Lecture Notes on HE

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MPH 1, Health Education 1 Semester 2, 2003

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HEALTH EDUCATION I - MPH I, SEM. 2, 2003

LECTURE NOTES

By: Shabbir Ismail MD, MPHAssociate Professor Department of Community HealthFaculty of MedicineAddis Ababa University

MAIN REFERENCES

1. Notes on the Behavioral Sciences and Health Education as they apply to Community Health inEthiopia. Ed. Frances Aboub, June 1994. [Found in the Library of the Department ofCommunity Health (DCH)]

2. An Introduction to Health Psychology. 2nd Edition. Ed. R. Gatchel, A. Baum & D. Krantz Newburry Award Records, 1989. New York. [Found in the Library of DCH]

3. Health Education: A New Approach. Ed. L. Ramachandran & T. Dharmalingam. VikasPublishing House Pvt. Lmt. Co. 1995. Delhi. [Found in the Library of DCH]

4. Behavioral Medicine: The Bio-psychosocial Approach. Ed. N. Schneiderman & J.T. TappLawrence Erlbaum Associates, Publishers. New Jersey. 1985. [Found in the Library of DCH]

5. Health Psychology. 2nd Ed. Editor S. E. Tylor. McGrew Hill, Inc. New York, 1991. [Found inthe Library of DCH]

6. Group Process for the Health Professionals. Ed. Sampson & Marthas. A Wiley MedicalPublication, John Wiley & Sons. New York. 1977. [Found in the Library of DCH]

7. Education for Health. A Manual on health education in primary health care (Draft). WorldHealth Organization, 1984. [Found in the library of DCH]

8. A seminar in Qualitative Research. Prepared for Academy for Educational DevelopmentHealth Communications Project, July 1986. [Found in Dr. Shabbir's Office]

9. Planning, Implementing, and Evaluating. HEALTH PROMOTION PROGRAMS. A Primer2nd Ed. Ed: J.F. McKenzie & J.L. Smeltzer, A Viacom Company, Neehahm Heights, MA,USA. 1997 [Found in the Main Library]

Shabbir Ismail MD MPH Behavioral Sciences Unit Associate Professor DCH, FOM (AAU)



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PART 1: I. INTRODUCTION & DEFINITIONS

A. INTERRELATIONSHIP BETWEEN BEHAVIORAL SCIENCES AND COMMUNITYMEDICINE

The behavioural sciences such as psychology, sociology, and anthropology make an importantcontribution to the understanding and practice of community health in two major ways:

1. Behavioural factors enter into a number of activities, which directly or indirectly influence a person's health. These are:a. Health services (motivation, attitude, skills of personnel); b. Economic/social institutions (education, family, religious leaders);c. Personality (locus of control, knowledge, attitude);d. Health behaviours (eating habits, infant care, personal hygiene, family planning, etc.)

Health behaviours of the community, family and individuals have a direct effect on theirhealth. These health behaviours are acquired, maintained, or changed with help of other psychosocial factors such as personality, social institutions like the family, and themotivation and skills of health professionals.

e. The motivation and skills of health professionals more directly influence a person's physical health through the services they offer. There are also other non behavioura(biological & genetic) factors which also influence physical health.

2. Because health includes mental and social well-being as well as physical health, it is importantto promote mental and social health and development in their own rights and also because theydirectly influence physical health. In this respect, mental and social problems of a person canaffect not only their own productivity and enjoyment of life, but also the development of theirchildren, the quality of their marriage, and the cohesion of their community.

B. DEFINITIONS OF MAJOR CONCEPTS

HEALTH : There are various definitions of "Health", among which few are sited:1. From a lay point of view, it just to say that a person is normally doing his activities and does

not outwardly show any signs of any disease in him.

2. In the Oxford dictionary health means `the state of being free from sickness, injury or disease bodily conditions; something indicating good bodily condition.

3. WHO (1948) defined it as "Health is a state of complete physical, mental and socialwellbeing and not merely absence of disease or infirmity." This definition may seem veryattractive but still has lots of drawbacks. It will be seen that even after having this definition iwill be difficult to conceptualize and standardize positive health with specific clear-cuattributes and criteria for measurement. A person may be enjoying mental equanimity andenthusiasm for doing something. He may also be physically able to do any amount of work, but he may be having some minor dysfunction or deficiency or even a mild infection causing avery minor disturbance which however does not upset his normal activities.

