|Education for Health (WHO, 1988, 274 p.)|
|Chapter 3: Planning for health education in primary health care|
Good health education is based on facts. It would not be correct to say 'I feel that poor nutrition is a problem because so many mothers do not know which foods are good for their children.' There must be facts. How many children are poorly nourished? What do we mean by poorly nourished? How do you measure or check whether children are poorly nourished? How many mothers know what to feed their children? How many do not? If many children are poorly nourished, is lack of knowledge the only reason? You need this information at the beginning of a programme so that by the end you can easily measure any change and improvement.
What information do we need?
We need to find out what are:
- The most important problems as seen by the person, group, or community you are helping.
- Other problems that you yourself may see.
- Problems that other community workers see.
- The number of people who have these problems.
- The practices that may have led to the problems.
- Possible reasons for these practices.
- Other causes of the problems.
To find this information, you will need to learn all about the community where you work. Among other things you will want to know:
- Local beliefs and values that affect health.
- The kinds of behavior that are acceptable in the local culture.
- Important local people and reasons for their importance.
- How decisions are made about local problems.
- Available health care services, both traditional and modern.
- Location of services.
- The main occupations for both men and women, the level of education in the community, and the quality of the housing, as these factors may help you learn something about the economic conditions of the people.
- Existing clubs, societies, and organizations.
- The religions practiced locally.
- Local ways of sharing ideas and feelings.
Do you know all these things about the community where you work? How did you learn them? If you do not know them all, work together with other health and community workers to collect the information. Each person can be responsible for collecting different types of information about the community. After collecting the information, meet with people and discuss it. See what new things you have learned about the community where you work.
The importance of collecting information
A family would not decide to build a new house without first investigating the availability of land and the cost of materials. A doctor would not begin to treat a patient without first investigating the nature of the illness through such methods as observation, questioning, and laboratory tests. Similarly, health workers practicing health education must also investigate a problem before starting a programme or activities to deal with it. Here are some of the reasons why.
- It is necessary to know how big the problem is (how many people are affected) and how serious or dangerous it is (how much death and damage are being caused). Clear information about the nature of a problem will make it easier to choose priorities.
- If information is collected about the nature and extent of the problem both before and after a programme, it will be possible to show what impact the programme has made.
- Information about the community will make it possible to choose the most appropriate way to deal with the problem ('strategy'), both as regards the problem itself and the culture in which the problem exists. You will find more about priorities and strategy.
How to collect information
There are three main ways of collecting information about people, groups, and communities. First, there is observation, which is the collection of information by watching and listening. Secondly, there is interviewing, which involves discussion and questioning. Thirdly, there are records and documents, which are the written observations and experiences of other people.
These three methods are often used together in order to give a complete picture of a problem or survey of a community and its needs. For example regarding the problem of waterborne diseases, it would be useful to interview people about where they collect their water and how they store it. Secondly, it would be valuable to observe the various local sources of water to see if, in fact, people use them in the way they said they used them in the interview. Finally, records at the clinic would give an idea of the number of people actually suffering from waterborne diseases.
Know what and how to observe Observation must be done carefully. Decide in advance what to observe, and how it will be observed. For example, parents and teachers may complain that children are passing blood in their urine. This may be caused by schistosomiasis, a disease caught by wading in streams (or ponds) contaminated by people infected by the disease defecating or urinating into the water. In this case it would be important (i) to observe whether the snails that harbour the disease are to be found in the streams, and (ii) to watch the behavior of the children around the streams. If observation shows that there are disease-carrying snails and that children do play and wade in the streams and defecate or urinate in or near them, then one can rightly suspect schistosomiasis. Another form of observation would be to look at samples of urine or faeces under the microscope.
The local market should be included in any community survey, many health problems can be identified, and important information can be gathered. For example from a study of the market you can find out what food is available locally, and at what price, and you may be able to identify hazards that cause disease.
The local market should be included in any community survey. Many potential health hazards can he identified. What problems can you observe in this picture?
Know when to observe
Observing at the wrong time may give the wrong impression about a problem. Observing a stream during school hours will not give a clear picture of children's wading and swimming behavior. The best time to observe would be after school and at weekends when children are free to go to a stream if they wish.
