Lecture Notes On HE

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------
HEALTH EDUCATION I - MPH I, SEM. 2, 2003 LECTURE NOTES By: Shabbir Ismail MD, MPH Associate Professor Department of Community Health Faculty of Medicine Addis Ababa University
MAIN REFERENCES 1. Notes on the Behavioral Sciences and Health Education as they apply to Community Health in Ethiopia. Ed. Frances Aboub, June 1994. [Found in the Library of the Department of Community Health (DCH)] An Introduction to Health Psychology. 2nd Edition. Ed. R. Gatchel, A. Baum & D. Krantz. Newburry Award Records, 1989. New York. [Found in the Library of DCH] Health Education: A New Approach. Ed. L. Ramachandran & T. Dharmalingam. Vikas Publishing House Pvt. Lmt. Co. 1995. Delhi. [Found in the Library of DCH] Behavioral Medicine: The Bio-psychosocial Approach. Ed. N. Schneiderman & J.T. Tapp. Lawrence Erlbaum Associates, Publishers. New Jersey. 1985. [Found in the Library of DCH] Health Psychology. 2nd Ed. Editor S. E. Tylor. McGrew Hill, Inc. New York, 1991. [Found in the Library of DCH] Group Process for the Health Professionals. Ed. Sampson & Marthas. A Wiley Medical Publication, John Wiley & Sons. New York. 1977. [Found in the Library of DCH] Education for Health. A Manual on health education in primary health care (Draft). World Health Organization, 1984. [Found in the library of DCH] A seminar in Qualitative Research. Prepared for Academy for Educational Development, Health Communications Project, July 1986. [Found in Dr. Shabbir's Office] Planning, Implementing, and Evaluating. HEALTH PROMOTION PROGRAMS. A Primer. 2nd Ed. Ed: J.F. McKenzie & J.L. Smeltzer, A Viacom Company, Neehahm Heights, MA, USA. 1997 [Found in the Main Library]
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Shabbir Ismail MD MPH Associate Professor
Behavioral Sciences Unit DCH, FOM (AAU)
PART 1: A.
I. INTRODUCTION & DEFINITIONS
INTERRELATIONSHIP BETWEEN BEHAVIORAL SCIENCES AND COMMUNITY MEDICINE
The behavioural sciences such as psychology, sociology, and anthropology make an important contribution to the understanding and practice of community health in two major ways: 1. Behavioural factors enter into a number of activities, which directly or indirectly influence a person's health. These are: a. Health services (motivation, attitude, skills of personnel); b. Economic/social institutions (education, family, religious leaders); c. Personality (locus of control, knowledge, attitude); d. Health behaviours (eating habits, infant care, personal hygiene, family planning, etc.). Health behaviours of the community, family and individuals have a direct effect on their health. These health behaviours are acquired, maintained, or changed with help of other psychosocial factors such as personality, social institutions like the family, and the motivation and skills of health professionals. e. The motivation and skills of health professionals more directly influence a person's physical health through the services they offer. There are also other non behavioural (biological & genetic) factors which also influence physical health. Because health includes mental and social well-being as well as physical health, it is important to promote mental and social health and development in their own rights and also because they directly influence physical health. In this respect, mental and social problems of a person can affect not only their own productivity and enjoyment of life, but also the development of their children, the quality of their marriage, and the cohesion of their community. DEFINITIONS OF MAJOR CONCEPTS
2.
B.
HEALTH: There are various definitions of "Health", among which few are sited: 1. From a lay point of view, it just to say that a person is normally doing his activities and does not outwardly show any signs of any disease in him. 2. In the Oxford dictionary health means `the state of being free from sickness, injury or disease, bodily conditions; something indicating good bodily condition. 3. WHO (1948) defined it as "Health is a state of complete physical, mental and social wellbeing and not merely absence of disease or infirmity." This definition may seem very attractive but still has lots of drawbacks. It will be seen that even after having this definition it will be difficult to conceptualize and standardize positive health with specific clear-cut attributes and criteria for measurement. A person may be enjoying mental equanimity and enthusiasm for doing something. He may also be physically able to do any amount of work, but he may be having some minor dysfunction or deficiency or even a mild infection causing a very minor disturbance which however does not upset his normal activities. MENTAL WELLBEING: The mentally healthy adult shows behaviour which confirms an awareness of self or personal identity, coupled with a life purpose, a sense of personal autonomy and willingness to perceive reality and cope with its difficulties. The healthy adult is active and productive, persists with tasks until they are completed, responds flexibly in the face of stress, receives pleasure from a variety of sources, and accepts one's limitations realistically. The healthy adult has a capacity to live with other people, to understand their needs, and to achieve a mutually satisfying heterosexual relationship. In sum, the mentally healthy person shows growth and maturity in three areas: cognitive, emotional, and social. Cognitive Processes: These are mental processes involved in awareness (consciousness), perception and thought. These include awareness, perception, learning, memory, reasoning, problem solving, creativity and imagination.
Emotional Processes: These are mental processes involved in states of emotions (happiness, sadness, anger, fear), mood (positive mood is a temporary feeling, less strong than emotion), and attitudes which are longer term evaluations of people/objects. Social Processes: These include interactions with other people, as well as the mental processes involved in relationships with others such as emotional attachment, perceptions of others and of one's relationship with others, and recall past social experiences. SOCIAL WELLBEING: This is the ability to maintain one's identity while sharing, cooperating, communicating, and enjoying others; participation in friendship, family and community life. Social health is in some ways subsumed under mental health. DISEASE: Disease denotes the condition of the human body in which something has gone wrong and has upset the normal functions of the body including the mind. The International Classification of Disease (ICD) distinguishes between three terms: a. IMPAIRMENT - this is any loss or abnormality of mental, anatomical structure, physiological function. b. DISABILITY - is any restriction or lack, resulting from an impairment, of the ability to perform an activity in a manner or range considered normal for a human being. Thus, the loss of a finger may be an impairment but not a disability because it is unlikely to restrict normal activity. c. HANDICAP - is a long-term disadvantage which adversely affects an individual's capacity to achieve the personal and economic independence that is normal for one's peers. Thus, for example, female circumcision would be considered an impairment, but in some cultures not being circumcised would be considered handicap because it reduces a girl's chances of getting married and achieving independence from her parents. The criteria for a disability, and especially a handicap, are more culturally determined in that they depend on the activities performed in that culture and the qualities required for independence. MENTAL DISORDER: This is a recognized, medically diagnosable illness that results in the significant impairment of an individual's cognitive, emotional, or social abilities. It results from biological, developmental, or psychosocial factors, and falls on a continuum according to degree of impairment and distress. Examples - depression, anxiety, paranoia. LEARNING: Learning is the process by which the individual acquire information and ideas which may later result in change of attitude and behaviour. Every process in life including eating, working, playing, singing, etc., is the result of learning. There is a basic element of learning governing all activities. Learning is also the basis of behaviour. Learning is a totality of change of behaviour through acquisition of knowledge. EDUCATION: Education is the process by which learning is facilitated. It is a process in which an individual or individuals or group of people are in the facilities or opportunities by an agent or educator to learn. HEALTH EDUCATION: A process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community wellbeing. This process based on scientific principles, facilitates learning and behavioural change in both health personnel and consumers, including children and youth. KNOWLEDGE: This is the information stored in memory.
MEMORY: Refers to storing and recalling past experiences and ideas. AWARENESS: This is the lowest level of cognition and means simply knowing about the existence of something. ATTITUDE: This is the predisposition to respond in a favourable or unfavourable manner toward a target. PERCEPTION: This refers to reception and interpretation of sensory input. PRACTICE: This is an overt behaviour, habits, or customs of a person. BEHAVIOUR: It is the various voluntary movements/actions undertaken by the body in response to imposed conditions, motives and decisions. Behaviour can also be referred to every activity of the body as an individual. According to the Oxford dictionary, behaviour means "the way in which a thing or person acts, conduct, manners, mode of behaviour; reaction under a set of imposed conditions." MOTIVATION: This is the stage of thinking process, which gets sufficient intensity to direct the body to do a particular thing to satisfy the perceived want. It is a combination of forces, which initiate, direct and sustain behaviour toward a goal. Hence, there are certain forces (psychological) arising from within the individual and various other forces from outside which due to a close interaction may result in a strong force which may motivate or make the person change his attitude and behaviour. If the forces outside and inside result by interaction in an unfavourable disposition there will be no motivation. DECISION MAKING: It is process of committing oneself to a particular course of action or behaviour to achieve a particular goal. It is defined as commitment to carry out a specific task or to adhere to a particular course of action in future. The decision making is used with reference to the final judgement a person has to make with regard to a change of behaviour or adoption of new practice. It will be appreciated that decision making is an indivisible component of motivation and adoption process. DEFENSE MECHANISM: Mental mechanisms which help an individual to smooth over the frustrations and conflicts are known as defence mechanisms. It helps the individual to divert the energy in such a manner as to relieve the tension and also to make it appear to others that the behaviour is not wrong, it serves the purpose of defence. CULTURE: Culture is that whole which includes knowledge, belief, custom, art, morals, law and any other capabilities and habits acquired by man as a member of the society. The term culture embraces a wide range of activates and characteristics of individuals as well as groups with regard to their way of life. The general mode of the life with its customs, beliefs and articles and artefacts used for various purposes by societies are all comprehensively known as culture or cultural characteristics. In other words culture refers to the more or less organised and persistent patterns of habits, customs, attitudes and values which are transmitted from generation to generation. It consists of a shared behaviour which is recognised, approved and cherished by society. COMMUNITY: Community is collection or a group of persons in social interaction in a geographical area and sharing a common social and cultural life. Community is characterised by (a) a geographical area; which can be delimited; (b) a population; (c) social and cultural traits and sentiments passed on from generation to generation; (d) economic status; (e) specific functions or occupations or pursuits as a whole for the community or with a variation amongst different sections of the community; (f) a group dependence or belongingness and an interdependent behaviour. SOCIETY: Society is something that is closely identified with the community. It arises out of community. While
community refers to the structure, location and size of the population, society refers to the human relationship, behavioural patterns, cultural traits, institution, etc., in the community. Society refers to the "totality of social relationships among men. Each aggregate or collection of human beings of both sexes and ages bound together into a self perpetuating group or possessing its own more or less distinctive institutions and culture may be considered a society. Society is any community of individuals joined together by a common bond of nearness and interaction - it is a group of people acting together in general for the achievement of a certain goal or purpose. BEHAVIORAL MEDICINE: This term is used for the broad interdisciplinary field of scientific investigation, education, and practice, which concerns itself with health, illness, and related physiological dysfunction. The field consists of disciplines such as psychology, medical sociology, and health education that have relevant knowledge which can assist in health care, treatment, and illness prevention. ANTHROPOLOGY: Anthropology is the science of mankind and is that branch of science, which investigates the position of mankind zoologically; studying is evolution, history, physiology and psychology. PSYCHOLOGY: Psychology is a science, which deals with the study of behaviour by analysing the mental processes responsible for different acts and actions. SOCIOLOGY: Sociology is a study of social aggregates and groups and the changes that they are capable of undergoing. The study of behaviour of man individually and in groups and in organisation and in institutions, therefore, gets the name SOCIAL PSYCHOLOGY. Sociology studies the nature of the behaviour and Psychology determines the reason and purpose of the behaviour. HEALTH PSYCHOLOGY: Health Psychology is the aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of health, illness and related dysfunction.
II. DETERMINANTS OF HEALTH BEHAVIOUR A. CULTURAL & COMMUNITY DETERMINANTS OF HEALTH BEHAVIOUR Many of the health beliefs have been acquired by people as members of a culture. As members of a community, they learn what kind of water is available for drinking, what food is available for eating, and how the climate can affect one's health. They hear about innovations from their community, such as installation of latrines, and they develop attitudes and habits towards these innovations similar to others in their community. Leaders may involve the community in making decisions about health priorities or may simply set priorities and enforce them. Similarly, communities may organise themselves and arrange for the expertise and services they need. Because of the ability of the people within a demarcated location to organize themselves for the benefit of most of their members, the community has been targeted as the place to initiate environmental and health activities. As members of a culture, people learn the values (attitudes) and beliefs (knowledge) of their parents and grandparents. The culture is also transmitted through religion and through the education system. It is known that culture is a complete whole of patterns of behaviour learnt by that society and standardised, approved and recognised. By repeated process of trial and error and learning, the society sets up expected patterns of behaviour. It is a set of behavioural expectation which consists of standardised expected ways of feeling and acting. The Cultural norms are generally derived from the previous generation from the way in which things were done for the good and convenience of the society. A social norm is a type of social behaviour that is valued by the society as appropriate and benefiting. A departure from these accepted and valued types of behaviour is socially condemned. Every individual places or gives a relative worth to everything around. This worth or preference or judgement or weightage is known as value. It is a cognition, a motor, and above of all a deeply appropriate disposition. Value has a strong influence on all actions and behaviour of every man. Value helps individuals and groups to make choices or alternatives for action. Value guides human behaviour. The education in the community will have to take into account the religious or cultural values with regard to what is being taught according to their own values. Beliefs are defined as a continuing permanent perception about anything the individual world. Belief is a social product of individual perception as well as group experience. Beliefs like values have an influence on behaviour and attitudes. There are many traditional beliefs on causation, cure and prevention of diseases since the ancient times, which continue to be perpetuated generation through generations. Habits & addictions can be contracted in a community, and these in turn influence behaviours of the addicted people as well as other members in the community. Custom represents the group behaviour. Custom is a pattern of action shared by some or all members of the society. It is the totality of the behaviour pattern carried by traditions. Habit is a personality trait whereas the custom is a group trait. Customs will mostly be based on beliefs, attitudes, and values and also past experience. Why are the community and the culture such powerful forces in influencing people? 1. In traditional cultures, people respect the customs handed down to them from past generations and the belief that these customs should be continued. They justifiably believe that these customs must be beneficial if they have persisted so long. Although these customs may be harmful to health, they clearly have other benefits in terms of reducing the stresses of life and providing meaning and direction to people's lives. 2. Transmitters of the culture, such as religious leaders, godfathers and parents are highly respected because of their age and experience, and so have a powerful influence on the younger generation. 3. Cohesion and conformity are important for survival in communities where illness, hunger, and death prevail and where co-operative work and social support is necessary to survive. Also, in fairly homogeneous cultures, people must conform in order to be liked and to belong to a social
group, otherwise they are outcasts and will not live long. 4. When everyone in a community holds the same beliefs and performs the same customs, the beliefs and customs are assumed to be true. Consensus is taken to be a sign of validity, because there is often no other way of determining what is right and wrong. For these reasons, communities and cultures are a strong force in teaching people ways to think and act and are equally strong in maintaining these activities. B. FAMILIAL INFLUENCE ON DEVELOPMENT, HEALTH & ILLNESS The family has a particularly powerful influence on individuals because it is the centre of economic and religious life, and because it produces, protects and socialise the new generation. Socialisation refers to the process by which a child becomes an integrated and contributing member of society. In other words, the entire process by which an individual, either as a new born baby or child or an adult, learns to adjust the behaviour to suit the expectation and needs of all others around. Socialisation begins at birth and ends at death, because throughout life there is need on the part of each individual to know what one has to do, when, why and how, with regard to responses from the others. It has not been difficult to understand that socialisation is the process by which the individual personality develops. Some countries like Ethiopia, emphasis the role of parents as learners of social conventions and the role of children as passive learners of these conventions. However, it is clear that socialisation involves more than learning social conventions (rules); it involves becoming a satisfied and productive member of a society, and knowing how to interact with others at a more intimate level. This kind of intimacy is not taught by parents; it is usually experienced by children during the period of attachment to their parents (birth to 2 years) and to their siblings, and it remains with the person until it is needed in later yours with friends and spouse. Thus, the role of the family can differ in different cultures depending on whether they emphasise parents as the exclusive teachers and whether they emphasise integration through social conventions. In any case, the most important function of the family is the optimal caring of children. Yet, some social and environmental factors have recently interfered with this role of families. These are: migration, industrialisation, subsistence farming, drought & famine, epidemics & high maternal mortality, and family breakdown. When families can no longer care for their children, society sets up orphanages to raise children. Research on orphanages around the world pointed out that institutions are not conducive to the normal development of children. Because of the high child: adult ratio and the high turnover of caretakers, children do not develop secure emotional attachments to an adult and do not develop good relationships with their peers. Because of the lack of verbal interaction with adults, intellectual development is impeded. However, this may not always be true. A study in Jimma conducted among communitybased orphanage, did not confirm the above facts. The study showed that community-based orphanages without institutional structure could adequately substitute for family caring; and that in some cases, families were unable to provide caring as much as it was in the orphanage. Families contribute to child development through both the forces of nature and the forces of nurture. At this point, researchers have not completely determined how much each factor contributes to the outcome. For some behaviours of personality, nature predominates; for others the forces of nurture dominate. The mother's education is the most important determinant of her children's health. For literacy and numeracy to be well established and functional, the person must have completed 4 years of schooling. The mother's education is one of the strongest predictors of her child's chances of survival. This is because maternal education is associated with many of healthy preventive and promotive behaviours. Parenting styles refer to ways in which parents interact with, control, and discipline their children in the process of socialisation. Parent's style of interaction affected the intellectual, emotional and social development of the child, i.e., certain parenting styles are more likely to produce competent, autonomous, and loving children. Three major parenting styles are discussed:
a.
1. The traditional parenting style places great emphasis on continuity with the past. Parents believe that children should uphold traditional values and behave in ways that have been worked out over time and passed down from previous generations. Parents reward close ties with the extended family and punish attempts to be independent from the family and behaviours that are different from the traditional ways of doing things. The result is that children are very attached to their parents and conforming, but as adolescents and young adults may fear innovation, risk-taking and autonomy. 2. The authoritarian-restrictive parenting style places great emphasis on obedience to authority. Parents believe that children need to be shaped, controlled and evaluated by fixed rules laid down by powerful people (such as elders and parents). Parents reward obedience to these rules and harshly punish disobedience and attempts to be autonomous. The result is that children are not strongly attached to their parents because of the restrictions and harsh discipline. As adolescents they do not know how to share responsibility or to be maturely autonomous or creative. If told to take responsibility or to change, they will, but it will not be self-motivated or self-initiated. They may be either very submissive and obedient or (else) impulsive and destructive. 3. Authoritative parenting style places great emphasis on rules and standards that are geared to the child's age and personality. Parents believe that children need to have rules that are enforced, but that these rules are not absolute or infallible but should be changed according to the child's individual characteristics. Beginning at a certain age (6 - 8 years) children are expected to share in the responsibility of setting and enforcing rules and can negotiate the nature of rules with parents. The same holds true for emotional and intellectual interactions between parents and their children which are geared to the individual child and for which children share responsibility. The result is that children are able to solve their problems, take responsibility, accept change and changing roles within and outside the family, and be autonomous. The responsibilities and changes may be too taxing and confusing for some children, leaving them bewildered. As a result, children may be attached to or detached from their parents depending on the degree of responsibilities put on them. Social capabilities The most important social capability in the first year of life is the formation of an attachment. Attachment is usually defined as a close emotional bond to a selected number of people, resulting in security. A child needs attachment for survival, growth, and later for the development of other intimate relationships. A mother needs attachment as an incentive to continue her effort to care for the child despite the obstacles. There are many known functions of attachment for the child: to feel secure (unthreatened and confident), b. to feel secure enough to reduce one's fear of strange situations and strange people and to then be able to explore, c. to internalise control over one's impulses; attached children show more self-controlled, persistent, and enthusiastic problem solving, d. to develop capabilities that later facilitate positive peer relationships and intimacy. The family environment most conducive to developing a secure attachment is one where the adult responds to the infant's cries, smiles, and gestures; and where the adult comforts and stimulates the infant according to the infant's temperament and current state. C. PSYCHOLOGICAL (PERSONALITY) DETERMINANTS Personality refers to relatively enduring characteristics of a person that make him/her different from others, and that are psychological rather than biological, but may have developed as a result of biological or social factors (i.e., nature or nurture). Temperament is an example of a constitutionally based aspect of one's personality that is present from birth, though over time it may be modified by the environment. Three health related aspects of personality will be discussed here.
a.
HEALTH LOCUS OF CONTROL (HLC)
This concept refers to a person's generalised expectancy concerning what determines one's health and illness, internal factors within oneself or external factors outside oneself. In other words, HLC is generalised expectancies that either self (internal) or external or powerful others or chance determine one's health and illness. Practice of Preventive Behaviour is linked up with various personality variables such as the HLC. It is assumed that people who expect to be able to affect their own state of health will seek more health information, be more receptive to changing their health behaviours, and manifest more promotive, preventive, and curative activities. Yet, research works have not strongly supported all of these assumptions. HLC has been measured by Multidimensional HLC developed by Wallstone and Wallstone (1978), and also by using the modified scale by Leu & Wary 1981. Using items for three dimensions, Wallstone and colleagues found that internal and chance items correlated negatively and so could be subtracted to produce one score along an internal-external continuum. The score for powerful others was sometimes positively correlated with chance but independent of the internal score. Validation studies would have to be conducted in different set up to find out how people view the control of powerful others and powerful spirits -- more in line with internal control or with chance. Concerning health education, some have advocated that educators try to teach people that they can control their health and illness. Others have emphasized the need to alter education messages to fit the locus of control of their listeners. For example, if health is thought to be under the control of God, then perhaps priests and other religious people should become involved in health education. If household heads are thought to be powerful in influencing health and illness, then these men should be involved more in health education; giving it and receiving it. b. Personality Types Type A is characterized by easily aroused hostility, anger, a sense of time urgency, and competitive achievement striving. Research suggest that the propensity for hostility may be the most lethal component of Type A behaviour and the only one reliably associated with coronary heart disease morbidity and mortality. Type A behaviour is associated with hyperactivity to stressful situations, including a slow return to baseline. Some have suggested that these exaggerated cardiovascular responses to stress may be genetically based and that Type-A behaviour may in, in part, result of excessive neuroendocrine reactivity to environmental stressors. Type-A behaviour can be identified early in childhood and may be related to a parental style involving escalating performance standards, disapproval, and punitive or harsh methods of control. Research with children has not typically translated into interventions because not all children who show Type A behaviour will become Type A adults, nor will all Type A adults develop CHD. The measurement of Type A personality or behaviour pattern is through a Structured Interview (Friedman & Rosen) or a structured questionnaire called the Jenkins Activity Survey. The later asks specific questions such as: How would your wife rate you? Definitely hard-driving and competitive. Definitely relaxed and easy going or anywhere in between. It is not as good at predicting disease as Friedman's interview which assesses verbal responses as well as the manner in which answers are given (nonverbal) such as explosive speech, interruptions, expressions of anger and impatience. According to this measure, people are classified in four ways: Type A-1 characteristics include expressions of vigour, energy, alertness, and confidence, and loud, rapid, tense or clipped speech, frequent interruptions, explosive speech, hostility and impatience. Type A-2 people are not as extreme as A1's. Thus A-2 people may be in a hurry but not be extremely impatient; they may be less hostile and aggressive. Type A's need to control events and outcomes. When their control is threatened, they increase their efforts to reassert control, thus appearing to be Internal. When exposed to loss of control or large amount of uncontrollable stressors, however Type A's give up more easily than others, and appear
helpless. Type A's also experience the physiological stress response on most tasks. That is, when a task is challenging, and requires accuracy, they show the typical sympathetic arousal of a person under stress (increased heart rate and blood pressure). This arousal is psychologically activated, and is not due to increased physical activity. They also respond to the usual stressors with excessive sympathetic arousal. It is assumed that this leads to the higher rates of CHD found in such people. Efforts to modify Type A behaviour through training in relaxation and stress management show promise in reducing not only cardiovascular reactivity to stressful situations but also morbidity and mortality due to CHD. Type B people show little evidence of any of these characteristics; they are less competitive, less hostile in their responses, and more relaxed. Type X people show A and B characteristics in almost equal proportions. People with Type C (cancer-prone) personality are those who are easy going and acquiescent, repressing emotions that might interfere with smooth social and emotional functioning. The cancerprone person is described as inhibited, over-socialized, conforming, compulsive, and depressive. He or she is said to have particular trouble expressing tension, anger, or anxiety, instead presenting the self as pleasant, calm, compliant, and passive. The Type C or cancer-prone personality has been characterized as responding to stress with depression and hopelessness, the muting of negative emotions, and the potential for learned helplessness. Yet, the association between personality and development of cancer has not been conclusively drawn through studies. c. Stress, Stressors and Coping Stress is the process of appraising events (as harmful, threatening, or challenging), of assessing potential responses, and of responding to those events; responses may include physiological, cognitive, emotional, and behavioral changes. Stress is used to refer to the internal state of tension or disequilibrium resulting from a stressor. In other words stress is the process by which environmental events threaten or challenge an organism's well-being and by which that organism responds to this threat. The environmental events are called stressors. Some of the examples of stressors are: unescapable pain, chronic illness, taking exams, increased responsibility at work, marital conflict, and the evil eye. In the Ethiopian context some additional stressors can be: school problems, stressful new job, imprisonment, pregnancy, social stress from family or neighbours. The measurement of stressors includes Holmes and Rahe's Social Readjustment Scale which asks how many major life changes have taken place in the past year. Each change is assigned a score based on the amount of adaptation or readjustment required by that event. Sarason included the same changes but asked each respondent to indicate the intensity or the impact of the event on their lives. Coyne, Kanner et al. developed a Hassles Scale to assess irritants that can range from minor annoyances to fairly major pressures, problems, or difficulties. They can occur few or many times, but it is their accumulation or repetition that creates stress. Lapore and others developed a measure of chronic strains to assess recurring and major stressors in the life of a family living in a developing country like in India. Mesfin Samuel modified this scale for use in Ethiopia, and included stressors such as parental imprisonment, mental illness, chronic physical illness, overcrowding, and unemployment. These were strongly associated with mental disorders in the mothers, which in turn lead to behaviour problems in her children. There are a number of factors that determine whether the stressors will lead to negative health outcome. One concerns the stressors -- their number, duration and intensity. A second concerns whether a coping response is available in the situation for the person to use. If one is available and is used, the outcome may not be as negative. A third factor concerns the characteristics of the person experiencing the stressor. Type A people or withdrawn people, and anxious people respond more strongly to stressors. Finally, someone with a large social network and strong social support from relatives, friends and spouse may be protected from negative outcome.