MENTAL WELLBEING :

The mentally healthy adult shows behaviour which confirms an awareness of self or personal identitycoupled with a life purpose, a sense of personal autonomy and willingness to perceive reality and copewith its difficulties. The healthy adult is active and productive, persists with tasks until they arecompleted, responds flexibly in the face of stress, receives pleasure from a variety of sources, andaccepts one's limitations realistically. The healthy adult has a capacity to live with other people, tounderstand their needs, and to achieve a mutually satisfying heterosexual relationship. In sum, thementally healthy person shows growth and maturity in three areas: cognitive, emotional, and social.

Cognitive Processes: These are mental processes involved in awareness (consciousness), perceptionand thought . These include awareness, perception, learning, memory, reasoning, problem solving,creativity and imagination.




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Emotional Processes: These are mental processes involved in states of emotions (happiness, sadnessanger, fear), mood (positive mood is a temporary feeling, less strong than emotion), and attitudeswhich are longer term evaluations of people/objects.

Social Processes: These include interactions with other people, as well as the mental processesinvolved in relationships with others such as emotional attachment, perceptions of others and of one'srelationship with others, and recall past social experiences.

SOCIAL WELLBEING :

This is the ability to maintain one's identity while sharing, cooperating, communicating, and enjoyingothers; participation in friendship, family and community life. Social health is in some ways subsumedunder mental health.

DISEASE:

Disease denotes the condition of the human body in which something has gone wrong and has upsetthe normal functions of the body including the mind. The International Classification of Disease (ICD)distinguishes between three terms:a. IMPAIRMENT - this is any loss or abnormality of mental, anatomical structure, physiological

function.b. DISABILITY

- is any restriction or lack, resulting from an impairment, of the ability to performan activity in a manner or range considered normal for a human being. Thus, the loss of a fingermay be an impairment but not a disability because it is unlikely to restrict normal activity.

c. HANDICAP - is a long-term disadvantage which adversely affects an individual's capacity toachieve the personal and economic independence that is normal for one's peers. Thus, forexample, female circumcision would be considered an impairment, but in some cultures not being circumcised would be considered handicap because it reduces a girl's chances of gettingmarried and achieving independence from her parents. The criteria for a disability, andespecially a handicap, are more culturally determined in that they depend on the activities performed in that culture and the qualities required for independence.

MENTAL DISORDER:

This is a recognized, medically diagnosable illness that results in the significant impairment of anindividual's cognitive, emotional, or social abilities. It results from biological, developmental, or psychosocial factors, and falls on a continuum according to degree of impairment and distressExamples - depression, anxiety, paranoia.

LEARNING:

Learning is the process by which the individual acquire information and ideas which may later result inchange of attitude and behaviour . Every process in life including eating, working, playing, singingetc., is the result of learning. There is a basic element of learning governing all activities. Learning isalso the basis of behaviour. Learning is a totality of change of behaviour through acquisition ofknowledge.

EDUCATION:Education is the process by which learning is facilitated. It is a process in which an individual orindividuals or group of people are in the facilities or opportunities by an agent or educator to learn.

HEALTH EDUCATION:

A process with intellectual, psychological and social dimensions relating to activities that increasethe abilities of people to make informed decisions affecting their personal, family and community well- being. This process based on scientific principles, facilitates learning and behavioural change in bothhealth personnel and consumers, including children and youth. KNOWLEDGE : This is the information stored in memory.




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MEMORY : Refers to storing and recalling past experiences and ideas. AWARENESS: This is the lowest level of cognition and means simply knowing about the

existence of something. ATTITUDE: This is the predisposition to respond in a favourable or unfavourable manner toward a

target. PERCEPTION: This refers to reception and interpretation of sensory input. PRACTICE: This is an overt behaviour, habits, or customs of a person.

BEHAVIOUR:It is the various voluntary movements/actions undertaken by the body in response to imposedconditions, motives and decisions. Behaviour can also be referred to every activity of the body as anindividual. According to the Oxford dictionary, behaviour means "the way in which a thing or personacts, conduct, manners, mode of behaviour; reaction under a set of imposed conditions."

MOTIVATION :

This is the stage of thinking process, which gets sufficient intensity to direct the body to do a particularthing to satisfy the perceived want. It is a combination of forces, which initiate, direct and sustain behaviour toward a goal. Hence, there are certain forces (psychological) arising from within theindividual and various other forces from outside which due to a close interaction may result in a strong

force which may motivate or make the person change his attitude and behaviour. If the forces outsideand inside result by interaction in an unfavourable disposition there will be no motivation.

