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Section 4 : Social, Behavioral and Communication Sciences113 Principles of Sociology in Health Care S S L Parashar 608

114 Family Health History & Individual Medico - Social History - Taking RajVir Bhalwar, SSL Parashar 613

115 Health Education SSL Parashar 619

116Planning, Implementation and Evaluation of Health Education Programmes

RajVir Bhalwar 624

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113 Principles of Sociology in Health Care

S S L Parashar

Social, cultural, psychological and behavioural factors are important variables in the etiology, prevalence and distribution of disease. The way the people live, their habits, beliefs, values and customs are significant determinants of individual and collective health. The behavioural sciences (sociology, social psychology, cultural anthropology) have made significant role in developing better understanding about the social etiology of health problems. It is recognized that causation and spread of a disease does not depend entirely upon biological organism. The cultural and social factors which govern human behaviour also have dominant role to play in the disease process. Any behaviour is determined by a combination of cultural, psychological, social and economical variables. Hence the study of health embraces the totality of life and ways of living.

Sociology : Sociology is the science concerned with the organization of structure of social groups. It studies the kinds and cause of variation in social structure, and the processes by which intactness of social structure is maintained. Sociology deals with the study of society. Society is a group of individuals who have organized themselves and follow a given way of life. The behaviour of man depends very much upon his relationship with other fellow beings. Man is a subunit of a small group; the family, while the family is the basic unit of society. Man’s behaviour is affected not only by his physical and biological environment but also, to a larger extent by social environments represented by his family.

Community : In the simplest terms, a community can be defined as a group of people who have some common characteristics and are bound together by “WE” feeling. This sense of ‘we’ feeling (i.e., shared togetherness) may be due to a place where they all stay or due to some other common interest.

Accordingly, communities can be either “structural” or else, “functional” communities. Functional communities are non-geographical aggregates which are bound together by some common factor other than geographical place of residence or work; e.g., religion (as, Hindu community), occupation (as medical community), special interest (as cricket lovers) or need (as socially backward communities). Structural communities are organised by geographical or political boundaries. It could be as small as an “indoor patient’s community in a hospital” or increasingly larger, according to a “Mohalla”, village, slum, city, district, state or even a nation. Community affiliations often provide a source of support for individuals and group. The sense of group identity eases the growth of motivation. For this reason the community is ideal for focal point of programme.

Culture : Culture is defined as learned behaviour which has been socially acquired. Culture includes all that man acquired in the mental and intellectual sphere of his individual and social life. It is a product of human societies.

Culture is necessary for human being; it makes life worth

living and socializes man. A culture denotes total way of life. It is recognized that cultural factors are deeply involved in all the affairs of man including health and sickness. The cultural factors such as customs, beliefs, values and religious taboos create an environment that helps in the spread or control of certain diseases and affect health of the community. The cultural factors are deeply involved in matters of personal hygiene, nutritional and breast feeding habits, weaning and rearing practices, family planning, immunization and seeking early medical care.

Family : “The Family is a group defined by a sex relationship precise and enduring to provide for the procreation and upbringing of children” (MacIver). The family is a primary unit of all societies. As a cultural unit, the family reflects the culture of wider society of which it forms a part and determines the behaviour and attitudes of its members. The family is an epidemiological unit, and a unit for providing social services as well as comprehensive medical care.

Family life cycle stages : A family passes through the following stages in its evolution :

Married couple - beginning of family ●Child bearing family ●Family with pre- school children ●Family with school age children ●Family with teenage children ●Middle age ●Aging family members/ retirement ●

Role of Family in Health and DiseaseFamily is the reproductive nucleus of society, a fundamental and social institution whose primary and essential task is to socialize the new born so that they may be placed in life as mature and independent. From the time the child is born, the course of his physical and mental development is determined by his initial experiences with the family. Every society from nomads to city- dwellers has its institution of marriage and stable family life. Through the family, human beings maintain physical continuity by reproduction, maintain social and cultural continuity through training and education.

The health of the child is bound up with the family’s internal and external environment even before it is born, and the foetus in the womb can be harmed by the health, nutrition and behaviour of the mother. Undernutrition of mother can give rise to infants born prematurely and of low birth weight with attendant high risks of mortality or damage to the nervous system. Her unborn child can be damaged by familial infections like rubella and syphilis. Subsequent experiences in infancy, in the quality of feeding and method of training for instance may further influence development, physique, stature and personality.

The members of family share a pool of genes and a common environment as well as common modes of thoughts and behaviour and family material and social environment which includes housing, sanitation and diet. A damp overcrowded house encourages streptococcal infections (Rheumatic fever and nephritis). Tuberculosis flourishes in poor and over crowded homes. It is not only infective agents that pass between the members of a family; parents may transmit distorted cultural

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perceptions & behavioural norms to their children; thus creating deviant behaviour and failures of adaptation among them.

Familial beliefs and attitudes go a long way in shaping the reasons for health and disease. The various causes for sickness, as understood, may be classified in two categories : Supernatural causes and Physical causes. Supernatural causes include diseases caused by (a) breach of taboos e.g. leprosy, sexually transmitted diseases; (b) wrath of god and goddesses e.g. small pox & chicken pox; (c) spirit intrusion, ghost intrusion and evil eye. The physical causes include excessive heat or cold, wrong combination of foods and impurity of blood etc. Prevention of disease and bringing improvements in the health conditions in any society is dependent upon our ability to understand and improve the social or environmental factors.

As families enter each new developmental stage, transition occurs. Events such as marriage, childbirth, releasing members as adolescents and young adults, and continuing as a couple or single person and aging years move families through new stages. Each new developmental stage requires adaptation and new responsibilities. Each new stage presents opportunities for health promotion and intervention. There are certain functions which are relevant to health behaviour, and are important from the medical sociology point of view.

Upbringing of children ● : One of the important functions of the family with which medical and health workers are concerned, is the physical care of the dependent young in order that they may be survive to adulthood and perpetuate the family. It is important to note that child care (e.g. feeding, nutrition, hygiene, sleep, clothing, discipline, habit training) are passed on from one generation to another. The ideas people have about nutrition exercise; sleep and clothing have a large social component which varies from society to society. Socialization in the family ● : By socializing is meant teaching the values of society and transmitting information, culture, beliefs, general codes of conduct, by example and precept, in order to make them fit for membership in the wider society of the family is a part. The family plays the most dominant role in the individual’s socialization. The child finds much to learn in the behaviour of his family members, parents, relatives and friends. He imitates them in their mannerisms, behaviour etc. He tries to avoid such activities which are considered bad in the family. It is the family environment which forms his good habits. It is in the family that the child acquires such important qualities as sincerity, sympathy, self submission and realizing responsibilities. The child’s first school is his home and family. It is the family which imparts practical education to children concerning the customs in society, preservation of health, love, sympathy, cooperation etc. Learning about health promotion and disease prevention begins at birth, with the family providing the environment for incorporating health in the value system of its members. Influence of family on personality ● : The environment of home has a comprehensive influence on the development of personality. In the family the relation of the child with the parents is the most intimate. The cultural development of the child is very much influenced by the behaviour of

the parents. The capacity of an individual to withstand stress and strain and the way in which he interacts with other people is to a large extent determined by his early experience on the family. The families acts as a placenta excluding various influences, modifying others and pass through it and contributes some of its own in laying foundation of physical, mental and social health of the child.Care during sickness ● : The family is expected to provide care during sickness and injury of adults and dependents from the public health point of view. Care of women during pregnancy and childbirth is an important function of the family. The joint family provides support, security and encouragement to the aged and handicapped.Family as strength in crisis ● : The family is understood as shock absorber. The family is an important source of support. During times of illness and crisis the family is there for the individual. The family provides an opportunity, both for adults and children, for release of tension so that the individual can attain mental equilibrium and strive to maintain a stable relationship with other people. The family has an important function in stabilization of the personality of both adults and children, and in meeting their emotional needs.Problems in families ● : The factors in most problem families are usually those of personality and of relationship, backwardness, poverty, illness, mental and emotional instability character defects and marital disharmony. These families are recognized as problems in social pathology. There is a need to render useful service in rehabilitating such families in a community.

The family therefore plays an important part both in health and disease - in prevention and treatment of individual illness, in the care of children and dependent adults, and in the stabilization of the personality of both adults and children.

Crowd : In common usage any large number of people gathered in one place is called a crowd. A crowd is potential medium for arousing emotion and for encouraging its expression. Large gathering people provide congenial conditions for emotional contagion. Simulation and suggestions are heightened. The presence of others gives a sense of security and approval and crowds convey a feeling of anonymity. By their very nature casual crowds and mobs are not part of organised system of social relations.

Mob : The term refers to one crowd that is fairly unified and single minded in its aggressive intent. Mob action is not usually destructive but tends to be focused on some one target or identity. Mob activity is the most goal oriented and the most dependent upon leadership for its direction

Sick role : ‘Being Sick ‘ is not simply a state of fact or condition, it is a specifically patterned social role. To be ill is more than a medical condition. The patient has a customary part to play in relation to his doctor and to his family members of his society & in turn they expect him to behave in certain prescribed ways.

Rights The Sick person temporarily is exempt from normal ●social roles. The more severe the sickness, the greater the exemption.

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The sick person generally is not held responsible for his ●condition. Illness considered beyond individuals control therefore not simply curable by willpower.The sick person has a right to be taken care of. ●

Duties / obligations The sick person has an obligation to try to get well. In this context exemption from normal responsibilities is temporary and conditional upon wanting and trying to get better.

The sick person has an obligation to seek technically competent help from a suitably qualified professional and to cooperate in trying to recover.

Social Pathology : Social pathology is the systematic study of human disease in relation to social conditions and disease process outside the human body. The cause is to be found in the society. These include Social Problems ( namely, poverty and destitution, illiteracy and ignorance, migration, lower status of women,, child neglect and child abuse, child labour, drug abuse, juvenile delinquency); social conditions (as housing, environmental sanitation, crime and corruption, stress, suicide) and social circumstances (Viz., stigma, social isolation, vulnerable populations). The causes of social problems, conditions which affect the health of the people are to be understood and actions are to be taken to prevent such problems through health education and rehabilitation.

Social Diagnosis : This is made by socio- medical surveys and by study of domestic and social conditions of individuals.

Social Therapy : Social therapy offers holistic development centered therapeutic and support services. The approach addresses and supports the total social, emotional and educational needs of young and the entire family. Clinical treatment of any disease with drug should be supplemented with social therapy as far as possible. The Social security measures link between hospital and community, health education, legislation serve as supportive measures.

Knowledge : Education is a process of learning undergone by individuals for gaining knowledge, developing attitudes and acquiring skills. Knowledge is the basis of health education where a person gets of information by many modes which become his knowledge. Some apply the term knowledge to what are held to be certainties. Knowledge is intellectual and passive. Awareness can be created through imparting knowledge on a particular topic. e.g. receiving information about harmful effects of smoking.

Attitudes : Attitudes are mental habits acquired from social experiences that predispose us to react to specific objects, persons or situations in a definite way. They are the crystallized habits of thoughts that we develop relative to social situations and that set us to respond in a certain manner. An attitude is an enduring system that includes a cognitive component, an emotional (feeling) component and an action tendency. They are manifested in conscious experience, verbal reports, gross behaviour and physiological symptoms. The people are motivated to change attitudes to adopt new health behaviour. e.g. the individuals are motivated to stop smoking through various methods of health education and individuals are ready to change behaviour.

