|Education for Health (WHO, 1988, 274 p.)|
|Chapter 2: People working with people|
In health education we are concerned about how people actually feel, not how we think they should feel. We are interested in how people look at their own problems, not only in the problems we see ourselves. We want people to develop the confidence and skills to help themselves. We do not look for thanks or praise, but we do aim at a feeling of pride in the fact that people have learned the skills needed to solve their own problems.
To enable people to learn these skills, we need:
- To establish good relationships
- To communicate clearly
- To encourage participation
- To avoid prejudice and bias
These are the four points examined in this chapter.
There are many people whose job is to help other people. For example' there are teachers, social welfare workers, extension agents, nurses, and others.
As a 'front-line' health worker, you also belong to the category of helping professionals. In order to be a successful helper, you must have a good relationship with those you want to help. If people like you, if they trust you, and if they feel comfortable with you, then you will be in a better position to help them.
You can get people to trust you by respecting them (regardless of who they are, what they believe, or where they come from), by listening to them, and by encouraging them to develop their own strengths.
The person you are
Who you are (your personality) and what you do (your actions) influence the way people look at you and think about you. Your personality and actions also influence the type of relationship you have with people in the community.
You are a health worker, but you are also many other things. You are a certain age and sex, you belong to a certain family, a social group, and a work group. You may be a member of a religious group. All these factors determine how the people in the community view you and what they expect of you. Different kinds of behavior may be expected of people according to their age, sex, religion, or type of work.
Know about the community's expectations and be aware of your own personality. This will help you in developing good relations within your community. Learn about yourself and your personality by observing how others react to you. If you find that community members generally are not listening to you or are avoiding you, ask trusted friends or co-workers if they have also observed this. Ask if they know any possible reasons for such a reaction. From what you learn about yourself, try to change the aspects of your character that worry the community.
How to establish good relationships
If you are to establish good relationships, people must see you at work. You must be visible to them. You must do things that people believe are useful and beneficial. You must reach out to people and explain your job to them. You must also listen to people and show concern about their problems and needs. You must always be available to give help when people need it.
In order to establish a good relationship, it is necessary to visit the community Often, using whatever means is available. These health workers travel by horse to reach the villages they serve. Others may use bicycles, motorcycles, public buses, or lorries, or they may walk.
When you start working in a community, you should introduce (or reintroduce) yourself to people in that community. Visit the leaders and representatives of all the various groups. Meet with the other people who work to improve the community. Visit religious and political leaders, teachers, agricultural workers, traditional healers, other health workers, and social welfare workers. Learn about their work. Explain your job to them. Discuss how all of you can work together to make your community better.
Finally, remember that the purpose of health education is to help people solve their problems by their own efforts. It is your role to help community members realize what they can do to help themselves, and to teach them the skills needed to do so. By using health education methods in your work, you will be able to help people to do something good about health. People will then feel better about themselves. They will also appreciate you for your concern and for your interest in their welfare. Your relationships will grow and improve.
Who are the people in your private or professional life you have good relationships with? What makes those relationships good! Are there any people you do not have such a good relationship with? What can you do to improve your relationships with those people!
Every day of our lives we try to share ideas, feelings, and information with other people. This is known as 'communication'. Talking is the most common way of communicating, but there are many others, for example: writing, making hand and body movements, drawing, singing, and so on. Many of the educational methods that we will discuss later are in fact communication methods. Communication skills are needed in health education.
Communication is part of our normal relationship with other people. A good relationship cannot exist without some sharing of ideas, feelings, and information. Likewise sharing happens most easily between people who have a good relationship. Building good relationships with people as discussed in the previous section goes hand in hand with developing communication skills. Three important skills needed for good communication are discussed below.
Talking and presenting clearly
The goal of communication is to make sure that people hear, see, and understand the message (idea or feeling) that is being shared with them. Therefore it is important to talk, write, or present this message clearly and simply.
First, use words that people will understand. Many words relating to health care, such as immunization, disinfection, antiseptic, hypertension, and tuberculosis, will be unfamiliar to people. Find simple, common words to explain what is meant. For example, say 'make very clean' for disinfect. Find out the local names for diseases. A health worker who participates in community activities and knows about the local culture will be able to use words and ideas that are familiar to the people.
Another aspect of clear communication is using as few words as possible. A long lecture will bore people. They will miss or forget the message.
When educational methods based on materials such as posters, films, and photographs are used, it is necessary for people to be familiar with those methods. A method that is strange to people may not communicate the right idea. Make sure all words, written or spoken, used to educate people, are clear and simple.
Listening and giving attention
Communication involves both giving and receiving. Not only should the health worker speak clearly to the community, he or she must listen carefully to its members in order to understand their interests and ideas.