DECISION MAKING :

It is process of committing oneself to a particular course of action or behaviour to achieve a particulargoal. It is defined as commitment to carry out a specific task or to adhere to a particular course ofaction in future. The decision making is used with reference to the final judgement a person has tomake with regard to a change of behaviour or adoption of new practice. It will be appreciated thatdecision making is an indivisible component of motivation and adoption process.

DEFENSE MECHANISM :

Mental mechanisms which help an individual to smooth over the frustrations and conflicts are known

as defence mechanisms. It helps the individual to divert the energy in such a manner as to relieve thetension and also to make it appear to others that the behaviour is not wrong, it serves the purpose ofdefence.

CULTURE :

Culture is that whole which includes knowledge, belief, custom, art, morals, law and any othercapabilities and habits acquired by man as a member of the society. The term culture embraces a widerange of activates and characteristics of individuals as well as groups with regard to their way of life.The general mode of the life with its customs, beliefs and articles and artefacts used for various purposes by societies are all comprehensively known as culture or cultural characteristics. In otherwords culture refers to the more or less organised and persistent patterns of habits, customs, attitudeand values which are transmitted from generation to generation. It consists of a shared behaviour

which is recognised, approved and cherished by society.COMMUNITY :

Community is collection or a group of persons in social interaction in a geographical area and sharing acommon social and cultural life. Community is characterised by (a) a geographical area; which can bedelimited; (b) a population; (c) social and cultural traits and sentiments passed on from generation togeneration; (d) economic status; (e) specific functions or occupations or pursuits as a whole for thecommunity or with a variation amongst different sections of the community; (f) a group dependence or belongingness and an interdependent behaviour.

SOCIETY :

Society is something that is closely identified with the community. It arises out of community. While Shabbir Ismail MD MPH Behavioral Sciences Unit Associate Professor DCH, FOM (AAU)



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community refers to the structure, location and size of the population, society refers to the humanrelationship, behavioural patterns, cultural traits, institution, etc., in the community. Society refers tothe "totality of social relationships among men. Each aggregate or collection of human beings of bothsexes and ages bound together into a self perpetuating group or possessing its own more or lessdistinctive institutions and culture may be considered a society. Society is any community ofindividuals joined together by a common bond of nearness and interaction - it is a group of peopleacting together in general for the achievement of a certain goal or purpose.

BEHAVIORAL MEDICINE:This term is used for the broad interdisciplinary field of scientific investigation, education, and practice, which concerns itself with health, illness, and related physiological dysfunction. The fieldconsists of disciplines such as psychology, medical sociology, and health education that have relevantknowledge which can assist in health care, treatment, and illness prevention.

ANTHROPOLOGY:

Anthropology is the science of mankind and is that branch of science, which investigates the positionof mankind zoologically; studying is evolution, history, physiology and psychology.

PSYCHOLOGY:

Psychology is a science, which deals with the study of behaviour by analysing the mental processes

responsible for different acts and actions. SOCIOLOGY :

Sociology is a study of social aggregates and groups and the changes that they are capable ofundergoing. The study of behaviour of man individually and in groups and in organisation and ininstitutions, therefore, gets the name SOCIAL PSYCHOLOGY. Sociology studies the nature of the behaviour and Psychology determines the reason and purpose of the behaviour.

HEALTH PSYCHOLOGY :

Health Psychology is the aggregate of the specific educational, scientific, and professionacontributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of

health, illness and related dysfunction.




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II. DETERMINANTS OF HEALTH BEHAVIOUR

A. CULTURAL & COMMUNITY DETERMINANTS OF HEALTH BEHAVIOUR

Many of the health beliefs have been acquired by people as members of a culture. As members of acommunity, they learn what kind of water is available for drinking, what food is available for eating,and how the climate can affect one's health. They hear about innovations from their community, suchas installation of latrines, and they develop attitudes and habits towards these innovations similar toothers in their community. Leaders may involve the community in making decisions about health

priorities or may simply set priorities and enforce them. Similarly, communities may organisthemselves and arrange for the expertise and services they need. Because of the ability of the peoplewithin a demarcated location to organize themselves for the benefit of most of their members, thecommunity has been targeted as the place to initiate environmental and health activities.As members of a culture, people learn the values (attitudes) and beliefs (knowledge) of their parentsand grandparents. The culture is also transmitted through religion and through the education system.

