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close this bookTeaching for Better Learning (WHO, 1992, 197 p.)
close this folderPart 4: Preparing teaching materials
View the documentCHAPTER 13: Initial planning
View the documentCHAPTER 14: Writing and evaluating the teaching material
View the documentCHAPTER 15: Layout and illustration
View the documentCHAPTER 16: Production and distribution of teaching materials and manuals

CHAPTER 13: Initial planning

The aim of this part is to help teachers to plan, write, produce, and evaluate materials that will help students to learn. These materials range from single-page handouts which are used in lessons, through to complete manuals which health workers use to help them in their jobs.

This chapter describes the initial planning that must be done. How will the material be used? Who will use it?

Chapter 14 describes ways of writing and evaluating the teaching material.

Chapter 15 explains the use of illustrations and layout.

Chapter 16 gives suggestions about methods of producing and distributing copies of the teaching material.

In each chapter, the first part is aimed at teachers producing material for use in their own classroom or with a small group of students. The second half gives more guidance on methods used in producing manuals for larger numbers of people.

13.1 What are teaching materials?

Teaching materials are any things that help people to learn. In other words, they are materials that teach, such as:

- notes summarizing the main points of a lesson or lecture
- a series of questions which students are asked to answer
- textbooks
- instruction cards for carrying out various tasks
- manuals which help health workers in the field to make a diagnosis.

13.2 Why should teachers prepare teaching materials?

Preparing teaching materials is usually difficult and often takes a lot of time. Why should teachers take on this extra work?

The reasons are:

· Students can learn from the material at any time, so they are less dependent on the teacher.
· Teaching materials help students to learn better.
· Teaching materials can make learning more active (see Section 6.6).

Of course teachers may use teaching materials prepared by other people. For example, many books and manuals have been written specifically for health workers. When these are available and suitable they should be used. But often the books and manuals are written for different categories of health worker or for use in different countries. So teachers often need to adapt these books or even write their own books or manuals for their students.

13.3 Starting to plan the material

Before you start to write any teaching material, there are some questions that you should consider. The questions are given below and then discussed in Sections 13.4-13.8.

Initial planning - A checklist of questions

· Is the material needed?
· How will the material be used?
· Who is the material for?
· Where will the health worker use the material?
· How will you organize the writing and production?

13.4 Is the material needed?

Teaching materials will only be worth writing if they fulfill a need. It is important to decide exactly what the need is, so that the material can be prepared for this specific purpose.

Examples: Situations where teaching materials may help

You may find that you have to explain how to use a particular piece of equipment very frequently. It might be easier to write down the instructions for its use, so that the students can learn how to use the equipment by themselves.

You may find that students find part of the course very difficult. So you could give them some exercises to practice what they have learned during that part.

You might prepare a list of the tasks that you expect students to be able to do. This would guide them and help them to make sure that they had learned all the necessary skills.

You might find that drugs are not being stored properly or they are being prescribed in the wrong doses. Written materials could help to prevent this.

If you find that there is a need for a manual or some other type of written material, you should also check that:

- no other suitable materials are available
- the people who you want to read the material are able and willing to use it.

13.5 How will the material be used?

There are different ways in which teaching material may be used. The style of writing, layout, and amount of explanation will all depend on the way in which you expect the health worker to use the material.

1. Used as training materials. Materials can be used to present new information or to describe skills that need to be learned by the students. In this case, the material should have detailed explanations, step-by-step instructions, a lot of examples and possibly some exercises.
Materials like this might be used during the initial training course or to explain new methods of doing a particular task. They might also be used for restraining health workers.

2. Used as reference materials. Materials can also be used to remind health workers about facts or skills that they learned during the training course.

These materials are called reference materials and are often written in the form of a manual.

A reference manual might contain dosages of drugs which the health worker constantly needs to refer to. On the other hand, the manual might contain details of procedures that are only carried out rarely. For example, medical assistants do not have to give advice about the siting of a well very often, so they will probably need to refer to a manual to find out the recommended distances of latrines from a well.

Reference materials must be well indexed so that health workers can find the necessary information quickly. Less explanation is needed because the purpose is to remind them about what they have already learned. Each part of the material must be complete in itself, because the workers will only be using one part at a time - they will not be reading through the book or manual.

Teachers and other people who write manuals should decide what kind of material they want to write at the very beginning. This is because the layout and style are affected by this decision.

13.6 Who is the material for?

Teaching materials must be designed to suit the people who will use them. Therefore you will need to find out about the audience. Below there are some questions that you should be able to answer before you start writing.

How much does the health worker know already?

Ideally, the material should not repeat information that is well known to the health worker. Nor should it assume knowledge that the worker does not have.

This ideal is hard to achieve and quite impossible if health workers come from different backgrounds. If you are in any doubt, it is usually better to assume that they do not know something. For example, there is little point in referring to oedema under a list of physical signs if some of the health workers do not understand what the word means. To overcome this problem, talk to some people who will need to use the material so that you can find out exactly how much they know.

How well can the health worker read?

Even though all the people who use the manual will be able to read, they will not be able to read equally well. This is especially important if the language of the manual is not the health worker's mother tongue. So the language and writing style must be simple enough for health workers to understand.

Test the manual with a group of health workers to find out what they understand. For example, this book has been evaluated with groups of teachers to find out whether it can be read easily.

Can the health worker understand the diagrams?

Diagrams are usually used to make an explanation clearer. A good diagram can save hundreds of words and can be remembered more easily. However, understanding diagrams is a skill that is learned, and some health workers may not have developed this skill fully. You should check whether the health workers can understand your diagrams.

Will the health worker have time to read the material?

There is no point in producing long and detailed manuals which are not read. It may be better to write a less complete manual which the health workers have time to use. Alternatively, you could write several shorter manuals instead of one long one. If you do this, the health workers may feel more encouraged to start using at least one of the shorter manuals.
Will the health worker have the time and the resources to do the jobs described?

