|Training Manual in Combatting Childhood Communicable Diseases Part I (Peace Corps, 1985, 579 pages)|
|Module 4: Health education|
|Session 20: Developing a health education project plan|
Among the most important ideas for anyone involved in community work in health education is to be acquainted with as many aspects of community life and its people as possible. The purpose of gathering this information is to help the health or other community worker have a fuller understanding of some of the problems of the community and some limitations on the solutions to these problems.
Once the community members and the community worker come to a joint understanding and desire to work on a project, a sequence of steps should be followed in planning the project. Each step will be discussed separately in this chapter. The four steps are:
Define the problem: it is important to involve the
community and focus on their needs.
Choose a goal and objectives: These should be measurable so
that evaluation is made possible; they should relate to the problem; and they
should be possible to achieve.
Assess the resources and barriers to the project: This will
involve finding the necessary materials; shills, people and funds; and
investigating possible obstacles to the success of the project. The importance
of doing this before carrying out the project is to make the plan for action
Carry out and evaluate the project: An outline should be
made of the specific activities aimed at reaching the goal. Because evaluation
is an on-going process and takes place throughout the life of the project, both
topics are covered together.
Step 3(a): Assessing Barriers to Changes in Health Behavior
This will involve investigating possible obstacles to the success of the project. The importance of doing this before carrying out the project is to make the plan for action more realistic.
As you have been getting acquainted in your community, you may have seen some evidence of poor health. You have observed that:
· many children are thin and small and have big bellies;
· the people live mostly on rice;
· few families have chickens, pigs, rabbits or goats for food;
· there is a year-round growing season, but few families grow vegetables;
· the only available milk is purchased;
· there is some fruit in the market, but it is expensive.
You have talked with the leaders and the people in the village about the problems of illness, fatigue, and deaths of young children. They show interest in doing something about it. You ask a group of leaders and a few parents to meet to discuss the problem and ways to solve it. In your meetings, you lead the people to discuss why the problems exist.
You and the group decide that there are not enough of the foods needed for good health and the villagers do not know about these foods What are the obstacles, habits and attitudes that now keep people from growing green and yellow vegetables? Possibly the following items are found:
· lack of knowledge, information or experience
· no suitable seed
· seeds not easily available
· trouble with insects
· not enough water
· no real interest
· traditions and beliefs which hinder the acceptance of these food items
· lack of shared community resources such as irrigation pump
· no banking resources
· high debts
Obstacles or barriers to health education exist in all communities and relate to many things. There may be interest in things other than health (for example, roads, schools, agriculture). Usually, a community has seen little change as to its health status - that is, whether the general health level is high or is low. They have nothing to compare their predicament with, and hence do not see it as a predicament at all. Therefore, when health competes with such paramount demands as: earning a living; providing shelter, food and clothing; bringing up a family; it may be far down on the community's list of priorities. If the community is satisfied, on the whole, with its state of health, changes in behavior will be resisted mainly because to make these changes, the people will be inconvenienced. Long distances, to travel for medical care, long waiting periods, even painful experiences such as an injection, could also be barriers to change in the community. They may want other help, though, such as freedom from bedbugs or opportunity to space children. Such needs create opportunities.
Many cultural traditions, practices and beliefs in every society are related to health and may also be barriers to change methods of child feeding. The following are examples: the usual length of breastfeeding; when the first foods are introduced and their nature; whether milk or its products are customarily employed; the traditional use of other protein sources, especially legumes, eggs, fish; the commonness of such "prestige" practices as: bottle feeding, the use of carbonated beverages and over-milled flour; and the dietary practices of women during pregnancy, lactation and after giving birth.
These practices may be passed on from one generation to the next. Until acceptance of a change is complete, the return to traditional or popular practices will occur due to the strong need of the individual to be accepted by his/her social group.
Other barriers to health education could result from differences in languages. Perhaps there is an indigenous dialect in the area that you don't know. Find an interpreter and, if possible, train him or her so that he or she can work directly with the people. Remember, the translator is an "insider" and therefore more readily trusted and accepted by the community.
Closely related to the language barrier is the communication problem caused by illiteracy or low educational levels. The concepts of modern hygiene, for example, may have no meaning to a people who have never been exposed to facts related to the cell, microbes and the use of the microscope. In this case, the importance of knowing what the community knows becomes evident.
Other things to keep in mind when considering problems and setting goals are: the economic ability of the people (do they have the money, time resources, with which to take action?) and the community attitudes towards solving the problems. If their attitudes are negative, a definite barrier to change exists. How does the community feel about other government programs and workers?
