(introduction...)

In health education we aim to encourage people to develop the confidence and skills to help themselves. In other words, the planning skills that are discussed in this chapter are not only for the use of health workers but also for the use of the community itself. Involving the community in the planning process is itself educational because once the skills have been learned and practiced, the community will be able to take more initiative in planning its own programmes and activities. That is how self-reliance develops.

In this chapter eight basic planning skills are described:

- Collecting information
- Understanding problems
- Deciding on priorities, objectives, and action
- Identifying and obtaining resources
- Encouraging action and follow-through
- Selecting appropriate methods
- Evaluating results
- Reviewing the process of planning

These skills should not be seen as steps to be followed in a 1, 2, 3 order. Of course information must be collected before action can begin, but evaluation, although listed near the end, should start at the beginning of the process so that progress or drawbacks can be charted all along.

The importance of using appropriate technology, the need for community involvement, the value of partnership between the community and the health worker, and the need to coordinate different levels of health planning are emphasized.

Collecting information

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.

Observation

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.

Observe groups

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.

Interviewing people

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	Never	To start with	Later
1. Does the baby eat fruit?
2. Welcome to the clinic.
3. How many times a day does the baby eat?
4. Don't you give the child eggs?
5. Please tell me about the child's favourite foods.
6. Do you give cereal, eggs, or bread for breakfast?
7. Shouldn't this child be eating more beans?
8. Let us discuss your child's feeding habits so both of us can learn how best to keep him healthy.
9. Are there any foods the child refuses?
10. Please tell me about any problems you may have in feeding this child.
11. Does the child eat most in the morning or afternoon?
12. Wouldn't it be better if this child could eat more meat?

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?

Understanding problems

Unless you understand clearly what factors are involved in a problem, you will not be able to control it. There are different causes that must be examined.

Why are there problems?

The most important word in this section is why. Information collected about the community or about individuals will show that some things are going well but that there are also many problems. Simply knowing that things are going well or badly is not enough for planning a programme.

It is important to know why a community project, for example, is succeeding or why people are healthy, so that you can learn from such information and promote similar successes in the future. In the same way, one must know why there are problems so that the most appropriate steps can be taken to find solutions.

Chapter I was written to help understand why problems occur, and why they don't. Read the four examples below. Look back to Chapter I and see if you can think of some possible explanations why some of the people in the examples have problems while others do not.

In one village 50 out of 100 mothers bring their children for monthly appointments at the c-hild welfare clinic. In another village, 85 out of 100 mothers attend. Why?

One man has come to the clinic complaining of roundworm twice in the past year. His neighbor has never had this problem. Why?

In October, there were very few people with a cough in one village. By March, there were three times as many people with a cough. Why?

In one village the people have built their own latrines, wells, and school. A nearby village has none of these things. Why?

Involving the community

It is not only the health or community worker who must understand why problems do or do not occur. The members of the community must also understand. Meetings and discussions with individuals, groups, or community representatives are useful for helping people look closely at the reasons for problems. In this way information gathered about the community can be shared and examined. When community members learn more about their problems, they will be better able to make good choices on action to solve them.

The role of behavior

Like beliefs, some kinds of behavior may promote health and some may lead to illness, while the effect of others may be neutral or at least unknown. We discussed this in Chapter 1.

When looking at health behavior, the first thing is to understand why people take certain actions that promote health. What resources, beliefs, values, and important people encourage healthy behavior or make it possible'! What activities can be planned to support and strengthen healthy practices?

Next comes consideration of unhealthy behavior. If people have shown that they want to improve the situation, at least three things could be done about unhealthy practices:

- Ignore the unhealthy behavior, and encourage instead an existing alternative way of behaving that is healthy.

- Slightly change the unhealthy behavior to remove some of its more dangerous aspects.

- Substitute completely new practices for the unhealthy ones.

An understanding of the situation is needed to help in deciding which of these actions would be the best. Since behavior is part of the way of life or culture of a community, the best step may be to encourage already existing healthy practices as an alternative to unhealthy ones. If no appropriate or acceptable alternatives exist, the next choice would be to find ways of slightly changing the harmful behavior. The most difficult line of action of the three is for people to try substituting completely new practices for old familiar ones.

Here is an example of how a good understanding of behavior can lead to appropriate action.

In one village the traditional midwives always used pieces of green glass to cut the umbilical cord of newborns. They believed that the glass had certain magic powers that protected the baby. Unfortunately, this village also had a high incidence of neonatal tetanus.