Sometimes manuals describe jobs that are not realistic. This may be because the health worker has many other jobs to do or because the necessary equipment, medicines or space are not available. If this is the case the manual will not help.

Will the ideas in the material be acceptable to the health worker?

You should take into account the different traditions, and religious and cultural backgrounds of the health workers. For example, a manual describing methods of contraception or sterilization might be of little value if these ideas conflict with their religious beliefs. Workers with other religions or traditions may have objections to other ideas which are good from a purely medical point of view but which conflict with their culture. Ideas such as this require very careful presentation.

13.7 Where will the health worker use the material?

If health workers are taking teaching material (such as a manual) away to their place of work, the explanations must be very detailed because nobody will be available to help them if they are confused. On the other hand, if the manual is to be used where supervision or advice is available, then a briefer explanation may be better.

If students are going to use the material in a training school where they can be helped, then you have much more freedom to use unfamiliar methods of presenting information. For example, you may make more use of diagrams or flow charts.

13.8 How will you organize the writing and production of the material?

When you have decided on the general features of the material, you need to prepare a plan for writing and producing it.

This will not be necessary for handouts or very short material used by one teacher. But when a larger manual or several different people are involved, a plan is essential.

The stages which are often followed are listed below.

Stages in writing manuals and written teaching materials

1. Make the initial planning decisions - as outlined in Section 13.3.

2. Decide on the overall content of the manual and what will be covered in each section.

3. Write out a rough draft.

4. Discuss this with colleagues and some of the people for whom you are writing (e.g. experienced health workers and your students).

5. Rewrite the draft using the layout you want in the final version. Add diagrams, illustrations and index.

6. Evaluate the material.

7. Rewrite the material.

8. Make arrangements for the printing or duplication of the material.

9. Produce and distribute the first edition.

These stages are not rigid. It may be necessary to rewrite the material several times. Additional stages may be required, such as the preparation of training sessions in which the health workers are taught how to use the material. There may be some evaluation at an earlier stage in the process. However, the broad pattern will prob ably be a useful guide.
A more detailed list of stages is given at the end of Chapter 16.

CHAPTER 14: Writing and evaluating the teaching material

This chapter describes ways of writing and evaluating the teaching material, while Chapter 15 describes how the words should be spaced on the page and how illustrations can be used to make the meaning clearer. Some writers prepare the words and layout at the same time, but for the sake of clarity, these processes are described separately.

14.1 Deciding on the objectives

Manuals and teaching materials are written to help people to do things. For example, one manual called Obstetric emergencies is designed to enable rural health workers to treat women with obstetric emergencies and to know when to refer them to hospital. Another much smaller piece of teaching material has the title Recording the administration of drugs. In both cases the general purposes of the materials are clear. The purposes were probably decided during the initial planning when the need for the manual or teaching material was identified.

You must then work out exactly what the health worker must be able to do. Which obstetric emergencies should be covered? Exactly how should rural health workers deal with each type of emergency? Probably the best way to do this is to carry out a task analysis of the work. (The author has carried out several task analyses of the work done by teachers of health workers so that this book would be helpful to teachers.)

Task analysis will help you to:

- include all necessary information
- leave out unnecessary information
- give information in the correct order
- describe all situations in decision-making
- avoid vague instructions.

Examples of how task analysis can be used in writing manuals are given in Sections 14.2-14.5.

14.2 Including all necessary information

Teaching materials and manuals should include all the information that the health workers need in order to do a job.

This point may seem obvious, but often manuals do miss out essential steps or facts. Look at the example of poor instructions below and try to find out what information is missing.

Example - Information missing from a manual

Taking a patient's rectal temperature

Follow the four stages described below:

1. Ask the patient to insert the small part of the thermometer into his or her anus. If the patient is a small child or is unable to do this, insert the thermometer yourself.

2. Leave the thermometer in this position for about 2 minutes. If the patient is an adult, he or she should be lying on one side. If the patient is a child, he or she should be lying face downwards and should be held.

3. Take the thermometer out and read up to which mark the line inside the thermometer has reached. If the line is above 37.5 °C the patient is feverish.

4. Clean the part of the thermometer that has been inside the anus with some cotton wool and soapy water. Put the thermometer away in a safe place.

You will probably have noticed that a health worker following these instructions would not:

- lubricate the thermometer
- shake down the mercury in the thermometer.

This error could have been avoided if a task analysis had been done, especially if it had been checked by watching a health worker doing the task.

14.3 Leaving out unnecessary information

There is a great temptation for writers to put down everything they know about a subject. This is bad practice because the unnecessary information distracts the reader from the essential facts.


Think about health workers who are responsible for storing vaccines. Which of the following facts do they need to know?

1. The definition of an attenuated vaccine.
2. Which vaccines are absorbed on alum.
3. How vaccines are freeze-dried.
4. How long a vaccine will last at room temperature.
5. How long a vaccine lasts in a refrigerator.

You will probably agree that health workers need to know how long each vaccine will last at different temperatures. They do not need to know what "attenuated" or "freeze-dried" or "absorbed on alum" means. Nor is it useful for them to know which of these types of vaccines they are using. Again, task analysis is a good method for deciding whether some information is necessary or not.

14.4 Giving information in the right order

When a procedure is being described, the description should follow the order in which the actions are done.


Try to rewrite these instructions in a more sensible order.

Instrucitions for cleaning a wound

Put antiseptic on and around the wound after shaving off any hair round the wound and washing the wound with soap and water.

These instructions would have been written much more clearly as a list.

Instructions for cleaning a wound

1. Shave off any hair round the wound.
2. Wash the wound with soap and water.
3. Put antiseptic on and around the wound.

Often, writing instructions in the wrong order makes them difficult to understand. Sometimes it can be dangerous. Look again at the poor instructions for taking a patient's rectal temperature. What is bad about the order in which the instructions are given?