Practices : Practices are application to particular and personal situation. Practices are guided by principles under the light of intellect. The individuals modify their behaviour and maintain the change for the rest of their life. e.g. the individual stops smoking after changing attitude.

Community’s social support systems : In medical practice the ability of a family to provide social support and material aid to dependent members is obvious importance. When patients who are disabled by sickness are reintroduced to normal social life, for example their family relationships and attitudes help to determine the outcome. Support comprises a network of family, friends, co-workers and professionals.

Social assistance implies provision of relief to individuals at critical times without having received any contribution from them. Social assistance is a non-contributory benefit extended to vulnerable groups including women, children and the aged. The community’s participation in health programmes and programmes which are developed locally is to be found through situational analysis. The programmes such as aid to families with dependent children, medical aid, family counseling services, crisis support (food, shelter, clothing, fuel), referrals to appropriate medical services, drug de-addiction services, treatment services for alcoholics, delinquency prevention, services for the retarded and emotionally disturbed, income generation, vocational training services are provided by the community through appropriate groups, organizations and agencies. The philosophy behind tertiary prevention of chronic diseases is that it is often possible to live with and die with disease rather than dying from the disease. It is possible to prolong time period of optimal physical functioning and social activity by providing social support and self management services.

Social Environment : The social environment includes all those things which arise out of social relationships such as customs, traditions, institutions social conduct, rituals, diet, way of life and economic status. Health is profoundly influenced by the social environment which acts in many ways to shape the contours of disease, in populations as well as individuals. For promotion and protection of health and prevention and control of disease, social environment should be free from harmful agents. Important measures for providing healthy social environment are :

Social security against fear and want (ESI scheme, old age ●pension, life insurance, provident fund and health and medical facilities). Fair distribution of food and other amenities of life such ●as housing Facilities for exercise and leisure ●Facilities for education for all ●Propagation of healthy customs, freedom of expression ●and thoughtProtection of property, life and honour ●Safe work place which involves establishing a stimulating ●work environment and making sure that the work place creates social contacts which do not interrupt the family networks.

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Non-Governmental Organizations (NGOs), Voluntary Organizations : NGOs form a bridge between the government and community and provide platform for people participation NGOs are many and diverse. Their scale may be large, medium, and small. Their support may come from external sources, from their own fund raising or from Government. Their principle activity may be direct service to those in need in the community, health education or research. Voluntary organizations could be defined as those organizations which are non- governmental and non profit making in character and not fully funded whether directly or indirectly only by government. Most voluntary organizations have four primary purposes (i) raise money to fund research and programmes (ii) provide education to both professional and the public (iii) provide services to individuals and families affected by the disease and health problem (iv)to advocate for beneficial policies, laws and regulations. (e.g. VHAI, Indian Red Cross Society, Hind Kusht Nivaran sangh, Tuberculosis Association of India etc. )

Social Security : Social security means public programmes designed to protect individuals and their families from income losses due to unemployment, old age, sickness or death and to improve their welfare through public services (e.g. medical care) and economic assistance. The term may include social insurance programmes, health and welfare services and various income maintenance programmes.

Social class and Socio-Economic Status : Socio-economic standard of people is conventionally expressed in terms of various social classes in which people are distributed which are referred to as social stratification. Social stratification is a horizontal division of society in to several socio-economic layers : each layer or social class has a comparable standard of living, status and life style. Social class is determined on the basis of three parameters of development, namely education, occupation and income. Education determines the knowledge, attitude, and value system of individuals and their socio-economic growth potential. Occupation determines the income generating capacity of individuals and their status. Income determines the purchasing power of individuals and their socio-economic status. On the basis of these parameters populations are divided in to social classes - upper, upper middle, middle, upper lower and lower. These social class gradients have helped to provide a deeper understanding of clinical phenomena. The poor had a higher incidence of some diseases, the rich of others. Health practices too, like the use of health services, welfare and maternity clinics, and methods of infant feeding were found to

be correlated with social class.

Kuppuswamy’s scale : The socio-economic status scale (urban) developed by Kuppuswamy attempts to measure the socio-economic class of family in urban community. It is based on three variables - education, occupation, and income. A weightage is assigned to each variable according to seven point predefined scale. The total of three weightages gives the socio-economic status score which is graded to indicate the five classes, as per details in Table - 1. To get current income group, a conversion factor based on current All India Consumer Price Index (AICPI) is used, which is given later.

For income, the conversion factor can be obtained by dividing AICPI by 60.04. The income group in the Kuppuswamy’s scale are multiplied with the conversion factor to get the appropriate income group (Indian Journal of Pediatrics, volume 70, March 2003). Now, since AICPI in June 2008 was approximately 650, hence 650 divided by 60.04 = 10.83. Thus all the income groups in the Kuppuswamy scale in the above table are multiplied with the conversion factor to get the appropriate income group. Thus, the conversion factor 10.83 is multiplied by Rs. 2000 which comes to Rs 21,660/- and rest income groups would be as given in Table - 2.

Table - 2 : Recalculated family income groups of the Kuppuswamy’s scale as on June 2008

Income Original

Modified by using conversion factor (multiplied by 10.83) Score

> 2000 >21660 12

1000-1999 10830-21659 10

750-999 8122-10829 6

500-749 5415-8121 4

300-499 3249-5414 3

101-299 1093-3248 2

<100 <1093 1

The Total score in Kuppuswamy’s classification is calculated as the sum total of the three scores, i.e., Education (A)+ Occupation (B)+ Income (C) Depending on the total score so computed, the five socio-economic classes are as given in Table-3.

Table 1 : Kuppuswamy’s Socio - Economic Status Scale (Urban)

Education of head of family Score Occupation Score Family Income per month Score

Professional Degree 7 Professional 10 Rs.2000and above 12

Graduate 6 Semi-profession 6 Rs1000-1999 10

Intermediate/Diploma 5 Clerical/shop/farm 5 Rs 750-999 6

High school 4 Skilled worker 4 Rs 500-749 4

Middle school 3 Semiskilled 3 Rs 300-499 3

Primary school 2 Unskilled 2 Rs 101-299 2

Illiterate 1 Unemployed 1 Rs <100 1

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Table - 3 : Socio-Economic Class

Total Score Class Description

26 - 29 I Upper class

16 - 25 II Upper middle

11 - 15 III Lower middle

5 - 10 IV Upper lower

Below 5 V Lower

Prasad’s Scale : Dr. B G Prasad’s social classification was developed in 1961 and is based on per capita per month income. There are five classes, as follows Upper class (per capita per month income Rs 100 and above); Upper middle ( 50-99); Lower middle ( 30-49); Upper lower ( 15- 29); and Lower (below 15). The income group can be recalculated by multiplying the above mentioned income as mentioned in Prasad’s classification with P Kumar’s conversion factor i.e.

Conversion factor = (Value of CPI X 4.93) ÷ 100

For example, the AICPI for June 2008 was 650. Thus the conversion factor will be

(4.93 X 650) ÷ 100 = 32.04, or roughly, 32. Thus the ranges of per capita per month income of this classification for 2008 will be >Rs 3200; 1600 - 3199; 960 - 1599; 480 - 959; and, < 480.

Pareek’s Scale : The Socio-Economic Scale (rural) developed by Pareek attempts to measure socio-economic status of a rural family. It is based on the nine items as follows : Caste; Occupation of head of family; Education; Levels of social participation; Land holding; Farm power (prestige animals); Housing; Material possessions; and, Family type. The combined score for the nine items is graded to indicate socio-economic class categories.

SummarySociology deals with the study of society. Society is a group of individuals who have organized themselves and follow a given way of life. Man is a subunit of a small group; the family, while the family is the basic unit of society. Man’s behaviour is affected not only by his physical and biological environment but also, to a larger extent by social environments represented by his family. A community can be defined as a group of people who have some common characteristics and are bound together by “WE” feeling. This sense of ‘we’ feeling (i.e., shared togetherness) may be due to a place where they all stay or due to some other common interest. Accordingly, communities can be either “structural” or else, “functional” communities. Community affiliations often provide a source of support for individuals and groups. Culture is defined as learned behaviour which has been socially acquired. The cultural factors such as customs, beliefs, values and religious taboos create an environment that helps in the spread or control of certain diseases and affect health of the community. The Family is a group defined by a sex relationship precise and enduring to provide for the procreation and upbringing of children. The family is a cultural unit, an epidemiological unit, and a unit for providing social

services as well as comprehensive medical care. The Family has an important role to play in Health and Disease. The health of the child is bound up with the family’s internal and external environment even before it is born. The members of family share a pool of genes and a common environment as well as common modes of thoughts and behaviour and family material and social environment which includes housing, sanitation and diet. For health promotion and intervention, every family has certain important functions like Upbringing of children; Socialization in the family; laying foundation of physical, mental and social health of the child; Care during sickness especially pregnant women, children, aged and handicapped; providing support in crisis and problems.

Any large number of people gathered in one place is called a crowd. A crowd is potential medium for arousing emotion and for encouraging its expression. The term mob refers to one crowd that is fairly unified and single minded in its aggressive intent. Mob action is not usually destructive but tends to be focused on some one target or identity. Social Pathology is the systematic study of human disease in relation to social conditions and disease process outside the human body. Social Diagnosis is made by socio-medical surveys and by study of domestic and social conditions of individuals. Social Therapy offers holistic development-centered therapeutic and support services. The approach addresses and supports the total social, emotional and educational needs of young and the entire family.

Education is a process of learning undergone by individuals for gaining knowledge, developing attitudes and acquiring skills. Attitudes are mental habits acquired from social experiences that predispose us to react to specific objects, persons or situations in a definite way. Practices are application to particular and personal situation. Community’s Social Support Systems comprise a network of family, friends, co-workers and professionals. Social Assistance implies provision of relief to individuals at critical times without having received any contribution from them. Social Environment includes all those things which arise out of social relationships such as customs, traditions, institutions, social conduct, rituals, diet, way of life and economic status. Health is profoundly influenced by the social environment. Important measures for providing healthy social environment are : Social Security against fear and want, Good Housing with all important facilities, Protection of property, life and honour and Safe work place. Social Security : Social security means public programmes designed to protect individuals and their families from income losses due to unemployment, old age, sickness or death. Social stratification is a horizontal division of society in to several socio-economic layers : Each layer or social class has a comparable standard of living, status and life style. Social class is determined on the basis of various scales like Kuppuswamy’s scale for Urban and Prasad’s scale and Pareek’s scale for Rural.

Study ExercisesLong Questions : (1) Describe the role of Family in Health and Disease. (2) Describe the role of Cultural factors in Health and Disease. (3) What is Social environment? How does it affect the health and disease? Enumerate important measures for providing healthy social environment.

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Short Notes : (1) Social pathology (2) Social Security measures (3) Kuppuswamy’s scale.

MCQs : 1. Kuppuswamy’s scale is based on the following variables

except (a) Education (b) Occupation (c) Income (d) Housing

2. According to Kuppuswamy’s scale, total score for upper middle class is (a) 11-15 (b) 16-25 (c) 26-29 (d) 29-31

3. According to Kuppuswamy’s scale, total score for upper

114Family Health History & Individual Medico - Social History - Taking

RajVir Bhalwar & SSL Parashar

It is abundantly clear by now that every disease has a tremendous social component. The various components of sociology, as described in previous chapter, decide whether a given human being will be exposed to the disease process or not; if exposed, whether disease process will perpetuate or not; and finally, what will be the outcome of the disease process. It is therefore extremely important that every Doctor should work up the psycho-social and behavioural components of a patient and not simply the clinical findings / laboratory investigative results, to effectively treat the patient and to prevent recurrence of the disease. For example, going simply by the clinical picture, we may treat a child with dehydration, with i.v. fluids and supportive therapy, and discharge her after a few days as “cured”. However, if we did not work up the details of environmental sanitation and water supply at the child’s house, the knowledge attitudes and health related practices of the mother, the family size, and so on, for certain the child will keep coming to us. Thus, for having a totalistic or holistic overview of our patient and to really treat the disease effectively, “from the root causes”, we must take a proper medico-social history, work out the various sociological parameters and treat, not only the clinical disease, but also the social causes.