Observe thoroughly and accurately
As pointed out above, observation is not only through the eyes. Important information can also be picked up through the ears, nose, fingers and tongue. Sound, smell, feeling and taste will teach you many things about your community. You should be able to tell people accurately what you have observed. For example, a health inspector sent three sanitary workers to look at a family's house. This is what each said:
- The first person reported 'the area was very dirty'.
- The second said 'the house was no worse than any others in the neighborhood'.
- The third person said 'the gutter in front of the house was full of leaves and paper. Behind the house was a pile of tins, broken bottles, paper and rags that was as high as my knee and as wide as I am tall. All the rubbish was in this pile. None was scattered around the house.'
The three men observed the same thing, but their comments were different. The first two men made judgements. They did not report their observations completely. Only the third man gave a fairly accurate description. After you have observed something, think carefully about what you have seen; you may even want to write down your observations. Then decide whether what you saw was good or bad. Ask other people to observe the same thing and see if you all agree on what you saw or heard. Having others check your observations helps improve accuracy.
Observe individuals Observation is very useful when you are helping individuals who are sick or have problems. The movements of their eyes and body can tell you much. Through observation you can see the signs of sadness, joy, worry, pain, fear, and other feelings.
Through observation you may also learn about a person's personal hygiene or attitude to health problems. For example, by observing cuts and wounds, you can tell if they are fresh, or if the person delayed coming to you. You can sometimes see whether traditional medicine has been used. Some people wear certain charms or symbols that tell you something about their beliefs and religion.
Sometimes you can learn about a person's financial condition or ethnic background by observing the style and condition of the clothes he or she is wearing. But be careful: if your eyes can teach you, they can also mislead you. Remember we all have prejudices. Clothing alone is not a sign of wealth or poverty, for example. Ask questions to see if your judgements are correct.
Use your eyes when you work with groups or committees. You can see whether some people are paying attention. Use your ears to hear if people are participating. You can observe whether the group is happy or angry. If you observe problems you can then help to solve them.
Observation of individual patients is important. Use your eyes to learn how the patient feels and see what modern or traditional remedies may have been tried.
It is useful to practice your observation skills. Gather a couple of friends or co-workers together. Choose one street in your village or neighborhood. All of you walk along the street and observe it from the standpoint of environmental sanitation. Do not speak to each other until you reach the end of the street. Then discuss what you have observed. See if you have observed the same things. Walk back down the street to check your observations.
Use your eyes. Do you see scraps of paper or old tins Iying about? Do you see blocked drains?
Use your nose. Do you smell garbage, stagnant water, or human wastes?
Use your ears. Do you hear many flies buzzing or goats, sheep, or dogs rummaging around in waste?
Involving other people in observation
Observation provides a good opportunity for participation and learning. Patients attending clinics can be encouraged to observe their own home environments. Community groups can be mobilized to observe their surroundings and undertake a community survey in order to discover problems and needs.
If the members of the community participate in collecting information, they will learn more about the problems facing their community. They will discover resources that meet their needs. They will gain ideas from community members about how to solve problems. And they will feel really involved in planning health activities.
The very best thing is when the people themselves start the survey, discuss their needs, determine with the health workers which needs are the most urgent, and then make plans.
A survey can be done by one person, but it takes a long time. It is best to have a small group. A school club could survey the community to learn what club-members could do to improve their village or neighborhood. Community leaders themselves could also participate in conducting a survey.
Participation should be encouraged when you are collecting information in a community about health and other needs. Schoolchildren, for instance, can be trained to use arm circumference bands. They could then participate in finding out how well or poorly nourished the pre-school children in the community are.
It is not enough simply to collect information. The information must be studied carefully so that people can learn from it. Hold discussions with the people. Share ideas. Help people reach some conclusions about what problems are most serious and why those problems exist. Find out if their survey has suggested any resources that could be used in solving the problems.
An interview is a way of gathering information through communication between someone who wants information (the interviewer) and people who can supply the information (the interviewees).
Your relationship skills are most important for interviewing. If a person does not trust you, he or she may not talk freely and may give false information. Always make sure the person knows who you are and why you want to talk to him or her.
An interview must be planned carefully. Interviewing may involve talking to a group of people at the market or a special meeting with a village leader over a serious community problem. In either case you must have a clear idea beforehand about what information you are trying to obtain.