The patient is asked to insert the thermometer and then the instructions say that the patient should be lying on one side (adult) or face-down (child). Obviously the first instruction should be to ask the patient to lie in the correct position. Only then should the thermometer be inserted.

This kind of error is very common and occurs even in respected manuals written by very experienced health workers. It can be avoided by doing a task analysis.

14.5 Describe all situations in decision-making

Sometimes manuals tell health workers what to do in a specific situation, but do not tell them what to do if the situation is a little different.

Example - Some possible situations are not described

1. A patient has been coughing and spitting for a few days

Take the patient's temperature.

1.1 The patient's temperature is less than 38°C. Other symptoms:

- a runny nose (with a discharge like water or a thicker discharge like milk) or
- a sore throat

Give the patient aspirin for 3 days and tell him or her not to cough on other people (especially children) or spit on the floor.

This manual tells the health worker what to do in two situations when patients have been coughing and spitting for a few days. The two sets of additional symptoms are:

- low fever and a runny nose or
- low fever and a sore throat.

It fails to mention another common situation when, in addition to coughing and spitting, the patient also has:

- low fever with no other symptoms.

A health worker using the manual can therefore come across a common condition that the manual does not cover. The least harmful effect of this will be dissatisfaction with the manual, but more serious effects are also possible, such as failing to recognize possible cases of tuberculosis.

A task analysis of the diagnosis of cough might have shown that all situations were not covered.

14.6 Avoid vague instructions

Vague instructions like "be careful" should be avoided. They do not say in what way care should be taken and are therefore a waste of time. Other examples which are commonly used are:

- "assemble correctly"
- "record the weight properly".

Example - Vague instruct/on
Treatment of cough
To treat people with a cough, see "Respirarory diseases" on page 25 and tell the people living in your village:

1. To stay at home when they have a cough and runny nose.

2. To take care of the children and old people and to return to the health centre immediately if....

What does it mean to "take care of the children and old people"? The health worker may not know what kind of care should be provided and so much more specific advice should be given.

14.7 Structuring the material

This paragraph refers to longer teaching materials such as manuals. The structure of these materials depends on how they are to be used.

For a manual that will be used for reference, the order of the sections is important but it will not be the same as the order in which the pages will be read. This is because the manual will not be read like an ordinary book. Health workers will look at the few pages they need and then put the manual away. So it is extremely important to have a good index that helps them to find the part of the manual they need at that particular time.

To make this possible, the manual will probably consist of a series of sections relating to the tasks to be performed, such as:

- treating patients with diarrhoea
- treating patients with respiratory diseases
- treating patients who are pregnant
- developing water supplies
- educating village people about nutrition.

Other ways of organizing sections are:

A. Systems of the body:

- respiratory system
- cardiovascular system.

B. The setting in which the worker will use the manual:

- dispensary
- health centre.

It is important that the structure of the manual is clear to the health workers, and that they can find the information they require quickly.

Manuals used in training will be read through from start to finish, and so the order of the sections is much more important. Points to note are:

1. Early sections should not depend on skills or knowledge covered in later sections.

2. Common techniques such as giving an intravenous injection or bandaging should be described in a separate section. The health worker can then be referred to the relevant section when necessary.

14.8 Writing simply
It is essential that manuals and teaching materials are written so that they can be understood easily. There is no point in writing if health workers find the material so difficult to understand that they are unwilling, or even unable, to read it.

This is particularly important if the material will be translated into another language or if the material is not written in the mother tongue of the health workers. For example, manuals written in English need to be especially easy to understand if the health workers normally talk in a different language. There are also serious difficulties with languages such as English or Arabic because several different levels of language exist. For example, the writer may use a higher form of Arabic than the health worker usually uses.

Some guidelines for writing simply are given below.

Guidelines for writing simply

1. Use of words

(i) Use simple, short, common words not complicated, long or unfamiliar ones. For example, use "tie" not "ligate". Use "press with your finger" not "apply digital pressure".

(ii) Be careful using idioms. If the manual is for local use then idioms may make it more interesting and "punchy" to read. But health workers from other countries may find it difficult to understand. For example, do you understand what "punchy" means?

(iii) Explain technical words. Where it is essential to use technical words, these should be explained fully and an example given. Then you should make a point of using the word several times so that the health worker can practice using it.

2. Sentence construction

(i) Use positive statements. The sentence "You should avoid negative statements" means almost the same as "You should use positive statements". The use of the negative makes it much more difficult to understand.

(ii) Use active verbs. Health workers will find it easier to understand sentences written using active verbs, for example:

"Ask the patient whether he or she feels feverish" is easier to understand than "the patient should be asked by the health worker whether he or she feels feverish".

(iii) Do not use pronouns. When pronouns such as "he", "she", "it" or "they" are used, the health worker has to decide exactly what or who the pronouns refer to. It is often better (but sometimes clumsy) to write out the full noun.

(iv) Use short sentences and paragraphs. Long sentences are difficult to understand. It is often better to rewrite a long sentence as two or more shorter ones. Long paragraphs are also boring and tiring to read. Simply break them down into shorter ones.

You should test what you write to see whether it is sufficiently easy to read. The aim of the testing is to see whether what you write can be understood by the health worker. Methods for doing this are explained in more detail in Section 14.12.

14.9 Writing

Everybody finds it very difficult to write. They may have good ideas about what they would like to say, but when they are faced with an empty sheet of paper, they cannot get started.

Different people use different techniques to help themselves. Some examples are given overleaf. None of these techniques is guaranteed to help, but you could try them. If you find that they are helpful, use them.

1. Set a target of so many words or pages for each day.

2. Arrange a meeting for 10 days ahead to discuss what you have written. Then you will have to prepare something for that meeting.