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Coping has been defined as the active utilization of biological, psychological, and social resources which assist in controlling, mastering, and preventing the distress imposed by external and/or internal demands (stressors) experienced by the person. Resources include one's health, energy, morale, problem-solving skills, defence mechanisms, and internal locus of control, as well as social support and social services. Falkman and Lazarus classified 8 coping strategies. These include: Confronting coping - aggressive efforts to alter situation Distancing - cognitive efforts to detach oneself and minimize the importance of the situation Self-controlling - efforts to regulate one's feelings and actions Seeking social support - efforts to seek information, tangible support, and emotional support Accepting responsibility - acknowledge one's own role in the problem and trying to put things right Escape-avoidance - wishful thinking and efforts to escape or avoid the problem Painful problem solving - deliberate problem-focused efforts to alter the situation Positive reappraisal - efforts to create positive meaning from the situation Others have classified coping into two categories: active and passive. Active coping is associated with stressors that are controllable and for which there is available active response. It is also associated with: activation of the Symapathetico-Adreno-Medullary (SAM) System; and increase in epinephrine particularly when there is emotional arousal; and increase in norepinephrine particularly when there is physical exercise, release of endogenous opiates such as enkephalines and endorphines; and a slight release of cortisol. When emotional arousal is not accompanied by vigorous physical activity, the free fatty acids mobilized for energy are not used and become plaques leading to atherosclerosis. Active coping can lead to psychosomatic illnesses. Passive coping is seen in highly aversive situations where one expects little control or ability to change the situation, such as intense temperatures, surgery, death of a close relative, uncertainty about the future. Passive coping is more closely associated with the Hypothalamic-Pituitary-Adreno-Cortical (HPAC) System and often leads to clinical depression, helplessness, hyper-vigilance, withdrawal, and susceptibility to disease. One can characterize individual people in terms of whether they prefer and habitually use active or passive coping. Learned helplessness (Seligman) What happens when control is not available - when we cannot, under any conditions, gain some sense of control over what happens to us? Work by Seligman (1975) and others suggests that if this response-outcome independence is prolonged, we may learn that we cannot affect outcomes and cease trying to do. Repeated exposure to uncontrollable events "conditions" us to expect responses and outcomes to be non-contingent, and the reaction that this produces has been called learned helplessness. Psychologists have long been aware that when an individual repeatedly fails to accomplish a goal or exert control effectively over something, he or she not only may stop trying in that but also may become unresponsive in new environments where success might be more readily achieved. Beyond the helplessness present in the setting where failure occurred, Seligman posited that people can learn to be helpless - that is learn that their attempts to control or succeed will not be successful. According to Seligman, the primary cause of learned helplessness is the recognition that response and outcome are independent - that the probability of achieving a given outcome is the same whether or not responses are made. Once repeated exposure to uncontrollable events has caused the organism to learn that the outcomes cannot be affected, responding ceases. One experience with uncontrollable events appears to affect motivation and cognitive ability in other settings as well as in the situation in which it
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was first learned. Learned helplessness creates three deficits. 1. The first is motivational, in that the helpless person makes no effort to take the steps necessary to change the outcome. 2. The second is cognitive, in that helpless people fail to learn new responses that could help them avoid the aversive outcomes. 3. The third is emotional, in that learned helplessness can provide mild or severe depression. Other psychological correlates of health behaviour Emotional factors play an important role in the practice of some health habits. For example, overeating is linked to stress for some obese people, and they are more likely to overeat when they are under stress than when stress is absent. Positive health behaviours may also be under the control of emotional factors. Self-esteem also relates to the practice of health behaviours. In both children and adults, those with higher self-esteem are more likely to practice a variety of good health habits than those with low self-esteem. Generally, good health behaviours are more likely to be practised by people with a sense of psychological well-being and a belief that their health is generally good. Health behaviours are similar to other aspects of life that require planful problem-solving activity. Health behaviours are also integrally tied into people's personal goals. The overall goal of simply staying healthy was only a partial predictor of these health habits. Some health habits are controlled by perceived symptoms. Cognitive factors, also determine whether or not individuals practice health behaviours. The belief that a particular health practice is beneficial and that it can help stave off a particular illness, as well as feeling of vulnerability to that illness, may all contribute to the practice of a particular health behaviour (Health Belief Model). D. GENETIC INFLUENCES ON HEALTH AND BEHAVIOUR (BEHAVIORAL GENETICS) Genetics have an effect on behaviour and health. The study of the observation of behaviours that could be transmitted from parents to offspring is termed behavioral genetics. Behaviour, in this usage, refers to numerous phenomena such as intelligence, aggression, emotionality, mental illness, and criminality. The three major methods of genetic investigation of humans are family studies, twin studies and studies of adopted children. 1. Family studies assess each member of a family in order to determine whether the prevalence of a certain characteristics exceeds that found in the general population. Of critical importance in such studies is the requirement that the considered characteristics be precisely defined. If this requirement is not met, then meaningful comparisons with a norm cannot be made. Family studies are generally the weakest kind of evidence to support the presence of genetic predisposition to a certain personality characteristic. Since family members have not only the same genes but also the same environment, it is impossible to determine whether the relationships found are due to genetic or environmental factors. 2. Twin Studies can provide somewhat stronger test of the possible presence of genetic factors because they compare persons raised in a highly similar environment who are either genetically identical (monozygotic twins) or similar but not identical (dizygotic twins). Twin studies are the most popular method of evaluating human inheritance. Twin studies, although strongly suggestive of the presence or absence of genetic factors, must be interpreted with some caution. We can argue that monozygotic twins not only are alike genetically, but also share a more nearly identical environment than dizygotic twins. They are of the same sex and commonly tend to be dressed alike, treated alike, and usually confused with each other by other people. One way of overcoming this potential argument is to examine monozygotic twins who were separated from each other very early in life and reared apart. But because of the time and expense involved in
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conducting such studies, only a small number of cases have been studied, primarily in the area of psychopathology. For example in the investigation of schizophrenia, such studies have suggested a genetic predisposition for this disorder. However, the small number of cases involved in these studies prevents any definitive conclusion. Another point concerning twin studies is worthy of comment. Identical twins, in comparison with fraternal twins or normal siblings, have a great risk of retardation and pregnancy and birth complications. Such an observation raises some questions about identical twin studies and the possibility of genetic involvement because it is possible that trauma to the central nervous system (birth complications for example), and not genetic factors, predisposes twins to develop certain forms of psychopathology and personality characteristics. 3. Adopted Child Studies attempt to eliminate the possible developmental effect of being raised in a similar environment. Such studies examine children who were adopted away from their original biological family at birth and raised by another family. These persons have the genetic endowment of one family and the environment learning experiences of another family. A number of meaningful comparisons can be made employing this method. For example, we can determine whether the adopted child resembled his or her biological parents with regard to the psychological characteristics in question. Other comparisons are also helpful in determining the impact of genetic endowment in a different environment. 4. Convergence: The strongest support for the inheritance of a particular personality characteristics or trait comes from the convergence of evidence from family studies, twin studies, and studies of adopted children. If it is found that there is familial similarity in a trait, if monozygotic twins are significantly more similar than dizygotic twins on that trait, and if adopted children resemble their natural parents more than their adoptive parents, then some involvement of heredity for that trait is beyond dispute. In the field of personality, the only trait for which all three methods of investigation has been amassed is intelligence. The data strongly suggest that there is a significant inherited component in intelligence. E. PSYCHOSOCIAL IMPACT ON HEALTH, DISEASE & DISABILITY Disease and disability have an impact on all levels of society; they reduce the economic productivity of a nation, demand a great deal of resources from the health system, affect the development of a community, place an extra burden on the family and on the healthy parent to take one the role of two parents, and cause a great deal of discomfort to the affected person. Psychosomatic illness According to one of Giel's reports, 20% of patients attending outpatient departments in rural Ethiopia with a somatic complaint had a psychological problem. People with psychosomatic illness create a burden on the family and on the community. They cannot contribute fully to the economic and social well-being of the family and the community. Often they are incapacitated by their own pain. They continue to seek health services because health workers are not able to identify the psychological problem and so treat only the somatic complaint, which recurs if the stressor continues. Example: headache. Mental Illness The social impact of mental illness is probably more severe than psychosomatic illness. Psychotics are generally feared and expelled by the community to become beggars, prisoners, or seek help from traditional healers in the Zar cult. Those who function within the community seek relief from their pain from health workers who do not know how to identify or treat such patients. Consequently, these people continue to return for medical help or shop around. In addition, mental illness is known to be the major cause of marital break down. Mesfin Samuel found that there was a correlation of 0.4 between maternal mental illness and child behaviour problems. Mental problems are assessed using the WHO Self-Reporting Questionnaire for Adults and the
Shabbir Ismail MD MPH Associate Professor Behavioral Sciences Unit DCH, FOM (AAU)
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Reporting Questionnaire for Children. Both were designed for use in developing countries. A new measure called Composite International Diagnostic Interview (CIDI) is on field tests, which may allow more specific diagnosis of mental disorders. Substance Abuse mainly: Alcoholism Alcoholism was defined by a WHO Expert Committee in 1952 as the following: Alcoholics are excessive drinkers who are so dependent on alcohol that they show interference with their bodily or mental health, their interpersonal relations, and their smooth social and economic functioning, or show the signs of such developments. Disability Disabilities include mental retardation, sensory disorders such as blindness and deafness, motor disabilities, and neurological diseases such as epilepsy and leprosy. Many of these disabilities have a great impact on the community. Because they are chronic and require special care, disabilities place an extra burden on family members. Because they are often unable to work, disabled people do not help support the family; sometimes they leave and wander into towns to beg. Also there are many negative attitudes towards disabled people; even though their family may protect them to a certain extent, disabled people are less likely to marry and lead an independent life. Unfortunately, many people do not realize that blind, deaf, and epileptic people are as intelligent as others; they only need to have their intelligence developed as all normal people do by using the senses that are still functioning. F. ACCESS TO HEALTH CARE SYSTEM Access to health care system also influences the practice of some health behaviours. Medically oriented preventive health behaviours are correlated with each other very well. The person who obtains a regular check-up is more likely to use a preventive screening service and is more likely to obtain immunizations. The reason that medically oriented health behaviours are modestly related is that all of them are influenced by a common factor: access to medical services. Thus in predicting medically oriented health behaviours, we need to know who uses health services more generally. Individuals who are low in socioeconomic status (SES), who are female, who do not have a regular physician, and who do not have convenient medical services are less likely to use health services generally and to practice health behaviours that require medical intervention. Research reveals that people with more education and higher income are more likely to receive immunization, have regular physical checkup when they have no symptoms, obtain preventive dental care, get PAP tests, and respond to breast cancer screening programs. Even when screening programs or other preventive services are specifically designed for low-SES groups, the more advantaged individuals within that group will use the program more than the less advantaged. To summarize, then, access to medical care prompts the practice of a variety of medically oriented health behaviours. Unhappily, however, access to medical facilities does not necessarily improve nonmedical health behaviours such as smoking, overeating, and so on.
HEALTH EDUCATION I PART 2 I. INTRODUCTION: DEFINITIONS OF HEALTH EDUCATION (HE) Health education has been defined in many ways by different authors and experts. In a WHO Technical Report Series (# 89 of 1954) it was defined as follows: "Health education, like general education is concerned with changes in knowledge, feelings and behavior of people. In its most usual forms it concentrates on developing such health practices as are believed to bring about the
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best possible of well beings." The above definition shows that it is a process that aids people to find out their health needs and activate them for suitable behavior. The education given for identifying the health need and matching it with suitable behavior can be termed as health education. In other words, the entire process of involving people in learning about health and disease and aiding them to act suitably for overcoming illness and preserving a positive health is health education. I.e. it is any combination of learning experiences designed to facilitate voluntary adaptation of behavior conducive to health. It is required for almost a very one in society and is required off and on, in a continuous manner. Health education is needed for all ages, both sexes, all classes of community (rich or poor), literate or illiterate and in all parts of world. Health education should be an active process of learning and doing by one's self. The individual has to assimilate and internalize the information and ideas and adopt a behavior necessary for health. The HE process must result in a permanent change or sustained behavior. HE will stabilize the good pattern of behavior by providing necessary information and creating a positive attitude for the behavior that has been already formed. In a more comprehensive way HE can be defined as a process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community well being. This process, based on scientific principles, facilitates learning and behavioral change in both health personnel and consumers, including children and youth. This definition can be elaborated as follows: Engage intellectual, psychological and social processes The intellectual processes are usually engaged during learning and decision making. This dimension includes what is sometimes referred as knowledge, beliefs, awareness, perceptions, memory and problem solving, i.e., the cognitive or thinking component. The psychological processes are particularly important for initiating health behavior and acting on one's decision. This dimension includes attitudes, motivations, values, as well as specific behaviors. The social dimension is important throughout, because it includes all aspects of relating to other people such as the influence of others, joint decision making and community organization. When discussing about these three dimensions of HE, COMMUNICATION plays the most vital role because it is the transmission of information from one person to another. It can be face-to-face and mass media, auditory and visual; it can be informative and emotional and persuasive; it can be positive (what to do and the benefits) and negative (what not to do and the disadvantages). Communication is a common activity used to encourage learning, behavior change and decision making. It can engage in all the three dimension of a person, i.e., intellectual, psychological and social dimensions. Encourage learning and behavior change What kinds of activities encourage learning and behavior change? A number of theories of health education have been proposed, each attempts to identify what skills or knowledge must be learned and how they are best learned and performed. A few of the models, which shall be discussed in very detail in later sections, are:
1. 2. 3. 4. HEALTH BELIEF MODEL APPLIED BEHAVIOR ANALYSIS THEORY OF REASONED ACTION THEORY OF PLANNED BEHAVIOR, and 5. THE PRECEDE-PROCEED MODEL (HEALTH PROMOTION PLANNING MATRIX).
Foster making decisions and acting The goal of HE is to possess the abilities necessary for making informed decisions about the health and acting on these decisions. These go beyond learning and performing specific health behaviors. It refers to having the abilities to make ongoing decisions about the health of oneself and others, as well as being able to organize personal and social resources to act on these decisions. Decision making
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abilities include skills that were described as being intellectual, psychological and social in nature. These include: 1. 2. 3. 4. 5. 6. 7. seeking and evaluating information considering one's priorities comparing the costs and benefits of an action solving problems feeling confident about one's control utilizing other's expertise and opinion, and coordinating the efforts of many people
Acting on these decisions requires even more in the way of skills, motivation, energy, and direction, as well as the means to obtain physical and social resources. Settings of health education can be any where including schools, communities, worksites, health care sites, homes & the consumer market place. Health Promotion: It is any combination of health education & related organizational, economic & environmental supports for behavior of individuals, groups, or communities conducive to health (has social context). It is the science and art of helping people change their life toward a state of optimum health. Health Behavior: These are actions of individuals, groups & organizations as well as their determinants, correlates, & consequences, including, social change, policy development and implementation, improved copping skills, & enhanced quality of life. kasl & Cobb define three categories of health behavior: i. Preventive health behavior: - any activity undertaken by an individual who believes himself to be healthy, for the purpose of preventing or detecting illness in an asymptomatic state. ii. Illness behavior: - any activity undertaken by an individual who perceives himself to be ill, to define the state of health, & to discover a suitable remedy. iii. Sick role behavior: - any activity undertaken by an individual who considers himself to be ill, for the purpose of getting well. It includes receiving treatment from medical providers, generally involves a whole range of dependent behaviors, and leads to some degree of exemption from ones usual responsibilities.
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II.
AIMS & PRINCIPLES OF HEALTH EDUCATION
Essentials of HE The following essential points are relevant and applicable to HE in all possible situations. 1. 2. 3. 4. 5. 6. 7. HE may be required for almost every one at some time or other. HE is not a one time affaire. It is a continuing education. HE can be organized as a self-learning process, and also can be a process of learning from others. HE consists of proper communication of ideas. All the principles and theories of education and learning are fully applicable in health education. Since HE has to do with health, correct knowledge about various aspects of health and disease is highly essential for communicating or disseminating ideas for the purpose of producing necessary attitude and behavior. Any one who knows what is good for preservation of health can impart HE. Though people who are trained for providing health care are much better fitted to give HE in the community than lay persons. This does not rule out the role of non-medical and non-health personnel as health educators but it only emphasizes the importance of acquisition of correct and complete information and knowledge on relevant health problems and their application. Since HE aims at change of behavior a health educator has to acquire and develop skills to educate, to communicate, to motivate and involve the client. He/she should have working knowledge of social psychology and principles and theories of community organization. HE is not like teaching of medical and health subjects to undergraduate medical, nurses and paramedical, etc. People in all walks of life have to be educated frequently on health practices and health related behavior from time to time throughout life and as applicable to changing conditions. It must be borne in mind that human behavior is governed by various influences and therefore, HE must take full cognizance of all the influencing factors in any given situation. A good health educator has, therefore, to combine in himself knowledge and skills of behavioral sciences with sufficient rational understanding of the health problems and their solutions from a scientific and logical stand point.
8. 9.
10.
Principles of HE 1. HE is primarily education and its purpose is to ensure a desired health related behavior. All HE should be need-based. If the problem is severe or serious from the health person's point of view but is not felt as much by the individual or the group then a proper diagnosis should be made about the different influences (perceptions, beliefs, attitudes, prejudices, resources, etc.) HE should not become an artificial situation or formal teaching-learning. One has to get into the culture of the community and introduce novel ideas with a natural ease and caution. It is better to start from where people are and slowly build up the talking points to avoid any clash of ideas and to allow for people's understanding, appreciation and internalization of fresh ideas that the health educator wants to seed in the community. It is necessary to discuss freely on the health problems and the solution and to ensure that all the good and bad points, advantages and disadvantages, difficulties, etc., are thoroughly dealt with. Education is the process or act employed to develop the mind, character and body by planned discipline. It is a methodical socialization of an individual. Since education aims at change of behavior, the sciences of sociology, psychology and anthropology are essentially required in 17
2.
3.
4.
understanding human behavior. The educational process has to take into account the learning process and the teaching process. For this the educational content has to be developed based on the diagnosis of the socio-psychological factors. Methods of teaching or providing learning opportunities also form part of the educational process. Lastly the media of communication has to be considered carefully for effective propagation of ideas. 5. Patients should be made to appreciate the objective of treatment for diseases. There is a great need for HE to make people understand curative aspects of many diseases but in times sickness people do resort to some care by and large. But in matter of preventive and promotive care people are not by themselves sufficiently aware of the various things that they have to do. Generally, it is also difficult to demonstrate the beneficial effects of preventive and promotive care to enable people to realize their importance. A continued education is necessary in every community to help people to identify their health problems and to help them to understand what steps they have to take to prevent any sickness. There should be a free flow of communication. The two way communication is particularly of importance in health education to help in getting proper feedback and to get doubts cleared. For people to understand and appreciate ideas, messages, methods, procedures, etc., with proper reasoning the communication should be simple, clear, brief and crisp. There are many principles of effective communication which require to be carefully remembered and practiced by the health educator. The health educator has to make himself acceptable. He should realize that he is an enabler and not a teacher. He has therefore, to win the confidence of his clients. The health educator should not only have correct information with him on all matters that he has to discuss but also should himself practice what he professes. Otherwise he will not enjoy credibility. The health educator has to adjust his talk and action to suit the group for whom he has to give HE. This is particularly necessary when the health educator has to deal with illiterates and poor people. A health educator has to employ all possible methods of education. He should also have a basic knowledge and should be fully familiar with all the learning principles. He should therefore apply the teaching-learning methods appropriately to different groups and individuals by using judgement. Since the ultimate aim of HE is to bring about desired health related behaviors, the health educator should as far as possible make every effort to reason out and rationalize, so that the client is able to internalize the relevant ideas. To ensure a full understanding of the problems and its solution by the clients a well planned program is necessary. The content of the program and the method of approach will have to be based on the educational diagnosis. Additionally care should be taken to include the implementation and evaluation along with the clients. The use of audio-visual aids for support and reinforcement is of particular significance in HE because of the different illiterate and literate groups that have to be involved also because of the technical nature of the subject matter. This is also particularly important to generate interest towards lectures, talks and discussion. The aid provide not only a comfortable diversion but help in focussing attention on the essentials and giving the eye and ear a greater role in 18
6.
7. 8.
9.
10.
11.
12.
13.
perception. 14. 15. HE should be specific and relevant to the problems and the available solution. The content should always aim at the focus or essence. It is the essential function of any health educator to find out the existing behavioral patterns and their basis. If any change of behavior is required from a wrong practice to a supposed right practice the process of HE should aim at removing the wrong idea and its connected attitude and then introducing correct ideas, attitude and practices. It should be remembered that people are not absolutely without any information or ideas. There is always some perception or belief, etc., which should be studied first before HE can be started. The health educator should remember that he his not merely passing information but he is giving an opportunity for the clients to analyze fresh ideas with old ideas, compare by past experience and take decisions which are found favorable and beneficial. A grave danger with HE programs is the pumping of all bulk of information in one exposure or enthusiasm to give all possible information. Since it is essentially a learning process the process of education should be done step by step and with due attention to the different principles of communication. HE should be able to provide an opportunity for the client or clients to go through the stages of identification of problems, planning, implementation, evaluation and so on. This is of special importance in HE of the community. The principles of community organization, viz., the identification of opinion leaders, identification of problems and planning, implementing and evaluating are to be done with full involvement of the community to make it the community's own program. The health educator should use terms which can be immediately understood. scientific jargon should be avoided. Highly
16.
17.
18.
19. 20.
Any attempt of drastic or quick change of behavior may not only be difficult but may generally cause unnecessary mental conflict and resentment particularly because the expected behavior may be much contrary to existing cultural pattern. HE should start from the existing culture and gradually try at change of habit and practices. Moreover, the HE effort should aim at small changes in a graded fashion and not be too ambitious. People will learn step by step and not everything together. For every change of behavior a personal trail is required and therefore the HE should provide opportunities for trying out changed practices.
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III. COMMUNICATION A. Purpose & Objectives of Communication
To communicate means (dictionary definition) "to impart, pass on or transmit a message, information, etc.; to exchange ideas or information with, be in touch with, to have access, to be connected with," and communication means "the act of communication, the things communicated, the means of communicating." Essentially communication deals with transmission of information or ideas and sharing and exchanging of information. It is needless to emphasize that in learning and education, communication gains great importance because education implies transfer of knowledge and skill and communication also means transfer of information and exchange of ideas. In learning information has to be gathered and acquired; and skills have to be observed, practiced and developed. Therefore, communication forms an indivisible component of the process of education and the process of learning. B. COMMUNICATION PROCESS & COMMUNICATION MODELS
