|Education for Health (WHO, 1988, 274 p.)|
|Chapter 3: Planning for health education in primary health care|
For a programme to succeed, we must know clearly what we want to do and how we are going to do it.
In the first sections of this chapter, we discussed how to find out the needs of the individuals, groups, and communities we are trying to help. People usually have many needs. It is not possible to do everything at once, therefore we must decide which problems we will try to solve first. This is known as setting priorities.
After people have decided upon their priority needs, they can think about what must be done to meet those needs. They must spell out exactly what they want-in other words, their objectives.
Then with an understanding of the problem and an eye on the objectives, they can consider how best to deal with the problem, that is, what action to take. This is called developing a strategy.
People must determine what their priorities and objectives are, and what strategies are acceptable to them. To do this, they need professional help, but the members of the community must make the final choices.
Setting priorities with individuals
It is not always easy to know what problem to face first. People have many pressing problems like those of the family described opposite.
Mrs Antia has five children. The oldest is eight years old, and the youngest nine months. Mrs Antia is pregnant again. The family shares one room, made of boards and metal roofing-sheets, stuck on the back of the house of Mr Antia's father. Mrs Antia is not very strong these days. She has not had a regular job for the past four years.
Mr Antia is a fisherman. He has not been very successful with his fishing lately. Now he spends several months at a time working in the city as a daily paid labourer. The small amount of money he brings back from the city is hardly enough to feed the family. In fact the children are all underweight and sickly.
Mr and Mrs Antia discuss their problems with a health worker. These are some of the needs they mention:
- A bigger place to live in.
- More money.
- A job for Mrs Antia.
- Skills for Mr Antia so that he can get a better job.
- Food for the children.
- Medicine for the children.
- Medicine and rest for Mrs Antia.
- A way to stop the family growing in size.
- New clothing so that other villagers will respect the family.
- A radio for Mrs Antia, to relieve her loneliness.
At first some of these needs clearly seem more important than others, but priorities cannot be chosen only on what seems or feels right. There must be a reason for the choice. Below are four questions that can help people see their problems more clearly and make their choice of priorities easier. Note that during discussion people will come to realize that many of their needs are related. Satisfying a priority need may in fact solve many other problems as well.
Which is the most serious problem?
For the Antia family, lack of food may be the most serious problem. Poorly fed children will be susceptible to many diseases which may handicap them for the rest of their lives.
Where does the greatest future benefit lie?
Concern is not only for temporarily solving problems today, but for making the future brighter. Providing Mr Antia with skills so that he could get a better-paid job would give benefit now and in the future.
What needs can be met with the resources available?
The Antia family has little money, and Mrs Antia is unlikely to get a job now. With their existing resources they probably cannot afford new clothes and a radio. They cannot even afford certain foods. But, within their resources, there are inexpensive, yet nutritious foods available at the local market.
Which are the problems of greatest concern to the people?
Mrs Antia is most interested in the radio, but both she and her husband are interested in getting a better-paid job for Mr Antia. People are more likely to take action to solve problems in which they have an interest than those in which they do not. Also the more people there are who take interest, the more likely it is that the problem can be solved.
After considering all these questions together, Mr and Mrs Antia decided that job training for Mr Antia and buying more nutritious foods within their present budget were their immediate priorities.
Setting priorities with communities
The same four questions should be considered at meetings in which communities are discussing their priorities. When more people are involved, there will be more views to consider. It may take longer to decide on priorities than when only one or two people are concerned.
Educational games can help make clear what is involved in setting community priorities. Such games can be played with a group of health and community workers, with a class of high school students, or even with a group of community leaders. An example is given below of their specific use in helping communities to select priorities, objectives, and strategies.
A simple scenario can be developed from a case study of a small village with many problems. Everyone who plays the game takes the role of a village member. Each person chooses a different occupation and identity and is asked to express his or her own opinion about which are the most important needs, and why, and what is a priority for immediate action. As the game progresses, it will become evident that people with different backgrounds and opinions will see more benefit in one problem being solved than in another. This will make the discussion lively. Around twenty is a good number for playing this game. Of course you can create as many parts as you need, depending on the number of people in the group.
First, slowly read to the group the story of the village. Assign each person a role such as farmer, barber, weaver, or food-seller. Then read the story aloud again, and read the four questions listed. Ask everyone to think about them. The group should then have a discussion and try to agree on one or two top priorities. People do not have to sit in a large group. They may break into small interest groups. Some may move back and forth between groups trying to get support for their own ideas. You should move around and listen. Remind people about the four questions on choosing priorities (you might write them on a board or poster, if people can read). Also remind people that meeting needs usually costs time and money. Encourage players to find the least expensive ways of meeting the needs with the resources available.