3. Give yourself a reward after doing a certain amount of writing - for example, a cup of coffee or tea.

4. Start anywhere in the manual. Often it is best to start on the part that you find most easy. This at least gets some words down on paper. 5. Do not worry about the quality of what you write. Once you have something written, you can then improve it.

The process of writing is always difficult, but the more you write, the easier it becomes.

14.10 The reasons for evaluation

There are two general reasons for evaluating teaching materials. The first reason is to find out how useful the material is to the health workers. This is called summative evaluation. You might use summative evaluation on manuals written by other people to decide whether your students would find them helpful. Or you might use summative evaluation on material you have produced to give other people guidance on how useful the material is.

The second reason for evaluation is to improve the teaching material. This is called formative evaluation. You should use formative evaluation on all teaching material you produce (even simple handouts) so that you can improve the quality.

14.11 What should you evaluate?

The basis for evaluation is to find out whether the teaching material achieves its purpose. For example, do students learn better if they use a handout? Do health workers do a better job if they use a manual?

To find out the answers to questions such as these, you should use your experience and look at the teaching materials. Think about the following questions:

· Are the important techniques covered? Are the important points made? Is the content right?

· Is the language used simple enough? Are the diagrams clear?

· Are all instructions correct? Do the methods suggested in the material fit in with current practice for your students?

· Can the health workers understand the instructions? Are they given in the correct order?

· Can the health workers find the information that they need? Is the index suitable?

· Can the health workers do the tasks described when they use the manual or material?

Obviously some of these questions are only appropriate when you are evaluating manuals. But most of the questions apply to teaching materials in general.

14.12 Methods of testing

When you are evaluating teaching materials, you should find out what the health workers think about the materials. You should also observe the students or qualified health workers using the material and find out for yourself whether they can use it. This is called performance testing.

For example, a section of a manual or handout describing how to give a patient an injection could be tested by watching a student perform the task. If the student gives the injection correctly, then the manual is satisfactory.

This kind of performance testing can be carried out by asking the health worker to perform specific skills in a test situation. It can also be done by observing health workers working in their normal workplace and seeing whether they follow the method described in the manual.

The manual can also be evaluated by looking at the results over a longer period. Manuals explaining how to convince village people about the need for a good diet can be evaluated by looking at the number of cases of malnutrition and diseases related to poor diet. If the number of cases decreases, then the manual can be considered to be effective. However, if there is no change or the number increases, you need to investigate the reasons and possibly change the manual.

14.13 When should you evaluate the teaching material?

Teaching materials and manuals should be evaluated before the final version is produced. This will allow you to improve the material before it is widely used.

It may also be useful to evaluate materials after they have been used for some time. If there are important weaknesses a revised version should be produced.

14.14 Summary

· Use task analysis:

- to decide on the objectives of the material.
- to include all necessary information and leave out unnecessary information.
- to give the information in the order in which it will be used.
- to describe all the possible situations.

· Avoid vague instructions.
· Write simply.
· Evaluate all teaching materials using performance testing when ever possible.

CHAPTER 15: Layout and illustration

The aim of this chapter is to help teachers to design and illustrate their teaching materials. The first part of this chapter is aimed at teachers who are involved in writing booklets or manuals. But the second part, which deals with illustration, applies equally to manuals, handouts and even the chalkboard and overhead projector.

Sections 15.1-15.8 describe the decisions that have to be made in planning a manual or booklet, such as:

- page size
- margins
- headings
- typeface
- use of space.

All these decisions are to do with the layout of the material.

Sections 15.9-15.17 describe different kinds of illustrations that can be used and offer advice on when to use the different methods.

15.1 What is layout?

Layout is the use of spaces, different typefaces, headings, etc. to make the words on a page have more meaning and interest. Page after page full of words with no spaces would be almost impossible to read. So layout is an essential part in the design of any teaching material.

15.2 Page size

The size of page to be used in the handout or manual must be decided first. This controls the amount of space you have available for illustrations and for words. Charts and large tables will need a large page size. Booklets designed for reference in the field should, if possible, be small enough to fit in a pocket. The sizes which are commonly used are called A-sizes. A4 is often used for books and handouts. If you fold a sheet of A4 in half as shown below, you will get two pages of A5 size. If these are folded in half, you will get four pages of A6 size.

There are larger A-sizes (A1, A2 and A3), but these are not suitable for books or pamphlets.


The size of A4 is 297 mm x 210 mm. The ratio of these lengths has been chosen so that when the page is divided into two, the ratio of the long side to the short side stays the same, as shown below:

For A4 long side/short side = 297 mm/210 mm = 1.414

For A5 long side/short side = 210 mm/148.5 mm = 1.414

This property allows printers to enlarge or reduce a page produced in the A-sizes to fit exactly any other A-size. For example, if a page of A5 is enlarged by 141%, it will fit A4. If it is reduced by 141% (i.e., to 70% of its original size), it will fit A6.

A5 may be used for reference manuals, and is often used for booklets, since it will usually fit into a pocket. This makes the booklets easy to carry and easy to use for reference - but also means that less information can be included.

Earlier systems of page sizes such as quarto and foolscap are going out of use and should not be used because this will increase the cost of printing the material.

15.3 Margins

A margin must be left blank round all the writing and diagrams on the page. This helps to make reading easier because it holds the words in a block. Margins are also useful places for the reader to make notes and increase the usefulness of the book or handout.

The best size of margin is to some extent a matter of taste. For A4 paper the following size is suggested:


Note: The above example is of a right-hand page. For a left-hand page, the left margin would be 30 mm wide and the right margin would be 20 mm.

However, the modern tendency is to allow larger left-hand margins - as in this book. If you use ring-binding or spiral-binding for a manual, you also need to allow a generous margin along the side that is bound. Otherwise the holes for the binding may pass through text or illustrations.