The process of communication is usually described by models with three distinct parts and their elements. These are: (1) Sender or communicator; (2) the receiver of the message or the communicatee; (3) the message which lies between the communicator and the communicatee and gets transacted. In other words, communication is a process by which an idea is transferred from a source to a receiver with the intent to change his behavior. The purpose of communication is change. Many public health programs are connected with change and require communication intervention. The most important thing is what happens when the message reaches the people it aims at. If they hear and understand it, and are inclined to believe it, good communication has taken place. The six components of any communication process are: 1. Source (Encoder):
This is the originator of message, which can be an individual or groups; or it can also be institution or organization. The communicator has to arrange his thoughts and ideas in such a manner that he organizes his message for the benefit of the receiver. This process of arranging the ideas and preparing the message is called encoding. Encoding is the transmission of ideas into a message by the source. 2. Message:
This is the idea that is communicated, something that is considered important for the people in the community to know or do. Many messages are expressed in the form of language symbols. Since this message is likely to evoke a response in the communicatee, it can be considered as a stimulus. The stimulation can be effected through any of the special sensory of the body. In a typical two-person conversation the verbal band carries one-third of the meaning; the non-verbal carries two-third of the meaning. Effectiveness of the message depends on:
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1. 2. 3. 3.
Psychological factors: intelligence, level of education, prior information, and selective perception. Linguistic factors: vocabulary, grammar, etc. Receiver factors: culture, class, etc. Channel: Physical means by which a message travels from source to receiver.
Classification of channels (1) Interpersonal (face to face) (2) Mass media 4. Receiver:
This is the person for whom the communication is intended. The receiver of the message exercises not only the sensory organs but also his brain and mind. The response to the message begins with the receipt of the stimulus and the perception. The response of the brain and mind can be visualized like something than happens in the receiving set of telegraphic message. The brain analyses the message and makes sense out of it. In social psychology this is referred to the same process as perception. It consists of decoding the stimulus and interpreting it. Decoding is the mental process by which the stimuli that have been received through the sensory organs are given proper meaning according to the individual's own way of thinking. 5. 6. Effect: change in receiver's attitude, knowledge and practice. Feedback:
This can be either positive when desired change in KAP occurs or negative when desired change in KAP does not occur. Feedback need not necessarily be a written message or written language, etc. Just like the onward process of communication feedback can also be by gesture, symbols or signs. MODELS OF COMMUNICATION Various authors have given their models in communication. The different models have been evolved according to the different situations and, therefore they will differ slightly from one another. 1. Aristotle model (1946)
It consists of three elements only: the speaker (source or communicator), the speech (message), and the audience (receiver or communicatee). Since Aristotle has visualized a public meeting for this model, we have the speaker, the speech and the audience. There is no mention of the feedback as such and we have to presume that this should be provided by suitable opportunity for questions and answers, etc. In a huge gathering it generally does not take place. It is possible in smaller groups. Source 2. Message Audience
Shannon and Weaver model
In this model the use and introduction of a medium for the transmission of message is distinctly seen as different from the Aristotle model. This consists of the following components: Source,
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transmitter, Signal, Receiver; and Destination. The parts of the medium are the transmitter and the receiver. The common application of this model is the radio transmitter or telephone mouthpiece.
Source Transmitter Signa l Receive r Destination
Communicatee is referred to in this model as destination. 3. Schramm model
This model has in addition to the previous model a process of coding the message at the source (communicator). The message is put in the form of code or encoded. It is then transmitted as a signal or energy form through a medium in the form of wires. This medium is called the channel. The communicatee in this model is the receiver who decodes the message that has been received. For this purpose the communicator is to employ an encoder who converts the message into code. This is what happens in the telegraph office when the telegram is handed. 4. Berlow model
This is not different from the previous model. The application is also seen in telegraph. 5. Leagans model (1963)
In this model the components are communicator, message, channel, treatment, audience and audience response. In this model, feedback mechanism is provided in the communication process. There is also a special effort to treat the message so that it is suitable for the audience. In other words, this process ensures a proper formation of message with sufficient trial, pretesting, etc., and also provides for feedback for the purpose of monitoring and evaluation. This model will be ideal in the class room situation where the public address system is arranged. It is also applicable in mass communication or in group discussion where the message has been treated for the chosen channel or medium of communication and a provision is carefully made for evaluation of effectiveness and impact on the audience. It is, therefore, applicable to cinema, television, posters, etc., where the communicator prepares the content with sufficient care and precision and simplicity, clarity, etc., and also he elicits the response of the audience as and when necessary to ascertain his own effectiveness.
Communicator Messag e Audience Channel Treatmen t
6.
Fano model
Audience Response
The components of this model are source, source encoder, channel, encoder, channel, channel decoder, user decoder, and users. This model is typically exemplified by the telegraph system in which the Morse code and any other code for simplifying or abbreviating messages are used. This model applies also to the transmission of wireless broadcast message particularly through secret codes in army operation or naval movements.
Source encode Sourc e Shabbir Ismail MD MPH Associate Professor Channel decoder
Channe l
Users
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Channel Encoder
User decoder
7.
Literer's model
The components in this model are selection, encoding, transmission, channel, noise, detecting, decoding, and selection. The sender selects the content of the message to suit the need of the audience or receiver. This selection is however based on the sender's perceptions or understanding of the receivers needs receptivity and power of understanding. The encoded message is transmitted through any medium, which is found suitable and available. The message is received by the receiving apparatus, which detects the signal. This is decoded into the original message selected or picked up by the receiver. (Noise is any obstruction or interference which prevents the message from being transmitted or carried over clearly to the audience. Or it refers to any kind of obstruction or distortion or failure of transmission of message. 8. Westly-Maclean's model
The components of the model are sender, encoding, channel, decoding, receiver, and feedback. This is obviously a simple and comprehensive and ideal model; because it has the element of source encoding, channel and decoding and receiver and the feedback from the receiver to sender. Therefore, it enables a two-way communication, which is highly essential in mutual understanding in teachinglearning situation. The advantage of feedback, as already mentioned, is for the improvement of the message by the sender in keeping with the need and power of understanding of the receiver. The model is applicable in the following situations: face to face communication, correspondence, telephonic conversation, wireless conversation, and lecture discussion, panel discussion forum. Sender>Encoding>Channel>Decoding>Receiver ^ Feedback< C. 1. FACTORS AFFECTING THE COMMUNICATION PROCESS
Source or the sender or the communicator
The communicator has to be intelligent and understanding. He should know the need of the audience. He should have proper judgment. The communicator should possess the following characteristics: a. Skill in communicating - verbal, written. including treatment of message, etc. b. Knowledge of the channel and audience. c. Attitude towards the subject (topic), channel and audience. d. Source credibility e. Skill in encoding and decoding f. Skill in utilizing the channel
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g. 2.
Confidence or attitude towards self. Message
A message is the information, which a communicator wishes the audience to receive, understand, accept or act upon. Message will, therefore, consist of statements made verbally during conversation or transmitted through any media. The message has 3 dimensions or parts: 1. The code 2. The content 3. The treatment The message, if delivered directly as in a face to face conversation does not require any particular coding normally. Words are merely uttered and are received directly by the receiver. But when the message has to be fed through the channel it has to be properly encoded. The content of the message refers to substance or the materials in the message for expressing the objective or purpose of the particular communication. The treatment of the message is the manner in which the message has to be prepared, processed and delivered. Treatment of the message is the most important dimension. The success or failure in communication depends to a large extent on the correctness or accuracy and essence or substance of the message. The following are some of the necessary characteristics of a good message; should satisfy the objective; should be clear; should be in level with the mental, social and economic capabilities of the audience; should be significant; should be specific; should be simple; should be timely and appropriate; should be accurate; should be appealing and attractive; should be adequate; and should be applicable. To ensure all the above qualities of a good message, the treatment is an essential prerequisite. It refers not only to the technique and details of procedure but also to the actual content for its presentation. Treatment of the message is directly connected with the technique employed, for presentation, and its purpose is to make the message clear, understandable and realistic to the audience and therefore, the communicator must have proper skill for treating the message. Treatment is the actual process of preparing the message for meaningful and purposeful assimilation by the audience. In general, treatment may be understood as the choice of words, the organization of ideas, the proper sequence of emphasis, repetitions, alterations of tempo, etc., which are required for ensuring clarity, simplicity, intelligibility and appeal to the message. 3. Channel
The sender and the receiver of the message have to be connected with each other through a medium or channel of communication. In face to face communication there is no particular medium except the atmosphere. When message have to be transmitted to distant places we resort to various types of media or channels of communication. The physical bridges between the sender and the receiver of the message are the channels. In general, there are three aspects of communication: a. Encoding and decoding of message b. Message vehicle - sound waves, electrical wave, etc. c. Vehicle - air, wire, microphone, radio, etc.
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4.
Selection of channels
It is very important for the communicator to find the proper channel for his message. The channel must be easily available and accessible to the receiver and also the receiver should be acquainted and accustomed to utilize the message coming through the particular channel. While selecting the channel the communicator has to make sure that noise is kept to the minimum or eliminated. Another important precaution is that the medium should not become a barrier. 5. Audience or receiver
Audiences/ Recipients of HE are people who may be reached as individuals, in groups, through organizations, as communities or sociopolitical entities. In a good communication process the receiver can take the role of source or communicator for the purpose of giving feedback. Therefore, in teaching/learning situation the communicatee has to develop skills for proper communication. The receiver should be able to receive the message physically, mentally and psychologically. He/she should be confident and eager to receive. He must have faith in the source and must view the source with due regard and cordially. The level of intelligence or knowledge is of particular importance to the communicator. The position or status of both the communicator and communicatee should also be considered. In certain situations the communicator will have the required credibility with the audience whereas in some other situations, he may be a 'persona non-grata'. Understanding of the value of position or to and from communication is of great utility in learning situations. This is of particular importance in communication in-groups for extension education. The greater the audience participation in the communication the greater the involvement and acceptance. There are 4 dimensions of audiences: 1. Sociodemographic characteristics 2. Ethnic & racial back ground 3. Life cycle stage 4. Disease & at risk status D. 1. PRINCIPLES OF COMMUNICATION
The perception of the sender and receiver should be as close as possible to each other. The sender or communicator should remember that the receiver has got his own individual perception. Individuals look at things in their own way and have likes and dislikes and attitudes depending on what they understand and how much. The extent of understanding will depend on the extent to which the two minds come together. In a class room teaching or in group discussion or in mass communication the sender must have some idea of the perception of the receivers. For effective communication there should be involvement of more than one sensor organ for giving a cumulative effect. While transmitting any information the communicator is performing voluntary act or movements, either he speaks, writes or makes gestures or produces noise or employs signals or symbols, etc. The receiver receives the message through the sensory organs. All the sense organs can perform the act of receipt of message depending on its nature. A communication in which there is an opportunity for the different sensory organs to participate is much more effective than when there is a lesser number of sensory organs involved. The more the communication takes place face-to-face the more is its effectiveness. In any 25
2.
3.
situation it is needless to mention that the direct face-to-face communication surpasses all other modes of communication. The face-to-face communication lends itself with out any special effort for a proper feedback mechanism. Further in the face-to-face communication there is o need to employ any other medium than air. The only additional support that may be required will be the use of suitable visual aids and demonstrations if found necessary. When face-toface communication is not possible one has to resort to the use of suitable media or channels of communication like the telephone, telegraph, mass media, etc. 4. Any communication without two way process is less effective because of the lack of opportunity for concurrent, timely and appropriate feedback. Whether in face-to-face communication or in indirect communication through various media and channels, the communication can be made effective, if a provision is made for feedback. To make this possible the communication process should become a two way or to and from process. There should be scope for a free exchange of ideas. A two-way communication not only helps in getting feedback but also improves the climate and relationship between the communicator and the communicatee. Since the two way communication is not always possible, such as in the case of use of mass media, one has to utilize other methods of getting feedback either though audience analysis, survey, etc (post-communication & feedback mechanism). Two way communication additionally brings together the perceptions, and subjective worlds so that they start thinking and feeling together.
What are the pre-requisites for effective communication? A. 1. 2. 3. 4. 5. B. 1. 2. 3. 4. Communicator: The communicator should possess the following characteristics. He/she should be knowledgeable and fully conversant with the subject under discussion. He/she should have credibility before the receiver, which is gained by sincerity, honesty and intellectual capability. The communicator need to have proper communication skill and should have skill in selecting and using the channel. The communicator should have proper attitude towards the receiver and the subject matter. Feedback should be ensured. Message: The message content should be brief and clear. It should be need-based and timely and appropriate or relevant. It should be supported by factual material to give it proper authenticity. The channel should be manageable by the communicator and should be appropriate. Treatment of the message is also important. Its purpose is to make the message clear, understandable and realistic and specially situated for the channel or media that has been selected. Some of the salient principles in treatment of message for effective communication are as follows: (a) proper emphasis where required; (b) repetition for the sake of emphasis; (c) contrast of ideas and comparisons; (d) logical sequence; (e) redundancy for reduction of noise; and (f) no entropy, i.e., wastage or loss of information due to uncertainty or lack of clarity. Entropy is the opposite of redundancy. Channel It should be familiar both to the communicator and communicatee. It should be appropriate to the message. It should be available and accessible. 26
C. 1. 2. 3.
D. 1. 2.
Receiver Like the communicator the receiver also should have proper attitude and the desire to receive the communication. The receivers sensory organs should be intact and in good working conditions.
In general, effective communication can be considered from three important purposes. With regard to the effect it should be able to answer specifically in the communicatee as well as the communicator, the three aspects, i.e., (a) what a particular idea or thing is, (b) why it should be so, (c) how it can be done. The "what" portion gives the change in the knowledge level by supplying the necessary information and ideas. The "why" gives the support for change of attitude and "how" provides the solution and therefore, brings about the change in behavior. E. INTERPERSONAL Vs MASS (GROUP) COMMUNICATION
In social interaction communication normally takes place between the individuals and among the individuals in groups. When groups meet, apart from the multi-dimensional communication, that takes place ordinarily, there can also be a two way process of communication between the speaker, lecturer or educator and the group. For the individual approach and the group approach, the communication is usually face to face with or without the use of visual or auditory aids. When the entire community at large has to be contacted simultaneously, one has to resort to MASS MEDIA. The communication that is aimed to reach the masses or the people at large is called mass communication. In the present day the commonly used mass media are microphones or public address systems, radio, cinema, television, newsprint, posters, exhibitions, etc. INTERPERSONAL COMMUNICATION Personal communication includes personal contact between doctor and patient, between teacher and student, between health educator and client, etc. The decisive criterion for personal communication is that communication happens at the same time and place. Personal communication means interaction between two or more people who are together at the same time and place. Advantages 1. 2. The transmitter speaks the receiver listens; then the receiver speaks, the transmitter listens; they both interact with each other. Questions can be asked and answered, facts can be stated definitely and specifically. The participants can repeatedly make sure that they understood each other. It is a constant feedback process in which both parties are involved. The same applies to communication within a group; here the interchange takes place first of all between the leader and the members of the group, and secondly among the individual members of the group. Multi-channel effect of personal communication. In mass communication one can either read, or hear and see the information. At most two channels are used. On the other hand, in personal communication two or more people sit together in a room, where they can see, hear, smell, touch and feel each other. That is to say, they transmit and receive on both verbal and nonverbal channels; far more senses are involved than is possible in mass communication. Useful in all stages of adoption of innovations. Useful when topic is a taboo or sensitive.
3.
4. 5.
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Disadvantages 1. 2. 3. The fact that it calls for the use of many languages; Requires personal status; Needs professional preparation and knowledge.
Some important ideas regarding the use of personal communication Education providers need: to develop a permanent exchange of ideas with clients, if not, " the health educator is no better or even worse than a TV set"; to realize the importance of the impression made when we meet a person for the first time; to learn to observe the person we face and to derive from this observation useful information for our work; to keep in mind that the same words mean different things to different persons; to pay attention to the body language of our partners and to our own: non-verbal behavior tells often more words about people's feelings.
USE OF MASS MEDIA OR MASS COMMUNICATION The aim of mass communication in health education is to create awareness of a problem, to transmit knowledge, to set and change norms, and if possible to offer alternative of behavior. Mass communication is one sided. The broadcaster transmits his message without knowing immediately what is going on in the receiver's mind, whether he feels concerned or understood, or whether he is unaffected by the message. Mass communication lacks direct contact. The word media is used currently to refer not only to print media, radio and television but also covers traditional means of communication such as puppet plays and folk art. In many countries health messages may be communicated through traditional media such as art, town criers, songs, plays, puppet, shows and dance. Combining with interpersonal approaches is very useful and may be critical to the success of communication. Despite all efforts to create better educational tools, still the most effective means remains the personal contact, with its one-to-one relationship where "teacher" and "student" change roles continuously, each learning from the other. This is the dynamic, constructive communication. Hence, the importance for health service providers to recognize the importance of two-way communication and be technically prepared to perform this function as integral to their daily tasks. Mass media have the greatest impact at the stage of awareness. Also on disseminating technological ideas particularly to pass to early adopters (opinion leaders) and from there to late adopters. Mass media is useful in increasing health knowledge. Mass media is also useful in increasing self-awareness and influencing attitude change, decision making and behavior change. Mass media messages, however, must be very carefully designed, so that the right message gets to the target audience in a form appropriate to their needs and lifestyles. It should be realized though that there is a poor feedback when utilizing mass media. By and large, the purpose of mass communication is to sensitize the minds of people. Mass media help in creating public opinion and public support. They can also help in giving an emotional appeal when any particular propaganda is launched. During natural disasters, calamities, the mass media have vital importance because it is not only useful to flash the information and alert the people but also serve in
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bringing about the required behavior. Mass media also serve the big purpose of providing entertainment to the mass. The communicator should be able to select the correct media. However, depending on the resources it is generally the practice to employ as many media simultaneously in order to get the message across in a short time. Moreover, there are certain constraints with regard to the mass media like availability, accessibility, popularity, etc. The information theory emphasizes on reduction of uncertainty or noise or disorganization of a situation at the receiving end. Apart from whether the information is reaching the receiving end or not, it is also subject to different kinds of mutations or interference. Distortion may occur due to barriers and other causes. Distortion is the twisting of the message and loss of clarity and certainty. The information theory mainly focuses on the need for clarity and the reduction of uncertainty. Advantages of a mass media: 1. 2. 3. They can reach many people quickly. They are believable. If people read something in a newspaper or hear it on the radio, they tend to believe that it is not only true but also important. This is especially true if the "voice" is from a highly respected person (e.g. respected doctor). They can provide continuing reminders and reinforcement. In order to promote breast-feeding, repeated radio messages help mothers to remember why it is important for their babies health.
Some of the disadvantages of mass media include the following: a. b. c. Mass communication may create anxiety (as in the case of HIV/AIDS) or insecurity when contradictory messages is transmitted. The fact that "others", in large numbers, are exposed to the same appeal may create a sort of "this doesn't concern me" type of attitude. The multitude of the stimuli emanating from this type of communication obliges the individual to develop a filtering mechanism in order to protect himself.
Three key principles in achieving successful mass campaigns, namely: 1. 2. 3. Clear definition of objectives based on reliable research findings, including public opinion; Co-ordination of the activities undertaken by all groups involved; Continuous evaluation and feedback.
F.
Communication aids - projected Vs non-projected
Whether in the classroom situation or in a conference or in a community gathering or individual approach, communication is facilitated and strengthened or reinforced by the use of suitable audiovisual aids. Aids are facilitators of communication both for the sender and for the receiver. Audio visual aids are various kinds and can be broadly classified as audio aids and visuals or projected and non-projected aids (or graphic or picturesque aids). The most essential principle of the use of aids is that the aid is so prepared and utilized that it facilitates communication rather than hinders. Since perception is at the base or the receipt of stimuli and their interpretation, aids will be useful if they can give meaningful message through the different sensory organs of the receiver.
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While discussing about media or aids in general, the principle underlying the proper selection of aids to ensure its relative efficacy or utility will be understood in a rational manner by depicting a model, which is known as the "cone of experience". The cone is so prepared that at one extreme the suggestion is the direct experience of the different senses, whereas in the other extreme is the abstraction or symbolization by words. The base of the cone represents the direct experience and when we move up we have different stages of decrease of direct experience ending up in mere visual and verbal symbols. However, the abstractness or the stimulus response through mere words, or gesture or visual symbols need not necessarily be of poor effect as compared to direct experience. Classification of Aids 1. PROJECTED AIDS: the film (cinema), filmstrip, slides and transparencies
Film or the Cinema Advantages: 1. 2. 3. 4. 5. 6. 7. True-life situation is reproduced. A complete view of all physical aspects of anything is made possible. Since the film is under motion an actual process of act or event is understood without having to be explained separately. It is self-explanatory. It adds a special interest in the audience to watch the film. It gets more attraction and attention than listening to a talk. Many emotional effects can be brought about in the film, which will leave a lasting impression in the mind. In the motion picture the coordination of sound and sight provides a realistic effect.
Limitations 1. 2. 3. 4. 5. Electricity or battery should be available. The place has to be darkened. Often a shelter is required to project special equipment. A technician to operate the projector is required. The equipment and the preparation of the film are both very costly.
Filmstrips This is a film in its process and preparation but it is a much smaller affair. While the film runs into greater length, a filmstrip is usually within a meter or two. The use of a filmstrip is especially suitable for educational methods with small groups. It is not suitable for large groups or as a mass media. It is specially used to tell things in a systematic and sequential manner with suitable illustration and necessary pause for the group to see and learn. Filmstrips are exclusively used only for educational purposes. Since it is done in a small group and since it is possible to manipulate it forward or backward there is plenty of scope for discussion, asking questions and repeating the same film if necessary for clarification. The filmstrip is relatively cheaper than the film. However, its use is limited to the availability of a projector and dark room arrangement and electricity. It is quite easy to operate. It has been found a very useful aid for supplementing technical information.
Slides
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Slide is a transparency of any picture or write-up prepared on transparent materials. It can be projected by the use of a slide projector. Slides can both be used for smaller as well as larger audiences and also for educational purposes too. Transparencies Transparencies are large size slides. They are projected with the help of an overhead projector. Transparencies are meant specially for group situation. It can be easily prepared within a short time. Transparencies are of particular value in a classroom, seminars, and symposium, etc., where a group of people has to discuss a technical subject. Television This is a combination of wireless and cinema. TV is widely used in schools, airports, railway stations, exhibitions, etc. The advantages of TV are many. Many topics can be projected and can be conveyed. It can provide entertainment as well as educational materials. It can cater to all groups. Disadvantages are the cost and accessibility. Electricity is required. 2. GRAPHIC OR PICTURESQUE AIDS
These aids essentially consist of drawings, sketches, cartoons, pictures, etc., and also graphs, chart, tables, etc. They are shown or displayed as such and do not necessarily depend on any projected equipment. Picture The picture is drawn or painted and is the expression of ideas and feelings. A picture is drawn according to the perception of the mind. Photograph A photograph is the actual image of any object or person, taken by the application of the principle of light devised in a photographic camera. Poster Poster is a picture with a message or caption or slogan written not only to explain but also to catch the attention of the passersby. Occasionally posters may have mere written matter and no picture or drawing. Posters are generally used for mass education and are displayed in prominent places where people move about in large numbers. Posters are also displayed in exhibitions. To make a good poster the following points should be remembered: 1. It size should be large enough to draw attention to the public from near and far. 2. The message in the poster should be able to stimulate the thinking of the audience. 3. Always put one single idea for each poster and not to bring in a number of ideas in the same poster and make it unintelligible. 4. The subject matter should be as short as possible, so as to fix and hold the attention of the people. 5. The letters and designs should be bold and big enough to seen from a distance. 6. The lay out of the picture must be properly balanced to give a correct sense of proportion and
