks on Typhus, published by the People’s Commissariat of Health of the USSR, 1938.

These two conditions are necessary both for expanding health education in the fight against communicable diseases and for increasing the effectiveness of this form of public education.

It is also essential to establish proper working relationships between medical personnel carrying out antiepidemic measures and health education institutions.

Health education centers and stations, as organizational and methodological centers in their respective areas, should make every effort to provide medical personnel with all the educational materials needed to combat epidemic diseases.

Medical personnel, in turn—particularly state sanitary inspectors, epidemiologists, and infectious disease physicians—should actively assist health educators in developing all necessary materials and in testing new forms and methods of health education in practice.

By conducting health education on a broad scale in the fight against communicable diseases and incorporating health education methods into antiepidemic practice, we shall achieve major new successes on the antiepidemic front.