During a discussion, the midwives admitted that they were worried about tetanus, but did not know what to do. Were any other methods of cutting the cord used?

No others were used in that village, but one woman mentioned that in nearby villages some midwives used knives. An elderly midwife then reminded the group that she believed that metal held evil spirits that could harm a young baby. Thus a knife was not an acceptable alternative. At this point the health worker who was attending the discussion realized that substituting a new practice such as the use of clean razor blades would not work, because they were made of metal. Possibly the existing practice could be slightly changed? The sharp pieces of broken glass certainly could cut the cord almost as well as a razor blade. The problem was that a dirty piece of glass could cause tetanus. A simple change could be to put the glass, before use, in boiling water for at least ten minutes to kill the tetanus spores. This was acceptable to the midwives.

Using a clean, new razor blade to cut the umbilical cord of a newborn baby is a healthy practice which traditional midwives could adopt if local practices are not safe, it is often possible to modify traditional practices or find alternatives that would be equally safe and more in line with local beliefs and culture.

Who can solve problems?

Some problems can be solved by individual effort alone, while others require the assistance or cooperation of several people, or of the whole community. For example, a community may be experiencing the bad effects of poor environmental sanitation. The behavior of individuals and families contributes to the problem because waste and faeces are spread about everywhere. In solving the problem, the whole community may need to set up a waste collection system and to provide latrine facilities through cooperative action. Then it would be the responsibility of individuals and families to make hygienic use of these facilities. Here are other examples:

- An individual can take responsibility for personal hygiene.
- Good nutrition is usually the responsibility of the whole family.
- In order to rent a tractor, a group of farmers may have to share the cost.
- Guaranteeing a safe water supply is the responsibility of the community.
- The national government, through the ministry of health, is responsible for providing vaccines.

Sometimes the whole community may have to take action to solve a problem. This is the case when the problem is associated with unhealthy practices that are usual and accepted in the community.

What is the type of help needed?

Look at a disease like tuberculosis. Some people in the community may have recently fallen ill with the disease. They need treatment. They need to take their drugs regularly. They have lost weight, have become very weak, and may even have lost their jobs. They need rehabilitation to help them recover their health and jobs so that they may live a normal life again. Many are not sick, but they need to take preventive action to keep well. This includes not only immunization, but also health promotion measures such as adequate nutrition.

You can see that different kinds of behavior are needed depending on whether we want to prevent tuberculosis, treat the disease, or provide rehabilitation. This is true for most problems.

Try to understand the appropriate behavior at each stage of the problem. Plan education programmes to help people adopt the kind of behavior that will prevent them from becoming ill, cure them if they are sick, and help them lead normal lives if they are disabled.

Deciding on priorities, objectives, and action

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

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.

Setting objectives

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.

Health objectives

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.

Educational objectives

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.

Problem	Type of action needed (strategy)	Possible educational methods
Lack of knowledge	Information	Posters, radio, press, talks, displays
Influence of other people	Support	Discussion groups, clubs; family counselling
Lack of skills	Training	Demonstrations, case studies, educational games
Lack of resources	Development	Community surveys, community meeting, resource linking
Conflict with values	Clarification of values	Role-playing, educational games, stories

Identifying and obtaining resources

In the first chapter we discussed the important effect that the presence or absence of resources can have on behavior. This section looks at ways of finding the resources necessary to promote health, and conduct health education programmes.

Resources inside the community

Be aware of the resources within your own community that can be used in solving the problems of individuals, of groups, or of the whole village.

Here are some examples of the many kinds of resources you will need:

- Places to hold meetings, discussions, and training sessions, such as schools, and town halls.

- Some people may be able to donate money to buy materials.

- Some people may have skills that would be useful for community projects. Among these are carpenters, teachers, masons, artists, traditional healers, weavers, and potters.

- Many able-bodied people can give their labour.

- Some people may own bicycles, motor cycles, or other vehicles. Transport is valuable for carrying materials for projects or taking sick people to the clinic.

- Materials such as wood, cloth, and food can be given by people for large community projects, or to help families in times of crisis; for treating sick people you may find that some local herbs work very well; you can encourage people to make tools and equipment for their projects.

Make sure you know who has any of these resources, and how they can be obtained. As can be seen from the list above, the members of the community themselves are the most important resources for solving problems.