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inter-relationship between pictures. Posters are widely used in public places to catch and fix the attention of the public. They are cheap and can be taken to distant places. But posters can also become monotonous and stale if not changed frequently; moreover, because they are stuck up or displayed in public places they may be damaged easily. Cartoon It is a design or sketch on paper or cloth usually of the nature of a caricature illustrating and making fun of topical events. Cartoons are generally made in newspapers or magazines to give satirical or jocular commentary on any events. Flash cards A set of pictures with suitable captions or write-ups is prepared on any theme. Each one will represent a particular idea, and the cards are arranged in proper sequence so as to send out the message to the audience. The flash cards can be used by any educator and shown to the audience with necessary verbal explanation. Charts & Graphs Chart is used to present numerical data as well as materials in abstract form. Graph is a chart form that is used to present statistical data and present the relationship between variables. Charts and graphs are useful to summarize, explain and interpret numerical facts by means of points, lines, areas, geometric forms and to facilitate comparison of values, trends, and relationships. Charts are more effective in creating interest and eliciting the attention of readers. They help in understanding the meaning of the mass statistical data, which are visualized at a glance. The visual relationships as portrayed by charts and graphs are more clearly grasped and can be easily remembered. Map Map is an accurate representation in the form of a diagram of the surface of the earth or of some parts of it, drawn to a scale. Printed materials: books, pamphlets, booklets, brochures Leaflets, folders, brochure; booklet and pamphlets A pamphlet is also called a brochure or booklet. Single sheet with one or more folds is often spoken of as pamphlets. They are folders of leaflets. An unfolded sheet is a leaflet file or handbill. A pamphlet must as brief as possible. Display boards: Flannel Board, Bulletin (notice) Board, and ChalkBoard 3. THREE DIMENSIONAL AIDS
Here the actual specimen, objects, models, etc. are put up for demonstration. Models are prepared to imitate the actual objects or specimens. Diorama is a model with background and other objects in the environment, which give a three dimensional effect. It is prepared on cardboard or suitable materials in such a way that the objects can be projected out for display and put back and folded when not in use.
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4.
AUDIO AIDS
The common ones in use are megaphone, microphone or public address system; gramophone records and discs; tape recorder and the radio. These serve very well to reproduce spoken words or any kind of noises made and help in repeating the same a number of times. They are very useful in teaching and also for entertainment and mass communication. 5. AUDIO-VISUAL AIDS
A combination of visual and auditory stimuli for communication can be more effective than either visual or auditory alone because of the involvement of two sensory organs. 6. OTHER AIDS: Folk songs, folk dances, drama, puppet show, puppet stage, puppet plays
These folk media are used to introduce sociological themes. G. 1. Counseling (Health Education with individuals) PURPOSE OF COUNSELLING
Through counseling, an individual is encouraged to think about his problems and thus comes to a greater understanding of their causes. From this understanding that person will hopefully omit himself to taking action that will solve the problems. The kink of action that a person takes, will also be that person's own decision although guided, if necessary, by the counselor. Counseling means choice, not force, not advice. A health worker may think that his advice seems reasonable, but it may not be appropriate to the situation in which the individual lives. Through counseling, the solutions are more likely to be appropriate. An appropriate solution will be one that the person can follow with successful results. 2. RULES FOR COUNSELLING
The health worker in this example had obviously not learned the techniques of counseling, otherwise he would have followed the simple rules below: Relationships: A counselor shows concern and a caring attitude. He pays attention to building a good relationship with the person he is trying to help from the beginning. People are more likely to talk about their problems with someone they trust. Identifying needs: A counselor seeks to understand a problem as the person sees it himself. The people must identify their own problems for them. The use of open comments will help here (see page 120). The counselors task is to listen carefully. Feelings: The counselor develops empathy (understanding and acceptance) for a person's feelings, not sympathy (sorrow or pity). A counselor would never say, "you should not worry so much about that." people naturally have worries and fears about their problems. A good counselor helps people to become aware of their feelings and to cope with them. Participation; A counselor never tries to persuade a person to accept his advice. If the advice turns
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out to be wrong, the person will be angry and no longer trust the counselor. If the advice is right, the person may become dependent on the counselor for solving all his problems. A Counselor helps a person to think about all the things affecting the problem, and encourages him to choose the solutions, which are the best for his particular situation. Keeping secret: A counselor will hear many personal and possibly embarrassing problems. This information must be kept secret from all other people, even from the person's relatives. If someone you are counseling discovers that you have told other people about the counseling session, that person will no longer trust you and will avoid you. A person may even get into trouble because of what the counselor told others. A counselor always respects the privacy of the people he is helping. He never reveals information unless he has been given specific permission. Information and resources: Although a counselor does not give advice, he should share information and resource ideas which the person needs to have to make a resource ideas which the person needs to have to make a sound decision. For example, many people do not realize the connection between their behavior and their health. A counselor does not lecture, but he should provide simple facts during the discussion to help people have a clearer view of their problem. All health or community workers can practice a counseling approach in their work. Parents and friends can be counselors too. The important thing is friends can be counselors too. The important thing is that the health worker, teacher, father or friend be willing to listen carefully and encourage the person in need of advice to take as much responsibility as possible for solving his or her own problem. Now that you have read about the rules for counseling, think again about the mother's problems? How could the other relatives in the house have been involved? Can you think of possible alternative solutions to the problem? 3. DIFFERENT TYPES OF COUNSELLING
Counseling with families A person may need the help of his family to solve a problem. Counseling skills are useful whether working with one person or a whole family. When working with a family, we are dealing with More than one person, therefore there may be more than one problem, more than one need and surly more than one solution. Also be aware that in families different people have different responsibilities and powers. The father, for example, may be the main decider on the types of food eaten. Grandparents influence the degree to which families follow traditional customs. Find and talk to the right person for each problem. Also show respect to the recognized head of the household. Counseling with children In a clinic, school or the community, you will find children with health, emotional or other problems. Counseling can be provided for them if they are old enough to talk. It is better, to talk to the child alone. Background information can be obtained from the parents first; then they can be politely asked to wait outside. Sometimes parents want to answer all the questions; they do not allow the child to speak for himself. The child may also fear saying certain things in front of his parents. The counselor should explain to the parents that the child might speak more freely without others around.
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Begin by talking about happy things. Ask the child about his favorite games, for example. Once the child is relaxed, begin talking about his problem. Let the child know that all he says will be kept secret. In this way he will trust you and speak freely. Always keep that promise. If parents, teachers, or others find out what the child said, he will fear the counselor and will never let him help again. Follow the counseling rules with a child as you would with an adult. The child will be able to learn much about his health from a good counselor. Home visits Counseling can be done in the clinic or at school, but it is also helpful to visit the person at home. A health worker should visit all homes in his community regularly. If the village is small, with 10-25 houses, visits can be made at least once a fortnight. In larger villages or neighborhoods visits can be made monthly. Here are some reasons for home visits: Keeping a good relationship with people and families; Encouraging prevention of common diseases; Detecting and improving troublesome situations early, before they become big problems; Checking on the progress of a sick person, or on progress towards solving other problems; Educating the family on how to help a sick person; Informing people about important community events in which their participation is needed. Much can be learned from home visits. We can see how the environment and the family situation might affect a person's behavior. Does the family have resources such as a well? What relatives stay in the house? Do they help or hinder the person's progress? When people are in their own home they usually feel happier and more secure. We often find that people are more willing to talk in their own home than when they are at the clinic. At the clinic they may fear that other people will see them or overhear the discussion. They may tell more at home, because they feel safer there. Nutrition demonstrations, for example, may be more useful if done in a person's home. There the health worker will be able to use the exact materials and facilities that the person must use. This will make the demonstration more realistic and make learning easier. 4. Education methods used in counseling
There are various education methods that can be used to help individuals and families solve their problems some help people understand the cause of their problem. Some help them see possible solutions, while other methods help them reach decisions for action. We have seen in chapters 1 and 3 how important it is for us to place ourselves in the position of other persons and understand why they behave as they do. But people themselves are not always aware of their motivations, or why there is a problem. Our role therefore is, first, to understand the problem and then, to help the people understand it themselves and to find the solutions that are appropriate for their situations. Sometimes a person may be reluctant to take the necessary action to solve his problem. He may not feel that it is worth the time and effort. Encourage him to examine his values in order to take some decision about the importance to be placed on his health and welfare. Another way to help people decide to act is the use of self-reward. People should decide on a reward
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that they will give themselves if they follow through with the necessary action. It is important to help the people choose solutions that will fit in with their way of doing things, and with their beliefs. Try to help people avoid solutions that are uncomfortable. Find workable alternatives. Always remember that counseling calls essentially for a personal approach and for skills in listening, in providing information, and in helping people determine what is best for them. H. HEALTH EDUCATION WITH GROUPS
THE VALUE OF GROUP EDUCATION Using the group approach to educate people has a number of advantages. 1. It provides support and encouragement. Keeping to a healthy behavior is not always easy. In a group one can find the support and encouragement needed to promote healthy actions and to maintain them. It enables the sharing of experiences and skills. People learn from each other. A member may have tried a new idea and found it successful. Through that experience he gained skills which he can teach to other group members. It makes it possible to pool resources. Group members can pool their resources. One farmer may not have enough money to buy a vehicle to transport his produce to market, but a group of farmers together could contribute enough money to meet that need. Members of a group can give money, labor or materials to one of their members in times of personal or family crisis. They can also give support to the promotion of community health through projects such as safe water supply.
2.
3.
In summary, because some problems are difficult to solve by individuals alone, a group approach to health education is important. EDUCATION WITH INFORMAL GROUPS The first thing when dealing with an informal group is to find out what the common interests and needs of its members may be. Women who attend market for example are concerned about good quality food at reasonable prices. Health education with informal groups should be based on common interestswhatever these may be. A topic related to the interests of the women attending market might be "preparing inexpensive but nutritious meals." As you often do not know who belongs to informal groups, you may have to find out their needs through indirect means such as clinic records. That is what was done in the sample program, which we will describe. Another concern in educating informal groups is that not all the members may know each other very well. You will have to develop relationships and encourage participation. Try to make people in the group feel welcome. Point out their common interests and needs. EDUCATION WITH FORMAL GROUPS
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It is possible to plan a greater number and variety of educational programs with formal groups. This is because formal groups have definite purposes and interests, specific leaders who can mobilize e the group, and commitments to meet regularly and carry out action. Since the members are known, it is possible to gain more participation from them in the planning and varying out of a program. Health Education with Communities Community health education is needed when a problem affects many or all people in the community and when the cooperation of everyone is required to solve the problem. How can you develop health education at community level? There are two points to keep in mind: 1. 2. One should get the support of influential people in the community, those who are called "opinion leaders" or "key persons", One should get a maximum number of people involved so that the community will really strengthen its capacity to do things for its health. This can be done through local community organizations, community health committees, interpersonal coordination groups, advisory or planning boards, etc.
Before starting a new structure - be it a health committee, an advisory board, local association or council to facilitate inter-sectoral coordination - investigate carefully the structures that already exist in the community and see if they could serve for the purpose you envisage. It is often tempting to create a new group but it may be wiser to extend an organization that has proven its worth.
ORGANIZING A HEALTH CAMPAIGN Campaigns can be planned to promote health knowledge, skills, attitudes and values on a particular health issue. They may also be used to accomplish a particular community improvement project. A health campaign is organized around one issue or problem. The campaign is said to have them participated. Examples are "Clean up the community", "Immunize your child", Good Food for Healthy Bodies", "Clean water for Good Health". The theme should be based on a real problem that has been identified by the community members themselves or is recognized as such. If there were a health committee in the community, it would be active in identifying issues for such campaigns and planning the action to be taken. The actual community activities of a campaign often take place during only one week or one month, For this reason, campaigns are often called "Health weeks". SPECIAL COMMUNITY EVENTS Every community has festivals, celebrations and ceremonies. These may mark special seasons of the year ceremonies. These may mark special seasons of the year such as harvest time, the planting season and the New Year. Some festivals are religious or political, others in remembrance of national events and heroes. There are usually many such events throughout the year. Some festivals are a time for enjoyment and relaxation. Others call for serious thinking and quiet
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devotion. Whatever the purpose of the festival may be, the whole community usually participates. I. Barriers of communication
The reasons for failures of HE programs can be separated into four overlapping groups, which are described in detail below. A. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. B. 1. 2. 3. 4. 5. 6. 7. 7. FAILURES IN THE PLANNING PROCESS TO APPLY EPIDEMIOLOGICAL AND BEHAVIORAL SCIENCES TO THE SELECTION OF APPROPRIATE OBJECTIVES Insufficient understanding of epidemiology so that the behaviors selected for the objectives of health education is not linked to the disease in question. Choosing inappropriate behavior objectives that are unrealistic for the community to change because of economic, social or cultural barriers and are low priority compared with other felt needs. Over-emphasis on behavior change as the path to good health without accompanying economic and social development, which tackles poverty and social inequalities. Failure to ensure that all the required enabling factors is provided, e.g., adequate money, resources, time and appropriate and accessible services. Health education programs in mother and child health which fail to take into account the already heavy workload of the women in the home and agriculture. Putting the emphasis on traditional beliefs as the cause of a health problem without looking for other possible explanations. Directing health education at the individual without taking into account the influence at the family, community and national levels, e.g., pressure of other people, availability of services, government policies, unemployment, etc. Ignoring influences at the national level, e.g., commercial advertising, powerful pressure groups, government policies, etc. Failure to carry out even simple research ("community diagnosis") on how the community view their problems, the role of beliefs, pressure from others, and economic and social factors. Failure to develop community participation in the health education planning process. COMMUNICATION FAILURE IN REACHING THE INTENDED AUDIENCE AND PROMOTING UNDERSTANDING AND ACCEPTANCE OF MESSAGES Using HE methods and channels of communication that only reach the better off and welleducated people and fail to reach those whose health is the poorest: the poor, mainly rural, low educational level, low utilizers of health facilities. HE messages not understood because of difficult and unfamiliar concepts, language, complex wording and confusing pictures. Cultural and social distance between the health educator and the community resulting in poorly designed communications, which take little account of the way ordinary people, think and talk. Use of HE materials produced abroad or from the national headquarters, which may not be appropriate for the local community. Failure to test HE messages to see if they are correctly understood and will promote change. Over-emphasis on the "hardware" of communication, e.g., slides, films, leaflets, and visual aids rather than the building up of understanding, empathy and trust between the health worker and the community. Too much emphasis on mass media such as radio. While efficient at promoting knowledge and 38
8. 9. 10.
awareness, mass media are poor at promoting behavior change compared with community level programs involving fact-to-face communication. Ignoring the traditional methods of communication such as story telling, songs, and drama which may be a familiar part of the culture of the community and are both popular and understood. Low credibility and respect of the health educator in the eyes of the community due to factors such as age, sex, training, personal behavior and perceived irrelevance of advice. Too much reliance on formal teaching method such as lectures, and talks rather than those in which the learner actively participates and feedback and discussion are encouraged, e.g., group discussions, problem-solving exercises and role plays. FAILURE IN THE ORGANIZATION OF HEALTH EDUCATION SERVICES AND THE WEAK STATUS OF THE SPECIALIST HEALTH EDUCATOR Lack of a clear government commitment and national policy for HE. Low priority for HE in health services compared to curative medicine. Poor understanding of the role and importance of HE and prevention on the part of politicians and the public. Failure to develop the HE potential of different agencies outside the health services, e.g., schools, community development, agriculture, adult education, radio and television services. Uncoordinated, conflicting and sometimes inaccurate advice on health from different field workers and agencies. HE is left to a small group of "HE specialists" only. Other health workers, teachers, etc., say that it is not their job. The weak position of the HE specialist e.g., low status, lack of training, low power, poor career and promotion opportunities. Frustration of the health educator because of isolation and lack of understanding, encouragement, support and practical help from others, including national health education services. The overall responsibility for health education in health services and the key decisions on the content of HE programs are in the charge of medical personnel with little training in the behavioral sciences and communication. FAILURE IN THE EVALUATION PROCESS AND THE DISSEMINATION OF RESEARCH INTO DECISION MAKING Failure to evaluate even at a simple level. Evaluation based only on measurement of effort and activity and not impact and change in the community. Failure to produce evidences that HE is effective and deserves funding. Reluctance to carry out evaluation of failures to determine the exact causes of failure and learn from them. Demonstrating that change has taken place but providing no evidence that change has been the result of the HE programs and not other factors. Insufficient description of programs making it difficult for others to assess special features of programs and community that affect success and replicability. Not sharing with other health educators the evaluations of success or failure. Lack of opportunities, e.g., a magazine or regular meeting places where heath educators can exchange experiences on their work and discuss wider issues on the organization and support of HE activities. Narrowly conceived concepts of research and evaluation, which allow no opportunity for participation of health workers and community in the evaluation process. 39
C. 1. 2. 3. 4. 5. 6. 7. 8.
D. 1. 2. 3. 4. 5. 6. 7. 8. 9.
IV. EDUCATION AND EDUCATIONAL METHODS Education is the basis of all learning. Learning is a totality of change of behavior through acquisition of knowledge. A subtle difference between education and learning is that the learning can be passive or incidental; whereas education is a deliberate effort. It is implied that education includes learning because when the process of education starts, learning also takes place; whereas learning can be purely incidental sometimes merely due to circumstances and not through a definite effort to learn. Both learning and education can take place through a teacher or instructor or by the individual selfalone. Learning is a process by which the individual acquires information and ideas, which may later result in change of attitude and behavior. Learning is the basis of behavior. Education is the process by which learning is facilitated. Or education is the process in which an individual or individuals or group of people are given the facilities or opportunities by an agent or educator to learn. There can also be the self-learning process or self-education. With regard to HE the target group or audience will vary from situation to situation. The variation will be according to sex, age, literacy, caste, economic status, occupational status, health status, residential status, location (hospital and community), etc. The educator must use his judgment and discretion to choose a proper educational method and also proper aids, media, etc., to enable the group or individual to learn and benefit out of the experience. EDUCATIONAL METHODS a. FORMAL PRESENTATION METHODS 1. Lecture or speech
It is an oral presentation. The speaker has to be conversant with the subject. He has to organize his thoughts and ideas. It is a simple and quick traditional way of presenting the materials. Lecturer or speaker can prepare the talk in a logical fashion and can talk uninterruptedly. Nobody can normally interrupt or intervene. Nowadays lectures are supported by suitable visual aids. As far as the audience is concerned lecture has advantages as well as disadvantages. They have to be passive listeners. So there is no need to read. They can take notes if they want. But if the speaker is not impressive and effective the listeners will get bored, sleepy, distracted and so on. Since the speaker is would not like to be interrupted a good feedback is somewhat difficult. The lecture method is more advantageous to a mature group than to an immature group. The lecture method may prove ineffective if: a. b. c. d. The speaker wanders from the subject; The speaker does not talk with proper introduction; emphasis, etc., The speaker talks in a high flown language not understandable by the audience; and The speaker distorts facts for selfish purposes. 2. Dialogue
Instead of a single lecture, two persons with expertise carry out a discussion or dialogue between themselves in front of the audience for the purpose of educating them. The dialogue as an educational method is easy to arrange and carry out. Since two persons take responsibilities there is likelihood of greater interest generated. However, care should be taken to see that the discussion does not deviate
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from the subject. Dialogue is also applicable to a more matured group. 3. Symposium
This is a lecture in one form but the difference is that different speakers are asked to give a lecture on the same subject. The speakers prepare the talk in such a manner that each one of them presents a particular aspect of the subject. Ultimately the audience gets the benefit of the understanding of the subject with its different aspects dealt separately by each speaker. The symposium is of special use and relevance in any subject where a number of experts are available to take up different issues and view points and thrash them out. Because of the variety of speakers the symposium is more interesting than the lecture by one person alone. The symposium does not allow or give any scope for audience participation and feedback. Symposium is of particular application to a mature group who has the listening attitude and the capacity to appreciate the different aspects of the subject by listening. Needless to say expert members must be available to make symposium impressive and effective. 4. Panel discussion
In this educational method a small group of persons get around the table in the presence of the audience and discuss among themselves the topic or subject which is relevant to the audience and in which the panel members have specialized knowledge. It is a to and from discussion among the panel members to touch on all aspects of the topic and the audience appreciates the same by listening. In a panel discussion also there is no scope for the audience to participate. However, if there is an arrangement by which the audience can be allowed to throw questions or comments towards the end then it becomes panel discussion forum. 5. Colloquy
In this method a few members from the audience are made to stimulate discussion by presenting the problems or raising questions to a group of experts on the stage and the experts give their comments and answers on the various aspects. A colloquy is especially useful when there are specific problems to be discussed for solution. One of the experts acts as a moderator and conducts the discussion. The effectiveness of the colloquy will depend on the efficiency of the moderator. The advantage of colloquy is the direct audience representation and participation. It provides opportunities to extract information from experts. If the problems were controversial in nature the experts would be able to pinpoint the solutions within the available time for discussion. 6. Forum
In the formal stage setting of lecture, symposium or panel, if it is desired to give opportunity to the audience to participate by raising questions, doubts, etc., the forum is arranged for at the end of the panel discussion, symposium or lecture. It is otherwise question time for the audience. It is a good feedback mechanism.
b.
GROUP DISCUSSIONS 41
Among the "discussion-methods", group discussion is the most commonly employed method. It is a valuable educational method because the participants are given equal chance to express freely and exchange ideas. It is a collective thinking process to solve problems. Problems are also identified collectively and the solution is worked out by pooling ideas and expertise. Group discussions have been found extremely useful because of the commonness of goal and collective planning and implementation. The group discussions can be formal and informal. In classroom situations and in the academic climate, group discussion tends to be formal. The extension educator working in a community has a scope to organize both formal and informal group discussions. There are specified types of groups, which have been evolved, and these are: 1. Buzz group or Buzz session
A large group is divided into small groups, or not more than 10 or 12 people in each small group and they are given time to discuss a problem. The different groups are either allotted different specific problems or the same problem is allotted for all. The whole group is reconvened and the reports of the large group will report their findings and recommendations. In the plenary session final documentation will be made (This is very similar to a workshop). 2. Workshop
A large number of people belonging to a particular or discipline or allied disciplines collect together to take up specific issues and problems for making recommendation for future action. The methodology of working is very similar to Buzz session but the workshop generally extends for the period of few days (usually a week's time). Moreover, experts, advisors, and speakers are employed to guide the group. In the buzz session there are no advisors except the guide of the entire group. The workshop is a meeting of people to work together in small groups upon problems which are of concern to them and relevant to them in their own spheres of activity and to find suitable solutions. Therefore, it is a problem solving method. Workshop is mostly applicable for people with previous experience on subjects and is more relevant to departments and institutions, etc., than in community groups. Workshops help in evolving policies, programs and methodologies. 3. Conference or Seminar
These are large groups convened amongst persons with common or allied discipline and interests. The technique for the discussion may be around a big table or panel discussion, symposium, etc. The conference can also be converted to a workshop if required. Seminars are generally with reference to learning or academic institutions. The members or participants of the seminar come together to exchange views on current problems or to share with others their own experiences and new encounter, experiments, discoveries, etc. The purpose of a seminar is to study the subject matter, by a group of persons under the leadership of experts in the field. Seminars very frequently are associated with research. Another type of seminar is the so-called convention. This is with reference to the particular organization or departments where groups from different administrative hierarchy come together to
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discuss about policy and ideas for strengthening the parent organization. Conventions are also spoken in connection with political and religious movements. They are merely conferences. 4. Brain storming
This is a modern method of eliciting from the participants their ideas and solution on debatable issues or current problems. Instead of discussing a problem at great length the participants in brain storming sessions are encouraged to make a list in a short period of time all the ideas that come to their mind regarding some problems without debating amongst themselves about the pros and cons of their own ideas. All the ideas are pooled and ranked according to the number of times that they think have been suggested by different individuals. Since the participants are allowed to think freely in sending their ideas in writing brain storming is also called ideation or image. 5. Role playing