15.4 Choice of typeface

The typeface is the set of letters used in the typewriter or composing machine used by the printer. Most authors will have little choice of typeface because their teaching material will either be handwritten or they will use the only typewriter available. In these cases, the only point to remember is that long strings of CAPITAL LETTERS (which are also called upper case letters) are less easy to read than lower case letters. Capital letters should only be used sparingly - for example, in headings.

If the manual is being printed, a much greater choice of typeface will be available. You will need to make choices about:

- size of typeface
- upper case or lower case
- italic or roman typeface
- density of typeface (bold or normal).

Most of the words will normally be in lower case, roman typeface. The size of typeface is usually 10 pitch or 12 pitch on typewriters. When a composing machine is used, the choice of size is much wider. Common sizes are 10 point or 12 point. The best way to choose the size of typeface is to look at examples of material prepared using different sizes. You should choose a size that is large enough to read comfortably.

If a typeface larger than necessary is chosen, the words will obviously take up more space. In a book, this could mean several extra pages and higher production costs.

If the teaching material is being printed and there is a wide range of typefaces to choose from, you should discuss the use of typeface with the printers and follow their advice.

If you want to emphasize a particular point, you can do this by using upper case letters, a bold typeface or a larger typeface.

However, you should use different typefaces sparingly. You should not use a lot of different typefaces, because this is confusing to the reader. Nor should you use upper case a lot. Upper case is more difficult to read and if all the words are written in upper case none of them is emphasized.

15.5 Use of headings

A solid block of writing on every page is very difficult and boring to read. It is also difficult to use the page for reference. Therefore most teaching materials use headings. These headings:

- break up the text so it is easier to read
- show what the next few paragraphs cover
- help readers to find their place again after they have been looking at a diagram
- help to give the page a pattern.

However, you should only use a few types of heading.

Most books should not need more than about four or five different types of heading. More types only confuse the reader - especially if they are not used consistently.

If you are writing shorter teaching material, then you may only need one or two different types of heading.

15.6 Use of space, lines and boxes

A page of text is divided into paragraphs. This helps to give shape to the page and to make clear to the reader where topics are changed. Space can also be used to emphasize any points that are important. For example, the point made below stands out because of the lines and the space around it.

Use lines and space to emphasize important points.
But do be careful. Too much space is as bad as no empty space. It breaks the continuity of reading and therefore decreases the reader's concentration. Also, if lines or boxes are used all the time they will have less impact. So save lines or boxes for the most important points.

15.7 Use of numbering systems

It is common to number the chapters, sections and even paragraphs of manuals. This has some advantages in making clear to the reader that a new topic is starting and also helps when referring to other sections.

However, the numbering system should be kept fairly simple. In this book, the chapters and sections are numbered. For example, this is Section 15.7. This tells you that it is the seventh section of Chapter 15. Numbering systems which are more complicated than this are not advisable in manuals or teaching materials for health workers.

15.8 Exercise on layout


Look at the layout of the double page reproduced overleaf. The layout has some good and some bad features. Make a list of the features that you think are good and those that you would like to improve.

Refer to the previous pages for guidance - then look at the comments below.


The title "skin diseases" is very clear, because it is large' in a bold typeface and surrounded by a lot of space. This is good. The use of upper case letters might be questioned, but it is satisfactory in a short title such as this.

The section "people who... on the skin" is given emphasis by using lines above and below the text This is good. On the other hand, the use of upper case letters all the way through the two paragraphs means that all the words are emphasized equally. They are also more tiring to read. This is poor. There is also no advantage in having the letters in italic script. It would have been better to use lower case, roman letters in a large typeface.

On the second page' the title is given emphasis by the use of upper case letters' underlining and space. This is good.

However, the underlining of "spots", "patches", "blisters"' end "scabs" seems unnecessary. The underlining draws attention to these words, but they are not especially important.





At the end of his training, the PHW should be able to:


find out whether an accident has been the cause of the skin problem


decide whether the skin condition covers a small or large area


recognize when there is a lump (or a swelling) underneath the skin


tell if the skin is covered with red spots, or red patches or blisters or scabs


treat a patient who is feverish and has red spots covering a large area of skin


treat a patient who is feverish and has blisters and scabs over a large area of skin


tell whether a patient has been scratching his skin


treat a patient who scratches his skin, when there are no scabs


treat a patient who scratches his skin, when a large area of the skin is covered by scabs


treat a patient who scratches a small area of his skin


treat a patient whose skin is covered with small scabs that have fluid coming out from underneath there


decide when a patient with a skin problem should be sent to the hospital or health centre


talk with village people about how to prevent skin problems.

15.9 Use of illustrations

Illustrations such as drawings or pictures can be worth a thousand words of written explanation. They can help to make the explanation clearer and easier to remember. But, if they are not well done, they can also confuse. The following paragraphs describe some of the methods of illustration and give some guidelines on using illustrations effectively.

The various types of illustrations that are described here are:

- photographs
- shaded drawings
- line-drawings
- symbolic or stylized drawings
- cross-sections
- cartoons
- flow charts.

15.10 Photographs

Photographs can be very useful for showing students objects and people that cannot be brought into a classroom. They can also be very helpful in books or manuals.

However, photographs are not used very much because of the practical difficulties of obtaining suitable photographs and because they cannot be copied cheaply.

If you want to use photographs, try to choose photographs that have a blank background or else remove the background as shown in the example overleaf. Photo 1 is much clearer than photo 2.

You will also need to use printing - see Chapter 16. This will only be realistic when large numbers of handouts or manuals are required.

15.11 Shaded drawings

Shaded drawings may be the most useful way of illustrating a point. The drawing can be prepared to show only those features that are important. Yet they can be realistic enough for the health worker to recognize what is shown.

Shaded drawings can be prepared by tracing a photograph. Another way is to project a photograph onto a white sheet of paper using an epidiascope, then to draw around the projected photograph. This allows enlargement of the original photograph. The results of this process are shown opposite.

Of course, artists can prepare a drawing from real life or from imagination. You can then add labels or notes to it. Look at the example below.