Resources outside the community

It is best to solve problems with resources from within your own community. Sometimes, though, the project may be too big for the resources available. Also the problem may be difficult to solve. Then it is necessary to look outside. Here are some resources you may find outside your community:

- Some agencies and ministries give funds and technical assistance for community projects or for individuals and families in need.

- People with skills, such as finding underground water for wells, may come from outside.

- Materials such as cement may have to come from outside as well; for educational material such as films and posters, you may look to different agencies; vaccines, drugs, and medical equipment are sent from outside; many kinds of machines and equipment are sold, loaned, or given by outside agencies.

Appropriate resources

We have said that it is best to find resources inside your community. For one thing, it saves money. But, more important yet, people are proud to be able to help themselves. This pride will encourage people to try to solve more problems by their own efforts.

Use local resources to solve problems. Carpenters in this community have helped by making crutches for handicapped children.

It may not be necessary to buy cement outside to make incinerators, for example. Mud, clay, bricks, and stone are appropriate local building materials.

A tractor may look like a wonderful answer to farmers' problems. After some time though, they may be disappointed when they see the cost of petrol and the difficulty of getting repairs when the tractor breaks down. An improved design for local ploughs or the use of horses, mules, oxen, or buffalos might be more appropriate and have better long-term results.

Linking people with resources

Once resources have been found that will help solve the problem of the person, the group, or the community in need, you must still bring the people and the resources together. Good relationships with people and communication skills are very important here. Only through good relations can you bring together the people in need with the people who have the resources.

This woman is collecting special leaves and grasses that can be used to make medicine these are often a valuable local resource.

When we talked about participation, we said that it was a mistake to do work for people that they can do for themselves. This is true with resources, too. Do not get resources for people if they can get them for themselves. If you do it for them, they may not be able to find help the next time they are in need. This is what happened to one community worker, Mr Neb.

Mr Neb was talking one day to a farmers' cooperative in his district. The farmers said that they needed money to buy seeds and fertilizers. Mr Neb promised he would help. He went to the Ministry of Agriculture and found the section that gives loans to farmers. He got the forms and brought them back. After asking the farmers a few questions, he filled in the forms for them. He took the forms back to the ministry and got the money for the farmers.

Later that year Mr Neb was transferred to another district. When the time came to repay the loan, the farmers did not know what to do. Only Mr Neb knew all about the resources at the ministry. Finally, an angry official from the ministry came to collect the money. The farmers gave it to him, but were afraid to ask him more about loans because they could see his anger. When the next planting season came, the farmers did not know how to get a loan.

Sometimes problems become more confused when a health worker tries to get people a resource that they could have obtained themselves. This is what happened to Mrs Sandos.

Mrs Sandos, a community midwife, heard that people in her community needed a reliable well. She volunteered to go to the provincial capital to seek help at the Ministry of Public Works. An official at the ministry gave Mrs Sandos plans for a well. The officer also promised to help with costs and supplies if the villagers dug the well exactly to plan.

The villagers were happy to receive Mrs Sandos' report and began digging the well right away. Before they were half-way down to the depth required by the plan, they struck water. Though they tried, they could not go deeper. When Mrs Sandos reported back to the ministry, the official said that he would not give any help now, because the well was not dug according to the plans. Mrs Sandos tried to explain the problem, but the officer would not listen. Mrs Sandos was embarrassed to return home with the bad news and, when she did, the villagers accused her of Iying. They gave up interest in the project and today they still have no reliable well.

Think about these two stories What could the two health workers have done to make a better link between village and resource?

Actually there are several things that you can do to assist individuals, groups, and whole communities in learning to link up with resources. First you must supply background information that will help people to make an effective link. Such information should include:

- Names of agencies, organizations, and individuals that have resources.
- Description of type of resources provided.
- Location of the resource agency.
- Special requirements the agency may have before giving resources.

Selecting the best resources

Discuss the benefits and difficulties that might come with each resource and what is best considering the culture and needs of the community itself. The people involved should make the decision. Do not force an idea on the people.

Exploratory visit

The community will learn more about the resource if a visit is made to the agency that has the resource. While you may provide some background information, it is better if the people learn at first hand what the resource agency offers.

You should not go to the resource agency alone. If the villagers are not confident enough to go by themselves, you can go with them the first time. But they must soon learn to go by themselves. If you are working with a group, the group may send a few representatives to see the resource agency. You can introduce the people but should encourage them to speak for themselves. The person or the group who made the visit will report back and encourage further discussion.