Another educational method, which has gained importance and popularity particularly where skills have to be demonstrated, is the role-playing. It is also known as Psychodrama. It is acting out of a situation with natural ease and without any artificiality. Role play can be done by one individual or a small group of people can stage a role play to bring out the actual way of behavior expected from different persons with different responsibilities. It generally lasts for a very short time. It is spontaneous in nature, and part of the overall teaching method. It should not be mistaken with drama or play where the actors have specially practiced for the audience. 6. Demonstration
There are two educational methods of demonstration. One is called method demonstration and the other is called result demonstration. In the former the demonstrator demonstrates the actual process of doing a particular activity. In the later, the ultimate results or any useful procedure are shown to the trainees. In between there can also be a method of learning by doing. To start with the teacher can demonstrate a method and later the learner or trainee can practice this method and appreciate for self the results. Some method or result demonstration has got a special value in extension educator or community education for introduction of innovative ideas and practice. Both the methods of demonstration of procedure and results help the learner not only to learn how things can be done but also to feel assured or convinced about the result. The demonstration method or technique can be of great support to lecture or group discussion.
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V. HEALTH BEHAVIOUR MODELS Why Modeling?
Too many determinants and factors
Factors / determinants differ by various characteristics disease entity, demographic variability, environmental context, etc. Modeling: Attempt to propose a working set of determinants which are thought to be the most important factors or determinants affecting behaviors. Mitike 1: slides 2-14 Various theories and models have been formulated and tested which are used to understand and predict health related human behavior. These theories attempt to analyze why people practice certain health behaviors. In other words, it is very important to know what kinds of activities encourage learning and behavior change. A number of theories of health education have been proposed, where each attempts to identify what skills or knowledge must be learned and how they are best learned and performed. Some of such theories and models are discussed in detail in this chapter. 1. HEALTH BELIEF MODEL - ROSENSTOCK 1990
The most highly influential and widely researched theory of why people practice health behavior is the health belief model. The health belief model of Rosenstock (1990) and Backer (Janz & Backer, 1984) emphasize the intellectual dimension of health behavior. Recently it has added the psychological dimension of Social Learning Theory (Bandura; Rotter), and we might also add the social dimension from the Theory of Reasoned Action (Ajzen, 1988). The theory identifies the following knowledge as relevant: 1. Perceived threat is made up of the perception that one is susceptible to the illness (i.e., personal risk) and the perception that the illness is serious. If these two perceptions are high, then the perceived threat is high, and one will be driven to act to avoid the threat. That is cue for action is triggered by an individual's perception or by reading about health matters. The perception of personal health threat is influenced by at least three factors: general health values, which include interest and concern about health; specific beliefs about vulnerability to a particular disorder; and beliefs about the consequences of the disorder (i.e., whether or not they are serious. Thus for example, a person may change his diet to include low-cholesterol foods if he values health, feels threatened by the possibility of heart disease, and perceives that the threat of heart disease is severe. Outcome expectations are made up of the perceived benefits of the specified action (e.g., effective, inexpensive) minus the perceived barriers to the action (e.g., costly, time consuming). If the outcome expectations are high, they will specify exactly what action is taken. Behavior is evaluated from an estimate of the potential benefits of health seeking action to reduce susceptibility or severity. The benefits are then weighed against perceptions of physical, psychological, financial and other costs of barriers inherent in the health-finding effort. Demographic, social, structural and personality factors are included in some versions of the model as modifying factors since in theory they indirectly influence actual behavior. For example, the man who feels vulnerable to a heart attack and is considering changing his diet may believe that dietary change alone would not reduce the risk of a heart attack and that changing his diet would interfere with his enjoyment of life too much to justify taking action. Thus, although his belief in his personal vulnerability to heart disease may be great, his faith that a change of diet would reduce his risk is low and he would probably not make any changes. Self-Efficacy is confidence that one has the skill and resources to perform the specified 44
2.
3.
action. This comes from Bandura's social learning theory. If one has self-efficacy, one can perform the action with confidence and pride, though not necessarily with skill or expertise. Practice enhances self-efficacy. 4. Subjective norm refers to one's perception that significant other people will approve of the action. This comes from Fishbein and Ajzen's (1988) Theory of Reasoned Action. If you think that most of the important people you know and live with will approve of the action, you are likely to do it.
The theory does not specifically say how to learn or strengthen these ideas, other than through communication where the message addresses perceptions of risk, benefits, confidence, and norms. A large number of studies suggest that the health belief model explains people's practice of health habits well (for reviews, see Janz & Becker, 1984; Kirscht, 1983). For example, the health belief model helps to predict who will make use of free health examinations, yearly medical checkups, vaccines, and disease specific screening programs. Participants in these disease-prevention programs were more likely to value their health highly, feel susceptible to the particular disorder in question, believe in the power of modern medicine to cure disease if detected early, and believe in the importance of medical research. The health belief model has also been applied to participation in flu immunization programs, preventive dental checkups, genetic screening, breast self-examination and dieting for obesity, among many others. Typically, results indicate that health beliefs are a modest determinant on intentions to practice these health measures. Janz & Becker (1984) examined 46 studies using the health belief model to identify which components best predict the practice of health behaviors. Overall, perceived barriers to the practice of the health behavior was the most powerful dimension influencing whether or not people actually practiced a particular health behavior. Perceived susceptibility to a health problem was also a strong contributor. Some components of the model predicted sick role (such as taking care of oneself or seeking medical attention), but did not predict health behaviors very well. In particular, perceived benefits of a practice and perceived severity of the problem were both associated with sick role behavior, but these factors were less important in explaining preventive health behavior, such as not smoking or weight control. Not all research supports the health belief model, however. One of the problems that has plagued tests of the health belief model is that different questions are used in different studies to tap the same beliefs; consequently, it is difficult both to design appropriate tests of the model and to compare results across studies. Another reason why research does not always support this model is that factors other than health beliefs also heavily influence the practice of health behaviors. These factors include social influences, cultural factors, experience with a particular health behavior or symptoms, an socioeconomic status (SES). The health belief model appears to predict health behaviors best when other demographic factors, such as SES and education, have already been considered. 2. APPLIED BEHAVIOUR ANALYSIS - HEALTHCOM Group (Graeff, Elder & Booth, 1993)
This comes from operant learning theory. The analysis emphasizes behavior itself rather than perceptions or knowledge. A behavior analysis scale is provided to identify what health behaviors should be changed. Criteria for choosing the target behavior include: high impact on health, observable consequences of behavior, compatible with existing practices, behavior not too complex or costly or
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lengthy. The theory specifies that learning and behavior change take place as a result of reinforcing feedback from the behavior. The consequences of an action determine whether it will be performed or not. Positive consequences such as good health and approval ensure that the behavior will be performed. Consequences of the behavior most effectively strengthening it when they immediately follow it are salient and relevant to the person. They need to be concrete but not necessarily material. Praise and social recognition from one's family, the school, health workers, and community leaders are very effective. So is a certificate of merit, a symbol on one's house, a bar of soap, and a Litre cup. There are few natural consequences to preventive health behaviors other than the absence of disease. For example, child immunization leads to the absence of child diseases for the following 5 or 10 years. This is not observable. Without sophisticated knowledge of the cause-effect relation between immunization and disease prevention, a mother would be unaware of the important consequences of immunizing her child. For this reason, planned artificial consequences must be given during the health education project and then gradually substituted with other positive consequences that help maintain the behavior. Although the theory deals mostly with behavior and its consequences, the antecedents of behavior must also be examined. Antecedents are things that trigger action; they do not force the action to happen but they inform the person that an action is required. Examples are: seeing a health worker demonstrate making ORS, seeing a handbill that pictures the substances and quantities for making ORS, seeing the ARI or diarrhea symptoms of a child, talking about child spacing with one's spouse, seeing a pictorial reminder on one's wall of the next immunization session, recalling what one learned about weaning foods for one's infant, and deciding to dig a latrine. According to this theory, health education activities must encourage learning and performance of health behaviors by arranging antecedents and consequences of the behaviors. It is called the A-B-C chain: antecedents, behavior, and consequences. In summary Antecedents: stimulate action Behavior: skill and performance Consequences: strengthen behavior 3. THEORY OF REASONED ACTION - FISCHBEIN & AJZEN (1977 - 1980)
Another cognitive theory that attempts to integrate attitudinal and behavioral factors is Fishbein and Ajzens Theory of Reasoned Action. According to this theory, a health behavior is a direct result of a behavioral intention - i.e., of whether or not one intends to perform a health behavior. Behavioral intentions are made up of two components: attitudes towards the action and subjective norms about the appropriateness of the action. Attitudes toward the action are based on beliefs about the likely outcomes of the action and evaluations of those outcomes. Subjective norms derive from what one believes others think one should do (normative beliefs) and motivation to comply with those normative references. These factors combine to produce a behavioral intention and, ultimately, behavior change. To take an example, a smoker who believes that smoking causes serious health outcomes, who believes that other people think he or she should stop smoking, and who is motivated to comply with those normative beliefs will be more likely to intend to stop smoking than an individual who does not have these attitudes and normative beliefs. What is the value of thinking about health habits from the standpoint of this theory? A strong element of this approach is that behavioral intentions are measured at a very specific rather than a general level. That is, when people are asked about very specific attitudes and normative beliefs, it is possible to obtain a fine-grained picture of their intentions with respect to a particular health habit. Changes in behavior are seen first in individual beliefs, attitudes, and norms. Behavioral intention is
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pivotal, as a necessary but not sufficient immediate cause of behavior. As with the health belief model, demography, personality and other social psychological variables are expected to influence intention only through the other components of the model. Fishbein/Ajzen is almost entirely rational and does not provide explicitly for emotional fear-arousal elements such as perceived susceptibility to illness. By defining attitude and organizing other variables as causal processes that affect behavior in an attitude-behavior relationship, this model has strongly influenced attitude-behavior research in the past decade. Numerous applications of it to health related concerns include family planning, substance abuse, weight loss, exercise, patient satisfaction, immunization, hypertension and use of child safety restraint devices. Field studies found that behavioral intention often does predict behavior, particularly when the time frame is short and the intent is clearly specified. From this and it seems that intention is a better predictor of behavior than attitude, but attitude's effect on behavior is not completely mediated by intent, perhaps because intention is less stable in a longer time frame. Behavioral intention takes into account barriers and other `moderating variables' to the extent that the respondent is aware of them. Also, the more specifically attitudes and behavior are defined, the stronger the correspondence between them, e.g., general attitudes toward birth control are weaker predictors of intent and behavior than attitudes toward using birth control pills. The advantages of this specific assessment can be seen in considering a college student's attitudes and practice regarding birth control. She might be favorable towards birth control in general and have a general intention to practice contraception. At the same time, however, she might be highly resistant to certain specific methods of birth control that are available to her. For example, she might be fearful of using birth control pills because of potential side effects, and she may not wish to use a barrier method, such as condoms, because she values spontaneity in her sexual relationships. Consequently, a general assessment of her intention to practice birth control would suggest that she might engage in these behaviors, whereas, the specific assessment of her intention to use particular methods would highlight the sources of resistance to these specific methods of making good on that general intention. 4. THEORY OF PLANNED BEHAVIOUR (TPB)
Recently, Ajzen his associates (Ajzen, 1985; Ajzen & Maden, 1986) undertook a revision of the Fishbein and Ajzen's theory, which they called the Theory of Planned Behavior (TPB). They argue that in addition to knowing a person's attitudes, subjective norms, and behavioral intentions with respect to a given behavior, one needs to know his or her perceived behavioral control over that action. In a test of the revised model, they found that people need not only hold a behavioral intention toward a particular attitude object but also feel that they are capable of performing the action contemplated and that the action undertaken will have the intended effect. Thus, feelings of perceived control and self-efficacy also appear to be important in demonstrating attitude-behavior consistency; even when there is a clear behavioral intention to act on the attitude. The theory of reasoned action as originally formulated applies well to behaviors that are under personal control. However, if a behavior is influenced by factors over which people have only limited control, then their perceived self-efficacy, or ability to carry out the recommendations, becomes an important predictive factor. The TPB, then, adds this additional element to cover behaviors that may be only partially under personal control. In summary, the TPB maintains that people will perform a health behavior if they believe that the advantages of success outweigh the disadvantages of failure, if they believe that other people with whom they are motivated to comply think they should perform the behavior and if they have sufficient control over internal and external factors (Locus of Control) that influence the attainment of the
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behavioral goal. (Transparency: from 2, page 72) 5. HEALTH PROMOTION PLANNING MATRIX - PRECEDE-PROCEED MODEL
Health Promotion Programs operate either at primary (hygiene and health enhancement), secondary (early detection) or tertiary (therapeutic) stages of prevention, it may accurately be seen as an intervention whose purpose is to short-circuit illness or enhance quality of life through change or development of health related behavior and conditions of living. The PRECEDE framework (predisposing, reinforcing and enabling constructs in educational / environmental diagnosis and evaluation) takes into account the multiple factors that shape health status and helps the planner arrive at a highly focused subset of those factors as targets for intervention. PRECEDE also generates specific objectives and criteria for evaluation. The PROCEED framework (policy, regulatory and organizational constructs in educational and environmental development) provides additional steps for developing policy and initiating the implementation and evaluation process. PRECEDE-PROCEED works in tandem, providing a continuous series of steps or phases in the planning, implementation, and evaluation process. The identification of priorities and the setting of objectives in the PRECEDE phases provide the objects and criteria for policy, implementation, and evaluation in the PROCEED phases. PRECEDE-PROCEED is a robust model that addresses a major acknowledged need in health promotion and health education: comprehensive planning. The PROCEED component of the model is of more recent inception and has head less exposure and testing. It is essentially an elaboration and extension of the administrative diagnosis step of PRECEDE, which was the final and least developed link in the PRECEDE framework. There are eight phases of the PRECEDE-PROCEED model PRECEDE Phase 1. Social diagnosis - quality of life Phase 2. Epidemiological diagnosis - health status indicators Phase 3. Behavioral and environmental diagnosis Phase 4. Educational and organizational diagnosis - predisposing, reinforcing and enabling factors Phase 5. Administrative and policy diagnosis - Health promotion, health education, policy regulation organization PROCEED Phase 6. Implementation (Phases 4 & 5 of PRECEDE) Phase 7. Process evaluation (Phases 3 & 4 of PRECEDE) Phase 8. Impact evaluation (Phases 3 & 4 of PRECEDE) Phase 9. Outcome evaluation (Phases 1 & 2 of PRECEDE) The concern for this chapter is Phase 4 of the PRECEDE which deals with Educational and organizational diagnosis, which deals with predisposing, reinforcing and enabling factors influencing health behavior. On the basis of cumulative research on health and social behavior, literally hundreds of factors could be identified that have the potential to influence a given health behavior. The PRECEDE model groups them according to the educational and organizational strategies likely to be employed in a health promotion program to bring about behavioral and environmental change. The three broad groupings are predisposing factors, reinforcing factors, and enabling factors. Predisposing factors include a person's or population's knowledge, attitudes, beliefs, and perceptions
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that facilitate or hinder motivation for change. These are those antecedents to behavior that provide the rationale or motivation for the behavior. Enabling factors are those skills, resources or barriers that can help or hinder the desired behavioral changes as well as environmental changes. They can be viewed as vehicles or barriers, created mainly by societal forces or systems. Facilities and health insurance, and laws and statutes may be supportive or restrictive. The skills required for a desired behavior to occur also qualify as enabling factors. Enabling factors thus include all the factors that make possible a desired change in behavior or in the environment. Enabling factors are the antecedents to behavior that enable a motivation to be realized. Reinforcing factors, the rewards received, and the feedback the learner receives from others following adoption of the behavior, may encourage or discourage continuation of the behavior. Or in other words, reinforcing factors are factors subsequent to a behavior that provide the continuing reward or incentive for the behavior and contribute to its persistence or repetition. The fourth phase of the PRECEDE consists of sorting and categorizing the factors that seem to have direct impact on the target behavior and environment according to the three classes of factors just cited. Study of predisposing, enabling and reinforcing factors automatically takes the planner on to decide exactly which of the factors making up the three classes deserve highest priority as the focus of intervention. Any plan to influence behavior must consider all three sets of causal factors. For example, a program for disseminating health information to increase awareness, interest, and knowledge (predisposing factors) that does not recognize the influence of enabling and reinforcing factors, most likely will fail to influence behavior except in the segment of the population that has resources and rewards readily at hand (usually the more affluent people). Normally we expect the sequence to be as follows: A person has an initial reason, impulse, or motivation (predisposing factor) to pursue a given course of action. This first factor (arrow 1) in the causal chain may be sufficient to start the behavior, but it will not be sufficient to complete it unless the person has the resources or skills needed to carry out the behavior. The motivation is followed by (arrow 2) deployment or use of resources to enable the action (enabling factor). This usually results in the behavior, followed by (3) a reaction to the behavior, which is emotional, physical, or social (reinforcing factor). Reinforcement strengthens behavior (4), future resources (5), and motivation (6). The ready availability of enabling factors provides cues and heightens awareness and other factors predisposing the behavior (6). An exercise in your home is more likely to prompt you to use it than one at the YMCA. Similarly, rewards and satisfactions from behavior make that behavior more attractive on the next occasion; today's reinforcing factor becomes tomorrow's predisposing factor (7) (transparency, page 153).
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VI. PLANNING BEHAVIOR CHANGE During planning, communicators use primary and secondary research results to segment target audiences; select behaviors; plan strategies; develop messages; and design management, distribution, monitoring, and evaluation systems. This chapter focuses on how the communicator analyzes the relation ships between the environment and the desired behaviors and takes those relationships into consideration when selecting target behaviors, planning communication strategies, and selecting communication channels. Specifically, this chapter describes the behavioral approach to selecting target behaviors that are most amenable to change and have the greatest potential impact on the health problem and organizing them in order of priority; developing communication strategies that remedy skills and performance deficits by reinforcement of support for maintaining learned behaviors; selecting integrated interpersonal, print, and mass media channels to function as consequences as well as antecedents to target behaviors. Selecting Target Behaviors The selection of target behaviors is one of the most difficult decisions made during planning. Traditionally, communicators, in an effort to provide comprehensive information on the health problem, have included too many behaviors and messages in their programs; the result is very little impact on behavior change. Communication programs that have achieved behavior change have focused on a limited number of feasible behaviors. There are several reasons why communicators should establish short list of behaviors to promote. 1. Behaviors related to desired health practices are frequently too numerous and complex to introduce, change and maintain all at one time. 2. Some behaviors are more easily changed than others are; some behaviors are simply not feasible for the target audience to perform, and others are incompatible with social and cultural norms. 3. Some behaviors have more potential impact on the health problem. Communication programs sometimes have promoted behaviors that have no clearly demonstrated relationship to the specific health problem. Steps in Selecting Behaviors The following steps will help communicators select a few key behaviors to be targets for a communication program. Step 1: Review Assessment Research. The planning process begins with a review of the data concerning a target audiences current beliefs, knowledge, and practices related to the health problem. This review will help planners understand existing behaviors and the consequences that maintain them, and to decide which behaviors are really feasible for the target audience to adopt. Step 2: Review the list of "Ideal" Behaviors. Ideal behaviors are the medically prescribed behavioral steps that the target audience should perform in order to prevent or treat the health problem. In the assessment stage, an interdisciplinary team initiates the definition of the ideal behavior. During the planning stage, the team reviews its list of "ideal" behaviors and adds steps that assessment research has identified as appropriate and necessary for the correct performance and maintenance of the health practice. Step 3: Select Target Behaviors. Target behaviors are the minimum number of behavioral steps essential for the health practice to be effective. All unnecessary and unfeasible behaviors list, so that the
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list is reduced to a manageable core, which will be the focus of the communication program. The selection of target behaviors is a process of elimination. The planning team includes existing approximations and excludes behaviors that have not demonstrated impact on the specific health problem and are not feasible for the target audience to adopt. The final target behaviors of the communication program will be a highly selective subset of the medically prescribed ideal behaviors defined during assessment. This process of elimination is not necessarily either-or but, rather, a balancing of all the factors that might determine whether or not a behavior would be adopted. Sometimes the behaviors are not feasible for the target audience to perform in their ideal form, but they are absolutely necessary to have an impact on the health problem. If the list of target behaviors is still too numerous to be manageable, the team will need to determine which behaviors should be focused on initially and which can be introduced later in the program. This shortened list of essential target behaviors allows the team to select communication strategies, communication channels, training objectives, monitoring tools, and program evaluation criteria to focus more explicitly and effectively on behavior change early in the program. Later, communicators can introduce target behaviors more critical to maintaining the health practice. Tools for selecting Behaviors To select the target behaviors, the interdisciplinary team first decides which behaviors on the ideal behavioral profile work sheet do not have any demonstrated impact on the selected health problem; these items are not considered as behaviors. Team members then compare ideal and existing behaviors and analyze where they are the same where approximations exist, and where the two are completely different. The behaviors on the two work sheets that are the same and are approximations are selected as target behaviors. In situations where ideal behaviors are radically different from what the target audience is currently doing, but are necessary for impact on the health problem the team enters into negotiation with a medical specialist to determine a more feasible intermediate target behavior. Again, this is not a scientifically rigorous methodology, but it assists the planning team in organizing discussions. Selecting Communication Strategies Communicators must consider many factors- medical, political, financial, logistical, and technical when deciding on the "best" communication strategy. Behavioral factors also should play a part in influencing strategy selection. This section describes how communicators analyze the relationships between the environment and desired behaviors and takes those relationships into consideration when selecting communication strategies. Skills and performance deficits In selecting communication strategies, communicators should consider whether the absence or incorrect performance of a target behavior is due to a lack of skills (Skills deficit) or the absence of conditions favorable for performing it (performance deficit). When the person has a skills deficit, communicators will select strategies to introduce and teach these skills. If the audience is already performing approximations to the target behaviors, the communication strategy will require those approximations and teach the skills necessary to shape them into target behaviors. In other instances, people have significant knowledge and skills, but they are still not performing the behavior correctly or at all one reason may be that performing the behavior does not produce any
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immediately perceivable consequences or may actually produce unpleasant consequences. IN THIS CASE, THE COMMUNICATION STRATEGY WILL FOCUS LESS ON TEACHING SKILLS AND SHAPING BEHAVIOR and more on developing an environment of support for continued performance of the target behavior. For example, communitybased primary health care volunteers, who are vital channels of interpersonal communication to mothers and other caretakers, generally receive some training and initially have an acceptable level of skills to provide basic health services and information at the community level. Despite a good beginning, however, attrition rates for these volunteers are high throughout the developing world, and their potential impact as conduits of health information, skills and reinforcement to their communities is greatly diminished (Elder, et al., 1992) Frequently, program planners conclude that community health workers need more training to "keep them motivated" The problem here however is more a performance than a skills deficit. An analysis of the situation form a behavioral perspective would lead to a strategy focusing less on retraining and skill building and more on increasing pleasant consequences and decreasing unpleasant consequences for the volunteers work. Research would be used to determine which consequences would be most likely to increase desired behaviors and which unpleasant consequences might be decreased. This information would be used in the design of a support system to help these workers continue to be effective and active volunteers. Performance deficits are also a common problem when mothers fail to perform target behaviors correctly. Once again, a communication strategy would focus less on skill building and more on creating an environment of support. Research could be used to identify what unpleasant consequences might be deterring this practice or whether it producers few, if any, pleasant consequences. For example, many mothers are convinced that breast-feeding is best for their infants and are taught how to breast- feed at the hospital. Breast-feeding can be extremely painful, however, particularly in the first several weeks. May feel overwhelmed and frustrated by this pain. The communication strategy in this case could focus on increasing social support during the first month of breast-feeding. Communication could be used to teach fathers and other women how to support the first-time mother during this initial month. Decisions for strategy selection The flow chart shown as Figure 4.2 is a decision tree that can assist communicators in selecting communication strategies. It is divided into two general areas: skills deficit (on the left-hand side) and performance deficit (on the right). To use the flow chart, communicators first consider whether people know about the target behavior. If they do not, communicators generally will select antecedent strategies to introduce a behavior, provide information, and create awareness of and demand for new health technologies and behaviors. For example, in the early days of diarrhoeal disease control, most ORT communication strategies first focused on introducing the concept of dehydration and the need for ORS to prevent deaths from dehydration. If people were aware of the behavior, communicators would then consider whether "people are able to perform the behavior if they are asked. "If not, they have a skills deficit, and communicators would select strategies to train and teach skills and to have approximations. If, on the other hand, people know about the behavior and know how to do it correctly, but still are not performing it, they have a performance deficit. In this case, communicators would consider the righthand side of the flow chart, which focuses more explicitly on how the consequences of the target behaviors function to support or deter these behaviors over time. In this case, communicators analyze the consequences of the behavior and select the communication strategy to influence those consequences, not the behavior itself.