15.12 Line-drawings

The figure overleaf is a line-drawing - there is virtually no shading. This kind of drawing is almost as easy to recognize as the shaded drawing and is usually easier to print using a stencil duplicator.

This kind of drawing can be prepared in the same way as shaded drawings.

It looks easier to draw, but often artists say that this kind of drawing requires even more skill than shaded drawings.

A line-drawing

A stylized drawing

15.13 Symbolic or stylized drawings

This style of drawing is the easiest to reproduce, but it does require skill in drawing. Also it may not be easily understood by the health workers, so you should always add an explanatory legend or note. For example, look at the stylized drawing above.

15.14 Cross-sections

A cross-section is a very useful way of showing what is inside a machine or the human body. But understanding a cross-section is a skill that must be learned. People who are not used to looking at cross-sections will have a lot of difficulty understanding them until they are taught how to do this. For example, the cross-section opposite will be extremely simple for a sanitary engineer who is familiar with cross-sections and the symbols used.


On the other hand, a nurse or doctor might find it more difficult to understand, because they might not know what the symbols represent. Students who have not seen cross-sections before would probably also be confused until the diagram was explained to them.

15.15 Cartoons

Cartoons are not just funny pictures. The word cartoon is also used to describe line-drawings, especially those showing people saying something.

Cartoons can be very useful for emphasizing important points. They are especially helpful because students are often used to seeing cartoons in newspapers.

The cartoon overleaf helps to make the point more dramatically than a paragraph of words. The words spoken by the people help to make sure that the health workers remember the important points.


15.16 Flow charts

Illustrations are usually thought of as pictures or diagrams. But teaching materials can also be made clearer by using flow charts. These are charts showing what has to be done in different circumstances.
For example, look at the written instructions opposite. You may agree or disagree with the clinical advice given. But this point of the example is that it is rather difficult for the health workers to find out what to do in a specific case. They must go through the whole page to find out how any one patient should be treated.

Example - Written instructions for treating people with a cough.

Take the patient's temperature.

1.1 The patient's temperature is less than 38°C. Other symptoms:

- a runny nose (with a discharge like water or a thicker discharge like milk) or - a sore throat.

Give the patient aspirin for 3 days and tell him or her not to cough on other people (especially children) or spit on the floor.

See the patient again on the 4th day:

- the patient is better. Tell the patient to come back to the clinic if he or she becomes feverish.
- there is no improvement and the patient is feverish - see 1.2.

1.2 The patient's temperature is over 38°C. Other symptoms:

- difficulty in breathing or
- a very sore throat or
- discharge from one ear or
- red spots all over the body and a runny nose and eyes.

Give the patient penicillin. If penicillin is not available, give the patient sulfadiazine.

See the patient again on the 3rd day:

- the patient is better.
- there is no improvement, send the patient to the hospital or health centre.

Now look at the flow chart overleaf. This gives exactly the same information as the written instructions in a much clearer and more economical way.

Example - A flow chart for "cough"

Flow charts are most useful in handouts or manuals where there is a need to describe a decision-making process, such as deciding what treatment to give patients with certain symptoms.

They are not useful when the task always follows the same sequence: for example, preparing a syringe for injections would not be a good topic for a flow chart.

15.17 General points

1. Students must learn how to read diagrams and pictures

Pictures are not understood automatically by everybody. People who are not used to looking at pictures just do not understand what they represent. Most students will be familiar with pictures - but the use of diagrams, symbols, cross-sections and flow charts is a skill that must be learned.

2. Be careful to explain the scale of pictures

There are a lot of stories about people who are shown pictures of mosquitos and say "There is nothing like that around here". They have not realized that the drawing which is 15 cm long is showing something that is actually less than 1 cm long. This kind of misunderstanding is very common and often occurs when teachers show drawings of objects that can only be seen under a microscope.

3. Test your illustrations

Find out whether your students really do understand the illustrations. Several studies have shown that health workers often do not realize what an illustration is meant to show.

For example, most health workers will understand that the message of this illustration is that drugs and tablets can be dangerous. They will remember the message well because it is drawn in a dramatic way, using the gun as a symbol of danger, and compares tablets with bullets.


However, some health workers might just see a gun and some tablets. Others may not even recognize the gun.

So you must test what the health workers understand and remember from the illustrations.

4. Keep illustrations simple

Only show the things that are necessary. Too much detail can distract readers and confuse the point of the illustration. Simple illustrations will be easier to reproduce.

For example, this illustration shows the important points, but it is still very simple to draw and copy.


15.18 Summary

1. Layout is very important. It helps the reader to understand the words and helps to emphasize the most important points. Think about:

- page size
- margins
- use of space
- headings
- typescript.

All these things must be used to help the reader learn from the teaching material.

2. Illustrations make teaching material and manuals more effective - if they are used correctly.

3. Check that readers can understand the illustrations that you use.

CHAPTER 16: Production and distribution of teaching materials and manuals

Teaching materials can be produced using very simple equipment and at very little cost. On the other hand, some manuals are very expensive to produce and require sophisticated printing machinery. The choice is yours. Some methods of producing teaching materials and manuals are described below.

16.1 Dictation

Teaching materials can be dictated by the teacher. The students simply write down what the teacher says. The disadvantages are that this method requires a lot of time and it rules out the use of diagrams. But the method is the cheapest possible in terms of the materials needed and can be used anywhere. However, dictation is not recommended because it takes up too much time.

16.2 Copying from the board

This is much the same as dictation, but allows the use of diagrams. The only resource needed is a chalkboard.

A further advantage is that the layout can be controlled to some extent, but remember that the chalkboard may not be the same shape as the page. Again, this method is not recommended because it takes up too much time.

16.3 Stencil duplicator

In this process you write on a master sheet or stencil using a special metal-tipped pen. This pen, called a stylus, removes wax from the stencil. Then you place the stencil on an inked roller and the ink is forced through the gaps in the wax onto the page.