Many different resources can be used to solve a problem. For example this health worker has many drugs to choose from when supplying a community medicine kit. The pharmacist can help her choose the most appropriate ones for her community.

Obtaining the resource

The people should make their own decision whether to accept the resource or not. They themselves should also make all arrangements directly with the agency. You can be with the people to make sure that they understand what is happening and that no-one is taking unfair advantage of them. People must know in advance what, if anything, the agency expects them to do in return.

Encouraging learning

At each step of the linking process, explain carefully to the people what is happening. Be sure that more than one person in a group or community knows how to link up with resources. Then, in case of sickness or travel, there will always be someone around who knows what to do.

Maintaining collaboration

Communities will benefit from the resources of many different agencies education, agriculture, social development, information, public works, and a variety of voluntary and special purpose organizations. Help the community establish ongoing links with these different agencies.

Health education resources

In this section we have talked about resources needed to achieve actual programme goalscement for a well, or volunteer labour to build a community meeting-hall, for example. We must also remember that special resources are needed to communicate the health message that will encourage people to undertake the programme in the first place. All the points we have raised about general programme resources (type, availability, and appropriateness) also apply to education and communication resources.

Local media

When collecting information about the community, you should look for local and traditional means of communication. These may include proverbs, stories, and fables which elders use to pass traditional values on to the young. Local leaders may use town criers or bell-ringers to announce coming events. Traditional songs or plays may communicate important ideas and values. Some people may own a print shop and be able to make posters to inform the public. There may also be a photographer in the neighborhood.

Consider which of these and other communication media are available in your community. Use the ones that will best support your health education efforts. By using locally available means of communication you will be involving the community in the programme. Get their ideas on which traditional proverbs, songs, or stories will be most appropriate for conveying the health message. Involve local leaders so that they would be willing to use their town criers to announce important health events and rally the community to take part. Local artists, printers, and photographers can be involved in designing, and producing educational material.

Outside resources

Also identify communication resources outside the community. These may include mass media such as newspapers and radio. The ministries of health and of information may have films, posters, and vans with loudspeakers that can be borrowed for local health education programmes. Find out who in the community has access to newspapers, radios, and other information sources. These people can be encouraged to share the health information they obtain. A local school-teacher who subscribes to a newspaper can save articles that relate to health and use them to teach pupils and inform parents. A community member who owns a radio could invite neighbors to listen when health programmes are broadcast.

You, as a local health worker, should be aware of such newspaper articles and radio programmes so that you can encourage community members to read and listen, and benefit from the information provided. This involves resource-linking. Contact the radio or television station and obtain their programme schedule. When health programmes are broadcast, encourage community members to listen. You may even encourage them to gather as a group to listen, so that after the programme a discussion can be held to make sure that everyone has understood the ideas presented.

Get in touch with the ministries of health and of information. Find out what resources they have and on what conditions they loan materials such as films. Read Chapter 7 to learn more about different educational media and communication resources.

Encouraging action and follow-through

If you have been following the steps described so far, you should have a strong foundation for your health education work. You know the problems, the priorities, the objectives, the resources. Now, all of this must be put together into a specific plan of action that will show what will be done, by whom, and when. In other words you need to prepare a timetable.

Preparing a timetable

Suppose your community feels that its most important health problem is the lack of a convenient drinking-water supply. The timetable on page 73 is an example of how to set out the timing of tasks and responsibilities. One thing to remember when setting target dates for various tasks is to be realistic. It takes time for people to get organized and it takes time to find resources. People will be disappointed if they set a schedule that is too short for the actual completion of the assigned tasks. A timetable is also useful in checking whether the programme is progressing as scheduled.

A copy of the timetable can be put up in the town hall or in another place where people will see it.

The timetable reproduced opposite was set up for a community programme, to improve the water supply. You can adapt the timetable and activities to your own community protects.

A timetable may even be drawn up for an individual; this would be less complicated than one for a community. An example is the case of a mother whose child is underweight. Together with the mother, you could work out a timetable showing the foods that might be prepared for the child each day. This might look like a one-week menu. On the same timetable you would also note follow-up clinic appointments.

If the mother could not read, you would not be able to write out a timetable for her, but you would discuss the schedule to help her remember. Also she might have a child or relative who is able to read. A timetable could then be written that someone could read to her.

Assigning tasks

When a programme involves more than one person, it is important to make sure as many people participate as possible.