Medico-social history taking is, therefore, also an essential requirement at the undergraduate and postgraduate level of medical curriculum, with a view to prepare the general and specialist Doctors to function effectively as Community physicians.

In addition to recording a detailed medico-social history from an individual patient, it is also very important for the public health manager to consider the “family” as a unit of action for her various health care activities. In the previous chapter, we have already emphasized regarding the tremendous impact

that the family has on the health and disease of individual members of the family.

In fact, it would be highly desirable that every Public Health Programme Manager and Medical Officers in-charge of a Primary Health Centre (PHC) / Community Health Centre (CHC) should develop “Family Health Folders” for each and every family in his / her area of health care, on the same lines as Departments of Community Medicine in Medical Colleges; maintain and regularly update such folders in their respective Rural Health Training Centres (RHTCs) and Urban Health Centres (UHCs). The contents of these family folders should be regularly updated by regular visits to the households by medical / paramedical staff, preferably once in six months and definitely once in a year. It would be a further good work if the contents of these folders be entered into a computer database, so as to help in quick retrieval and analysis of data, which would greatly assist in planning and evaluation of public health programmes.

In the present chapter, we shall be dealing with the details of firstly, the ‘family health folder” and secondly, regarding medico-social history taking and how to draw conclusions from such history.

The Family Health Folder & Family Health RecordsAs said above, it should be an endeavour of all health care providers to ensure that they have a detailed family health folder for each and every family in their area of health care jurisdiction, and these folders should be updated very regularly.

General description : The family health folder should be generally 12 inches X 10 inches and preferably having a hard cover to ensure durability. It should have a system so that various cards / papers can be filed in the folder. Having a “multiple leaflet” folder may be even better as it will assist in filing various records separately, for various members of the family, within the same folder.

The cover of the folder should be printed with the name of the PHC / CHC or any other health care providing unit who is responsible for health care of that family, and the address

lower class is (a) 11-15 (b) 16-25 (c) 26-29 (d) 5-104. The Socio-Economic Scale developed for rural setup is

(a) Kuppuswamy (b) Pareek (c) Prasad (d) None of the above

5. The following are Social security measures against fear and want except (a) ESI scheme (b) Old age pension (c) Housing (d) Life insurance

Answers : (1) d; (2) b; (3) d; (4) b; (5) c.

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and telephone number of the health care unit. In addition, the following details should be printed on the cover :

The “Family Registration Number”. This is a unique number ●which is allocated to a particular family and acts as a unique identifier for the family, especially when computer based records have been made. The number is unique in that no two families should have the same number. The number may be allocated based on some registration given by the local self governmental body as panchayat, or may be developed by the health care providing unit. What is more important is that whatever system has been developed should be enforced, ultimately taking care that every family under health care has a registration number which is unique for that family. Secondly, every family head should be communicated about the number (preferably, given a laminated card having the number printed on it) and they should be advised to bring the laminated card whenever they come to the health centre.The name, father’s / husband’s name and date of birth of ●the head of the family.The detailed address of the household, including the post ●office and police station.Telephone number or any other contact number. ●The permanent address in case the family is of a “migratory” ●nature or is not a permanent native of that place.The date on which the folder was opened. ●The date on which the folder was last updated as a part of ●the regular survey for updating the family folders.The date on which the folder was updated, since some ●individual member of the family came in contact with the health care system (e.g., one of the ladies may be seen in an ante-natal clinic).

The inside surfaces of the folder may be provided with pockets made of thick plastic or strong cloth, for keeping important slips.

Confidentiality of Information : It should be ensured by the health care providers that all information recorded in the folder should be kept strictly confidential, and used for sole purpose of health / medical care, as per the laid down / acceptable codes of medical ethics.

Summary-Sheet : The inside of the front cover should have a printed table, in which the information should be filled up in pencil (to enable making changes); alternatively, the first sheet in the folder should have the information as given in Table-1.

In column (7) of Table - 1, a person who comes to stay temporarily

(as one of the sons who may be working in a town and coming to stay only during festivals) should be indicated accordingly. In column (8), if the person is known to be having any disease, the details should be entered; this should also include entries regarding current pregnancy. The remarks column should include any relevant which is considered to be important for the health care provider to know, at the first glance.

Sheet for Socio-Demographic DetailsThe next sheet in the family health folder should be for the socio-demographic details of the family, recording the following details :

Total number of members in the family ●Distribution according to age and sex ●

Age groups Males Females Total

Upto 1 year

1 to 5 years

6 to 14 years

15 - 45 years

45 - 64 years

> = 65 yars

Total family income per month (all sources included) Rs. ●Per capita per month family income & Social Class ●Distribution according to Educational level ●

Educational level Males Females Total

Graduate & above

Matriculate but not graduate

Educated more than 5th standard but not literate

Educated upto 5th standard

Illiterate

Vital Statistics Record Sheet : Information regarding births, deaths, marriages, divorces, in-migration and emigration should be recorded in this sheet, starting from the day the family folder is commissioned for the particular family, recording the date and details of each such event.

Table - 1

Sl. N

o.

Nam

e

Dat

e O

f B

irth

Age

Sex

Rel

atio

n W

ith

Hea

d

Perm

anen

t O

r Te

mpo

rary

R

esid

ent

Curr

ent

Hea

lth

Stat

us

Imm

unis

atio

n st

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Sheet for Record of Housing and Environmental Sanitation: This sheet should record the following information

General description of the area, approach, access roads ●Evidence of water logging and potential mosquito / housefly ●breeding pointsType of house, condition of roof, floor and walls ●Total floor area ●Total living rooms ●Total floor area per person and total space (in cubic feet) ●per personAny evidence of overcrowding ●Area of Doors and Windows ●Ventilation ●Availability of electricity ●Details of water supply (source, safety and potability, ●quantity, storage)Condition of kitchen, eating place and food sanitation ●practicesDetails of disposal of night soil ●Details of disposal of solid wastes ●Details of disposal of waste water and storm water ●

Individual Health Record Sheets : One health record sheet should be prepared for each individual. It should contain the details of the general health check up as well as the records of results of investigations and hospitalization, if any. The same sheet should continue to have entries of treatment given, as and when the individual reports sick to the health care facility. The special health cards (as ante-natal card, under-fives health card and child health record card) as applicable should also be filed alongwith the general health record card for that individual.

Special Health Record Sheets : These would include the ante-natal and post-natal health care card, the under-fives health card and the school-age child health record card. These should be prepared for each individual member of the family, as applicable, as per details given in the relevant chapters in the section on maternal and child health care. These special health record cards should be filed, in the family folder, alongwith the general health record sheet for that individual.

Sheets for Record of Special Studies / Surveys : There should be a separate sheet for recording the findings of special studies in respect of the family. For example, if a nutritional survey or a geriatric age group survey and so on have been conducted in that area, the findings of these studies / surveys in respect of the concerned family should be recorde on this sheet.

Medico-Social History Taking & Family Case StudiesAs said earlier, every medical, nursing and paramedical person should view a given disease in totality, in context of the various socio-cultural, psycho-emotive and economic factors which initiate and perpetuate the disease process, and not simply confine themselves to only the medical aspects of the disease. It is for this reason that undergraduate medical and nursing students as well as post-graduate students in the specialty of Preventive & Social Medicine (Community Medicine; Public health) are required to be trained and examined in the various aspects of medico-social case taking and family case studies,

as a part of the University curriculum. Similarly, considering the over-riding importance of the role of family in health and disease, a family is allotted as a project and often during the examination, to be studied and presented as a “unit”, rather than presenting an individual case with a disease.

The details of family-case taking have been already dealt with in detail, earlier in this chapter, while discussing the family health folders. The details of medico-social case work up are being discussed herewith in the succeeding paragraphs.

Approach to the patient : Introduce yourself with a friendly greeting, giving your name and status. Explain the purpose of your visit, ask for and remember the patient’s name and request permission to interview and examine the patient. Some patients rapidly tire of being questioned or examined, and others may be depressed because they are ill or apprehensive. If there are difficulties in establishing a rapport, try to determine the reason; if in doubt, consult the medico-social worker or nursing staff. Show tolerance, particularly with the elderly and the challenged. Seek first to understand and not judge the patient so that you don’t react to patients with criticism, anger or dismissal. Some additional tips for effective medico-social case taking are :

Maintain good eye contact. ●Listen attentively. ●Facilitate verbally and non-verbally. ●Touch patients appropriately. ●Discuss patients’ personal concerns. ●Give the patient your undivided attention ●Keep your notes-taking to a minimum when the patient is ●talkingUse language which the patient can understand ●Let patients tell their own story in their own way ●Use open questions initially and specific (closed) questions ●laterClarify the meaning of any lay terms which patients use ●Remember that the history includes events up to the day ●of interviewSummarize (reflect back) the story for the patient to check ●Utilize all available sources of information ●

The fundamental principles underlying medico-social case work-up : The basic principle which must be kept in mind while undertaking a medico-social work-up is that while the patient is the core issue, his disease is actually a result of complex psycho social interactions between the patient, his / her family members, the environment at the workplace (including school), the immediate community members comprising of friends and close associates, the community at large within which the patient lives, and the larger society which consists of the governmental and non-governmental systems. A systematic assessment of all these factors is therefore necessary to be able to reach the root of the problem and to effectively plan a holistic therapy, taking care of not only the biological cause of the disease but also the wider social reasons that lead to the causation and perpetuation of the disease. The factors to be considered at various levels are :

1. Factors Within the Individual : The following variables should be recorded in detail :

Age ●

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Education ●Occupation ●Level of protection against common infectious diseases, by ●way of immunization or previous infectionLifestyle : details of habitual physical exercise, diet, ●tobacco, alcohol and substance abuse, sexual promiscuity Knowledge, Attitudes & Practices (KAP) as regards common ●diseases and their preventionPsycho-Emotive state : whether cheerful and optimistic or ●anxious / depressed or concerned.Separation from family members / near & dear ones. ●Attitudes towards ●

- Personal protection, as use of helmets, use of mosquito-nets, etc.

- Personal hygiene, as regular bathing, hand washing, oral care, etc.

- Health Care System, whether positive and trusts the health care system or unhappy / skeptical.

- Attitudes as regards the disease from which the patient is suffering, and his / her concerns as regards it’s perceived future course / management / rehabilitation

2. Factors in the family : These will include three broad categories of factors, viz., Social Factors, Physical Factors And Psycho-Emotive Factors.