A typewriter can be used to write on the stencil. This is generally more successful than using a stylus. However, if you wish to include diagrams, you will need to use a stylus.

It is difficult to draw pictures or diagrams, but quite possible. A stencil cutter may be available. This will allow you to prepare a high-quality stencil from a line-drawing prepared on ordinary paper.


- The costs of paper and ink are fairly low (there is no need for high quality or chemically treated paper).

- Many copies (at least 500) can be produced with no loss of quality.

The stencils can be stored for use the following year (some teachers do this quite successfully; others find that the stencils are difficult to keep in good condition).

- The quality of print is usually good.

- Electrically powered or hand-operated duplicators are available.


- Only one colour (usually black) can be printed at a time.

- The stencil duplicator is fairly expensive to buy - but much cheaper than printing machinery or photocopiers.

- Some people find stencil duplicators difficult to use.

16.4 Photocopying

The main advantage of photocopying is its convenience. Almost any original can be placed on the machine and a good quality copy produced in seconds. However, the machine is expensive to buy or rent and there are usually extra charges made for each copy. In comparison with offset printing (Section 16.6), the first few copies are usually cheaper, but a large number of copies usually cost much more.


- Generally good reproduction of printing or diagrams.
- No limit to the number of copies. The originals are easy to prepare. Easy to use.
- The copies are available immediately.


- More expensive than other methods - except for a very small number of copies.
- Poor reproduction of photographs.
- Certain colours cannot be reproduced - for example, light blue.
- Equipment requires good standard of maintenance.

16.5 Word processing and desk-top publishing

Over the past few years, computers have become very much cheaper, more reliable and easier to use. It is now possible to buy a sophisticated personal computer for not much more than a good quality typewriter.

In many countries, this means that it is now possible for training schools to purchase a personal computer. Computers can be used by training schools in a number of ways, as discussed below.

The most common use is as a word processor. When used in this way, the computer acts like a very sophisticated typewriter that can remember hundreds of pages of text. This leads to several advantages:

· If a mistake is found or a change is needed, only the change needs to be typed in. Everything that is unchanged is remembered by the computer and retyped automatically. This encourages teachers to improve handouts and teaching materials each year.

· Because it is easy to correct mistakes, teachers find it easier to type their own teaching material. They are less dependent on secretaries.

· Word processors have many other features. For example, they can be used to check the spelling of most words. They also give you much more control over typeface and layout, so documents look better and are easier to read.

The document is stored as a file in the computer. When all the corrections have been made and the layout is satisfactory, the document can be printed using a dot matrix printer (fairly cheap and reasonable quality of printing) or a laser printer (more expensive and better quality of printing).

Desk-top publishing is the name given to a more sophisticated kind of word processing. To use desk-top publishing, you need a reasonably sophisticated personal computer, a laser printer and the appropriate software. The advantages of desk-top publishing over ordinary word processing are that more sophisticated graphics can be used and there is more flexibility over the use of typefaces and layout. However, this also means that you need to have a good knowledge of layout and illustration.

At present, few training schools have the equipment for these techniques. However, the advantages of these methods, combined with steadily decreasing costs and high reliability, mean that more and more training schools will use the techniques in the future.

16.6 Offset printing

There are two main kinds of printing - offset and letterpress. Offset printing (also called lithographic or litho-printing) has many advantages over letterpress.

In offset printing, the original page or drawing is photographed to make a "printing plate". This plate is then put into the printing machine. The machine prints onto plain paper, giving a high quality at a fairly low cost. When many copies are needed or when photographs are required, this is the best method of producing teaching materials or manuals.


- High quality of reproduction.
- Very large number of copies possible.
- Cheap, especially for long print runs.
- Photographs and shaded drawings can be printed.


- The equipment is expensive.
- A trained technician is required to operate and maintain the equipment.

Summary - Choosing the method of production

The best method of production depends on the number of copies, the quality you require, and the equipment available

If you are preparing a one- or two-page handout for a few students, use the stencil duplicator Photocopying might be useful if you want to copy diagrams from a book (with the author's and publisher's permission), but this method is expensive and is rarely available If you cannot use any of these types of equipment, write your own notes and make carbon copies for the students to copy in their own time

For longer documents or a larger number of copies, you need to use the stencil duplicator or offset printing Offset printing is generally better, but if it is not available, the stencil duplicator gives satisfactory results

16.7 Proofreading

Proofreading is the process of checking the original or "proof" before it is printed. All teaching materials or manuals must be carefully proofread before they are distributed. An error in a manual could lead to injury or loss of life - so the greatest care must be taken.

Proofreading is necessary before copying the original manuscript and at a second stage if the material is printed. If the material is printed, it should be checked in the draft form before it is sent to the printers. The printer will then send proofs to you to be checked. It is essential that at both these times all errors are found. If errors are discovered later, it may be impossible to correct them and will certainly be expensive.

The worst people for proofreading the material are the people who have written it. They tend to miss errors because they know what should be there. So choose at least two other people who are thorough and careful to read the final draft or proof for you.

You must allow enough time for proofreading. If it is done in a hurry, there is much more chance of missing errors.

16.8 Distribution

If the teaching material will be used by your own students, then you can simply hand it out in the classroom. But if the material is a manual for health workers in the field, you must plan how to distribute it.

When the teaching material or manual has been printed, it must be distributed to the people you want to read it. You should not simply put the manual in the post and hope that it will be read by the health workers. If you do this, then health workers will often not even open the material or may just glance at it before putting it away on a shelf.

The best method of distribution will depend on local circumstances and the amount of time and resources available. However, you can encourage health workers to read the manual by using some of the following ideas:

· Write a letter to the health workers, explaining why the manual will be useful to them. It will help if the letter is addressed to the health workers by name and signed by their teacher or supervisor.