In the timetable there is a column headed 'people responsible'. We used general terms like 'leaders', 'volunteers', and 'local people'. In a real timetable you would list the names of the people who have agreed to take responsibility for one task or another.

For example, with the community water supply project: Who will be on the fund-raising committee? Who will get the cement? Who will find the shovels? Who will be the volunteer workers? Who will be in charge of the volunteers?

Follow-through action

This involves the steps listed below:

- Set a specific date on which to start your main action.

Sample timetable for the provision of a community water supply
Tasks	Completed by	People responsible
1 Community leaders discuss the problem of waterborne diseases	1st week	community health workers
2. Leaders trained on cause and prevention	3rd week	community health workers
3. Public information activities begin, using local media and home visits	4th week	leaders, community health workers, schoolteachers
4. All sick people report for treatment	5th week	leaders, community health workers, local people
5. People boil and filter their water	6th week	leaders (one for each town/village/section)
6. Funds raised for well construction	12th week	fund-raising committee, leaders
7. Voluntary labour recruited	12th week	leaders
8. Well sites selected	12th week	leaders and local people
9. Materials obtained	15th week	materials committee
10. Construction begins	15th week	volunteer labourers, community health workers
11 Maintenance committee selected for each well	15th week	leaders
12. Maintenance committee members trained in maintenance of wells	16th week	health worker
13. Wells completed	20th week	volunteer labourers
14. People use water only from wells; maintain wells hygienically	20th week onwards	leaders and local people

- Be sure each person knows his or her duties: Can each person tell you from memory what he or she must do and when he or she will do it?

- Keep in contact with people; provide encouragement; answer questions; help solve problems.

- Hold regular meetings to review progress: at these meetings each responsible person can report on what he or she has done; the group can then compare each report with the timetable and see if the work is progressing according to schedule.

- If there is some delay in the schedule the group should look into the problem immediately: Can it be corrected at once? What are the needs? More materials? More volunteers? More time? More funds?

Remember that it is better to correct problems early, before they spoil the programme.

Selecting appropriate methods

It is not enough to decide what will be done, by whom and when, we also need to decide how it will be done.

In Chapter I some of the reasons for people's behavior were discussed. Once a health worker understands the reasons behind behavior that is causing a health problem, he or she can use many different methods to encourage a change in that behavior. There are some important points to take into consideration when we choose a method. First of all, the method must suit the situation and the problem; it must therefore be selected carefully.

There are many methods, because these are many ways of solving a problem. Before choosing a method, the person practicing health education must understand the problem at hand. A doctor, for example, has many methods to choose from in solving medical problems. If a patient is found to have a stomach ulcer, the doctor will try to understand the problem and choose the best method to use in dealing with it. If the ulcer is not too serious, diet may be the chosen method. By controlling what, when, and how much a person eats, the problem might be overcome. If the ulcer is slightly more serious, drugs may be used. In an even more serious case the doctor may choose to do an operation. It is likely that two or more methods will be used together.

People practicing health education must make decisions about which methods should be used to help solve problems related to health behavior. There are six things to consider before choosing health education methods:

- How ready and able are people to change?
- How many people are involved?
- Is the method appropriate to the local culture?
- What resources are available?
- What mixture of methods is needed?
- What methods fit the characteristics rage, sex, religion, etc.) of the target group?

How ready and able are people to change?

Remember the story in Chapter I about three women who were asked to buy shoes for their children. The midwife gave a talk in which she provided information, ideas, and suggestions. After the talk, not all the mothers decided to buy shoes.

One mother was ready to change. She had no major problems in her way. She accepted the ideas in the talk and carried out the midwife's suggestion. When people are ready to change, posters, radio, songs, plays, stories, displays, and photographs are some of the educational methods that can be used.

A second mother was interested in changing; she liked what the midwife had to say but she did not know if the family could spare the money for buying shoes. Also she was not sure if the grandmother would approve. The talk certainly gave this woman useful ideas about helping her children, but did not help her organize her family finances.

Approaches that might have helped this woman would have been discussion with family members about how much money they earned, how much they spent, and what they spent it on. Then, through demonstration or teaching, it might have been possible to show the family how to manage their money better so that shoes could be bought for the child. Linking the father with the local farmers' cooperative or with the agricultural extension agent might have helped him find ways of earning more money. Then if money was no longer a major problem, discussion with the grandmother about her love for her grandchild could have been used to win her support.