Step 3(b): Assessing Apparent and Potential Resources
What are some of the resources you can use in your work with the community? Each situation offers different possibilities, but do not forget that you are a very important resource person in the area where you work. To function efficiently then, it is important that you know as much about your community as possible. What has been the history of its involvement in health issues in the past? You may have to dig deep to find a cohesive force, but all communities work together in some form.
The term "community" implies a sense of togetherness and, if you try, you will probably find that neighbors have helped each other in the past, even though it may not have been on a large scale. Perhaps one family helped another to build a house, or to take a sick child to the hospital. Perhaps the local church has a youth group which convenes and raises funds for various projects. Look; you will find potential resources.
What organizations or agencies exist? What are their activities and interests? Many communities have official (governmental), voluntary (private), professional, religious and civic groups. What are they doing? Are they interested in health? What approach do they use? Can you work together, one complementing the other?
Are there any extension workers other than yourself in the community? Find out and introduce yourself and what you are doing. Perhaps you. can work together toward a common goal rather than fragment efforts and duplicate work.
Get to know the background, skills and strengths of those in communication with the community. These could be the teachers, the traditional healer, the merchants, the religious leaders, the heads of community organizations and clubs. Also available are the people involved with your specific project - your staff. There are those people working in various government and private agencies at local, national and sometimes international levels. Get to know what goes on in the local government and national ministries, who is available for contact, and what other agencies they can suggest as sources of further information and support. Acquaint yourself with the existences and services of the agencies and organizations in the country where you work. If possible, visit these agencies and take with you a leader from the community.
What kinds of supplies, materials and equipment will be necessary for the health plan? A vaccination campaign will need vaccine, possibly some means to keep it cold, needles and syringes, a place to sterilize equipment, paper on which to keep records, a means to publicize the campaign, a place to work, etc. To build latrines, you will need to know the geography of the area, where wood, sand, gravel and cement are available, etc. How can your project adapt to the available materials?
What will you need for educational supplies? Does a mass-information system exist? (radio, TV, newspapers) Where will you get paper, crayons, tape, tacks, projector, film? Can you make a bulletin board, blackboard, flip chart? Decide what you need and investigate your resource agencies, the schools and people. Who can be responsible other than yourself? Look for talent within the community. Utilize relevant materials already in use. Make your own only when necessary so that time and efforts are not wasted.
How will you maintain your supplies? Will you need a place to work? In almost every project, some monetary source must be available. Where can you get money? Can funds be raised? How? Who will organize a fund raising project? Who will handle the money? These are all very important questions because trust can be lost if funds are mismanaged.
In Nicaragua, funds to build a community clinic were raised by the local Health Committee. The officers volunteered their time and visited the various merchants in the surrounding communities, asking for donated items Such things as pots and pans, soap, fabrics, paint, food and toys were obtained and made as prizes to the winner of various community contests and games set up by the Committee. The contestants purchased a ticket for the contest at minimal fee and nearly everyone participated. A local leader who manufactured beds donated a bed for a raffle. The provisional clinic collected a voluntary fee for injections. All of these are possibilities for fund-raising projects, but remember to plan who will be responsible for safe-guarding the funds and who will make the decisions about their use raising them.
You are not working alone in this investigation of resources. Talk with the leaders, your supervisor, heads of community organizations. Get suggestions. Experiment. Publicize. But, most important, work together.
Step 4(a): Developing and Implementing a Project Plan
You have learned to know the people of the village and how they live. You have probably already helped them with some of their simple problems. You may have given some demonstrations and talked over village problems with the people. The Health Committee has identified a problem, defined a goal, and written objectives; barriers and resources have been assessed. Planning ahead to know what to do, when to do it, and how it should be done is essential in any kind of work.
"But why is a planned program needed?" A plan of work is a picture or "map" of what to do. If you and a friend started walking down a road, you would need to know which way to go in order to get to your destination. There could be several different roads leading to the same place, but perhaps one has advantages over the others. You need to decide between you which one to follow. A planned program is a guide to help the community get where it wants to go.
The importance of planning cannot be stressed too strongly. There must be joint planning on common problems by all of the interested groups. Attempts at cooperation too often fail because one person or one organization decides on a plan to be followed and then tries to get the others to follow a plan they did not help design.
If there is joint planning on a common problem, all are working toward the same goal. Independent action causes competition of the sort that is fatal to the success of a health plan because it can lead to competition for the attention and actions of the people, and create wasteful demands on limited resources.
The people must participate in each step. They need to decide just what to accomplish and what their targets are. When the people have agreed on their goals, they must decide how they are going to reach them. Sometimes it is harder for people to agree on how to do something than to decide to do it. Sometimes, each person thinks his or her own way is better.