(a) Social Factors in the FamilyType : Whether joint, three generation or nuclear ●Organisation & Composition : Total number of members, ●head of the family, description of family members by name, age, sex, and position relative to the head. Religion and caste ●Education : general level of education; attitudes towards ●formal education; proportion of members who are professionally qualified / having degree / educated / illiterateOccupational patterns in the family ●Income : Total family income; income of the index case; Per ●capita per month incomeSocio Economic Status according to acceptable scales as ●Kuppuswamy or Prasad scale. Knowledge, Attitudes & Practices in the family, in general ●towards healthy lifestyle, personal protection and prevention of common diseases. Health Care services for the family. These should be ●assessed in terms of :

- Availability- Accessibility- Affordability- Quality- UtilisationSocial Aberrations if any in the family, as promiscuity, ●alcoholism, delinquency

(b) Physical Factors in the Family : These will include -Housing : General description, type of construction, area & ●space, ventilation, overcrowding, lighting, other comforts.Water Supply : Source, hygienicity, adequacy, storage ●Disposal of night soil, solid wastes, animal wastes, waste ●

water. Food hygiene : Methods of cooking, storage of raw and ●cooked food, food hygienic practices.Nutrition : Assessment of intake of overall calories and ●major macro / micronutrients; deficiency diseases; relative distribution of food among various members; percentage of monthly income spent on food.Exposure to and protection from insect vectors of ●diseases.

(c) Psycho-Emotive Factors in the Family : These include Level of Interactions / Bondages ●

- Between family members- Of family members with the Index CaseFamily Support System : In terms of financial support, ●physical support (as readiness to physically assist the patient in activities of daily living) and emotional support; and, readiness of family members to provide “support”.Understanding, by the family members, of the disease and ●it’s determinant psycho-social problems that the patient is facing

3. Factors in the Workplace : (Note that for children, school is to considered as workplace)

General description of the workplace or school ●Attitude & Support (Emotional, Physical, Financial) on ●part of

- Employers / Superiors / Teachers- Colleagues / Classmates- Subordinates / ancillary staff in schoolAvailability of facilities, in school / workplace, to cater to ●special needs of the patient

4. Factors in the Immediate Community : (Immediate community consists of the Village / Mohalla in which the patient is living).

General description (income levels and standards of living ●in general, major occupations, general types of housing, educational levels, social aberrations as alcoholism, delinquency, etc.)Community Organisation, strength of “we” feeling, ●cohesiveness between the families in the community.Interactions, of various community members, with the ●Index Case and his / her family members General attitude of community towards disease prevention ●& health careAvailability of Physical, Financial & Emotional Support ●Systems within the community. Health care facilities available ●Availability of School / Special School catering to the ●special needs of the index case.Availability of NGOs / Voluntary Bodies and description of ●their capabilities.Availability of organised public health & social services ●as central water supply and it’s purification, disposal of wastes, transportation and communications. Political will of the community as strength of its ●representation in elected bodiesIdentification of peers & influential leaders and their ●capabilities.

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5. Factors in the Community at Large : This includes the larger social environment as the District / State where the patient is living.

General Attitude ●- Towards Health maintenance, Disease Prevention &

Rehabilitation- Towards the disease in questionAvailability of treatment facilities ●Availability of Rehabilitation facilities ●Statutory and Administrative provisions to protect / ●facilitate the index case.Availability of VHAs / NGOs ●

6. Summarize The Medico-Social FindingsWhat are the “ ● Key Psycho-Social Issues” in the index case, his / her family, workplace, immediate community and the community at large. What is the “ ● Social Pathology”, i.e. the major “weaknesses”; for example, in a medico-social case of an adolescent polio affected girl child, the major weaknesses and hence the social pathology operative in that case could be summed up as “Alcoholism in the family” with “Poor purchasing power” with “ Adverse attitudes towards the girl child”What is the “ ● Social Diagnosis” i.e., those adverse psycho-social effects that the social pathology (major weaknesses) would lead to; for example, in the hypothetical example of the case of polio affected girl child, “ Gross Physical handicap with Poor Rehabilitation facilities with Broken family and adversely predisposed community” may be identified as the social diagnosis, which will result from the identified social pathology, and will therefore need to be “treated”, the way we treat a disease diagnosed by us.What are the “ ● Major Strengths” in our case. This will be worked out by analyzing the support systems - Physical, Social, Vocational, Emotional and Financial, which are available within the family, workplace, and community systems, as also the strengths within the index case (as determination, residual abilities, etc.).

7. Write down the Plan of Management & Social therapyWrite down in a line each, the following, for the case being ●worked up :

- The social pathology- The social diagnosisWrite down your summarized analysis of the Strengths, ●Weaknesses, Opportunities and Threats (SWOT) in this case. Write down what all ●

- Should be done, ideally, in this case - Can be done in this case (“Do-Ability” analysis), after

considering the SWOT.Write down the overall aim and key objectives for the ●medical management part as well as the psycho-social management for the case.Now, write down a detailed plan for each of the following ●aspects, indicating “who will do what, how, and in what time-frame”

- Medical management

- Prevention of Other Diseases and for leading a healthy life

- Disability Limitation - Physical rehabilitation, eg, physical help for activities

of living, for going till the health care centre, etc. - Vocational rehabilitation - training, education, earning

a livelihood, reservation in job and education, etc. - Emotional Rehabilitation - Social Security

SummaryIt is abundantly clear by now that every disease has a tremendous social component. Thus, for having a totalistic or holistic overview of our patient and to really treat the disease effectively, “from the root causes”, we must take a proper medico-social history, work out the various sociological parameters and treat, not only the clinical disease, but also the social causes. Medico-social history taking is an essential requirement at both under and postgraduate level but other than focusing on the individual patient, it is also very important for the public health manager to consider the “family” as a unit of action for her various health care activities.

It is highly desirable that Medical Officers in-charge of a Primary Health Centre (PHC) / Community Health Centre (CHC) should develop “Family Health Folders” for each and every family in their area of health care and these should be regularly updated. Family folder should be generally 12 inches X 10 inches, with hard cover and having “multiple leaflets” so as to record separately, for various members of the family, within the same folder. The cover of the folder should be printed with the name, health care providing unit along with the address and telephone number. In addition on the cover it should have “Family Registration Number” (unique number for each family), name and date of birth of the head of the family, detailed address of the household, telephone number, date on which folder was opened and date on which folder was last updated. On the inside of the front cover or the first sheet in the folder should have a printed Summary-Sheet which would have details of all the members of the family. Other details of the family would be recorded on Sheet for Socio-Demographic Details, Vital Statistics Record Sheet, Sheet for record of Housing and environmental sanitation, Individual Health Record Sheets, Special Health Record Sheets, Sheets for Record of Special Studies / Surveys. Finally it should be ensured by the health care providers that all information recorded in the folder should be kept strictly confidential.

All medical professionals should not simply confine themselves to only the medical aspects of the disease but view a given disease in totality. This can be achieved by training in the various aspects of medico-social case taking and family case studies. The various essential aspect of medico-social case work up are, to start with, initial approach to the patient whereby you should introduce yourself with a friendly greeting, try and remember the patient’s name and request permission to interview and examine the patient. Show tolerance, particularly with the elderly and the challenged. Seek first to understand

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and not judge the patient so that you don’t react to patients with criticism, anger or dismissal.

The basic principle which must be kept in mind while undertaking a medico-social work-up is that while the patient is the core issue, his disease is actually a result of complex psycho social interactions and a systematic assessment of all these factors is therefore necessary to be able to reach the root of the problem and to effectively plan a holistic therapy. For this factors need to be considered at various levels, these are Factors within the Individual which would include age, education, occupation, lifestyle including consumption of tobacco, alcohol etc, Knowledge, Attitudes & Practices (KAP) as regards common diseases, Psycho-Emotive state and attitudes towards personal protection, personal hygiene etc. Factors in the family which would involve taking detail history under following headings Social Factors in the Family, Physical Factors in the Family, Psycho-Emotive Factors in the Family. After family one would like to find out factors in the Workplace, Immediate Community and Community at Large influencing the individual and the disease. Now summarize the Medico-Social findings under the following heads Key Psycho-Social Issues, Social Pathology, Social Diagnosis, Major Strengths. Finally write down the plan of management & social therapy keeping in mind SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) for this case and details indicating “who will do what, how, and in what time-frame”.

Study ExercisesShort Notes : (1) Enumerate broad headings under which one would do medico social case work up (2) SWOT analysis.

MCQs & Exercises1) All are true about “Family Registration Number”

except : (a) This is a unique number (b) no two families would have the same number (c) may be given by the central government (d) may be developed by the health care providing unit

2) Following dates should be written on the cover except : (a) The date on which one of the family members were vaccinated (b) The date on which the folder was updated, since some individual member of the family came in contact with the health care system (c) The date on which the folder was last updated as a part of the regular survey (d) The date on which the folder was opened

3) Immunization status is recorded in : (a) Vital Statistics Record Sheet (b) Sheet for Socio-Demographic Details (c) Summary-Sheet (d) Sheet for record of Housing and environmental sanitation

4) Special Health Record Sheets include all except (a) Under-fives health card (b) School-age child health record card (c) Post-natal health care card (d) Ration Card

5) For effective medico-social case taking one should : (a) Not Maintain good eye contact (b) Touch patients appropriately

(c) Not discuss patients’ personal concerns (d) Not give patient undivided attention.

6) In KAP “P” stands for : (a) Prevention (b) Practice (c) Psycho-emotive state (d) Physical factor

7) “SWOT” analysis stand for all except : (a) Strength (b) Weakness (c) Opportunities (d) Treatment.

8) Health Care services for the family should be assessed in terms of all except : (a) Availability (b) Accessibility (c) Affordability (d) Accountability

9) Socio Economic Status according to Kuppuswamy or Prasad scale is calculated under which broad heading: (a) Social Factors in the Family (b) Physical Factors in the Family (c) Psycho-Emotive Factors in the Family (d) Factors in the workplace

10) Physical Factors in the Family include all except : (a) Total no. of family members (b) Housing (c) Water Supply (d) Nutrition

11) Family Support System includes : (a) Financial support (b) Physical support (c) Emotional support (d) All of the above

12) Immediate community consists of : (a) Village (b) District (c) State (d) Country

13) Factors in the Immediate Community include all except : (a) Community Organisation (b) Strength of “we” feeling (c) Interaction between family members (d) Cohesiveness between the families in the community

14) “Major strengths” of a case can be worked out by analyzing : (a) Social Diagnosis (b) Social Pathology (c) Psycho-emotive state (d) support systems

15) Plan of Management & Social therapy includes all except: (a) Medical management (b) Giving money (c) Disability limitation (d) Emotional support.

Fill in the Blanks1. Public Health manager should consider_______ as a unit.2. Family health folder should be updated regularly by visits

to household by the paramedics preferably once in ______ _______ and definitely once in ______________.

3. Family health folder should of size_____ by _____ inches. 4. Factors in the family include three broad categories of

factors which are ________, _______ and _______ .5. KAP stands for ____________ , _________ and _________Answers : MCQs : (1) c; (2) a; (3) c; (4) d; (5) b; (6) b; (7) d; (8) d; (9) a; (10) a; (11) d; (12) a; (13) c; (14) d; (15) b.

Fill in the Blanks : (1) Family (2) 6months; one year (3)12; 10 (4) Social factors, Physical factors and Psycho-Emotive factors (5) Knowledge, attitudes and practices.

Further Suggested ReadingVatsyanan. Principles of Sociology. Publishers : Kedar Nath Ramnath, 1. Meerut (India).Susser MW, Watson W. Sociology in Medicine. Oxford University Press, 2. London 1971. Mandel E. Health Promotion. Elsevier, USA 2006.3.

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115 Health Education

SSL Parashar

Health education is the application of scientific health knowledge or translation of what is known about health into desirable individual and community health behaviour and actions. It removes ignorance and promotes intelligent understanding of individual and community health needs. It helps people to achieve health by their own actions and efforts.