Listening is a way of showing respect. Pay close attention to what people tell you. Encourage them to speak freely. Do not stop them, interrupt them, or begin to argue. This will cut off communication, and you may get only half the message, or nothing at all.
The art of listening is very important in health education. By listening carefully, the health worker learns how a person feels about a problem and the reasons for his or her behavior. Then, it becomes possible to help the person find appropriate solutions.
While listening, do not look at something else. Do not busy yourself with work while the other person is talking. If you do these things, the other person will think you do not care about him or her.
Discussing and clarifying
After listening, it is important to make sure you have heard the other person correctly. Similarly, after talking, you should find out if the other person has heard you correctly. Asking questions can help clarify what someone said. Never be afraid to ask questions. Questions can make communication between people more accurate.
It is also good to summarize. After listening, try briefly to tell the other person what you think was said. Then ask the person if you have understood their ideas and meaning. Do the same when you do the talking: encourage the other person to summarize your words. Then you will know whether what you said was understood. This kind of discussion between people leads to good communication.
Here is something you can do to practice your communication skills.
Ask two other health workers or two friends to meet with you. Ask one friend to tell you briefly about something important that has happened in the past week. Listen carefully. Ask the coed friend to listen also. After the first friend finishes, summarize briefly and repeat the information. Ask both friends to correct you if you made mistakes. In this way you will learn how to listen better.
Next you tell one friend about something that you did last week. Ask your friend to summarize what you have said. This way you will learn to speak clearly. Repeat this exercise several times to practice your skills.
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?
All people have prejudices. This problem was discussed briefly in Chapter 1. Prejudice means judging a person in advance simply because they are a member of a certain group. Prejudices are strong feelings either in favour of or against a person because of their age-group, tribe, religion, level of education, or place of birth. To succeed with health education, you must be aware of your own prejudices and attitudes. It may be difficult, but you should not let them influence you in your work. You should not favour one group above another. Above all, do not let your prejudices bring pain or damage to the communities you are trying to serve. Here is an example of what can happen if we let prejudices get in the way of our work.
Mrs Selma has been a health worker in the district for many years. One day she learns that there is a new community development worker in the district. The previous community development worker was a good friend to Mrs Selma. She was sorry to see her leave. The new community worker is very young. He has just finished training. Mrs Selma thinks to herself 'How can this young boy help our district? He is younger than my own son. I doubt if he will be very useful.'
Mrs Selma goes to the preschool clinic every day to talk with the mothers. On one particular day they were complaining that they needed skills so that they could earn more money to feed their children. Mrs Selma's first thought was of the community development workers. Her old friend always used to help over matters like this. But now she fears that the new community development worker will be too young and inexperienced to be of much help. She does not ask him to help.
Mrs Selma has a prejudice against the new community development worker. Because of her prejudice, she is probably hurting the mothers she wants to help. The community development worker is a valuable resource, but now the mothers will not be able to benefit from his help.
Here is another example:
Mr Tess is a health worker in a district where there are many villages. He is supposed to visit each village once a fortnight. He has many friends in Bola Village. He visits Bola once or twice a week. Because he visits Bola Village so often, he does not have time to visit some of the other villages. Mr Tess has a prejudice in favour of Bola Village. This prejudice causes him to neglect the needs of the other villages.
The third example shows that we should never let our biases bring gain to us, while bringing cost or pain to the community.
Mr Sam works in a local dispensary. He knows all the drugs very well. He is grateful to his uncle who helped him to go to school to learn his job. The uncle still gives him money sometimes. The uncle has a small drug store in the town. If patients come to the dispensary and the drugs they need are in short supply, Mr Sam will sometimes tell them to go to town to buy the drug in his uncle's store rather than try to get the drug for them. This will cost the patients more money.
Although Mr Sam has good reason to like his uncle, this is not a reason for allowing his bias to hurt the patients who come to him for help.
We must be careful about our prejudices and biases. They may affect the trust and relationship we have with the community. They may make our work in health education much more difficult. If we want everyone to participate in solving community health problems, we cannot let our prejudices and biases dominate our reason.
Through health education we should learn about our own behavior too. We should try to improve ourselves so that we will be better able to serve the people and communities that need us.
Think about Mrs Selma, Mr Tess, and Mr Sam. What are the reasons for their prejudices and biases? Do you think that they can change their behavior? It may be difficult. What would you recommend that each of them do so that their prejudices or biases will not harm the community? Is there someone else who could help?
What are your own prejudicesabout other community health or social workers, about certain villa"" or neighborhoods, about certain community leaders, about certain groups of people (young people, elders, people of the opposite sex, people from other areas, people of different religions)? Do you feel biased in favour of some people?
What can you do to make sure that your own prejudices or bias" do not harm the people you are supposed to help?