What to ask
You will probably find that you need two types of information. At the beginning of a programme it is likely that you will be seeking general information. This may concern the way of life in the community and the various needs that people see.
Later you may be seeking specific information. Through general interviewing you may have found, for example, that many people feel that the town needs a new market. A specific interview would aim at finding out what problems there are with the present market; the action that has already been taken; ideas for improving the market; and the contributions that people are willing to make to solving the problems.
Who to interview
Next you must decide who to interview. People can be interviewed in groups. If the concern is a new market, you could attend a meeting of the association of people who sell at the market, and ask them if they would discuss their ideas and feelings with you. If they agree, you can go ahead with an interview in which you will collect information more quickly than if you had had to talk to individuals.
A group interview can be a starting-point for solving community problems. Not only can group members identify pressing problems. They can also discuss and come to understand the reasons why these problems exist. Once this is done, the group can go on to discuss possible solutions.
Interviewing a group of people at a community meeting is one way of gathering information about community needs and problems. Here, the residents of a village have gathered to share their concerns with a community health worker.
At other times an individual interview is necessary. Not everyone will be willing to share their true opinions in a group. In our market example, views may be very diverse and talking in a group may cause a lot of anger. In such a case, it would be better to find out through individual interviews what each person really wants. An individual interview is of course the usual way of helping patients who come to you for health care.
In addition to interviewing the general population, it is very important to interview local leaders. Also talk to people who have accepted new ideas such as family planning methods or ventilated latrines. Find out why they accepted these new ideas. This will help you learn about the process of change in your community.
If you are seeking the ideas of many people concerning a problem, set out the topics you want to discuss and the questions you want to ask, before going to meet them. Then be sure to ask the same questions in the same way to each person. Questions asked in different ways to different people will result in many different and confusing answers. If that happens, the information will be useless.
How to ask for information
Interviewing uses questions and comments to encourage people to supply information. The words used must be chosen carefully, because words influence how a person answers.
There are four types of question or comment, but not all of these will yield useful information.
Let us take once again the example of the market to see how these four types of question could be used to gain specific information about the problem. As you will see, some approaches are better than others.
'Does our village need a new market?'
This is a simple direct question that could be answered with a simple 'Yes' or 'No'. But starting an interview with this type of question may bring problems. First, people may try to guess the opinion of the interviewer or the village leaders and answer in the way they think they are supposed to, not the way they really feel.
Secondly, this type of question does not give room for discussion. An answer of 'Yes' or 'No', does not show the full range of feelings and opinions a person has on the subject. A person may answer 'yes', but in fact feel that the market is not the most important problem in the village at that moment. A direct question will not encourage the expression of that opinion.
It is best to save direct questions for later on in the interview. After the person has begun sharing opinions freely, a direct question can then be used to help clarify points.
'Don't you feel our village needs a new market?'
This is a leading question because it leads a person to give only one answer. People easily say "Yes" to such a question. Questions that start like this:
'Don't you think...', 'Isn't it true...', 'Wouldn't you believe...', 'Shouldn't you have...': make people give one-sided answers. They are dangerous to use in interviews because interviewees will almost always agree and rarely reveal their true opinion.
'Should our village have a new market this year or next year?'
This is a forced-choice question. It gives the interviewee a choice of only two answers-'this year' or 'next year'. People being interviewed will almost certainly make one of the choices, although they may have a completely different opinion. They may really want to say 'in five years' or even 'never'.
'Please tell me your views about our market.'
This is an approach that leads to open comments. Such a statement allows people to answer freely. Listen carefully so that people will be encouraged to express their views fully.
After a person has expressed some ideas, you might say, 'That is interesting. Could you tell me more?' You might also use direct questions now that the person has felt free to talk.
Suppose you were interviewing a mother about her sick child. You observe that the child is quite small for its age, so you want to find out more about what the child is eating. Opposite are some sample questions and statements that might start off an interview with the mother. Put an X in the column you consider appropriate; questions that should never be used; questions that may be used at the beginning of the interview; and those that may be used later in the interview.
Think carefully about the reasons why you marked the statements the way you did. Discuss this among your co-workers. Then compare your list with the answers below.
Now assume that you will be interviewing a member of the local farmers' cooperative. The farmers have been having problems with snakebites. Make up some sample questions and comments that you could use to start the interview.