In earlier times, public health dealt with the sanitation of the environment and the control of communicable diseases enforced by law, if found necessary. However stimulating and helping people to assume responsibility for themselves needs understanding people’s behaviours and the factors influencing it. Health education attempts to influence the health related knowledge, attitudes and behaviours of individuals and communities. In fact, in contemporary public health practice, providing health education, with a view to achieve positive health related attitudes and behaviour form community members is the most important requirement, be it prevention and control of HIV / AIDS or lifestyle (non-communicable) diseases or prevention of infectious diseases and so on.

Definition : Health education is a process that informs , motivates and enables people to adopt and maintain healthy practices and lifestyles. It also advocates environmental changes as needed to facilitate this goal and conduct professional training and research to the same end. In other words, Health education may be defined as a process of bringing about change in the individual’s knowledge, attitude and behaviour so as to enable him to achieve health.

Principles of Health Education : 1. Community involvement in planning health education is

essential. Without community involvement the chances of any programme succeeding are slim.

2. The promotion of self esteem should be an integral component of all health education programmes.

3. Voluntarism is ethical principle on which all health education programme should be built without it health education programmes become propaganda. Health education should not seek to coerce but should rather aim to facilitate informed choice.

4. Health education should respect cultural norms and take account of the economic and environmental constraints face by people. It should seek positively to enhance respect for all.

5. Good human relations are of utmost importance in learning.

6. Evaluation needs to be an integral part of health education.

7. There should be a responsibility for the accuracy of information and the appropriateness of methods used.

8. Every health campaign needs reinforcement. Repetition of messages at intervals is useful.

Information Education Communication (IEC)IEC is a broad term comprising a range of approaches and activities. Visible component of IEC is frequently the material produced and used. Effective IEC makes use of a full range of approaches and activities. IEC activities are grounded in the concepts of primary health care, concerned with individual behaviour change and changes in social or community norms. IEC can be defined as an approach which attempts to change or reinforce a set of behaviour in a target audience regarding a specific problem in a predefined period of time. It is multidisciplinary and client centered in its approach drawing from the field of diffusion theory, social marketing, behaviour analysis and anthropology. Embodied in IEC is the process of learning that empowers people to make decisions, modify behaviours and change social conditions. Activities are developed based upon needs assessments, sound educational principles, and periodic evaluation using a clear set of goals and objectives.

CommunicationA good working definition for effective communication is to share meaning and understanding between the person sending the message and the person receiving the message. The key element is “understanding.”

Verbal & Non-verbal Communications : In verbal communication, the tone of voice can communicate feelings and emotions that are as significant as the words being spoken. Accordingly, it is important to choose words that do not offend in any way and that are easily understood. One should avoid using trigger words, jargon, medical or other sophisticated terms. The use of particular languages may be important in reaching all sections of a community. In non-verbal communication, body position, gesture and facial expression, often referred to as body language, can communicate as much as words. It is often through such body language that we express our attitude towards an issue, a person or a person’s behaviour. Service provider must become skilled in interpreting the body language of users as this may assist them understanding users’ needs and concerns more fully. Service providers must also be aware of their body language and signals they may be unknowingly sending to users (e.g. movements or expressions that indicate fatigue, boredom, fear, frustration, indecision) (women may speak fewer languages than men, for example).

Communication Process In health communication we communicate for a special purpose to promote improvements in health behaviour through the modification of the human, social and environmental factors that influence behaviours. It is necessary to understand how communication works. The various components involved in the process of communication are depicted in Fig. - 1.

Components of the Communication process : It is apparent that several elements are involved in the process of communication. It will also be appreciated that communication is two way process. This implies that just as the sender (source) is communicating with the receiver; so is also the receiver communicating with the sender. The components are :

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Fig. - 1 : Communication process

Sender with message Communicate or Relaysfeed back

Decodes or Understandsthe message. Encodes the

messageDecodes or Understands

the message

Choose medium andmethod

The Receiver receivesthe message

The Sender : Sender is the source of Communication. Sending the message to the receiver will depend on his personality, mannerism, conviction conduct etc. The following aspects need to be particularly considered with regards to the sender : - His own competence and expertise in the subject.- His own convictions about what he speaks.- His own mannerism, which include non-verbal

communication skills.The Receiver : Also called the audiences who are receiving the message sent by sender.

The Message : This refers to the information which desires to communicate and must possess the following attributes :

Message should be precise and to the point ●The ambiguity in the message may create more harms ●than good.The information should vary from person to person or from ●group to group depending upon their background.The message must necessarily contain clear concrete ●suggestions for action in day to day life of the receiver.

The Medium (Channel) : The communication channel through which the message moves from the sender to receiver is the medium. These include the various methods (as lecture or exhibition) and the “aids” (as slides, slide projector) which are utilized to communicate the message.

Encoding : This process includes the language expression, gestures and actions utilized for the purpose of making the information intelligible to the receiver. Obviously the receiver must be familiar with the code.

Decoding : The process by which the receiver assigns meaning to the symbols transmitted by the sender. In other words, the process by which the receiver understands or interprets the message is called decoding.

Feed back : Feedback is the mirror of communication. Feedback is the receiver sending back the message to the sender, the message as perceived. Without feedback communication is one-way. The part of the receiver’s response that the receiver communicates back to the sender.

Propaganda and Advocacy : Propaganda is merely a publicity campaign aimed presenting a particular thing or concept in a favourable light in such a way that public may accept it without thinking. It is a deliberate attempt planned with a view to altering and controlling ideas and values along predetermines lines. The widely employed techniques are an appeal to emotions, feelings and sentiments. It prevents or discourages thinking by readymade slogans. The knowledge is

spoon-fed and passively acquired. As a mass-communication activity propaganda tends to have short-run situationally-defined aims with an appeal to diverse population on the basis of immediate interest, fears or desires. The objective is to not so much influence the individual deeply as to win his support for some immediate issue.

The aim of ADVOCACY is to place health problems issues on the political agenda and effectively reach the influential group of policy makers, elected representative, professionals and other interest group to formulate and implement policies to create pressure groups and supportive systems in order to respond appropriately to the health problems. It helps in identifying potential allies and building alliances and relevant policy and decision making channels. The information concerning position on the issue is collected and provided. A common understanding among stakeholders concerning issue is created through advocacy and negotiating action on the basis of common understanding is taken. Through advocacy reasoning, influencing, lobbying, pushing and persuading decision makers and other stake holders. The directions of advocacy are; (a) Advocacy for policy design (b) Advocacy for decision making at various levels (c) Advocacy for implementation .There are two types of advocacy : Proactive and Reactive advocacy. Proactive advocacy is bringing a particular issue in to public focus and providing a definite shape for the audience that is sought to be influenced and reactive advocacy entails addressing particular situation or problem once it has already surfaced in the open. It involves addressing attitudes and opinions after they have been formed in the recent past.

Barriers in Communication Unplanned distortion during the communication resulting in the receiver obtaining a different message than that sent by the sender is referred to as barriers in communication (also called as “Noise” or “distortions” in communication). These can be :

Physiological : Difficulties in hearing, expression.

Psychological : Emotional disturbances.

Environmental : Noise, invisibility, congestion in the classroom, etc.

Cultural : Level of knowledge, understanding and receiver’s beliefs, etc.

All barriers should be identified and removed for achieving effective communication. One of the main challenges in the design of effective health communication programs is to identify the optimal contexts, channels, content, and reasons that will motivate people to pay attention to health information.

Communication skills are required to make communication effective, the following are the skills required at source level. These include greeting skills, speaking skills, listening skills, questioning skills, and summarizing skills. In short communication process would be effective if the communicator has skills in introduction, skills in presenting and skills in conclusion. The non-verbal skills play an important role. It affects the communication process. Body language is an important constituent of non-verbal communication and consists of gesture, postures facial expressions, eye contact, manipulating the eyebrows etc.

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Behaviour Change Communication Process (BCC)This is depicted in Fig. - 2.

Fig - 2 : Behaviour Change Communication Process

Unaware

Informed / Aware

Maintenance /adoption

of new behaviour

Informed / Aware - Initially a person isunaware that a particular behaviour maybe harmful. The first step in a behaviouralchange programme is therefore to makepeople aware through various channelsusing mass media, group methods andthrough interpersonal communication.

Concerned : Information must be given insuch a way that the audience feels itapplies to them i.e. the audience becomesconcerned and people are motivated toevaluate their own behaviour. Targetedcommunication and interpersonalapproaches are more useful.

Knowledge & skill : Once concernedindividuals may acquire more knowledgeand develop skills by talking to peers,social workers or healthcare providers.More interpersonal communication areneeded at this stage specially trainingprogrammes to build and develop skills.

Motivated and Ready to change :Individual might now seriously begin tothink about the need and importance ofnew health message and measures.Positive message from peers areparticularly effective.

Trial change of Behaviour : Theindividuals decide and try new healthbehaviour. The result of any trial will beevaluated and if satisfied than adoptiontakes place.

Concerned

Knowledgeableand skilled

Motivated tochange

Trial change ofnew behaviour

Components of Health Education ProcessHealth Education has three broad components :

Levels of Health Education ●Methods of Health Education ●Activities undertaken in individual methods ●

Levels of Health education : Health education is carried out at three main levels, viz. individual and family, group level and general public (mass) level.

Individual and Family Health Education : There are plenty of opportunities for individual health education. It may be administered during personal interviews in the consultation room of the doctor or in the health centre or in the homes of the people. The individual comes to the doctor or health centre because of illness. The opportunities are utilized in educating him on matters of interest - diet, causation and nature of illness and its prevention, personal hygiene, environmental hygiene etc. Topics for health counseling may be selected according to the relevance of the situation. By such individual health teaching, we will be equipping the individual and family to deal more effectively with health problems. The patient will listen more readily to the physician. A hint from the doctor may have

a more lasting effect than volumes of printed word. The nursing staff has also ample opportunities for undertaking health education. Public health supervisors are visiting hundreds of homes; they have plenty of opportunities for individual teaching in working with individual. The health educator must create an atmosphere of friendship and allow the individual to talk as much as possible. It is useful to remember, “An effective communicator is not the one who talks too much but one who listens too much.” An effective method of individual education is, Counseling, which is defined as a confidential dialogue between a client and a health care provider aimed at enabling the client the cope with stress and take personnel decisions related to disease. The counseling process includes an evaluation of personal risk of disease transmission and facilitation of preventive behaviour. The aim of counseling must always be based on the needs of the client. The purpose of counseling is three fold : to help clients manage their problems more effectively, to develop unused opportunities to cope more fully, and to help and empower clients to become more effective self helpers in the future. Helping is about constructive change and making a substantive difference to the life of the client. However, ultimately, it is only the client who can make the difference. The counselor is merely an instrument to facilitate that process of change. In the short-term, counsellors use basic skills to help clients make personal decisions about their behaviours. The counsellor’s role is to provide accurate and complete information to help the user make her / his own decision about which, if any, part of the service(s) she / he will use. The role of the counsellor is not to offer advice or decide on the service to be used. For example, the counsellor will explain the available family planning methods, their side effects and for whom they are considered most suitable. The user then makes a decision, based on the information given, about which method she / he wishes to use.

Group Health Education : Our society contains groups of many kinds - schools children, mothers, industrial workers, patients etc. Group teaching is an effective way of educating the community. The choice of subject in group health teaching is very important it must relate direct to the interest of the group health. The methods in group health education are focus group discussions, health talks, demonstration, panel discussions, workshops etc. The group health education methods are effective in promoting behavioural change, influences opinion, develop critical thinking and increase motivation. Use of “aids” to education greatly facilitates group education. Examples of commonly used “aids” are given in Box - 1.