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Strategies to Respond to Skills Deficits. When the failure to perform the target behaviors is caused by a skills deficit, the target audience may never have tried the target behaviors. In other cases, they are already performing approximations to the target behaviors. The flow chart illustrates the questions asked to decide whether one has more of a skills or a performance deficit. Does not know How to perform the Behavior. In this case, the target audience knows about the behavior but does not know how to perform it. For example, mothers know that they should use ORS, but they may not have the skills to prepare and administer it correctly. The communication strategy is to provide training and teach the skills necessary to perform the target behavior correctly. Performs Approximations to the Behavior in this case, the target audience is performing approximations to the target behavior, but not in sufficient frequency, duration, the correct form, or at the right time. The communication strategy is to reward approximations and teach correct frequency, duration, accuracy, and timing. Strategies to Respond to Performance Deficits In other instances, most people in the target audience can demonstrate how to perform the target behavior correctly, but still are not performing it in their daily lives. The communicator then looks to the right side of the flow chart and begins to consider why this performance deficit exists. When considering strategies to address performance deficit, the communicator needs to recognize that a behavior leads to more than one consequence. A behavior can actually produce a wide range of consequences- from positive to negative, from immediate to delay, and from consequence - from positive to negative, from immediate to delayed, and from concrete too abstract. Communicators might want to start their strategy selection by listing all the consequences that, according to formative research, occur when a person performs or does not perform the behavior. This list can help communicators organize their discussion and select the most effective way to use those consequences to support target behaviors. Consequences that are culturally relevant, individually salient, and immediate will be the most powerful. Delayed or abstract consequences are much less so. A communication program cannot eliminate some negative consequences, such as the pain caused by breast-feeding or side effects of medication; nevertheless, a creative communicator can develop ways to lessen the impact of this punishment by focusing on other consequences. The following sections provide examples of communication strategies that respond to performance deficits. When performance is immediately punishing. In this case, a person actually receives perceptible punishment for performing a behavior. The punishment may come from individuals in his or her social network. In other instances, punishment may come from the health system: doctors may scold mothers for waiting too long to bring their children to the clinic when they are ill. Finally, punishment can come from performing the behavior itself: ORS, if administered too rapidly, can cause vomiting. The communication strategy is to decrease unpleasant consequences and/or increase the saliency of positive ones. To decrease an unpleasant consequence, communicators must first determine where the punishment is coming from and then develop strategies to change or lower the impact of this
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punishment. If the punishment is coming from the behavior itself, communicators may want to develop a strategy to incorporate or strengthen another salient source to provide positive consequences. When performance creates No Immediate Results. Because of their preventive nature, many target behaviors aimed at child survival have no immediate, salient consequences that the person performing the behavior can easily perceive. For example, a mother may not be able to see that, because of new feeding practices, her child is maintaining his weight during a diarrhea episode. The communication strategy is to introduce new positive consequences for behavior. The communication strategy might introduce planned consequences in order to support the behavior until naturally occurring consequences are perceived. Material consequences could be introduced. If a communication program introduces planned consequences, communicators will also need to develop antecedent strategies to increase the saliency of the new consequence. As discussed, the choice of the most culturally appropriate, personally salient, and immediate consequence to introduce should be guided by research with the specific target audience. What communicators may deem as the "best" consequence may not be the one perceived as "best" by the target audience. Communicators also must consider how the planned consequences they introduce will be phased out over time and what naturally occurring consequences will take their place. For the long-term performance of behavior, communicators cannot rely on planned consequences. The maintenance of behavior change is discussed further in chapter seven, When non-performance is more rewarding than performance. In many in many instances, the household responsibilities of children's caretakers compete with their performance of many health practices. The communication strategy is to increase rewards for the target behaviors. Caretakers often have not experienced any positive consequences from performing a target behavior such as obtaining immunizations several times over the first year of a child's life. In order to make the immunization process more attractive to and feasible for a mother, the communication strategy would combine actual changes in clinic practices with communication messages to promote clinic services. Clinics would try to make visits more positive through better service (faster, more polite), better care and motivational schemes (diplomas, lotteries). After experiencing more positive consequences from the behavior, the mother is more likely to do rather than not to do. When other Behaviors Are More Rewarding. In child survival programs, mothers frequently perform behaviors deemed counterproductive for the health of their children. For example, mothers bottle-feed rather than breast-feed. The communication strategy is to increase rewards for the target behavior or increase punishment for undesired behaviors. Communicators generally prefer to develop strategies that increase rewards for the target behaviors. Rather than openly attacking mothers' existing practices, the communication strategy promotes a new practice that directly competes with it. Communicators could also consider a strategy to increase negative consequences or punishment for a competing or non-desired behavior, but this strategy generally has not been used in public health programs in developing countries. When Behavior is too Complex, Difficult, or Costly. In this case, 1. The interdisciplinary team has selected target behaviors that are not feasible because of high cost, complexity, or difficulty; or
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2.
The target audience still does not know how to perform the behavior correctly (a skills deficit).
If (1), the team must return to the step of selecting target behaviors. If (2), communicators must return to the left-hand side of the flow chart to select their communication strategy. Selecting Communication Channels 1. Interpersonal channels - such as face to face communication, community distribution, home visits, training, group discussions, and counseling- are generally best for giving credibility to messages, providing information, and teaching complex skills that need two -communication between the individual and a credible source of information. Interpersonal communication facilitates the discussion of information or messages that the target audience regards as "sensitive" or "personal." It is also important for providing positive feedback and immediate reinforcement to the people performing the target behaviors. Broadcast channels generally provide broad coverage for communication messages, reaching a large number of the target audience quickly and frequently. In developing countries, radio has been a powerful channel to reach large numbers of people with communication messages, and to model target behaviors and their consequences. In some countries, such as Egypt and the Philippines television has also played an important role. Print channels - such as pamphlets, flyers, and posters- are generally considered best for providing a timely reminder of key communication messages. Pamphlets and other graphic materials distributed at the individual or home level can provide complex information in a digestible form, so that the target audience can use that information when it most needs it Audio-visual materials - such as videos, slide-tape shows, and flip charts- visually portray key messages during interpersonal communication sessions.
2.
3.
The rules for selecting channels are basic but very important: 1. Select channels that reflect the patterns of use of the specific target audience, not the tastes of the communication team or decision-makers. Almost all communicators have their 'favorite media, whether video, puppets, or radio In order to have an impact, however the channels selected must be hose that "reach" their target audience with the greatest degree of frequency, effectiveness, and credibility. Recognize that the different channels play different roles. Use several channels simultaneously. The integrated use of multiple channels increases the coverage, frequency, and effectiveness of communication messages. Select media that are within the program's human and financial resources. Select channels that are accessible and appropriate to the target audience. Radio messages should be scheduled for those radio stations that the target audience actually listens to and at broadcast times when that audience listens. Print materials should be used only for literate or semiliterate audiences who are accustomed to learning through written and visual materials. Materials should be distributed in accessible and visible places where the target audience already goes. Interpersonal communication should be provided reliably by credible sources (United States Department of Human Services, 1989).
2. 3. 4. 5.
The combination of these channels is called the media mix. The media mix selected should be one that enables communicators to reach many people many times within the stipulated time frame, to supply the appropriate information in an understandable form for each target audience, and to remain within a budget that can be maintained by the institution conducting the communication program.
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Summary Communicators plan for a behaviorally focused communication program by analyzing the relationships between the environment and the desired behaviors. They take those relationships into consideration when selecting target behaviors, planning communication strategies, and defining the role of communication channels. Specifically, this chapter provides a behavioral approach to selecting target behaviors that are most amenable to change and that have the most potential impact on the health problem; selecting and developing communication strategies that focus on skills development and creating an environment of support to maintain learned behaviors; and selecting integrated interpersonal, print, and broadcast channels to function as consequences as well as antecedents to target behavior.
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VII. THE TRAINING PROCESS Training groups Training is an organized program for teaching people new skills. Training is most often done with groups of people, all of whom need to learn the same skills. Since training involves learning skills, there must be many opportunities for participants to practice these new skills and participate in the planning and running of the program to make sure it meets their needs. A planning committee made up of trainees and trainers is very useful. Finding out training needs We have already mentioned several groups in the community who could benefit from training programs that you might organize: 1. 2. 3. Community health workers need training in health care and health education skills: Teachers may need knowledge and skills in health and health education; Various groups of the community may want to develop specific skills: for instance, pregnant mothers expecting their first babies may desire training in parenting and child care skills: workers may want to train in first aid; and so on.
There are different ways of discovering what kind of training people would like to receive: 1. 2. 3. 4. 5. 6. Talk to people in groups or during individual interviews: What skills do they want? Observe people at home, at work: do they seem to be performing well, or is there room for improvement? Look at the duties given to the community health workers: have they been taught properly how to carry out those duties? Think about the community: are there special problems for which the community health workers need to learn new skills? Read reports or review progress made on programs organized by your agency: were the programs successful? If not, do the program managers feel that a lack of skills among staff members was a cause of failure? What so you think? Read magazines or newsletters put out by professional groups such as nurses and health inspectors; also talk to your supervisors: what are some of the latest ideas in health care? What training is needed to practice the new skills?
Objectives and methods a) Education objectives Training, like any other health education program has an objective. The objective is the new behavior that people will practice by the end of the training program. The behavior in this case involves new skills. An objective for a community health worker may be to know how to clean, treat and bandage a small cut or wound. For a teacher it may be to know how to demonstrate to pupils how to clean their teeth.
b) Health objectives
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After community health workers, teachers and other local workers have learned new skills, they should be able to provide better services. Hopefully, services should result in improved health of the community. For example, training staff to do an immunization program should result in the health objective of a marked reduction in the number of children who suffer form measles, polio and other diseases, and elimination of deaths from these diseases. c) Involving people in setting the objectives The people who are to receive the training should discuss their training needs and the education objectives. They should agree on what they want to learn. In this way, people will be more interested in the training and will want to attend all training sessions. d) Training methods A training program should give people as much chance as possible to practice new skills. Therefore health education tools that encourage participation and practice should be used. Audio- visual aids such as posters and projected materials can give background information and knowledge. To learn the actual skills, tools such as demonstrations, case study, games and role-play should be used (See chapter 7). Planning the training session At this stage, you have to keep in mind several important factors. While you can certainly help people to acquire new knowledge and skills, you may not know everything the participants want to learn. You may need to bring in resource people who have special knowledge and skills to share with the others. How long will it take for people to learn the new skills? Remember to allow enough time for everyone to practice. Some training programs last a few days, others a week, a month or longer. This depends on how much need to be learned. The time should be convenient for the participants the trainees. Discuss with the trainees how to arrange the best schedule. Can they take a week off from their work? Are they able to meet only once a week? Is daytime or evening better? Find a meeting place that is big enough to hold all the trainees. Make sure the place is comfortable and those eating and toilet facilities are available. Find a place that is easy for all trainees to reach. You may be able to use a local hall or school without change. Educational materials such as posters, projectors and photographs may be needed. Also trainees will need materials with which to practice their new skills. These should be gathered well in advance. Use educational materials that you can make yourself as far as possible. Try to plan training programs using local materials and resources. What about transport and housing? Are there problems that require your attention? Find out if there are people who would be willing to transport and hose your trainees. If money is needed, contributions might come from the trainees or from various agencies. Money
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received for the program must be carefully and accurately accounted for so that one can see where it came from and how it was spent. Also note that people may be glad to contribute again in the future if they are thanked for their donations. In any case, you must express appreciation for the support, which you have received. Curriculum Planning Any organized training requires to be done with proper planning with regard to what is to be taught and how it is to be taught and by whom. All this will depend on the training needs. It is a common practice to develop curriculum. Curriculum is a design for enabling the learning in a training situation. It is a systematic sequential arrangement of the objectives, the content, the methods of instruction to be adopted and the materials to be used in support of the educational methods. Curriculum development entails the following steps. 1. 2. 3. 4. 5. Job analysis and study of job specification. This is done to know the training needs. The objective should be framed in keeping with the job description or expectation. Listing of subjects, topics or areas that is essential. The method of instruction for each area or unit should be discussed and evolved and time allotment shall be made with regard to the method of instruction. Scheme of evaluation should be worked out to monitor the levels of comprehension and change of attitude and behavior among the trainees, during the training and at the end of it.
A well-developed curriculum may require modification from time to time depending on the changing training needs for the job and also the feedback of the evaluation. Running the training session Pay attention to relationships by making sure that all the trainees and trainers know each other. In this way they will work better together. Even if you have involved the trainees in the planning, it is good to review with them the proposed objectives and activities at the beginning of the session. Make sure that the plan is acceptable. Ask for suggested changes. If time and other resources allow, make the desired changes but make sure first that all agree to these changes. In order to encourage participation, trainees should lead sessions, demonstrate skills, share their own ideas and experiences and make suggestions for improving the program will be successful. Evaluating the training Evaluation occurs throughout the program. The following questions will help you think about how you will evaluate training: During the training sessions: are the learning of skills and the availability of resources going as planned? At the end of the program: can all the trainees practice the skills they were taught? After the program: are the trainees able to put their new skills to use? Are there changes in the health behavior of the people in the community?
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Steps in evaluating a training program 1. Ascertain the objectives 2. Decide on the criteria for evaluation as against the objectives - qualitative and quantitative. 3. Develop indicators or indices or measurement 4. Decide the design of evaluation 5. Data to be collected 6. Analysis and interpretation Skills Training Training can then be based on responses to these questions or on tallies of direct observations. For example, all skills necessary for effective face-to face communication need to be included in training, but if evidence from assessment shows that trainees are already performing some skills fairly well, these skills could be reviewed briefly in training. On the other hand, if assessment shows that certain communication skills are not being performed or not being performed well, this need to be introduced and practiced in training. The same goes for content areas. Scores from assessment will indicate what information is accurately or inaccurately stated and what information is not mentioned at all in most health talks the trainees give. This will guide the trainer in what health information needs correcting and practice or simply needs reinforcement in training. In this way, training is customized to the needs of the trainees and makes the best use of precious training time. Five Steps of Skills Training Step 1;Instructions Instructions are similar to didactic teaching, whereby knowledge about general skills and component behaviors is transmitted. This step, although necessary, should play only a minor introductory role in the skill development process. Effective instructions serve only as preparation (an antecedent) for skills development and cannot replace behavioral practice in the learning process. Instructions generally include a description of the skill, specifying action to be taken rather than knowledge to convey or attitudes to portray. Instructions also can include the rationale for using a skill. In the training of health workers, a rationale for asking mothers about their current practices before giving instructions for home care is "You ask a mother about her current practices first so that you can fit your messages to her demonstrated skill and knowledge level." By using this type of instructional approach (in other words, setting up a dialogue about a topic), the trainer establishes a more personalized type of communication and a feeling of openness about the message. Through two-way communication trainers also gain direct evidence about their effectiveness as communicators. If a trainee is not able to state important parts of the message correctly, the instructions themselves should be reexamined. Perhaps the vocabulary is inappropriate, too much information was given too rapidly, more concrete examples should be given, and so on. Step 2;Demonstration In the demonstration phase, the trainer demonstrates the target skill and further ensures that the participants fully understand the instructions that have been given. Demonstrations help clarify the verbal description of the component behaviors. Such clarification is especially important when the language or manner of speech of the trainer and trainee is different-for example, when a health worker and mother are from different regions or ethnic groups. Demonstrations are also important when target skills are relatively complex for example, when health workers are learning to fill out a child's
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immunization or growth- monitoring card or combining effective case management with counseling in a clinic visit. Step 3:Practice Practice is performance of the behavior in the presence of the trainer. This is the only way to ensure that those trainees really master the targeted squalls and are able to do them on their own after training. In the practice sessions, as many of the trainees as possible try target skills. They may simply repeat the component behaviors, or they may simulate real-life situations in a role-play. After the training sessions are over, practice continues in the trainees' work place or home. Practice in the training sessions should be set up to resemble the real-life situations participants will face later. In this way, the health worker will know for certain that the mother is capable of carrying out the prescribed task. When health workers are the trainees, they may take turns playing "mothers" in order to make their practice of health talks or demonstrations as realistic as possible. Practicing a skill once in training greatly helps trainees move from knowing about a skill to being able to do it. Practicing the skill several times in training allows them to go further and become fluent in the skill. With repeated practice and feedback in training, trainees leave the session better able to perform the task in their work place or home and are less likely to lose the skill level they achieved in training. Training sessions and workshops are often the first segments to be cut. Step 4:Feedback and Reinforcement Feedback is information given to individual participants about the quality of their performance. If properly given, feedback will function as reinforcement by encouraging the participant to try the new behavior again, with specific strategies on how to improve. To be effective as reinforcement, feedback must be specific, constructive, and pleasant. Positive feedback must be specific, constructive, and pleasant. Positive feedback must give the trainees a clear idea of what behaviors they were doing correctly, so that they can repeat those behaviors. Negative feedback must make clear how trainees can correct behaviors they were performing incorrectly, and it should not overwhelm them by enumerating too many expected changes at one time. When selecting what skills or behaviors to reinforce, we need to remember that optimal skill levels are developed through successive behavioral trials and feedback experiences. In other words, individuals enhance skills by actually performing them and receiving response-specific feedback in order to eliminate ineffective behaviors and repeat the effective ones. Practice does not "make perfect" unless it is combined with feedback. Thus, trainees must be given constructive and encouraging feedback for behaviors that get closer and closer to a desired skill; catch them doing something right and reinforce them." After the trainer has demonstrated the method of giving feed back participants themselves should use the same feedback methods when they watch others do a role-play. The participants should state specific strengths they observed and should give suggestions for what can be changed. Finally, the trainer should give participants feedback on how well they gave feedback. Step 5:Homework Homework with feedback is critical to maintaining the skills learned in training. Homework constitutes additional practice, similar to the practices done in training that the trainees must perform outside the training session. For homework to be most effective in strengthening and maintaining learned skills, it must be checked by the trainer, and constructive feedback must be given; in other words, the behavior
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of carrying out a homework assignment (using new skills) must result in positive consequences, so that trainees will continue to use the skill in their own clinics or homes. The trainer should seek out opportunities to check homework assignments through occasional visits to local clinics or, if travel is logistically impossible, come up with creative ways to provide feedback to health workers newly emerging from training. Homework with feedback is also effective at other levels of training. Health workers can assign mothers homework after a counseling session in the clinic. For example, the mother may be asked to try using two packets of ORS over the next forty-eight hours, after which the health worker will check on progress during a home visit, give the mother constructive and encouraging feedback, and deliver a ling-term supply of additional packets. If the mother is aware that someone cares enough to check up on her success or problems with this or any other health-related skill, she is much more likely to practice it. To help mothers maintain the skills they have learned -especially if home visits are not possible- the health worker might ask the mother to demonstrate various aspects of the skill (for instance, the treatment of diarrhea) during subsequent clinic visits. This practice session, with feedback from the health worker, can serve as a valuable refresher session, because a mother whose child has not had a significant diarrhea episode for some time (for in stance, six months may have forgotten how to treat the condition. Training as Reinforcement Training, as it is typically designed, serves to prepare people for their work. In other words, it functions as an antecedent in the A-B-C chain. In this position, Training can introduce new skills and begin the learning process, but as an antecedent, it is in a relatively weak position to maintain long-lasting skill development and behavior change. One can, however, shift training's function in a program to that of a consequence, so that it reinforces participants' learned behavior and contributes to skill enhancement and maintenance over the long term. These activities turn training into a tool for maintaining a trainees performance over the long term. Follow-up training sessions might be incorporated into an already functioning general supervision or monitoring program if organizational structure, financial backing, and logistics are favorable. But whether called in-service training, continuing education, or group supervision, these follow-up sessions must be positive learning and motivational experiences for participants. In this way, training has become a positive consequence following behavior rather than an antecedent-triggering behavior.
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VIII. EVALUATION OF BEHAVIOR CHANGE The aim and purpose of health education is to bring about health related behavior for maintenance of good health. The change of behavior or adoption of new practice and its sustenance marks the ultimate impact of health education. Acquisition of proper information, change of ideas or knowledge from wrong to right and internalization of useful ideas are as important as change of behavior. It has already been considered in an earlier chapter that there can be a desired change of behavior even without required change of knowledge and attitude. In such a situation health education has not had full impact. The evaluation of any health education program is, therefore, to measure the change in the knowledge, change in the attitude and change in the behavior. A corresponding level of change in the three components of knowledge, attitude and behavior will signify a successful impact, whereas the absence of any change in one of the components will indicate only a partial impact which requires to be further reinforced. The parameters or the criteria that have to be developed for evaluation of health education efforts will be the changes in the level of knowledge, attitude and behavior. Evaluation may be directed to ward the health education program itself to find out to what extent it is in accord with sound educational principles. Practices that are in harmony with generally accepted policies can be expected to produce better results than those that are not. This approach is justified inasmuch as results in terms of changes in pupils and their environments often do not become evident for some time. As mentioned earlier, there is a lag between health education and its measurable application. Evaluation is the process of determining to what extent a program has accomplished its objectives. The task of evaluation in health education, as in any other field, is much broader than finding out how much factual knowledge is retained by a group of people after their exposure to a specified amount of health instruction. Evaluation serves the following purposes: 1. It helps the educator to know where to place emphasis in a teaching program. It may show which behavior patterns and which home, school, and community conditions have been improved as a result of the program, and which need further attention. 2. It helps to show strengths and weaknesses in teaching procedures. When a teaching program has produced results, evaluation may reveal which procedures have proved worthwhile. Conversely, when a program has failed, it may show which procedures have been ineffective. 3. Evaluation aids health committees and other groups in curriculum planning. It gives information that should help to determine content and methods. 4. Evaluation gives data of value in "selling" a program to administrators and to the citizens of the community. Evaluation may be required in a health education program concurrently and terminally. For example, if a health education program for control of tuberculosis is planned and it consists of a series of events like group discussion, lecture demonstration, cinema shows, display of exhibition and so on, there is a need to evaluate each event then and there, to ascertain how many people participated, whether effectively or not whether the message is clear to them and whether they found the message advantageous, etc. at every stage. If the community is the same, one should try to find out how much the different health education activities are having for the decided effect. Such evaluation on groups of
