|Education for Health (WHO, 1988, 274 p.)|
|Chapter 2: People working with people|
In health education, participation means that the person, the group, or the community works actively with the health workers and others to solve their own problems. Participation is necessary at every step, from identifying problems to solving them. After you have established your relationship with people and communities, you should immediately begin to encourage participation. Use your communication skills and encourage people to talk while you listen. In that way they can participate in identifying their own problems.
Why should people participate? First, if people participate,
they will be more interested in helping themselves. They will also be more
committed to taking the action necessary to improve their health.
Second, people are responsible for their own health. Health workers can guide people in finding solutions to problems, but cannot take direct responsibility. If a mother arrives with a poorly fed baby, a health worker cannot take the baby home and feed it. If health workers give drugs to people to cure fever, they cannot follow the people home and put the tablets in their mouths every four hours. If a community complains that it does not have a good water supply, health workers cannot give the money for digging the well. Of course they can help, but the most important help is self-help. Health workers have many opportunities to encourage self-help.
Participation in identifying problems
Health workers make a mistake if they say to a community 'we know what your main problems are.' It is true that health workers see many problems. They may look at clinic records and see that many people suffer from malaria. This is a problem. They may visit the community and see refuse scattered about. This is a problem, too. But, until the people concerned understand that there is a problem, they will not be interested in solving it. You may make people angry if you assume that you know all about their lives.
This community health worker is using health education to encourage self-help. While she is treating the husband, she is also teaching him and his wife the simple skills needed to care for the wound.
Encourage people to identify their own problems first, then they will be more ready to deal with them. Most of the problems will be related to health somehow. Health workers should show an interest in helping with the problems that the members of the community see. This will help build trust and strengthen relationships.
Participation in finding solutions
If health workers say 'we know the best solution to your problem', they are making another mistake. Things that are 'best' for one person or one community may not be so for another. Communities have different amounts of resources. They have different beliefs and values. They have different types of leaders. The solution for a problem must fit the real-life situation of the person or community. This can be done through the participation of the person or community concerned.
Of course a health worker can make suggestions, but ideas should come from the people firstthe more ideas the better. Examine each suggestion carefully with the people concerned to see if it will work. Then encourage people to select the solution that is best for them.
Participation in action
A health worker also makes a big mistake if he or she says 'Don't worry. I will do what is needed to solve your problem.' Remember that people are responsible for their own health. If you do all the work for them, they may criticize the results and blame you. But this does not mean you should let them do everything by themselves. On the contrary, be clear about what you can and should do, and about what people can do and learn to do for themselves. While there are certain health tasks that a trained person must perform, there should also be as much opportunity as possible for participation so that, through experience, community members will gain skills.
Remember to avoid the common mistakes mentioned above. Think about what we' can do to solve problems, not what '1' can do. You are a guide and a helper.
Don't worry. I will do what is needed to solve your problem.' This approach is likely to create more problems in the long run, rather than solve any. Why? Because people become dependent on the health worker. A major objective should be to help people become self-reliant and give them the skills that will enable them to participate actively at every step of primary health care from identifying problems to solving them.
Together with the people, you should ask 'What problems can we identify? What are the best solutions we can select? What action can we take?'
As you try to foster participation there are three points you should keep in mind:
First, there are some health education methods that are useful for encouraging participation. Meetings and group discussions are examples (see Chapter 5). These may be formal meetings called by village leaders. They may be informal friendly discussions with individuals and small groups. Visit people in their homes. Go to places where people gather to relax. Talk with them and listen. In this way you will learn about their problems. At meetings, encourage all views to be presented. Quiet people have just as good ideas as people who talk a lot. Whenever possible try to get everybody to agree (this is called 'consensus'), so that the final plan is acceptable to all. This too will help guarantee participation and commitment.
Second, when fostering participation, remember the local culture. The method of participation will depend on the culture. Take meetings, for example: in some cultures it is not acceptable for young people to voice their opinions in public. If this is the case, then you will need, through discussion with the people concerned, to find some other way in which young people may express themselves. Maybe the youth leader could speak privately with some of the elders. You may also need to educate community leaders politely on the value of participation. Solving a problem is not easy and it may take a long time' but participation by the people will help a lot. Other examples of participation will be found in Chapters 3 and 6.
Finally, within communities it is important to encourage local leaders to play their part. If the problem affects the whole community, make sure that the planning group concerned is representative of all sections of it. Ways of identifying opinion leaders are discussed later. These people should lead the group in determining what are the main problems, then in developing solutions and plans to work them out. There should be a job for every member of the group. In this way no-one will feel left out. Everyone will then be committed to solving the problem. This will help more people gain skills and learn leadership responsibilities for the future. Follow-up is needed to check that each person has understood his or her job and does it well.
Action does not happen by itself. You will often need to encourage people to take responsibility.
Participation in evaluation
During a programme or planned activity, progress should be evaluated all the time. Similarly, at the end of a programme, success or failure must be measured (see pages 82-83, on how to do this). Participation plays its part here too. By discussing results with people, you can help them learn. If they know why a programme or action succeeded or failed, they will be able to make better efforts next time.
How much participation in health activities is there in your community now? How many people helped with the last big project? Do many people lake responsibility, or do only a few do all the work? If participation is poor, why is this? What can you do to improve participation in your community? How best can the community health worker help promote participation?