You could also have a role-play on the subject with a friend or co-worker pretending to be the farmer you are interviewing. Get others to watch you. They can tell you if your comments and questions were good, or whether they made the other person give one-sided or false answers.
Here are the answers to the statements and questions on page 51. You should have put 'X' in the first column for these numbers: 4, 6, 7, 11, 12; in the second column for 2, 5, 8, 10; and in the third column for 1, 3, 9 (5 could go here also).
When would you use the questions and statements?
Sample questions and statements
To start with
1. Does the baby eat fruit?
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2. Welcome to the clinic.
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3. How many times a day does the baby eat?
4. Don't you give the child eggs?
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5. Please tell me about the child's favourite foods.
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6. Do you give cereal, eggs, or bread for breakfast?
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7. Shouldn't this child be eating more beans?
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8. Let us discuss your child's feeding habits so both of us can learn how best to keep him healthy.
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9. Are there any foods the child refuses?
10. Please tell me about any problems you may have in feeding this child.
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11. Does the child eat most in the morning or afternoon?
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12. Wouldn't it be better if this child could eat more meat?
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Using records and documents
Written information can help us learn much about the people and communities with whom we are working. Most agencies and organizations keep records and reports of their activities. By looking through these, we can sometimes discover something about the nature of health problems. For example, we may see that certain diseases are more prevalent at certain times of the year, giving us ideas on when to plan action.
Some examples of records are: files on patients at the clinic; annual reports of agencies; monthly figures on clinic attendance and common diseases; newspaper reports on important events; written programme plans; agency reports on the use of drugs and supplies; absentee reports from schools and work-places; and certain books, pamphlets, and magazines.
Useful records for working with individuals
You may be working in a health centre. A mother brings in a child who has diarrhoea (frequent watery stools). The child's card may give information that would help in understanding and solving the problem. Check how many times the child has had diarrhoea. If the child has come to the health centre several times in the past year with the same complaint, then it might be reasonable to suspect, among other things, that there is something wrong with the sanitation of the home. This clue could be followed up by an interview about hygienic practices in the home, and a home visit.
The child's recorded weight would be another useful piece of information. A sudden drop or no gain for several months should cause concern. Possible reasons for a drop may be: the child's illness; removal of the child from breast-feeding, with a poor weaning diet; a family financial crisis; or a death in the family. The weight record provides a clue to the problem which can then be followed up with an interview.
Medicaments prescribed at previous visits are also recorded on patients' cards. This information can be used to find out whether the patient has taken the drugs correctly, benefited from them, or suffered side-effects. Such information is useful for planning future treatment. Finally, look for other useful information such as personal and family history, plus the recorded observations of previous health workers.
Useful records for working with groups
School attendance records will show whether many children have been absent recently and from which classes. If absence is high or shows a change from the normal pattern, it should be investigated. The school curriculum is a document of what the Ministry of Education thinks children should be taught. Look at the curriculum and compare it, through observation and interview, with what is really being taught about health.
The records of a farmers' cooperative would give an idea of the farmers' needs. Food production is related to nutrition and health. Records of the types of food crop and the amount produced will show where improvements could be made.
Clinic records may also help you understand the problems and needs of a group of farmers. Look in these records for complaints common to farmers, such as hookworm and snakebite.
Useful records for determining community needs At the community level, clinic records show the main diseases people are reporting. Study the records of past years to see if diseases have been increasing or decreasing. Remember, though, that not everyone attends the clinic. The records there may not tell you the whole story about a community's health problems.
Another source of information is offered by annual reports, pamphlets, and other material from government and voluntary agencies. These will tell you about the programmes that are organized to meet your community's problems.
Visit your local health centre or clinic. Find out what kind of records are kept and what kinds of reports are sent to the regional or state headquarters. Ask to see some of the reports and study them with the following questions in mind.
What are the most common health problems? Which cause the most illness? Which are the most serious and cause the most death and disability?
Are there clinic attendance figures? Is attendance increasing decreasing or slaying the same? What might be the reasons?
Do you think the clinic records accurately show the community's health needs? Are there many people who do not go to the clinic when they are sick?
Do your community leaders know what are the most common and most serious problems seen at the clinic? If they don't, how can you help them learn about these problems?
Visit the local schools. What kinds of records do they have? Weal can you learn from those records?