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people or individuals can be done by face to face questions or questionnaire or asking them to narrate or By observing whether there is any change in the knowledge, attitude and behavior. The change of attitude is rather difficult to measure because it had to be done as measure of opinion and it is not always reliable. One can be surer of measuring knowledge level and behavior and then attitude. A terminal evaluation takes into account the same parameters of knowledge, attitude and behavior but comparison is done with levels before the program is commenced and after it ends. One has to be careful in the interpretation of the findings with regard to behavior. Behavior has to be observed and confirmed and that too not once but many times to make sure that it is a sustained behavior. Besides, a scientific evaluation of a health education program should enable one to find out whether the following criteria are satisfied or not. Relevance. It should be problem- oriented and need-based. It should also have relevance to the existing culture of the community. Coverage and progress of health education activities. The coverage refers to the community population or area to be covered and also the topics and subject matter and events that have been planned for. Evaluation should find out if the target group has been covered or not. Efficiency. The program has to be carried out by expending efforts in terms of people, time, money, materials and technologies. Evaluation should therefore, be done to find out the extent to which the facilities are being used and whether the resources are used economically. This will further reveal whether the effort or purpose is economically feasible and worthwhile or a waste. One of the by products of the evaluation process is the inevitable review of the objectives of the total health education program, of the peoples' needs and interests, of the experiences provided in conditions in the schools, homes and community. Another by product is the positive influence on human relationships that are involved in the co-operative teamwork of continuous evaluation. Since a complete evaluation of health education covers all parts of the program, it is required that an attempt be made to measure the degree of success in accomplishing each of the evaluation is school -wide understanding of the health education program, and crystal-clear listing and describing of its objectives. Evaluation instruments Even though he may not be particularly conscious of the fact, an educator is constantly evaluating his audience. When teaching plans are carefully made in advance, the teacher's purposes are clarified and his choice of experiences or subject matter is more appropriate. By the same token, if the methods of collecting information for evaluation in health education are planned in advance, the collection of such data is more orderly, more complete, and probably will portray more accurately the situation as it really exists. Some of the more common procedures or methods of collecting evaluation information used by teachers are; 1. Observations - of health behavior, of particular skills, or of events in the home or community. 2. Surveys, Interviews 3. Health records 4. Case studies - Detailed study of individuals may show changes in health behavior in relation to other factors that influences his total life. 5. Health knowledge tests
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Each of these instruments or techniques can be used to good advantage. The resourceful teacher will not limit himself to the use of only one, but will become skillful in using many of them.
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IX. RESISTANCE TO CHANGE IN HEALTH BEHAVIOUR Given the compelling evidence that an individual's personal behaviors play such an important role in determining his or her health, why is it that people still practice unhealthy habits? Unfortunately, unhealthy behaviors are stubbornly resistant to change and highly subject to relapse. Two broad sets of causes are considered to be major obstacles to lifestyle modification. The first is the learning theory notion called the gradient of reinforcement. This refers to the fact those immediate rewards and punishments are much more effective than delayed ones. Thus, if engaging in a behavior provides immediate relief or gratification, or if failing to engage in this behavior provides immediate discomfort, the behavior should be easily acquired and difficult to extinguish. Furthermore, the health threats posed by the so called risky habits seem remote compared to the immediate pleasures of indulging, and the inconvenience and effort involved in adopting more healthful preventive behaviors also acts as barriers to behavior change. The relative influence of remote or delayed reinforcement may also be a reason why the strategy of prevention receives less attention from physicians, patients, and the health care system in general compared to that afforded treatment of diseases after they become problems. Forces in the social and physical environment comprise a second major set of barriers to lifestyle modification. Healthy or unhealthy habits are developed and maintained by social and cultural influences deriving from the family and society. In the last twenty years Americans have made significant progress in changing their attitudes toward exercise and proper nutrition and have become well informed about the modifiable risk factors for cancers and cardiovascular disorders. However, there are still powerful social pressures that lead teenagers to smoke and economic pressures such as the lack of insurance reimbursement for helping patients prevent illness that lead physicians and other health care providers to put less energy into prevention. Moreover, further economic and physical barriers are found in the higher cost and lower availability of healthier foods and in the lack of time and opportunity for exercise at many work sites. In the Ethiopian context, health education is supposed to be given regularly in all health institutions and during home visits throughout Ethiopia and is considered one of the major ways of changing health behaviors. The other less common way is to mobilize people by informing them they must participate in an activity such as bringing their child for immunization on a specific day. In the case of health education, people as a group are informed about certain diseases and what actions prevent these diseases. The assumption is that the information will change people's knowledge and attitudes and these in turn will change health behaviors. However, for a number of reasons, these changes do not usually take place. To evaluate the impact of health education, one must first determine whether new knowledge is acquired, then whether attitudes and behaviors change. Obviously, these changes take place gradually, if at all. There are a number of reasons why it is hard to change people's habits, particularly those, which have been practiced for a long time. The following are some sources of resistance. 1. Behaviors are often learned when very young, so that one acquires habits without knowing or questioning their rationale. 2. After performing the same action for a long time, the behavior is over learned and subsequently performed automatically without thinking. 3. People feel secure doing what is familiar; they feel insecure doing something new. 4. Doing what everyone else does, at the same time and place, provides one with the opportunity for social interaction. 5. If one does what everyone else is doing, it implies that the behavior is correct, i.e., agreement implies validation. 6. People may fear disapproval and rejection if they change to a new behavior. 7. People find it hard to admit that their parents and other respected people and traditions are wrong, especially if one is strongly attached to these people and traditions.
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In addition to these general sources of resistance, there are many reasons why health education as it is typically given at health institutions is unsuccessful. Some of these reasons concern characteristics of the communicator, the receiver, or the message itself. For example, the communicator should be wellliked (popular) and have a reputation for successfully treating patients in order to be credible and in order to be identified with. A communicator who does not express respect for understanding of people will not be listened to. Communicators who advocate new behaviors that are culturally unacceptable are dismissed as insulting and not credible. Listeners may believe that forces outside themselves control their health and illness, e.g., change events, supernatural forces, or health professionals, and consequently do not feel that their own behaviors make a difference. Listeners are not interested and therefore do not attend to the talk if the topic is not the priority. Listeners have not usually attended formal school and so are unused to acquiring new information through the lecture format. The communication itself is usually in lecture format; it is too long in duration; it uses words rather than pictures or concrete demonstrations; the works are often abstract medical jargon; it is impersonal and addressed to a large audience; it is only interested in informing, not in understanding the receiver's point of view. To overcome some of these problems, one could try the following alternatives: 1. Concerning the COMMUNICATOR: To give health education, use most often a local popular health worker who has some experience in curative work with the people. Ask people in the audience what are their health priorities among a list of topics that could be covered. Cover these topics only. After each topic, ask if people want to know more about X Y or Z. Ask the names of individuals, introduce oneself, and look at each person as if he/she mattered -because they do. Offer something to each attendee, such as water to drink in case they are thirsty after walking, or water to wash their hands and the face and eyes of their children. If you give the water to each person yourself, you will be able to meet and greet each individual. Concerning the COMMUNICATION: It is very important that the communicator practice speaking to improve their delivery. Focus on 2 or 3 topics at most, ones that are relevant to the audience, e.g., for women, ask if they want to hear about EPI, nutrition, child diseases and home treatment, or pregnancy. Within each topic, give 3 or 4 key items of information only. The book Facts for Life, produced by WHO and UNICEF and for which there is an Amharic translation, provides the day information to communicate regarding health. The message should be short, repetitive, and use lay language. Alert people to integrate services and encourage them to ask for all the necessary services for themselves and their families while they are now here. Give positive feedback to mothers by telling them something good that you know about their health practices and concerns, e.g., I know that you are good mothers because you breast feed your babies. Give positive to their children, which the mothers will feel vicariously, such as weighing children in front of the audience and praising him/her for having a healthy baby, or checking eyes and praising them for having clean bright eyes. Rather than always giving a lecture, show objects that you are talking about and demonstrate the activities. Concerning the RECEIVER: Form smaller groups, say of 5 or 6 people, to give a talk to. Giving an 8-minute talk to 5 people rather than a 40-minute talk to 25 people will be much more effective. This way you can even have enough personal contact with your listeners to ask them if they have any questions and to answer their question in a more personal manner. You can at the same time give them more confidence that they can control their own health and illness rather than relying on external forces. This creates self-reliance. Target certain groups who are similar in their priorities and education level.
2.
3.
Other settings besides health institutions can also be used for effective health education, partly because groups in these settings may have similar priorities. For example, CHAs can give health education to
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community meetings and during their home visits. Work places, military camps, prisons and schools are also good because places for health education because the people there have similar health problems and priorities. At schools, children are used to the lecture format; children are also more malleable. They also look up to teachers, health professionals and police, who can teach them about health and avoiding injuries. Children can also be involved in community health activities such as reminding parents and neighbors about the upcoming immunization session in their community, collecting materials for a latrine or planting a garden at their school, or cleaning up garbage in the town. When reading literature on health education, one must be aware that there are some important differences between results of health education in developed and developing countries. For one, rural uneducated people have more external locus of control, and so they need education on the fact that they can control their health even before starting health education. Secondly, they are less concerned about apparent inconsistencies in their health beliefs. For example, they are not bothered by the inconsistency of believing in both bothering by the inconsistency of believing in both modern and traditional cures for illness. Consequently, there may be little point in trying to eliminate their traditional beliefs unless they are harmful. Finally, they may respect or fear health professionals, but only to the extent that they listen but not follow what to tell them. The respect that leads to identification and adopting your suggested changes is based on liking and not fear. To be a good role model you must gain their trust and also act in accordance with your words. It is not enough to simply tell people what to do. The following are five strategies for learning new health behaviors and maintaining them: 1. Observational learning and Imitation. One learns new behaviors by watching a role model. At a later appropriate time, one can imitate what one has learned. This is an important strategy for acquiring new practices. 2. Rehearsal and Reward/Punishment. Practices will likely be perfected and maintained if one practices them often and is rewarded for the practice. If children practice cleaning their schoolyard and classrooms and using the school latrine, they may continue the practice at home. If children are given stars for good hygiene, they and their parents feel rewarded. Punishment such as elimination of sugar rations can also be effective but should only be used when negligence is the cause of noncompliance, such as when a mother has been informed and given the opportunity to immunize her children but has neglected to do so. This strategy is also relevant to changing practices. Communication and Persuasion. This is the attempt to change knowledge and attitude by imparting information. The communication may arouse fear and then show the person how to reduce their fear by performing the health behavior. Fear about the consequences of smoking, not immunizing, having multiple sex partners can be aroused with the help of vivid pictures of what can happen. Immediately after, one should provide the opportunity to reduce their fear by describing appropriate practice. Dissonance Reduction. Dissonance is the state of tension aroused by performing practices inconsistent with one's knowledge and attitudes. By getting mothers to immunize their children before they have the correct knowledge or attitude, they will be more receptive to the health education you give them at this time about the reasons for immunization. By having adolescents boys give a talk to their classmates or to other classes about AIDS and the use of condoms, they will begin to change their own attitudes about safe sex. This strategy is based on the idea that a change in practice will lead to a change in knowledge and attitude if the correct knowledge is available when the new practice is being performed. It is the reverse of the usual health education strategy, which tries to change knowledge and attitude first and then, waits for 68
3.
4.
the practice to change. It may also be quicker. 5. Social Pressure. Influence form respected leaders of the community can be brought to bear to make sure people maintain the changes you have brought about through health education. Religious leaders or community elders can exert effective social pressure. Conformity is the tendency to go along with others because of social pressure. Problem Solving. Focus groups and dyads of mothers or spouses are an excellent social context to encourage people to identify obstacles that interfere with their practicing good health practices. They can then generate solutions and evaluate how well they could implement these solutions in their daily lives. This helps to develop skills at solving daily problems and gives the participants the feeling of controlling their own lives. Very often they can do this without much input from an expert.
6.
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X. SOCIAL MARKETING (Getting and Keeping People Involved in a program) After putting a great deal of work and energy into planning a health promotion program, planners naturally hope that the target population will want to participate in it. Then also hope that, once involved in the program, the participants will want to continue with the program for its duration. Hoping is not enough, however. Planners must not just hope these things will occur, but work to make sure they occur. Planners need to have skills in marketing and psychology in order to get the target population involved and keep them involved. Only when the participants continue the behavior learned in a health promotion program over a long period of time can the health goals of both the individual and the program be met. MARKET AND MARKETING For the purposes of program planning, the people in the target population make up the market. Kotler and Clarke (1987,p.108) have defined market as "the set of all people who have an actual or potential interest in a product or service." A key to getting and keeping these people involved in a health promotion program is to be able to market the program effectively. The process of marketing operates on the underlying concept of the exchange theory. "Marketing is the planned attempt to influence the characteristics of voluntary exchange transactions exchanges of costs and benefits by buyers and sellers or providers and consumers. Marketing is considerably different from selling in that selling concentrates on the needs of the producer (to sell more products), whereas marketing, which may have the same ultimate objective, concentrates necessarily on the needs of the buyer or the public". Applying the definition of marketing to health promotion suggests that program planners would like to exchange costs and benefits with those in the target population. That is to say, program planners would like to exchange the benefits of population. That is to say, program planners would like to exchange the benefits of participation in health promotion programs (the objectives or outcomes of the programs they planned), such as "a longer healthier life, looking and feeling better, and having fewer but healthier children" for the costs of the program, which come from the participants, such as time, money, and effort. Health promotion programs are social programs, as such; they do not have material objects to market, but instead must market awareness, knowledge, skills, and behavior. The marketing of health promotion programs falls into a special type of marketing called SOCIAL MARKETING. Social marketing is distinguished by its emphasis on so-called non-tangible products - ideas, attitudes, lifestyle changes - as opposed to the more tangible products and services that are the focus of marketing in business, health-care, and nonprofit service sectors. MARKETING AND THE DIFFUSION THEORY One analytical tool that has been most useful in understanding the importance of marketing principles is the diffusion theory (Rogers, 1962). The theory provides an explanation for the diffusion of innovations (something new) in populations; stated another way; it provides an explanation for the pattern of adoption of the innovations. If we think of a health promotion program as an innovation, the theory describes a pattern the target population will follow in adopting the program. The pattern of adoption can be represented by the normal bell-shaped curve (Rogers, 1983) (Figure 11.1) Therefore, those individuals who fall in the portion of the curve to the left of minus 2 standard
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deviations from the mean (this would be between 2% and 3% of the target population) would probably become involved in the program just because they had heard about it an wanted to be first. These people are called innovators. They are venturesome, independent, risky, and daring. They want to be the first to do things, and others may not respect them in the social system. The second groups of people to become involved are those represented on the curve between minus 2 and minus 1 standard deviations. This group would include about 14% of the target population; but they are not the first to sign up. They wait until the innovators are already involved to make sure the innovation is useful. Early adopters are respected by others in the social system and looked at as opinion leaders. The next two groups are the early majority and the late majority. They fall between minus 1 standard deviation and the mean and between the mean and plus 1 standard deviation on the curve, respectively. Each of these groups comprises about 34% of the target population. Those in the early majority may be interested in the health promotion program, but they will need external motivation to become involved. Those in the early majority will deliberate for some time before making a decision. It will take more work to get the late majority involved, for they are skeptical and will not adopt an innovation until most people in the social system have done so. Planners may be able to get them involved through a peer or mentoring program, or through constant exposure about the innovation. The last group, the laggards (16%) are represented by the part of the curve greater than plus I standard deviation. They are not very interested in innovation and would be the last to become involved in new health promotion programs. Some would say that this group would not become involved in health promotion programs at all. They are very traditional and are suspicious of innovations. Laggards tend to have limited communicating networks, so they really do not know much about new things. As time passes, the number of adopters of an innovation increases. Figure 11.2 presents an S-shaped curve showing the cumulative prevalence of adopters at successive points in time. The real plus of using the diffusion theory when trying to market a health promotion program is that "the distinguishing characteristics of the people who fall into each category of adopters from innovators to early adopters to middle majority categories to late adopters (laggard) tend to be consistent across a wide range of innovations" (Green, 1989, March). Therefore, different marketing techniques can be used depending on the type of people the program planners are trying to attract to a program. THE MARKETING PROCESS AND HEALTH PROMOTION PROGRAMS If everyone in a given population were an innovator or early adopter there would be no need for marketing plans. Since that is not the case, there is a need for program planners to understand the marketing process and be able to apply its principles. Syre and Wilson (1990) have identified five distinct functions of the marketing process as they relate to the health care field. These include: 1. 2. 3. 4. Using marketing research to determine the needs and desires of the present and prospective clients from the target population. Developing a product that satisfies the needs and desires of the clients. Developing informative and persuasive communication flows between those offering the program and the clients. Ensuring that the product is provided in the appropriate form, at the right time and place, and at the best price. 71
5.
Keeping the clients satisfied and loyal after the exchange has taken place.
SUMMARY An important aspect of any health promotion program is being able to attract participants initially and to keep them involved once they have begun the program. An understanding of the diffusion theory is helpful in determining strategies for marketing a program. The actual marketing mix for a program should take into account the four Ps of marketing: product, price, placement, and promotion. Special attention should be given to segmenting the target population. Once people are enrolled in a program, they need to be motivated to remain involved. Strategies of contracts, social support, media recognition, incentives, and competition can be most helpful in motivating people to continue their participation in a program.
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VI. RESEARCH METHODS IN BEHAVIORAL SCIENCES: QUALITATIVE STUDIES Qualitative research is a type of formative research that offers specialized techniques for obtaining indepth responses about what people think and how they feel. It enables program management to gain insight into attitudes, beliefs, motives and behaviours of the target population. When applied properly, qualitative techniques are used along with quantitative techniques in a manner that is interrelated as complementary. By its very nature, qualitative research deals with the emotional and contextual aspects of human response rather than with objective, measurable behaviour and attitudes. Qualitative research is conducted to answer the question "why" whereas quantitative research addresses questions of "how many?" or "how often ?" The qualitative research process is one of discovery; the quantitative research process pursues proof. Additionally, qualitative research is not simply the qualitative techniques for eliciting responses but the qualitative nature of the analysis required to apply it. Qualitative research is interpretative rather than descriptive. It involves small numbers of respondents who are not generally sampled on a probability basis. No attempt is made to draw firm conclusions or to generalize results to the population at large. The two primary qualitative research techniques are: 1. individual depth interviews, and 2. focus group discussions. A. WHY USE QUALITATIVE RESEARCH ?
There are both conceptual and practical reasons for using qualitative research. The primary conceptual reason for using qualitative research is that it provides greater depth of response and, therefore, greater consequent understanding than can be acquired through quantitative techniques. In addition, qualitative techniques, particularly one-on-one interviews, enable the researcher to tie together clusters of behaviour that relate to a given consumer decision or action--for instance, when a program manger wants to know how the decisions were made to use an ORS product. Another conceptual reason for using qualitative techniques has to do with the nature of qualitative research itself and how it relates to the decision process in research. It can be argued that the qualitative research process and the broader formative process both retain major subjective or intuitive elements. The initial steps in the formative research process-- that is, defining the problem and information needs, formulating hypotheses and defining variables-- are all essentially intuitive and therefore qualitative in nature. In addition to the above, there are many pragmatic reasons for using qualitative research methods. 1. 2. 3. 4. 5. Cost. In general, qualitative research is more economical than quantitative research. Timing. Some qualitative techniques, particularly focus groups, can be executed and analyzed quickly without the necessity of data processing capabilities. Flexibility. The study design can be modified while it's in progress. Direct link with target public. Qualitative techniques give program management the opportunity to actually view and experience the target groups directly. Lack of technical facilities. Qualitative research can be done in areas where no computer or other technical facilities are available. 73
B.
PROBLEMS WITH QUALITATIVE RESEARCH
One major problem exists with qualitative research; that is that it is often applied inappropriately. In other words, qualitative research will sometimes be used when a quantitative technique is more appropriate. Or, qualitative research will be analyzed as if it were a quantitative study, drawing hard and fast conclusions or projecting responses instead of developing hypotheses and gaining insights. Another problem with qualitative research is related to its subjectivity. Since it is highly dependant upon insight and interpretation, qualitative research also is highly susceptible to subjective bias on the part of the researcher or observers. Because no hard data analysis is conducted, it is very difficult to verify whether the analysis of a qualitative research project is correct or not. And, because of the nature of qualitative techniques themselves, it is even difficult to determine if the research is being conducted properly. Finally, because qualitative research has a high degree of flexibility and does not require a highly structured questionnaire format, it can allow the researcher or program manager to be undisciplined and not fully think through the research issue. Much controversy has long been associated with qualitative research as a result of the potential pitfalls. A good deal of discussion in the research field centers on how to ensure the quality of qualitative research, yet users and practitioners still do not agree on many of its aspects. C. HOW IS QUALITATIVE RESEARCH USED ?
Qualitative research is used largely in the following four general ways. 1. An idea generation tool To stimulate ideas by providing program management with firsthand experience in observing and hearing the target population, observing them interacting with the product and listening to their language about the issues. This behaviour and language may be quite different from that used or imagined by the program manager. To develop new ideas for the communications strategy, positioning and execution. To explore communications in order to learn what ideas and messages are perceived from visual or verbal stimuli such as advertising, brand names, packaging and posters. To explore a category which is relatively unknown and for which the researcher is unable to provide the specifics required to develop a quantitative study.
2.
A preliminary step to aid in the development of a quantitative study To develop hypotheses about the thought and decision making processes of the target population as they relate to the product or issue being researched. To specify particular information needs for the quantitative study. To help identify the types of people to be interviewed in the quantitative study--for example, the primary and secondary target populations and the relevant decision makers. To aid in the development of question wording and sequencing--for example, to identify 74
all of the attributes of a particular product which should be included in the quantitative questionnaire. To assist in problem identification and definition--for example, to develop hypotheses about the reasons for a sudden drop in usage of a particular product. To select and refine materials for a larger quantitative study - for example, qualitative research can be used to reduce the number of concepts being evaluated or to refine the concepts prior to going into the quantitative phase.
3.
As follow-up to aid in the understanding of the results of a quantitative study Explain, expand and illuminate quantitative data--for example, to understand the reasons for an unexpected finding. To gain some understanding about the reasons for certain trends for example, to understand why mothers who have tried ORT are not reusing it. To describe the factors which are affecting an attitude change--for example, to illuminate why one particular piece of advertising or promotion is more persuasive to the target audience.
4.
The primary data collection method _ Some research problems do not lend themselves easily to a quantified approach and, therefore, qualitative research may be used as the primary data collection strategy.
Three Keys to Successful Qualitative Research First, the research must develop the art of asking "why ?" Second, the researcher must develop the art of listening. Third, the researcher must approach the research as a creative process of investigation. The art of listening takes time and practice to develop fully. Qualitative researchers must be acutely aware of the fact that accurate listening is extremely difficult and that listeners often make errors of which they are not conscious. Truly creative listening requires a high degree of sensitivity, intuition and reflection as well as accuracy. Qualitative research, then, is very much like the investigatory process that would be carried out by a detective. Although there are some specific techniques and standard questions are almost always applied, the key to getting the right answer is to adapt and create the process to suit the specific research issue. It generally does not work to apply an "Off-the-shelf" approach. Just as no two crimes are alike, no two qualitative research projects are alike. A high level of creative thinking must be applied to each new situation if the qualitative research process is to be truly successful. Distinctions of qualitative and quantitative research QUALITATIVE Depth of understanding
QUANTITATIVE -----------Level of Occurrence