· Invite comments on the manual to show that you are interested in the health workers' opinions.

· Arrange a meeting where a group of health workers can discuss the manual. This may be done as an introduction to the manual or it may take place about a month after the manual is sent out.

· Arrange for supervisors to deliver the manual personally. They can then explain to the workers why the manual is useful.

· Arrange workshops in which the manual or teaching materials are used. Then allow the workers to keep the manual at the end of the workshop.

· Do anything that will encourage the health workers to open the manual and start to use it.

16.9 Summary of Part 4

A checklist is given below, summarizing the whole of Part 4. It is based on a checklist used in India by a group who produce manuals for health workers. It is aimed at people who write manuals rather than teachers who produce a few handouts. But the checklist will still be useful (even though some of the questions are unnecessary) for anyone producing any teaching material.

You should not follow this checklist rigidly. Instead, read through it and use it as a guide. Sometimes you may want to follow the stages in a slightly different order. Or you may leave out some of the stages. However, the checklist should provide a useful reminder of the stages.

Checklist for preparing and distributing manuals

1. Decide on the category of health workers for whom the manual is to be prepared.

2. Decide on the language in which the manual is to be written and whether it is to be translated into other languages.

3. Decide who is to prepare the manual: one person? a team of two or three people, with one person acting as coordinator and general editor? several contributors? In this case, one person should act as coordinator and general editor to ensure conformity of style and to assign the topics that need to be covered. Each contributor should be given a list of instructions regarding content, length of chapters, general format, etc.

4. Familiarize yourself with the health organization in which the health workers will work.

5. List the tasks that the health workers will need to be able to perform.

6. Analyse the tasks.

7. List:

- the information required to be able to do the tasks
- the skills required for carrying out the tasks the stages involved in the tasks (the sub-tasks)
- the points for health education.

8. Decide on the format of the manual

(i) Parts, chapters, sections, subsections, annexes.

(ii) Whether the manual is to be written as a series of chapters on:

- tasks
- topics
- systems of the body.

(iii) Title of the manual.

(iv) Style of writing:

- formal
- informal
- use of "you" or "the worker".

(v) Inclusion of:

- cross-sectional diagrams
- photographs
- line-drawings
- shaded drawings
- symbolic or stylized drawings
- cartoons (black and white/colour)
- flow charts
- tables.

9. Collect existing literature and documents used for education and training in the various health programmes and discuss the topics with the programme officers concerned.

10. Write or type the draft chapters:

- outline each chapter, then fill in details
- write in sequence starting with chapter 1, or start with whichever chapter is easiest.

11. Decide what illustrations need to be included in each chapter. Collect references for illustrations. Prepare diagrams, photographs, cartoons, etc. List the captions.

12. Discuss relevant chapters with programme officers and check for accuracy of facts, figures, illustrations, etc.

13. Prepare a chapter of instructions for the health workers on how to use the manual.

14. Prepare the list of contents and index.

15. Prepare the foreword and acknowledgements.

16. Read through the whole manual to check for continuity and completeness. Edit and rewrite where necessary.

17. Decide on the style for typing and give instructions to typist regarding spacing, boxes, flow charts, headings, numbering of chapters, insertion of illustrations, etc.

18. Prepare final typescript according to instructions.

19. Check typescript against original manuscript.

20. Decide on style of manual and copy-edit typescript accordingly. Pay attention to punctuation, abbreviations, numbering, typeface used for text, chapter headings, headings and subheadings, and instructions for insertion of illustrations, tables and flow charts.

21. Discuss the layout and design of the manual with a graphic designer:

- cover design and colour
- binding
- size of manual
- page format (full page or columns)
- right-side justification
- printing process (e.g. offset or letterpress)
- typeface, etc.

Clear instructions in writing regarding the style decided upon should be given to the designer as well as to the printer.

22. Decide on the number of copies to be printed, based on intended distribution. Work out costing. Obtain financial approval or aid from other sources.

23. Call for tenders. Select a printer on the basis of:

- finances available
- quality of work
- process and type of printing available
- time constraints
- convenience.

24. Send edited typescript to printer. When proofs arrive, check immediately.

Galley proofs

- compare with typescript
- read through
- mark any corrections needed
- check continuity of numbering of pages, paragraphs, etc.

Page proofs

- check that all corrections in galley proofs are made
- read through
- mark any further corrections needed.

Paste-ups/blueprints (offset) or final page proofs (letterpress)

- check that all corrections in page proofs are made

- read through

- check continuity of numbering

- make sure that text and illustrations, etc. are not broken at inappropriate points

- check page headings, including page numbers and section numbers used

- check that illustrations, flow charts and tables are in the right places and check figure numbers and captions (If offset printing or printing blocks are used, be careful to see that illustrations are not reversed or placed upside down.)

- mark corrections on paste-ups in soft pencil in the margins. Do not disfigure or dirty the paste-ups.

25. Prepare a distribution list of names and addresses of institutions and individuals, together with the number of copies to be sent to each. Check that a sufficient number of manuals is kept in stock.

26. Arrange for the receipt of printed copies and for storage and preservation from insects and rodents.

27. Arrange for packing and dispatch of the manual.

28. Decide on method of evaluating the manual.

29. Carry out evaluation of the manual, based on postal quest ionnaires, interviews, observations, tests, etc.

30. Invite comments and suggestions from health workers on ways of improving the manual.

31. Revise the manual, basing your revision on:

- results of evaluation

- comments and suggestions received up-to-date information to be supplied to workers changes in policy.


The steps listed may not be followed exactly in the sequence in which they have been arranged. This list can serve as a checklist of things to be done in preparing a manual. It is based on the experiences of people involved in preparing manuals for health workers and community health workers under the Rural Health Scheme of the Indian Government.

This checklist is reproduced with the permission of the Training Division of the Ministry of Health and Family Welfare, Government of India.