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I enjoyed reading Roberto Briceño-León's "Siete Tesis sobre la Educación Sanitaria para la Participación Comunitaria" and I very much appreciated your sharing of the manuscript with me. I think that the author does an excellent job at discussing several key aspects of Health Education and pointing out their relevance for successful Community participation in Tropical Disease Control. The article has prompted me to respond with two points which I have found relevant in my own work to achieve community-based control of tropical disease in Central America and the Caribbean:

a) The importance of conducting social science formative research prior to implementing the disease prevention program. This research has a "formative" purpose in that its results will be utilized to inform the program's design. If the problem as perceived by the community seems to lie with a fundamental belief that, for example, the real cause of malaria is abrupt changes in the hot-cold equilibrium, then the education effort should perhaps introduce other potential causes of malaria, such as mosquitoes, e.g. If the problem, on the other hand, seems to be that the gold miner's life style, for example, is incompatible with routines of any kind, including the regular use of a mosquito net or the regular taking of anti-malarial treatment, then the program should perhaps look into themes that might excite these nomadic individuals enough to adopt a malaria preventing routine in some compatible way or perhaps work more with their direct employers to get them to institutionalize a feasible measure.

In many instances more than one factors operate to create the disease problem, in which case the program will need to focus on more than one fronts at a time. But how will the program planners know which situation applies? A typical program budget often times includes funds for a KAP type survey, which itself alone does not yield the information needed as respondents might reveal their knowledge but not really their beliefs, and only their reported practices rather than the actual ones. Qualitative research such as in-depth interviews with prospective program beneficiaries, for example, or focus groups or observation will alone or in combination with a KAP Survey elicit the beliefs, habits and circumstances that Roberto describes so well in the article. Research, however, often produces a negative set of reactions among Ministries of Health which consider it too theoretical or abstract to be useful, probably because some times it has actually been that way. Social science research in particular, is often perceived as an unnecessary luxury, either due to unfamiliarity with the research methods or due to negative past experiences where the fruits of research were never linked to a program. If used appropriately, this is the only tool that we have, though, to understand the problems research included in tropical disease control programs. Furthermore, I think that this kind of applied research should not just be a one-time try but it should be conducted periodically during the life of the program in order to assess the latter's progress and among its beneficiaries.

b) The second point I want to make has to do with the definition of community. Often times the word "community" 1) denotes one geographically defined; and 2) assumes a single social class represented by the residents of an area. This might still be true for a rural setting type community of farmers, for example, who do in fact live next to each other and all own similar sized lots. With the rapid urbanization taking place at the outskirts of formal Latin American cities, however, such a definition of community is often inadequate. Residents might live next to each other, but are away all day, working in greatly diverse jobs, holding diverse levels of education and belonging to more than one social class. As a consequence they are not the "one happy family" that we public health experts often assume. This calls for diversifying of our health education and community participation strategies according to each of the groups within a single geographical area. One strategy might be develop appropriate community-based programs but based at the work place, for instance. We need a strategy for factory workers, another for people working in banks, offices or stores, yet another for middle class women working inside the home, one for business owners, one for school children, for adolescents and so on. This kind of "community" lacks the geographic element; nevertheless, is a community. I think that we will be at an advantage if we try to apply Roberto's Seven Theses to each one of such communities separately.