Box - 1 : “Aids” in Health Education

Auditory : Radio, Telephone, Audio cassettes, Tape records

Visual : Text Books, Posters, Charts, diagrams, film strips, comic strips, pamphlets, internet

Audio-Visual : Movies, lectures combined with slide presentations, Television.

Focus Group Discussions (FGD) : A Focus group discussion is a group discussion of 6-20 persons guided by a facilitator during which group members talk freely and spontaneously about a certain topic or health problem. The purpose of a focus

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group discussion is to obtain in-depth information on concept, perceptions and ideas of group on a particular topic.

Education of the General Public (Mass education) : For education of the general public we employ “Mass Media” of communication. Mass media are generally less effective in changing human behaviour than individual or group methods because communication is one way. Nevertheless they do have quite an important value in reaching large numbers of people with whom there is no contact in a short period of time. The continuous dissemination of information and views about health through all the mass media contribute in creating awareness and raising of the level of knowledge in the community. Examples of Mass-Media are given in Box - 2.

Box - 2 : Examples of “Mass Media”

Television; Radio; News Paper; Films; Health Magazines; Posters ; Health Exhibitions; Health Museums; Printed Materials

For effective health education mass media should be used in combination with other methods. Television, News Paper, and Radio are the most basic channel of health information communication. In addition, the internet is one of the new channels of health information communication that is becoming more popular. The internet and other advance communication technologies such as mobile telephone message and satellite television are important channel for health information communication. They have had more influence in the younger generation and in urban community. These communication channels are emerging and being adapted rapidly in the movement toward modernization.

The communication of health information is important for changing knowledge, attitudes and behaviour. Suitable communication methods are adopted by health care providers. Thus the integration of communication methods has much potential and more effective strategies.

Methods of Health Education : Methods are generic descriptions of how change is to be brought about within the target group; for example, mass media and community development are two terms being used to describe a host of health education activities. While planning health education programs, it is not that any method can be used (as delivering lectures to all concerned) but rather the most appropriate method most suited for the topic and the target audience should be selected. The available methods are listed in Box - 3 (2).

Activities in Health Education : The various methods of health education, as enumerated above, are utilized through different activities, depending on the objectives and the type of target audience. For example, a small group / focus group discussion can be undertaken using a LCD projected slide show, or through a flip chart, or may be simply an open multi-way discussion without using any teaching aid. Similarly, mass education process may be through the activities of traveling through the streets with a loud speaker or by inserting TV footages or through a documentary cinema. The appropriate of the method and how this method is going to be processed (i.e., the activities) should be decided by the health education planner.

Box - 3 : Commonly Used Health Education Methods

Individual Instruction (as counseling, patient instruction)

Lecture - Discussion

Educational Television / Computer (Use of television, computer and internet for viewing of prepared programs)

Audio-Visual Methods (See Box - 1)

Mass Media Methods (See Box - 2)

Peer Group Discussion / Focus Group Discussions

Programmed learning (use of teaching machines or programmed texts)

Simulation & games (games, dramatizations, role playing)

Inquiry Learning (an approach in which students formulate and test their own hypothesis)

Behavioral change methods (including behavior modification and skill development methods)

Central Health Education Bureau (CHEB)Central Health Education Bureau (CHEB) is an apex institution created in 1956 at Delhi under the Director General of Health Services (DGHS) Min. of Health and Family Welfare, Govt. of India for health education and health promotion in the country on the recommendation of the Bhore committee and the Planning commission. It plans and formulates programmes for the promotion of health education in the country through organizing training programmes to prepare health education professionals conduct behavioural research, studies in the field of health education and promotion provides training in social research methods to the health professionals, providing training to the teachers, Para medical professionals for promoting health education activities. Production of various printed and electronic mass media material and educational aids is another important activity of the Central Health Education Bureau (CHEB). The objectives of CHEB are as to : 1. Interpret the plans, programmes and achievements of the

Ministry of Health and Family Welfare.2. Design, guide and conduct research in health behaviour,

health education processes and aids.3. Produce and distribute ‘proto-type’ health promotion and

education material in relation to various health problems and programmes in country.

4. Train key health and community welfare functionaries in health education and research methods. Evolve effective methodology and tools of training.

5. Help schools and teacher training institutes for health education and health promotion of the school population.

6. Provide guidelines for the organizational set-up, functioning of health education units at the state, district and other levels.

7. Render technical help to official and non-official agencies engaged in health education and health promotion and coordinate their programme.

8. Collaborating with international agencies in promoting health education activities.

Divisions of the Bureau : In order to achieve its objectives,

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CHEB has four technical and one administrative Division, each headed by a senior officer. These Divisions are :

Media and Editorial Division ●Health Promotion and Education Division ●School and Adolescent Health Education Division ●Training , Research and Evaluation Division ●Administrative Division ●

The CHEB provides Pre-service training, in-service training and orientation training (refresher course) to the health personnel.

Since health education of the various social groups of population can be taken by state Govts, a scheme was formulated in 1958 for the establishment of State health education bureau with central assistance. Now the State health education bureau are called Information Education Communication Bureau (IEC).

SummaryHealth education is a process that informs, motivates and enables people to adopt and maintain healthy practices and lifestyles. It is a process of bringing about change in the individual’s knowledge, attitude and behaviour so as to enable him to achieve health. It helps people to achieve health by their own actions and efforts. The principles of health education are Community involvement; promotion of self esteem; Voluntarism; respecting cultural norms and taking into account of the economic and environmental constraints; developing good human relations; Evaluation of needs; responsibility for the accuracy of information and the appropriateness of methods and lastly reinforcement.

IEC is a broad term comprising a range of approaches and activities. It can be defined as an approach which attempts to change or reinforce a set of behaviour in a target audience regarding a specific problem in a predefined period of time. It is multidisciplinary and client centered in its approach drawing from the field of diffusion theory, social marketing, behaviour analysis and anthropology. A good working definition for effective communication is to share meaning and understanding between the person sending the message and the person receiving it. It is either Verbal (the tone of voice) or Non-verbal (body language). The various components involved in the process of communication are Sender (source of Communication); the message, encoding and decoding it; the communication channel (as lecture or exhibition) and the “aids” (as slides, slide projector); the Receiver (audience); and the feedback.

Propaganda is merely a publicity campaign aimed presenting a particular thing or concept in a favourable light in such a way that public may accept it without thinking. The aim of Advocacy is to place health problems issues on the political agenda and effectively reach the influencial groups. Barriers in Communication can be Physiological (Difficulties in hearing, expression); Psychological (Emotional disturbances); Environmental (Noise, invisibility, congestion in the classroom, etc); Cultural (Level of knowledge, receiver’s beliefs). All barriers should be identified and removed for achieving effective communication. In Behaviour Change Communication Process (BCC), Information is given to the unaware people so that they become concerned, acquire more knowledge and develop skills and motivated to change their behavior & adopted a new one.

The three broad components of Health Education are Levels of Health Education, Methods of Health Education and Activities undertaken in individual methods. The three main levels are individual and family, group level and general public (mass) level. The various methods of health education, as enumerated above, are utilized through different activities, depending on the objectives and the type of target audience. An effective method of individual education is counseling and the methods in group health education are focus group discussions, health talks, demonstration, panel discussions, workshops etc. Television, News Paper, and Radio are the most basic channels of health information for general public. For effective health education mass media should be used in combination with other methods. Central Health Education Bureau (CHEB) is an apex institution created in 1956 at Delhi under the Director General of Health Services (DGHS) Min. of Health and Family Welfare, Govt. of India for health education and health promotion in the country on the recommendation of the Bhore committee and the Planning commission. It plans and formulates programmes for the promotion of health education.

Study Exercises Long Question : Discuss the Principles of Health Education with examples.

Short Notes : (1) Principles of Health Education (2) Components of Health Education (3) Components of the Communication process (4) Barriers in Communication (5) Counseling (6) Focus group discussions (7) Mass Media.

MCQs : 1. Which of the following is not a one way communication

(a) Symposium (b) Lecture (c) Group Discussion (d) Stage show

2. The best method of health instruction is (a) Providing reading assignments (b) Organizing film show (c) Setting an example (d) Giving lectures

3. The best way of teaching an urban women about ORS is (a) Lecture (b) Flash cards (c) Role play (d) Demonstration

4. Receiver’s false beliefs are a ______________ type of barrier in communication. (a) Physiological (b) Environmental (c) Cultural (d) Psychological

5. The method which is generally more effective among the following in changing human behaviour is (a) Counseling (b) Focus group discussion (c) Mass media (d) A series of lectures

Answers : (1) c; (2) c; (3) d; (4) c; (5) a.

ReferencesDignan MB, Carr PA. Introduction to program planning : A basic text for 1. community health Education. Philadelphia, Lea & Febiger, 1st ed 1981.Green LW, Kreuter MW, Deeds SG, Partridge KB. Health Education Planning : 2. A Diagnostic Approach. Palo Alto, Mayfield, 1980 : 86 - 115.J.E. Park , K. Park Textbook of Preventive and Social Medicine Ms Banarsidas 3. Bhanot Jabalpur, Edition Dr. (Brig) Sundarlal TextBook of Community Medicine (PSM) CBS Publishers 4. and DIstributers , New DelhiT.Bhaskar Rao Text book of Community Medicine 5.

Further Suggested readingMahadevan K . Health Education for Quality of life. BR Publishing 1. Corporation Delhi, 2002.Keith and Tone. Health Education. Sylvia Tilfard second edition, 1994.2.

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116Planning, Implementation and Evaluation of Health Education Programmes

RajVir Bhalwar

In contemporary public health practice, health education of the community (whether small groups or large masses) or of individuals (patients or healthy individuals) is one of the most important health care activity. Medical officers and specialists in Community Medicine (Public health and Preventive Medicine) should therefore be well versed in the various steps to be undertaken while planning, organizing, implementing and evaluating health education programmes. This involves a series of scientific and sequential steps, which are being explained in this chapter.

Step 1 - Situational Analysis : The first, and one of the most crucial steps in health education programme planning is “Situational Analysis”, also known as “Community Analysis” or “Needs Assessment”. This is the essential step for gaining insight into the health problems, so that programmes can be developed and directed towards conditions which are significant issues for the community members. This step of community analysis consists of following five sequential steps, viz. analyzing the community backdrop, analysis of the health status of the community, analysis of the health care system of the community, analysis of social systems of the community, and SWOT analysis. These sequential steps are vital for making the community diagnosis. We discuss each of these steps, as follows.

Step 1 (a) - Analysing the Community Backdrop : The first thing is to get to know the area and the community in your health care jurisdiction (or the community for which you are planning the health education program) very well. Drive (preferably walk) around the entire area. Find out where are the work places, location of various governmental and non-governmental offices, location of various, markets, eating joints, recreation facilities, industrial areas, schools, hospitals, other health care facilities (as PHCs / subcentres), residential areas, slums, etc. See for yourself the minute details, as what are the roads and other communication systems, the pattern of residential accommodation, water supply system, night-soil disposal system, solid-waste disposal system, and environmental conditions. Don’t forget to find out about sensitive issues like defined red-light areas, clandestine sexual avenues, tobacco kiosks, alcohol shops and so on. Listen to the local radio and see the local television programmes, which would further assist you in getting an insight into the community backdrop.