The third mother was hard to reach. She was so worried about her problems that it was difficult for her to take an interest in what the midwife said. She also lacked money and resources. To reach this woman, the midwife needed to use methods that allowed personal contact: counselling and home visits were needed. These would have shown the woman that the midwife was concerned, and would have helped the midwife to learn more about the woman's problems. The more she was able to learn, the more she would have been able to help.

This woman might have benefited from belonging to a group or club in which people with similar problems can support and encourage each other. Links with other community agencies could have provided the resources needed to help her care for her child. She could also have been helped by training in skills that would enable her to earn more money to provide for her child.

How many people are involved?

Some methods of health education are designed for reaching a large number of people (for example a group, a neighborhood or a town) with a message or idea. These methods involve the use of such means as posters, lectures, displays, plays, role-plays, puppet shows, newspapers, radio, films, and town criers.

Providing good ideas quickly to a large number of people is a very useful step in health education. It creates awareness of a problem or idea. If the message is a good one, it will help prepare people to participate in desired action. However, other methods are usually needed to follow up the initial impression made through the mass media. Sending out health messages alone is usually not enough to change health behavior in a large number of people.

In order to make large-group methods more useful in health education, there needs to be an exchange of views and ideas between the health or community workers who use the methods, and the people who see and hear the health messages. This exchange of views and ideas is called 'interaction'.

You will probably not be working alone. Share the responsibility of interacting with the community with other health workers, particularly with community health workers and staff from other community agencies.

Here are some suggestions for developing such interaction:

- After a film or talk, divide the audience into smaller groups for discussion.

- When putting up posters around the community, make home visits and discuss the ideas on the posters with families.

- After a play, ask the actors to go into the audience to talk with people.

- Organize small groups, in various parts of the community, for radio listening combined with discussion.

- Work with an existing community council or, if one does not exist, organize a community health committee.

Activities such as practicing new skills, discussing personal feelings, values and money matters, and sharing difficult experiences are best done person-to-person or in small groups (ideally in, groups of no more than ten people).

Methods suitable for use with groups include story-telling, demonstrations, role-playing, case studies, discussions, educational games, and others that will be discussed in Chapter 5.

Teaching aids such as projectors and flip-charts may be used with groups of up to 25 people, although again it should be remembered that, when there are too many people, there will be less interaction and personal contact between the health worker and the members of the group.

Role-playing can help individuals and small groups of people understand their problems and work out solutions to them. Some members of the group act out a situation, while others watch and make comments and suggestions.

Note that posters, radio, and other media designed to reach large groups can also be used with a small number of people.

Is the method appropriate to the local culture?

In Chapter I we described culture as the way of life of people in a community. Culture will determine the educational methods that will be acceptable and understandable to people. It will also determine the methods to which people will respond by changing to healthier behavior.

For example, the role-playing method requires people to speak out freely in front of others. In one culture people may like to act and speak out. In another they may prefer to be quiet and careful about what they do or say. Role-playing would work well in the first culture. It may work in the second, but only after people in the group know and trust each other.

To take another example, photographs have different meanings in different cultures. If you are working in a community where most people are illiterate, they may not be used to seeing photos as a source of news or information, because they have little experience of books and newspapers. If you are doing a programme on breast-feeding in such a community, and show the women a picture of a mother breast-feeding her baby, their first thought may be that the photo is of your mother or sister. They would not realize that the photo is there to help them learn. Similar problems may arise in using films. We must make sure that people understand why they are being shown photographs or a film.

Role-playing and the use of photographs and films are examples of methods that will not work unless they are adapted to the culture of the community. Ways of adapting methods to culture are mentioned in Chapter 7. But we do not need to worry about adapting methods if we use some of the means by which the people themselves communicate ideas and share knowledge and skills. These include proverbs, town criers, plays, and so on. Such forms of natural communication should be part of any educational programme.

Practical demonstrations are good ways of teaching skills. In a good demonstration people will be given the chance to practice new skills.

Instead of just talking about hygiene, this health worker is showing mothers how to bath their children.

What resources are needed?

Consider the resources necessary. Some methods require only yourself and the people around you: these include the use of stories and songs, role-playing, group discussions, and community meetings.

Other methods require the use of materials or teaching aids such as posters, flannelgraphs, demonstrations, models, puppet shows, newspapers, and flip-charts.

Then there are methods that use machines: tape recorders, film or slide projectors, etc. Machines usually need electricity. Machines and materials cost money. Try to look for methods that are inexpensive and at the same time effective.