Allow the game to go on for about an hour. After that time, stop the discussion even if no priorities have been chosen. Discuss with the participants what they have learned about setting priorities. Discuss how the group could improve its priority-setting skills.
Here is the story of Poro Village which you can use as it is or adapt to make the village sound more like those in the area where you are working.
Poro is a small rural village of 300 people. It has a big market which used to attract people from all over the surrounding area. Unfortunately the five kilometres of dirt road leading into Poro have become very rough. Fewer people are coming now, so business at the market is not good and the villagers are losing money. The road needs repairing.
The closest water source is a stream two kilometres away which dries up at certain times of year. The main town of the district, about ten kilometres away, has a piped water supply. The residents of Poro feel that they deserve the same.
The nearest school to Poro is in another village reached by a path through the forest. Children using the path have been bitten by snakes and injured through tripping over fallen trees. People in Poro want their own school.
The nearest health centre is in the main town. This is far to travel for a sick person, and the health workers who promise to visit Poro never come. The villagers want a health centre too.
Finally, because the main town of the district has electricity, people feel that Poro should have electricity too. This would help their children study and make life at night more interesting.
Here are some of the roles people can play: farmer, carpenter, baker, weaver, potter, tailor, trader, seamstress, food seller, religious leader, chief (or political leader), bicycle repairer, mason, herbalist, shopkeeper, midwife, housewife.
If at the beginning of a programme people have a clear idea of what they want, by the end of the programme they will know if they have succeeded. An objective is exactly what people want to see achieved by the end of the programme.
The result of a primary health care programme should be an improvement in the people's health. For example, if measles is a serious problem in a community, a programme to solve the problem might have the following as its health objectives:
- Fewer children will get measles.
- Those who do get measles will recover quickly and suffer no disabilities.
- No children will die from measles.
Since people's behavior affects their health, there will be certain actions that people must carry out to solve their health problems.
Such actions are the educational objectives of a programme. Here are some examples of educational objectives for a programme against measles:
- Mothers will bring their children for immunization.
- Mothers whose children get measles will bring them quickly to the health worker for care.
- To prevent blindness, mothers will keep children who have measles in a darkened room and make sure that they rest.
- Children who get measles will be fed as well as possible to help them recover more quickly.
Participation in setting objectives
The individuals, groups, or communities with whom you are working should be encouraged to select their own objectives and receive guidance on doing so. This is only reasonable, since they are the ones who are experiencing a problem.
When people set their own objectives, it is more likely that the health behavior they decide upon will fit with the local culture and available resources. As a guide, the role of the health worker is always to encourage people to examine and discuss the feasibility of the objectives, in other words whether the objectives chosen are likely to be achieved.
It may be some months before the results of activities can be seen. Remind people of this so that they are not disappointed if things haven't changed as soon as the initial action is finished.
Some factors in success
Looking at existing alternative practices is one way of ensuring a successful outcome. Supposing that a group of mothers want their children to grow bigger and healthier. As part of a balanced diet they would need to include enough protein foods. There are many alternative forms of protein that they can include in the normal diet: beans, meat, groundnuts, milk, seeds, cheese, chicken, fish, snails, and certain insects.
A health worker could guide the mothers in their choice by asking questions like: At what times of the year are these different foods available'? What is the price of these foods? Is it against local beliefs for children to eat any of these foods? Can these foods be easily prepared by the mothers? Which of the foods do children actually like? Through such a discussion, feasible objectives could be set regarding exactly what foods mothers should try to give their children.
You have probably realized that, for the mothers to achieve their objectives, other people must also act. Perhaps fathers will have to provide money. Perhaps mothers-in-law will have to be convinced. Farmers are also involved: the ministry of agriculture may have to provide loans and expert advice to local farmers producing the food. The Ministry of Labour or Social Development may have to help mothers and fathers find better ways to earn money so that they can buy food. Objectives need to be set at the individual, community, and national level, because all must play their part.
The steps to take to achieve objectives
Decisions on what steps to take that is on the most appropriate 'strategy' will be based on the different reasons behind behavior that causes health problems. It will also take other factors into consideration, such as the local culture, economic problems, etc.
The chart below explains this idea. It includes suggestions for educational methods, that will be discussed in detail in Chapter 7. Some of the methods are also discussed briefly in this chapter and in Chapters 5 and 6.
Since problems often have several causes, it may be necessary to use different strategies in a programme. Also note that although certain educational methods are listed next to certain types of action, they can also be used with others. However, some methods work better with one type of problem than with another.
Type of action needed (strategy)
Possible educational methods
Lack of knowledge
Posters, radio, press, talks, displays
Influence of other people
Discussion groups, clubs; family counselling
Lack of skills
Demonstrations, case studies, educational games
Lack of resources
Community surveys, community meeting, resource linking
Conflict with values
Clarification of values
Role-playing, educational games, stories