After the initial inspection, define some tentative boundaries that can demarcate the larger area into smaller, more homogenous aggregates. The most obvious choices are the major physical boundaries as major roads, rivers or government boundaries as those delimiting the village or Taluka or district. Another workable method may be to divide the area into five or six “sectors” for purpose of various preventive health care

activities. Having done this detailed exercise, make a detailed “spot map” showing all these various aspects as described above. For a public health manager, developing and regularly updating such spot maps should be considered an indispensable duty. Whenever you take over as the District health Officer / Public Health officer or a health programme manager, the first thing you should do is to undertake a detailed, on-ground assessment of your area under health cover and update the spot maps. Similarly MOs in-charge of PHCs / CHCs should assess the details and update the spot maps for their respective areas.

Find out the details of the socio-demographic characteristics of the community under your health care. Find out the total population, distribution according to social status, according to age groups, according to women and children, and further according to the different geographical sectors that you have made to demarcate the community. See the main occupations, industry and business patterns. Now write down the details in a textual form, complemented by the spot maps, tables of various demographic characteristics and other graphics. It is important to develop a written document at this stage since it will come very handy later on while implementing the health education programme. It is very desirable that all Public Health programme managers should always keep such a written document, duly updated, since it will be an essential and basic document for planning all health care activities including health education; the document can also be placed before the Governmental Administrators, as and when they visit them.

Step 1 (b) - Analysis of Community Health Status : In this step, the data related to important epidemiological parameters is collected from various sources as hospital records, official reports, and, if required, by a quick sample survey (Details of important epidemiological parameters and sources of epidemiological information have already been covered in the section on “Epidemiology”). The main parameters, depending upon requirements include Birth rate, death rate, IMR, MMR and Neonatal MR according to major socio-economic categories (as age groups, sex and social class). Thereafter, mortality and hospitalization rates per 1000 (or per lac) population are worked out, for the past 3 years, for the leading 10 or 15 causes, separately for males, females and children (preferably for different age groups). These rates give us a clear idea of the leading causes of death and disease for various age and sex groups. These rates are then compared with the rates for various leading causes of death and hospitalization that have occurred, overall, in the state or in the country, to see if there is any particular difference in the leading causes of ill health between the area where we are planning our health education activities and the overall state or country. The data should be arrayed in simple tables, showing the names of leading diseases in the first column, the rates per 1000 (or per lac) in the second column and the overall rates in the state / country in the third column.

Sources which need to be explored to obtain this information include Census office, Registrar of vital events, Civil hospital/ PHC / CHC and Private hospital records and interviews with medical practitioners / government Doctors.

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An additional and extremely important part of this step is to also obtain data on health-behaviour related aspects of the clientele. This is best done by undertaking a cross-sectional and quick survey from a representative sample, obtaining data on leading lifestyle factors (diet, exercise, tobacco and alcohol use, obesity and sexual practices), personal hygiene and use of personal-protective measures (use of road safety and occupational safety devices, protection against insect vectors of diseases, bathing, hand washing and oral hygiene) and on water and food hygiene practices. This quick survey may bring forth some very important issues (which may not be evident by simple comparison of routine mortality / morbidity data) and which need to be tackled by health education programmes.

Step 1 (c) - Analysis of Community Health Care System : The third step of situational analysis (community analysis) is to collect and analyse data describing the resources for providing health care (both curative as well as preventive) as are available to the community. This is undertaken by describing, firstly, the formally recognized health institutions, as government and private hospitals, dispensaries, health centres, sub-district hospitals, preventive health care programmes and institutions executing them. Secondly, informally recognised practitioners as those of traditional systems are described. The medical and paramedical manpower is thereafter described, as number of physicians, surgeons, according to sub-specialties, nursing personnel, health / sanitary workers, laboratory trained personnel and so on. The organization of service delivery, referral systems and local health departments are studied. Finally the “grey areas” in health care, including communities/ locations which are underserved or disadvantaged are identified. The last step is important since community groups who are actually in maximum need of health education are usually also the ones who are underserved / disadvantaged or living in inaccessible areas.

Step 1 (d) - Analysis of Community’s Social Organization and Support Systems : In this step, the social structure and the social support systems are studied and analysed. The overall organisation of the community, the major community groups, the interaction between various community groups, the peers / leaders, the opinion formers and the political climate is studied. In addition, the various “Support Systems” available in the community (Voluntary organizations, NGOs, agencies which can organise financial assistance, charitable organizations, and so on) are studied, with a particular reference to how these can be gainfully utilized in relation to the proposed health education programmes.

Step 1 (e) - Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT) : Strengths are advantages that are of a permanent nature and exist in the community ethos or in the general environment, and they must be gainfully utilized by the health provider; e.g. conservative attitude of a community is a strength for anti-alcohol educational programme. Weaknesses are disadvantages of permanent nature in the community ethos or environment which will need to be neutralized or bypassed for success of the programme; e.g. conservative attitude in the community may be a disadvantage while launching a sex education programme for school children. Opportunities are temporary, often flitting occurrences which the health provider

should always be on the look-out for and utilize them to her benefit; e.g. if an outstanding sportsperson becomes the mayor of the city, it is an opportunity to contemplate launching a community educational program for healthy lifestyle and physical fitness. Threats are temporary phenomena which may be inimical to the programmes; recent occurrence of vaccine related adverse effects among children may be a threat to educational program for promoting vaccination coverage and this would need to be either circumvented or else tackled energetically.

Step 2 - Making the “Community Diagnosis” : This is a vital step, wherein we identify the “target populations” and their health problems. The first step in making the community diagnosis is to summarize the findings of the earlier step of “situational analysis” (community analysis), through sub-steps 1 (a) to 1 (e). This summary will give us an idea of the “needs” of the community. The needs so identified are of 2 categories; firstly the “professionally assessed needs” also called as the “normative” needs, i.e. those needs which are worked out by the health care provider, based on community analysis data. This would include the leading causes of morbidity and mortality (as chicken pox, hepatitis, injuries, etc.) and leading determinants of diseases (as smoking, inadequate levels of physical exercise, dietary patterns, sexual promiscuity, etc.). Secondly, equally important are the “felt needs” of the target population, i.e. those areas of concern which are articulated most commonly by the target population. These felt needs are the most pressing problems experienced by groups and individuals in the target population and usually reflect the problems currently in focus (1 - 4).

In short, in the step of community diagnosis, we clearly define the following aspects. A consolidated statement clarifying these undermentioned issues would serve as the basic guideline for further planning of our health education programme :

What are the “target communities” ● which are to be addressed by our proposed health education, or by other health care programmes or by a combination of health education and health care programmes? Delimiting the target audience(s) will define premises of our proposed programme and help us focus our entire energies on to these defined groups, with a view to get the maximum results. Target communities are those groups or subgroups which have the maximum ill-health (mortality, morbidity or unhealthy lifestyle) and are likely to give significant results, if concerted health education programmes are focused on them. What are the major health problems as assessed by us ● which need to be addressed by health education programmes or health care programmes?Besides our assessed needs, ● what are the other “felt needs” of the target audiences, which should also be addressed either by health education or other health care programmes.

Step 3 - Defining the “Premises” and “Goal” of the Proposed Programme : Premises are the outer boundaries within which our proposed programme will function; we will not be going out of these limits in so far as the particular programme is concerned. Thus, this helps us focus our attention our

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programme and our goal and not mix up our actions with other issues. Premises are generally defined in terms of the population characteristics, place, time and the broad issues which will be the concern of the programme. While defining the premises and the goal, one should be clear that while a number of issues may be identified as major “needs”, it is not necessary ( and also not usually feasible) to address all these identified needs through health education programmes. Some of the needs would be better resolved using public health or other medical care approaches. For example if we have two major issues as HIV - AIDS and problem of open defaecation, we may, depending on the situation, decide to focus on HIV - AIDS through educational efforts and tackle the problem of open defaecation by sanitary measures. It is therefore important to clearly delineate at this stage, which of the needs will be addressed by health education programme and which would be addressed by other public health / medical care steps.

Once we have defined the premises and sorted out the “needs” according to which all will be addressed by our proposed health education programme, we enunciate the overall “goal” of the programme. Goals are broad statements which reflect the end result that we desire to achieve, i.e. they are the intended consequences of the program (5). Program goals should not be confused with “educational goals”, which will be discussed later under step - 6. Step 4 - Consolidating Data on Knowledge, Attitudes and Behaviours : It is apparent that the ultimate goal of any health education program is to increase the knowledge and obtain a favourable change in attitudes and behaviour by the target population. Hence, we will need data as regards the current state in respect of the knowledge, attitudes and behavior, for the goals that have been identified. Behaviour should be assessed in terms of “events” and “outcomes”. An event is the actual behaviour (e.g. smoking, sexual promiscuity); an outcome is the result of that event (e.g. IHD, AIDS). A sample survey of the target population, if the same has not been done in step 1 (b), should be now undertaken and data on current levels should be recorded (6 - 9). Step 5 - Assemble the Planning Group / Coordination Council: Community health education cannot be accomplished by a single health educator. All representatives from the community, especially those who can facilitate the program should be approached to consent for being a part of the planning group (also sometimes called as coordination council or governing board). From this step onwards, all plans are discussed and finalized, progress monitored and difficulties sorted out by personal involvement of members of this group. This group should include the public health manager / health education specialist, who should be the secretary of this group. The chairperson is usually an eminent / influential political or administrative person. The members include technical specialists, administrators and above all, representatives of each of the target populations identified earlier.

Once a planning group has been constituted, all members should be given an initial briefing to orient all members as regards the various aspects of the program. This activity is very relevant since many of the members may not be very aware about the technical intricacies of health education and medical care, as

also about the details and sequence of planning process.Step 6 - Reconfirming the program goals, enunciating the educational goals and the objectives : Once a planning group has been formed, one of the first activities to be undertaken by this group is to firstly, reconfirm that the original program goal (vide step - 3) is finally acceptable or else it needs to be changed. Secondly, the group should enunciate broad statements, for different identified “needs” and different target groups, as to what the educational process aims at finally achieving. The overall program goal should be kept in mind when formulating the educational goals. The educational goals should be stated in precise language so that all members of the planning group thoroughly understand the exact intention of the statements (5, 10).

Having specified the educational goals, the educational objectives are enunciated. As compared to goals, which are generalized & broad statements, objectives are precise statements which indicate as to how the goal will be realized. For one goal, there could be a number of objectives. Objectives should be specific, measurable and quantifiable in terms of magnitude of change and time-line. Within each objective, the parameter which will measure change is called the “indicator” and the magnitude of change proposed to be achieved is called the “target”. For example, in an objective “Proportion of persons who are smokers should reduce from current 45% to 25% in next 2 years”, the statement “Proportion of persons who are smokers” is an indicator while the part “reduce from current 45% to 25% in next 2 years” is a target.