Even if you are able to borrow films, projectors, and an electricity-generating plant, the films may come from a country whose culture your people will not understand. They may not even be in the language of your people. If that should be the case, a wiser decision would be to put on a play. A play simply needs people and a few materials. The local language can be used, and members of the community have a chance to participate. Expensive machines are not required.

Think of other ways in which you can use local resources to make or provide aids to education.

What mixture of methods is needed?

Select a mixture of methods. Variety and repetition are both important. By using a variety of methods you will make your programme more interesting. If you repeat the ideas in different ways, people are more likely to remember them.

If, for example, you are telling a story you may want to show some pictures or posters that relate to the story. Then after the story, you may ask some of the listeners to do a role-play in which they act out the story for all to see.

A health talk should be more than just talk. Of course, you will do some lecturing, but you should also show posters. There should be group discussion. Demonstrations and practice will also help people learn more from the talk.

A community meeting can be made more lively if a short play is also presented. This will help make issues more clear to people, display could be added too. People coming to the meeting could look at the display and learn something about the subject before the meeting starts.

Which methods fit the group best?

You will meet different people and groups. Some will be old, some young. Some will be made up of women, some only of men and some will be mixed. Select and adapt your methods to fit the' type of people you meet.

Fables using animals might be better for children than for adults. Lectures may be better for educated people, than for those who have never been to school. If the people belong to one religion, select proverbs from the scriptures and books of that religion.

Evaluating results

If you have given time and effort to a project, you will want to know if it has been successful. In judging success, it is not enough simply to say 'we were very successful', or 'we had some success', or 'we failed'. If possible, a specific measure of the amount of success is needed.

Checking on the progress made

Observation, interviews, and records will supply information for evaluating a programme.

It is important to select the method (or methods) most appropriate (or the group concerned. It is also important to use a mixture of methods that will help people to understand better and to remember.

To take an example: it has been planned that the funds for the water supply project will be raised by the 12th week. If not enough money has been collected by that time, then something is wrong. The planning group must start to check and find the cause. Maybe the neighborhood leaders were not adequately informed about how to organize fund-raising. Maybe it was a bad time of year for people to donate money because the harvest was not yet in.

If the plans were to dig four wells within six months, but only one is under way by the 17th or 18th week, then the group should immediately try to find out why. Maybe more materials are needed than originally planned. Maybe some of the labourers misunderstood their instructions.

Problems should be corrected as soon as they are seen.

Final results

By the end of the educational activities, you should be able to measure their success by counting how many people are behaving according to the original objectives: is this number more than before the programme started?

Use observation to check results. With community wells, for instance: is there evidence that they are maintained hygienically? Are people keeping them covered? Are they using clean buckets for gathering water? Are they storing the water in clean, covered containers at home? Are people still going to the stream to fetch water?

If people are using the wells hygienically and storing water safely at home, the educational objectives of the programme have been achieved.

As for the health objectives, there should be a decrease in the amount of waterborne disease. Depending on the type of disease, it may take several months for this to show. If a reduction in illness does not occur, test the well-water and look for other sources of contamination. If, in fact, waterborne disease is decreasing, then the programme has been successful.

Learning from evaluation

At the end of the programme, a final meeting can be held to discuss how far the programme has succeeded. Two main questions must be answered:

1. Did the action go as well as planned?

- Did people participate?
- Were resources available on time?
- Did people gain new skills and learn from the programme?

2. Was the problem eliminated or reduced? Using the example of schistosomiasis:

- Do people now have access to safe water supplies?
- Are people disposing of faeces and urine in a safe manner?
- Are fewer people suffering from the disease now than before the programme started?

Discussing such questions will help people evaluate and learn from their programmes. We can obtain the answers to these questions in the way in which we originally gathered information about the community when we started planning through observation, interview, and records. Compare information gathered before the programme started with information collected after it ended.

Even if the programme did not turn out as desired, a meeting should still be held to find out why. A review of the timetable will help show if every person carried out his or her duties.

Questions such as these might help:

Were there any unreported difficulties earlier in the programme? Did other community events disturb or distract people from participating in the action? Were there any disagreements among community members that stopped them working together? Was the time set for the programme unrealistic? Were the activities chosen inappropriate to the local culture?

Once sources of difficulty have been found, the group can decide if it wants to try again. Learning can come from mistakes as well as from successes. It is a hopeful sign if people can sit down maturely and work out the cause of a problem. At such times, a health worker can provide much-needed support and encouragement. With new knowledge about the problem, the group will know how to plan a better programme in the future.