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"Why" Motivations Subjective Discovery Exploratory Gains insights int. Interpretive
------------------------------------------------------------------------------
"How Many?" "How often?" etc. Actions Objective Proof Definitive Measures level of... Descriptive
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Summary of Qualitative research applications EARLY EXPLORATION FOR DEA GENERATION AND DIRECT EXP- ERIENCE OF TARGET POPUL- ATION PILOT FOR QUANTITATIVE EXPLAIN,UNDERSTAND AND STUDY: ILLUMINATE QUANTITATIVE EXPLORATION,HYPOTHESIS BEHAVIORAL AND ATTITUDE DEVELOPMENT,LANGUAGE DATA IDENTIFY INFO- MATION NEEDS UNDERSTAND OF POTENTIAL QUALITATIVE TRENDS TARGET SEGMENTS RESEARCH IN BEHAVIOUR APPLICATIONS OR ATTITUDE SHIFTS PROBLEM IDENTI- HELP DEVELOP COMMUNI- FICATION AND CATION STRATEGIES, DEFINITION CONCEPTS AND TREATMENTS TIE TOGETHER CLUSTERS OF BEHAVIOUR ON AN INDIVIDUAL OBTAIN INFORMATION FROM SMALL, BASIS "ELITE"SAMPLES D. THE TWO MAJOR QUALITATIVE METHODS
Two leading qualitative research techniques are individual depth interviews and focus groups
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discussions. Focus groups capitalize on group dynamics and allow a small group of respondents to be guided by a skilled moderator into increasing levels of focus and depth on the key issues of the research topic. They are by far the most widely used qualitative technique. Individual depth interviews, like focus groups, are characterized by extensive probing and open-ended questions, but they are conducted on a one -on-one basis between the respondent and a highly skilled interviewer. When to use individual in-depth interviews Although individual depth interviews are less widely used, there are specific circumstances for which they are particularly appropriate. These includes and practices regarding the treatment of diarrhoeal disease. Highly sensitive subject matter. Conducting a study among women who have had an abortion, regarding their feelings about sexuality and family planning. Geographically dispersed respondents. Conducting a study among population by policy makers regarding their reactions to a document on child spacing and maternal health. Peer pressure. Conducting a study among consumers to obtain their reactions to a potentially controversial advertisement where a "social desirability" response might cloud the real persuasive power of the message. When individual depth interviews are being considered as the research technique, it is important to keep several potential pitfalls or problems in mind. _ There may be substantial variations in the interview setting. Depth interviews generally take place in a wide range of settings and therefore limit the interviewer control over the environment. Interviews conducted in a hospital or at a store may have to contend with many disruptions, all of which inhibit the acquisition of information and limit the comparability of interviews. There may be a large gap between the respondent's knowledge level and that of the interviewer. Individual depth interviews are often conducted with knowledgeable respondents (Such as physicians) yet administered by less knowledgable interviewers. Therefore, some of the responses may not be correctly understood or reported. This type of "elite" respondent generally also has a greater desire to speak beyond the limits imposed by the interviewer and to seek more interaction with the interviewer, compounding the problem even further. The potential for sponsor observation and feedback is limited. As there generally is no sponsor observing the interviews, the feedback procedure either does not exist or takes considerably longer to conduct. Debriefing the interviewers after each of the initial interviews is conducted (So that changes can be made) is a time-consuming process.
Additionally, there also are some key interviewer behaviours which are important to the success of conducting depth interviews and which should be kept in mind. It is important that the interviewer be able to: 1. 2. 3. 4. accurately receive the information; accurately recall the information; critically evaluate the information; and act upon the information as it is received to regulate the interview process.
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Accurately receiving the information can be inhibited by interviewer fatigue, interviewer boredom, interviewer bias or expectation of answers, interviewer preoccupation with taking notes, and by technical language foreign to interviewer. Steps should be taken to avoid these problems if possible. Accurately recalling the information can be inhibited by a confusion of content between interviews, selective retention on the part of the interviewer, and by the interviewer's attempt to retain too much information. Critically evaluating information during the interview is a function of the interviewer's ability to identify the actual level of richness of the content being provided. It is important that the interviewer steer the respondent away from irrelevant information and induce richness when superficial answers are being provided. Acting upon the information being received and altering the interview process as it occurs is important both within a given interview as well as across the series of interviews. The ability of the interviewer to regulate the interview within a given interview is really an issue of probing, focusing and staying on track with respect to the interview objective. Regulating or altering the process across a series of interviews is a matter of assessing information that has been accumulated from one interview to the next in order to refine the interview guide and make it more responsive to the overall objectives of the research. When to use Focus groups ? Focus groups are far more widely used than individual depth interviews. The key reasons why focus groups are selected more often as the qualitative technique include: Group interaction. Interaction of respondents will generally stimulate richer responses and allow new and valuable thoughts to emerge. Observation. The sponsor can observe the discussion and gain "first hand" insights into the behaviours, attitudes, language and feelings of respondents. This is particularly important in the early, "creative" stages of program development. Cost and timing. Focus groups can be done more quickly and generally less expensively than a series of depth interviews. Specific applications of focus group research: Idea generation. A group discussion is conducted among pharmacists or physicians to generate new ideas for an improved ORS product (food additives, vitamin A additives, flavour additives, etc.) A group works best to build on ideas generated. Package design screening. Alternative package designs, either in concept or in prototype form, are presented to potential user groups to reduce the number of concepts to a smaller amount for a quantitative test. A group works best because design personnel can be present to view the group. Evaluation of message concepts. Messages in some rough, pre-production form are presented to potential target audience groups for evaluation and refinement. A group works best because creative personnel can be present to view the group. Problem identification and definition. A group discussion is conducted among condom users to
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generate hypotheses about why a successful condom brand failed when introduced into a new region. groups work best to get a quick reading before planning a quantitative study.
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WHICH TO USE: FOCUS GROUPS OR INDIVIDUAL DEPTH INTERVIEWS ? Issue to Consider Group Interaction Use focus groups when.. Use individual depth interviews when..
...interaction of respondents ...group interaction may stimulate a richer is likely to be limited response or new and valuable or non-productive. thoughts. ... group/peer pressure will be valuable in challenging the thinking of respondents and illuminating conflicting opinions. ..group/peer Pressure would inhibit responses and cloud the meaning of results.
Group/Peer pressure
Sensitivity of ...Subject matter is not subject Matter so sensitive that respondents will temper responses or withhold information. Depth of individual Responses ...the topic is such that most respondent can say all that is relevant or all that they know in less than 10 minutes
...subject matter is so sensitive that respondents would be unwilling to talk openly in a group. ...the topic is such that a greater depth of responses per individual is desirable; as with complex subject matter and very knowledgeable respondents. ...it is desirable to have numerous interviews on the project. One interviewer would become fatigued or bored conducting the interviews.
Interviewer fatigue
...it is desirable to have one interviewer conduct the research; several groups will not create interviewer fatigue or boredom.
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TABLE Continued Issue to consider Stimulus materials Continuity of Information Use focus groups ... ...the volume of stimulus material is not extensive. ... a single subject area is being examined in depth and strings of behaviours are less relevant. ...enough is known to establish a meaningful topic guide. ...it is possible and desirable for key decision makers to observe "first hand" consumer information. ...an acceptable number target respondents can be assembled in one location. ...quick turnaround is critical, and funds are limited. Use individual depth interviews when... ...a larger amount of stimulus material must be evaluated. ...It is necessary to understand how attitudes and behaviors link together on an individual pattern basis. ... it may be necessary to develop the interview guide by altering it after each of the initial interviews. ..."first hand" consumer information is not critical or when observation is not logistically possible. ...respondents are geographically dispersed or not easily assembled for other reasons. ...quick turnaround is not critical and budget will permit higher cost.
Experimentation with interview guide Observation
Logistics
Cost and Timing
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A Summary of specific applications Individual Depth Interview Complex subject matter and knowledgeable respondents. Highly sensitive subject matter. Geographically dispersed respondents. Peer pressure. Focus Groups Idea generation. Package design screening. Evaluation of message Concepts. Problem identification and definition.
E.
GROUP DISCUSSION TECHNIQUES
Many focus group techniques have evolved over time. Broadly, the difference between those techniques relate to: 1. different moderating approaches; 2. functional group differences; 3. structural group differences; and 4. the variety of processes which have emerged to address specific marketing or informational need. Moderating approaches to focus groups There are two primary aspects of the moderating approach. First, the questioning technique can be either directive or non-directive. Second, the flow of the focus group can be either structured or nonstructured. 1. Questioning Technique
A directive moderating approach uses questions which are very pointed and which specifically restrict the range of responses which might arrive. This questioning technique is used only when the objective of the focus group is very narrowly defined. A non-directive moderating approach uses questions which are open ended and non-biasing. This type of question permits respondents' honest feelings to emerge, minimizes the moderator's influence and helps to eliminate later confusion in separating fact from fiction of what was said in the group. This type of questioning is almost always the best style to use when conducting focus groups. 2. Focus Group Flow
In a structured focus group the moderator works from a prepared topic guide which contains the issues to be addressed and the specific areas for probing. The topic guide ensures that all areas relevant to the research objectives are covered. The probing outline ensures that the specific information needs of management are met in each topic area. Structured focus groups are readily compared across a series of groups. A non-structured focus group is conducted using a very sketchy topic guide. The group participants
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themselves largely determine the content and flow of the group. The rationale for conducting this kind of group is that it eliminates moderator-management judgment as to what issues are salient. This style is rarely used as it often misses many important information needs of program management. It is sometimes used in the early problem-definition stage of a project when no prior research has been conducted and when management has little experience with the subject and has no hypotheses regarding the relevant issues of the subject. Except in unusual situations, focus groups should use the non-directive, structured moderating approach. In practice, most effective groups are actually semi-structured--the moderator is skilled enough to cover all of the issues in the structured topic guide while maintaining a flexible flow of conversation; a conversation which pursues issues as they are mentioned by respondents and relevant new topics as they arise. 2. Functional group differences
The type of focus group being conducted is determined by the group's purpose-- what it is intended to accomplish. Traditionally, groups have been divided into three broad categories: Exploratory groups. The purpose of the group is to generate ideas or to stimulate a rich level of respondent thinking on specific topics. the moderator generally plays an active role, encouraging respondents to build on each others ideas. It is often used to help design a quantitative study. Clinical. The purpose of the group is to uncover the psychological and sociological motivations for attitudes and behaviour. Projective techniques are often used, and analysis relies on clinical judgement. Clinical groups have limited use in marketing; however, the approach may be very useful to enhance and expand the understanding of previous research findings. Phenomenological. The purpose of the group is to provide researchers with a direct link to the target population as they describe in detail and in their own language, their thinking and behaviour in real-life situations and decision making. Such a group is generally more focused and generates more concrete specific responses such as reactions to products, packaging concept statements, communication and other stimuli. 3. Specialised Group Processes
Over time, special qualitative techniques have been developed or modified to suit the needs of researchers in the field of marketing. These include: a. The Laddering Technique
In this technique, the line of questioning proceeds from product characteristics to user characteristics. For example, the method might begin by asking respondents to indicate how one product or behaviour differs from another to identify key variables such as "easier to use". That reason is then probed to determine what is important about it--what its benefit to the user is. For example, "Doesn't take time away form household chores". That answer is then probed until multiple layers of underlying benefits are elicited. This is often referred to as "tapping into the user's network of meanings," and is meant to uncover deeper levels of benefits and barriers. b. Hidden Issue Questioning
This technique focuses on individual respondents' feelings about sensitive issues in their lives.
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Common themes which surround a particular topic such as child care or sexual intimacy are drawn out so that intimate personal issues are developed into widely shared, sensitive life themes. The procedure calls for individuals to construct specific "best case" and "worst case" scenarios about topic areas so that their daydreams, anxieties and hopes are brought to the surface-- for example "what was the happiest time in your life?" or "what would you do with your time if you were given 5 million dollars?"-- with probing the answer to these questions represent significant leverage points for motivating behaviour. c. Symbolic Analysis
This technique calls for researchers to examine how consumers perceive the opposites to the behaviour or product under study. For example , in order to learn about diseases, medical researchers often study health and well-being. There are three ways to study such opposites. The first is to investigate nonusage. For example, the research might ask "what is someone like who never uses this?" or "What would it be like if you could no longer use this?" The second way is to imagine a "non-product" or a non-version of the existing one, like "nonfattening" or"nonalcoholic." A third way to study opposites is to investigate perceptions regarding opposite types of products. For example, the opposite of ice cream might be yogurt because it is less fattening, or it might be soup because "a good meal begins with soup." Understanding how respondents determine opposites unlocks keys as to the real meaning of the product or issue. 4. Projectable techniques
A projectable technique is an instrument which obtains responses in an extremely indirect manner. These instruments were devised to overcome the inability or unwillingness of individuals to express their true interests, opinions or motivations in response to more direct questioning. It can reduce the bias of approval-seeking because the respondent does not know exactly what the moderator is going after. The most common techniques used by marketing and communications specialists include the Thematic Apperception Tests (TAT). Visual stimuli depicting a situation are presented, and the respondent is asked to comment on the situation by explaining it and tell what might have gone on before and what is going to happen next. Role playing. The respondent is asked to give the opinions and attitudes of other people. Cartoon Completion. The respondent is asked to complete a cartoon caption which fits the sketch provided or which responds to what another cartoon character has said. Association. This includes word association and sentence completion techniques where the respondent is asked to give the first word or phrase that comes into his/her head in response to those given by the interviewer. 5. Structural group differences
In order to meet the objectives of the research, many different focus group formats have evolved. While the application of these new formats is limited, they are worth mentioning briefly. Traditional groups. An interactive, focused discussion of 8-10 people. Mini-groups. An interactive, focused discussion of about six people. Dyadic groups. An intense discussion between two people such as husband and wife or a product user vs.a non-user. 85
Family unit, cross-generational groups. An interactive, focused discussion on a topic which is highly influenced by family ties and values (e.g., child bearing or rearing). The entire family, including the grandparents participate. Ad labs. Groups designed specifically to create and refine advertising. Repeat focus groups. Respondents are generally asked to do something between groups such as buy or use a product so that responses can be tied together. Qualitative panels. These are similar to the above but generally consist of more respondents, are repeated over a longer period of time and are often connected to quantitative studies. THE FOCUS GROUP MODERATOR
F.
The focus group moderator's role is critical to conducting an effective focus group. In selecting the moderator it is important to evaluate: a. personal characteristics; b. moderating style; and c. experience and background. 1. Personal characteristics
Some individuals simply have the right combination of personal traits and "raw talent" to make effective moderators. Things to look for in a potential moderator include: The ability to feel at ease and comfortable with other people: someone who is relaxed, and unthreatened by personal interaction with others. The ability to put others at ease: someone others just naturally "open up" too quickly. The ability to project unconditional regard and acceptance of others: someone who is genuinely non-judgemental or who can appear to be. The ability to convey warmth and empathy. Good verbal and interpersonal skills: someone who gets along well in many different situations and with many different kinds of people and who can use language to seem like "one of them." Good listening skills: someone who pays close attention to what others say and does not feel compelled to always inject his/her own thoughts and comments into the conversation. The ability to project enthusiasm: someone who seems genuinely interested in others and whose general enthusiasm stimulates heightened interest among others. An awareness of his/her non-verbal reactions: someone who is capable of maintaining body language and facial expressions which project the above traits and do not convey annoyance or frustration. Someone whose physical characteristics are not threatening, intimidating or off-putting to others. 86
2.
Someone who matches the focus group respondents as closely as possible to facilitate rapport. Moderating style
Styles of group moderating vary greatly. Some moderators facilitate the group discussion by being friendly and involved, others by being more "laid-back". Still other moderators are challenging, almost argumentative in their style. An extremely experienced moderator often can vary his/her style to suit the type of respondents and the objectives of a group. In selecting a moderator, it is important to be aware that such differences in style exist and to match the moderator style with the needs of the group if possible. 3. Moderator experience and background
Moderators who have specialized moderating experience dealing with the subject matter to be discussed (i.e., specific health issues, a specific product) or with the type of respondents (i.e., teens, professionals) generally will be more effective. The academic background of moderators tends to vary widely. Many are psychologists trained in group dynamics. In dealing with marketing issues, a moderator with some marketing or social science background may be useful. In some cases (for example, dealing with underlying motivations on a particular subject) it may be most useful to select a moderator with skill in using projective techniques or with experience in one of the qualitative approaches develop for that purpose, such as laddering or hidden issue questioning. Occasionally circumstances are such that an experienced moderator is not available and someone with experience in the field such as a nurse or other health provider must conduct the group discussions. In this case, it may be necessary to stress certain key points to the acting moderator: Also 4. The focus group is not a text-- there are no right answers The focus group is not a time to inform The focus group is not a time to persuade Briefing the moderator A moderator is not a teacher A moderator is not a judge A moderator does not look down on respondents A moderator does not agree or disagree with what is said A moderator does not put words in the respondents' mouths
Once a moderator is selected, he/she must be thoroughly briefed on the project. This generally occurs as the moderator works together with the sponsor to develop the topic guide. If the moderator is working form an independently prepared topic guide, it will be necessary to brief him/her as to why the research is being done, what is to be achieved from the research, and the specific application of the research findings. In order for the interviewer to be adequately briefed for the study, the sponsor of the project should familiarize the moderator with prior research findings, important issues, hypotheses and opinions.
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Anything that helps to inform the moderator about the subject area or the sponsor's thinking is important and enables a skilled moderator to listen better and to ask meaningful, follow-up questions. Prior information reduces the possibility of exploring directions that have been previously researched or that are irrelevant to the study objectives. 5. Evaluating the moderators' work
Focus groups are commonly evaluated by the volume of respondent output produced--that is, by the moderator's ability to keep the group actively talking for 60 to 90 minutes. While this is a simple and easy way of determining if the group was productive, it is far from inclusive or "correct." The quantity of the focus group is,of course, far less relevant than the quality or "richness"of the group. Richness refers to findings that are thought-provoking and that communicate much relevant information in a parsimonious fashion. Additionally, the following key points deserve consideration in evaluating a focus group: G. Did respondents feel comfortable enough to openly discuss their attitudes ? Were respondents mode aware of the task at hand ? Level of interaction among group members: a true group or ten individual interviews? Did moderator ask questions in an unbiasing manner? Is the viewer able to tell how the group felt about an issue? Is a substantial amount of post-hoc analysis necessary to separate true respondent feelings from those expressed due to moderator demands? During the course of a single group, did the moderator demonstrate enough flexibility to pursue new directions? Across a series of sessions, was each group conducted identically, or did the moderator permit the discussions to evolve ? Did the moderator exercise the proper amount of control-- loose enough to permit expression among respondents, yet tight enough to avoid chaos and interruptions ? K.A.P. SURVEYS
Knowledge, attitude and practice are thought to be important determinants of health, in addition to biological and health service factors. Practice refers to health behaviours. The practice may promote health and prevent diseases or the opposite. Because favourable health practices contribute to health and prevent illness, they are of interest to health professionals and may have to be learned or changed if they are not already present. Many health educators believe that the best way to teach or change practices is to teach correct knowledge and favourable attitudes, and that good practices will follow. Generally, it is assumed that Correct knowledge + Positive Attitudes = Health Practices. Because of the importance attributed to knowledge, attitudes and practices in health, researchers want to find out what people know, feel, and practice. For these purposes they develop and use KAP questionnaires. K.A.P. questionnaires are designed usually in order of P.A.K. Practice is assessed by asking what the person currently does and giving an exhaustive list of options, to each of which the person responds yes or no. It is possible for a person to report doing several of the options in the course of a day or week. Some important guidelines on such questions are: be specific about behaviour; ask about most recent practice, include all practices not only good ones, and verify through observation or questioning. If you include an open-ended question, follow it up with specific response alternatives in case the person has not provided you with a complete description. Attitude is assessed in terms of what the person prefers to do, what they would do if they had the choice, or how favourable - unfavourable or positive - negative they are to the object.
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Knowledge is assessed in terms of what the person knows about the item and whether this knowledge is true or false. A good way to do this is to have some open-ended questions, which are respondent must answer as in a short-answer test, e.g., What is a germ ? This would be followed by a series of True-False Statements or Yes-No-Don't questions to test recognition knowledge. Correct and incorrect statements must be included in the latter and the respondent is asked to indicate whether a statement is true or false, or whether the question should be answered Yes or No. The number of correctly answered statements is their knowledge score. Some hints: include all relevant knowledge, a pilot test may be required first and mix correct and incorrect items. How to develop a KAP questionnaire: 1. Define conceptually what is meant by Knowledge, Attitude and Practice. Keep to these definitions when you make up the items. 2. Develop items systematically to include all the relevant ones. This may first require a probing pilot test with personal or group interviews to elicit the respondents' KAP spontaneously. The content must be complete and include all important practices, attitudes and knowledge. 3. Phrase items in lay terms not in professional terms. 4. Combine items that bear on the same practice. 5. To improve reliability, include at least 10 items for each K, A, and P. Reduce data by summing across items. Make sure scoring is appropriate for summing, e.g., 1 point each for each correct item on the K test, 1 point for each healthy practice, and 1 point for each healthful attitude. 6. Order items as follows - PAK - to minimize contaminating P answers with K items. Critique of KAP studies: The KAP questionnaire is useful for finding out the Knowledge, Attitude and Practices of a group of people, and identifying those that require change. It is often assumed that K+A=P and that to change P, one must first change K and A. However, this equation is faulty. Changing K and A does not always lead to a change in P. Also other variables enter the equation, such as access and social pressure. Another problem with the KAP questionnaire is that the respondents' answers are often biased by their limited recall and their desire to please the interviewer. Finally, the questionnaires are limited to KAP that are being questioned; items must be continuously improved to reflect the new situation. Add items that are found to be predictive of practices, even though they do not fit the categories of K and A. Ask the respondent to keep a daily record of their practices, rather than reporting on them from memory.
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Lecture Notes On HE

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MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

I. INTRODUCTION & DEFINITIONS

INTERRELATIONSHIP BETWEEN BEHAVIORAL SCIENCES AND COMMUNITY MEDICINE

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

HEALTH LOCUS OF CONTROL (HLC)

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

AIMS & PRINCIPLES OF HEALTH EDUCATION

Shabbir Ismail MD MPH Associate Professor

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

III. COMMUNICATION A. Purpose & Objectives of Communication

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shannon and Weaver model

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Communicatee is referred to in this model as destination. 3. Schramm model

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Source or the sender or the communicator

Behavioral Sciences Unit DCH, FOM (AAU)

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Confidence or attitude towards self. Message

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------

Shabbir Ismail MD MPH Associate Professor

MPH 1, Health Education 1 Semester 2, 2003 ------------------------------------------------------------------------------------------------------------------------------------------------------------