Step 7 - Resource Analysis : The important issue at this stage is how we can convert the desired objectives into an effective “action plan” so that the objectives can be achieved. For this purpose, we have to now analyse our resources, i.e. what all do we have to take action. In general, resources are analysed in terms of 3 broad headings, viz. men, money and material. Resource analysis for manpower would include the medical and paramedical personnel, and other key personnel as epidemiologists, trained health educators, data operators and statisticians, along with their locations, who would be available for the health education program, either full-time or part-time. This aspect of manpower also includes the ‘supportive manpower” as political leaders, administrative authorities and peers who would support the program. Money refers to assessment of funds / finances which will be required for development of health education material, training material, communications and transport, purchase of health educational and medical equipment if required, payment of salaries, etc. The source of finances could be government (public funds) or funds generated by voluntary / non-governmental organizations. Finally, material refers to technical equipment, expendables and logistics. This would need assessment of various aspects like availability of class-rooms, lecture halls, buildings, electricity, announcement systems, projection systems as slide / overhead projectors, computers, LCD projectors, posters and charts for exhibitions and mobile panels for posters; models, and so on. In addition, equipment pertaining to “logistics” as vehicles for transportation of target population, petrol, tentages, generators, etc., would also need to be assessed, as required. It is only after making a detailed assessment of resources (already available

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and expected over reasonable period of time), that the program planner would be able to decide as to how best can an action plan be drawn to meet the objectives; at this stage, it may also be a consideration to drop one or two objectives if adequate resources are not available.Step 8 - Identify Methods and Activities for Health Education : In the earlier chapter, we have deliberated on the various types of methods (as lectures, focus group discussions, exhibitions, mass media communication methods etc.) and the activities that are conducted within each of these methods. Detailed decisions should now be taken to see which particular method(s) will be most appropriate to address the objectives for different target groups, and within each method, what all educational activities will be undertaken. The details of the decided methods and activities for each target group should be written down. Step 9 - Writing and disseminating the Action Plan (Implementation Plan) : Having clearly enunciated the methods and activities, a detailed action plan should be written down. This is a detailed document which clearly specifies as to who will do what, to whom all, where, in what manner and how frequently. The document should specify all details of

Dates / days of the week or month and timings, on which ●the educational sessions will be held for the entire duration of the educational program.The locations at which the sessions will be held. ●Who all will attend the sessions at the particular locations, ●dates and time.Who will be administratively responsible for ensuring ●that the target audience reaches the particular location of educational session, well in time.Who will be responsible for providing the administrative ●support.Who will conduct the session. ●Who will be responsible for technical aspects of the ●session.Who will be the overall coordinator for the educational ●activities.

The details should be discussed by the Program Planning Committee (PPC) and then issued by a senior administrative officer to all concerned.

Step 10 - Implementation and Evaluation : Once the instructions for implementation have been issued, the health educator’s responsibilities further increase since he is now not only responsible for providing health education to the various target populations but also often responsible for coordination of the various administrative aspects, and to ensure that all aspects of the program progress as scheduled in the action plan. In real life scenarios, everyday there will be problems, which would need to be actioned and rectified. Sometimes the vehicle may not turn up to ferry the health educator’s team and equipment, sometimes the officer responsible for administrative coordination for one of the target populations may simply forget that there was a session planned for that day, sometimes a holiday may be announced suddenly on the day of planned session. All these issues need to be visualized and addressed. In health education programmes & for that matter in any public health program, perseverance and determination always pays.

Alongwith implementation of action plan, evaluative process also needs to be planned and conducted. As explained in detail in the section on epidemiology (planning & evaluation of programs), evaluation is undertaken for six different aspects, viz. relevance, adequacy, process, and outcome (including efficacy, effectiveness and efficiency). In the usual settings of health education programs, evaluation is undertaken for “process” (i.e. whether the activities are being undertaken as planned) and for outcome (i.e. to what extent the objectives have been met). Evaluation for process is to be undertaken concurrently, say once in 3 months for a program planned for 1 to 2 years. Outcome evaluation is undertaken both, concurrently (e.g. what percentage of target population have shown improvement in knowledge and behaviour) and terminal evaluation at the end of the program (whether targets as envisaged at the planning stage have been achieved). It should be remembered that evaluation should always be an ongoing process, with the drawbacks/deficiencies noticed further analysed and change in program actions undertaken to rectify defects that have been identified.

Step 11 - Writing the Final Report : Once the program has been completed or terminated for whatsoever reasons, the program planner must write down a detailed report of the program, including the background, the target audience, the educational and program objectives, the action plan, details of process, final results, and recommendations for future programs. Such report is invaluable in assessing the current program and also serves as a basic reference document for any subsequent health education programs.

SummaryTo make an effective IEC campaign the public health functionaries must be aware of various steps to be undertaken in planning, organizing, implementing and evaluating health education programmes so as to make it successful. The first step in this regards is situational analysis which aims at gaining insight in the health problems of the community to enable us to make a community diagnosis. It involves analyzing the community backdrop in the defined area, by taking the information about socio-demographic characteristics and other issues of relevance. Thereafter, analysis of community health status is done by collecting data about important epidemiological parameters about health problems of the communities from various readily available sources or by a quick sample survey. Thereafter, the community health care system is analysed so as to find what all are present and what all are lacking. Based on the collected information, a SWOT analysis is done to identify the Strengths, Weaknesses, Opportunities and Threats in the community.

The next step involves making a community diagnosis based on the situational analysis. The aspects which are clearly defined in community diagnosis are target communities, professionally assessed needs and felt needs of the communities. The third step includes defining the premises and goals of the programme. Premises are the outer boundaries within which our proposed programme will function and goals are broad statements which reflect the end result that we desire to achieve. In the fourth step, data as regards the current state of knowledge, attitudes and behaviours is assessed by a sample survey of target population.

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In the next step, the planning group / coordination council is assembled. This includes the public health manager / health education specialist as the secretary, an eminent / influential political or administrative person as chairperson, while the other members include technical specialists, administrators, and above all, representatives of each of the target populations identified earlier.

In the sixth step, the planning group reconfirms the original program goal. Having specified the educational goals, the educational objectives are enunciated, and within each objective indicators and targets are defined. In the next step, resources are analysed in terms of men, money and material. Men include primary manpower as health care workers and supportive manpower. Money refers to assessment of funds/ finances which will be required, while material refers to technical equipment, expendables and logistics. It is only after making a detailed assessment of resources that the program planner would be able to decide as to how best an action plan can be drawn to meet the objectives. In the eighth step, detailed decisions are taken to see which particular method(s) of health education will be most appropriate to address the objectives for different target groups, and within each method, what all educational activities will be undertaken. In the next step, after having clearly enunciated the methods and activities, a detailed action plan should be written down. This is a detailed document which clearly specifies as to who will do what, to whom all, where, in what manner and how frequently.

Finally the programme is implemented and measures are taken to ensure that all aspects of the program progress as scheduled in the action plan. Along with implementation of action plan, evaluative process also needs to be planned and conducted. Evaluation is undertaken for six different aspects, viz., relevance, adequacy, process, and outcome (which includes efficacy, effectiveness and efficiency). Evaluation should always be an ongoing process, with the drawbacks / deficiencies noticed further analysed and change in program actions undertaken to rectify defects that have been identified.

Once the program has been completed or terminated for whatsoever reasons, the program planner must write down a detailed report of the program. Such report is invaluable in assessing the current program and also serves as a basic reference document for any subsequent health education programs.

Study ExercisesLong Question : Describe your plan of planning, conduct and evaluation of a health education programme for HIV - AIDS prevention at the level of a district.

Short Notes : (1) Peer Groups (2) Community Diagnosis (3) Assessment of health educational needs

MCQs & Exercises

Match the following

1. Objectives a. Precise statements which indicate as to how the goal will be realized

2. Goals b. Parameter which will measure change

3. Indicator c. Magnitude of change proposed to be achieved

4. Target d. Generalized & broad statements

MCQs1) Which of the following is not part of situational analysis:

(a) Analysing the Community Backdrop (b) Analysis of Community Health Status (c) Analysis of Community Health Care System (d) Defining target communities

2) Which of the following is not a part of community diagnosis : (a) Defining target communities (b) Defining major health problems (c) Defining felt needs (d) Defining the premises

3) The aspects considered for outcome evaluation does not include : (a) Relevance (b) Adequacy (c) Process (d) Resources

4) The correct order of following steps is : 1. Assemble the Planning Group / Coordination Council; 2.Consolidating Data on Knowledge, Attitudes and Behaviours; 3. Resource Analysis; 4. Reconfirming the program goals, enunciating the educational goals and the objectives (Pick up your choice from one of a, b, c, or d as follows : (a) 1,2,4,3 (b) 2,1,4,3 (c) 2,1,3,4 (d) 1,2,3,4

5) The best method for health education on treatment of diarrhea/ ORS use for urban slum population is : (a) Lecture (b) Demonstration (c) Focussed group discussion (d) Symposium

6) Resources include all of the below except : (a) Money (b) Material (c) Manpower (d) Methodology

7) Which type of study is most convenient to undertake to obtain data on health-behaviour related aspects of the target population : (a) Cross-sectional study (b) Case-control study (c) Cohort study (d) Ecological study

8) Source for assessing health status of the community include all except : (a) Census office (b) Registrar of vital events (c) Civil hospital (d) Labor office

9) Normative needs is : (a) Needs felt by community (b) Health needs of community assessed by health workers (c) Normal day to day needs of community (d) Needs other than health

10) Chairperson of health education programme should be (a) Public health specialist (b) Influential politician (c) Superspecialist doctor of concerned topic (d) Senior teacher

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11) Target communities are the groups of people who : (a) Have the maximum ill-health (b) Have maximum representation (c) Are the most influential section of society (d) Are poor

12) Which of the following is an individual health education method : (a) Lecture (b) Focused group discussion (c) Counseling (d) News paper

13) Following is/are the type/s of outcome evaluation : (a) Concurrent (b) Terminal (c) Both (d) None of the above

Fill In the Blanks1) “Situational Analysis” is also known as _____ or _______2) __________ are advantages that are of a permanent

nature & exist in the community ethos or in the general environment.

3) The first step in making the community diagnosis is ____4) __________ are those areas of concern which are articulated

most commonly by the target population.5) ____________ are the outer boundaries within which the

proposed programme will function.6) __________ is a detailed document which clearly specifies

as to who will do what, to whom all, where, in what manner and how frequently.

Answers

Match the following : 1-a; 2-d; 3-b; 4-c.

MCQs : (1) d; (2) d; (3) d; (4) b; (5) b; (6) d; (7) a; (8) d; (9) b; (10) b; (11) a; (12) c; (13) c.

Fill in the Blanks : (1) Community Analysis, Needs Assessment (2) Strengths (3) To summarize the findings of situational analysis (4) Felt needs (5) Premises (6) Action Plan

ReferencesBedworth DA, Bedworth AE. Health education : a process for human 1. effectiveness. New york, Harper & Row, 1978.Burbach HJ, Deker LE. A growing imperative. In : Planning and assessment 2. in community education. Eds : Burbach HJ & Deker LE. Midland, Michigan, Pendell, 1977.Dubos R. Man adapting. New haven, Yale Univ, 1965.3. Rossi PH, Freemen HE, Wright SR. Evaluation : A systemic approach. Beverly 4. Hills, Sage, 1979.Weiss CH. Evaluation research : methods and assessing program 5. effectiveness. Englewood Cliffs, Prentice Hall, 1972.Ciminero AR, Calhoun KS, Adams HE (Eds). Handbook of behavioral 6. assessment. New York, Wiley, 1977.Miller LK,. Principles of everyday behavior analysis. Monterey, California. 7. Brooks - Cole, 1975.Peterson DR. The clinical study of social behaviour. New York, Appleton-8. Century-Crofts, 1968.Rose SD. A casebook in group therapy : a behavioral cognitive approach. 9. Englewood Cliffs, Prentice Hall, 1980.USDHEW, PHS, HRA. Educating the public about health : a planning guide. 10. Washington, HEW publication No. (HRA) - 78 - 14004, Oct 1977.