Reviewing the process of planning

We have seen the different steps that are involved in planning health education activities in primary health care. You will have noticed that, at each step, the health worker uses health education approaches that facilitate and reinforce the involvement of communities in health development. Through that involvement, you can make sure that the technology used is appropriate.

Using appropriate technology

Appropriate technology is an important factor for the success of primary health care. The word 'technology', as employed here, means an association of methods, techniques, and equipment which, together with the people using them, can contribute significantly to solving a health problem.

'Appropriate' technology means that, besides being scientifically sound, the technology is also acceptable to those who apply it and to those for whom it is used. This implies that technology should be in keeping with the local culture. It must be capable of being adapted and further developed if necessary.

In addition, the technology should be easily understood and applied by community health workers, and even by members of the community; although different forms of technology are appropriate at different stages of development, simplicity is always desirable. The most productive approach for ensuring that appropriate technology is available is to start with the problem and then to seek, or if necessary develop, technology that is relevant to local conditions and resources.

Involving the people in health care

The report of a WHO Expert Committee on New Approaches to Health Education in Primary Health Care' states that:

'to involve people and to enable them to formulate their own health care objectives, the health care providers will have to:

(a) provide opportunities for people to learn how to identify and analyse health and health-related problems, and how to set their own targets;

(b) make health and health-related information easily accessible to the community, including information on practical, effective, safe, and economical ways of attaining good health and of coping with disease and disability;

(c) indicate to the people alternative solutions for solving the health and health-related problems they have identified;

(d) create awareness of the importance of effective communication in fostering mutual understanding and support between the people and the health care providers;

(e) translate the targets set by the people into simple, understandable, realistic, and acceptable goals which the communities can then monitor; and

(f) help people to learn how to set priorities among the different health problems they have identified and to understand the need to refer to relevant policies in doing so, e.g., that priority should be given to the deprived sections of the community and to certain diseases on the basis of the degree of their contagiousness, susceptibility to treatment, etc.'

The report adds:

'It is essential that communities have a clear understanding of their role in the implementation of strategies for solving health problems. Here, health education should facilitate the dialogue with the people through culturally and socially acceptable forms of communication.'

Developing a partnership with the community

The subject of the Technical Discussions held in May 1983 on the occasion of the Thirty-sixth World Health Assembly was 'New policies for health education in primary health care'. More than 300 delegates to the Assembly took part. They discussed the need to develop a real partnership between health workers and the community at every stage of health planning, from identifying problems, through facilitating and reinforcing health action, to evaluating results. There should be a constant dialogue and interaction between the community and the health workers.

People may 'feel' many health and related problems, but they may not be able to express them clearly. There may be other major problems that they do not see. The health worker should encourage and guide the community in self-study so that the community can better understand its problems, identify local resources to solve them, and call on outside help when needed.

As action to solve a problem is developed, the health worker will assist the community in examining whether its efforts are worthwhile and effective. Are the desired changes occurring in the community? Have obstacles to progress arisen? Are the chosen technologies and strategies appropriate? In other words, the health worker should involve the community in a constant cycle of planning, action, and evaluation. By encouraging involvement and continuous self-examination, the health worker will be educating the community about the planning process. This makes future self help efforts possible.

Coordinating levels of planning

Coordination is an important job in health education. We need to provide a link between people and the various resource agencies and to foster communication between the people and the agencies. We should also encourage communication among the agencies themselves so that they will make the most effective use of their resources in assisting the community. We must also be aware that this assistance will come from different levels district, regional, state, and national.

This chart shows how a real partnership develops between health workers and the community through the various stages of identifying problems then facilitating and reinforcing health action.
This chart was developed in connection with the Technical Discussions on 'New policies for health education in primary health care' at the Thirty-sixth World Health Assembly in May 1983.

Primary health care is a national concern, not just a local one. Ministries and agencies at the central level are also planning for the effective delivery of primary health care services. It is necessary for the community to be aware of these central planning efforts so that it may benefit from the resources. An example of a central function would be the supply of essential drugs to all communities. Another important central function of direct relevance to health education is the planning of mass media (radio, television, etc.) programmes on priority health needs.

The community and health workers together must make sure that their needs for essential drugs, basic transportation, educational media, and other resources are constantly communicated to the central planning authorities. Likewise the central planners must always be in touch with local communities to hear their needs and thereby be in a better position to plan for primary health care.