The leaders may need help in deciding what will happen if they do it one way and what will happen if they do it another. Which will be better for the people? Does one cost more than the other? They must set priorities and decide on which is the better way for their community at this time. Deliberate involvement of as large a number of people as possible is good because it means that many more people know and understand the problem. All those who participate learn something. Men, women, children, young people, old people, merchants, housewives, speakers, farmers; all have some skill which can be utilized in carrying out a community health program.
The community leaders or the Health Committee must make the plan. This plan may have many parts. It will need a time schedule. What should be done first, and what comes next? How much time is needed for each job so that each will be done at the right time?
The planners must find out what is needed to do the job, who can do it, how much it will cost, and many other things. They must find the time, the people, the money, the equipment and anything else that is needed. Educational methods for each stage of the plan should be selected as part of the plan. See Chapters V and VI.
Once the steps to be taken have been defined, the Health Committee or planning group must decide who will be responsible for each step. For some jobs, workers will need special skills and equipment. Other jobs can be done by village people with no prior training. There will be many things to do: planning for equipment, arranging meetings, explaining procedures.
Everyone must feel that he/she has a chance to help. Doing the job is the actual step for which you have been planning, be it building a road, planting vegetable gardens, or vaccinating against measles. This step will give the community members a great measure of satisfaction and will draw the group more closely together.
To summarize, when planning a project with the community, the Health Committee or other community planning group will need to write down a Plan of Action. This is the "map." it will serve as a guide and will help in implementing and evaluating the project and planning another one.
Step 4(b): Evaluating the Project
Don't stop yet - evaluate! Planning never ends, so, each time a project or step of the program is completed, the Committee should look back over what has been done to be sure that things are going as they should. This is called evaluation and is an on-going, continuous process just like planning. You must evaluate past efforts to plan for changes.
Develop a means for evaluation when defining the goal and writing up a Plan for Action. Keep in mind your community survey and any responses from questionnaires and statistics you might have collected as possible sources of information for evaluation.
Following each step or activity, ask questions such as:
· How well did we do?
· Did the plans work?
· Why did we succeed? or
· Why did we fail?
· What should we be doing now?
· What do we do next?
· If we made mistakes, can we keep from making them again?
Encourage the community members to begin to evaluate the project shortly after its initiation. Are people using the latrines that have been installed? Are they keeping up their vegetable gardens and eating the harvest? Are the children really going to school? Did the group for whom you intended your activities come?
After each phase of the project is over, you must follow-up to determine how successful it has been. At the end, ask yourself all of these questions again. Did you get the job done? What can be done to make your efforts more successful?
Possible kinds of measurements you might use to evaluate your project, if planned from the beginning, are:
1. Quantity or amount
a) How many persons were reached?
b) How many posters, pamphlets, home visits were made?
2. Quality - What do the people think?
a) the leaders?
b) the participants, villagers?
c) other health workers?
d) the pupils?
3. Changes in knowledge shown by:
b) requests for opinions
4. Changes in attitude
a) Community support for the program.
b) Requests for further cooperation by the Health Department.
c) Less opposition by groups in the village who had previously been against the project.
d) Public opinion poll
5. Changes in behavior, such as:
a) Increase in visits to the clinic or health worker
b) Improved habits and conditions noted at the school
c) Increase in the number of children immunized
d) Increase in the sale of milk, meat, vegetables or other good foods
e) Increase in the number of pregnant women seeking early prenatal care
f) Increase in the number of births that occur in the hospital or with the trained midwife
g) Increase in the number of infants under medical supervision
h) increase in the number of women who breast teed their babies
i) installation of sanitary facilities (latrines, garbage pits)
6. Changes in health status as shown in:
a) Child growth
b) Numbers of sick people (as shown in a survey)
c) Number of deaths as reported in public health statistics
d) Improvement in health as shown in individual cases
e) Reduced accident rate
f) Reduced exclusion from school due to illness, lack of clothing or poor hygiene 1
[ 1 Turner, Claire E. Community Health Educator's Compendium of Knowledge. International Journal of Health Education, Switzerland, 1964. pages 105-108. ]
In the case of evaluating an educational approach, you will find it difficult to measure the results. The mere giving of lessons or demonstrations and the ability of the people to repeat them are surely not the only measure. Behavior change is the goal, yet these changes are not easily evaluated immediately since they may occur slowly over a long period of time.
As always, throughout your work with the community, it will be necessary to record your observations. This is a form of written record which you've already done during your community investigation. You should discuss the importance of record keeping with the Health Committee.
Evaluating the progress of complex activities such as public health is never simple, but it can be made easier by clearly defining the project's objectives early and relating your evaluation plan directly to those objectives. With careful planning, evaluative data will help to assure that the project is better managed, and that those who support the work, and particularly members of the community, will feel confident in the progress being made.
(From World Education Reports, "Evaluation". pp. 5-10.)