It is known that culture is a complete whole of patterns of behaviour learnt by that society andstandardised, approved and recognised. By repeated process of trial and error and learning, the societysets up expected patterns of behaviour. It is a set of behavioural expectation which consists ofstandardised expected ways of feeling and acting. The Cultural norms are generally derived from the previous generation from the way in which things were done for the good and convenience of thesociety. A social norm is a type of social behaviour that is valued by the society as appropriate and benefiting. A departure from these accepted and valued types of behaviour is socially condemned.

Every individual places or gives a relative worth to everything around. This worth or preference or judgement or weightage is known as value. It is a cognition, a motor, and above of all a deeplyappropriate disposition. Value has a strong influence on all actions and behaviour of every man. Valuehelps individuals and groups to make choices or alternatives for action. Value guides human behaviour. The education in the community will have to take into account the religious or culturavalues with regard to what is being taught according to their own values.

Beliefs are defined as a continuing permanent perception about anything the individual world. Belief isa social product of individual perception as well as group experience. Beliefs like values have an

influence on behaviour and attitudes. There are many traditional beliefs on causation, cure and prevention of diseases since the ancient times, which continue to be perpetuated generation throughgenerations.

Habits & addictions can be contracted in a community, and these in turn influence behaviours of theaddicted people as well as other members in the community.

Custom represents the group behaviour. Custom is a pattern of action shared by some or all membersof the society. It is the totality of the behaviour pattern carried by traditions. Habit is a personalitytrait whereas the custom is a group trait . Customs will mostly be based on beliefs, attitudes, andvalues and also past experience.

Why are the community and the culture such powerful forces in influencing people?

1. In traditional cultures, people respect the customs handed down to them from past generations andthe belief that these customs should be continued . They justifiably believe that these customs mus be beneficial if they have persisted so long. Although these customs may be harmful to health, theyclearly have other benefits in terms of reducing the stresses of life and providing meaning anddirection to people's lives.

2. Transmitters of the culture, such as religious leaders, godfathers and parents are highly respected

because of their age and experience, and so have a powerful influence on the younger generation.3. Cohesion and conformity are important for survival in communities where illness, hunger, and

death prevail and where co-operative work and social support is necessary to survive. Also, in fairly homogeneous cultures, people must conform in order to be liked and to belong to a social




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group, otherwise they are outcasts and will not live long .4. When everyone in a community holds the same beliefs and performs the same customs, the beliefs

and customs are assumed to be true. Consensus is taken to be a sign of validity, because there isoften no other way of determining what is right and wrong. For these reasons, communities andcultures are a strong force in teaching people ways to think and act and are equally strong inmaintaining these activities.

B. FAMILIAL INFLUENCE ON DEVELOPMENT, HEALTH & ILLNESS

The family has a particularly powerful influence on individuals because it is the centre of economicand religious life, and because it produces, protects and socialise the new generation.

Socialisation refers to the process by which a child becomes an integrated and contributing member ofsociety. In other words, the entire process by which an individual, either as a new born baby or childor an adult, learns to adjust the behaviour to suit the expectation and needs of all others aroundSocialisation begins at birth and ends at death, because throughout life there is need on the part of eachindividual to know what one has to do, when, why and how, with regard to responses from the others.It has not been difficult to understand that socialisation is the process by which the individual personality develops.

Some countries like Ethiopia, emphasis the role of parents as learners of social conventions and the role

of children as passive learners of these conventions. However, it is clear that socialisation involvesmore than learning social conventions (rules); it involves becoming a satisfied and productive memberof a society, and knowing how to interact with others at a more intimate level. This kind of intimacy isnot taught by parents; it is usually experienced by children during the period of attachment to their parents (birth to 2 years) and to their siblings, and it remains with the person until it is needed in lateryours with friends and spouse. Thus, the role of the family can differ in different cultures dependingon whether they emphasise parents as the exclusive teachers and whether they emphasise integrationthrough social conventions. In any case, the most important function of the family is the optimalcaring of children. Yet, some social and environmental factors have recently interfered with this roleof families. These are: migration, industrialisation, subsistence farming, drought & famine, epidemics& high maternal mortality, and family breakdown.

When families can no longer care for their children, society sets up orphanages to raise childrenResearch on orphanages around the world pointed out that institutions are not conducive to the normaldevelopment of children. Because of the high child: adult ratio and the high turnover of caretakerschildren do not develop secure emotional attachments to an adult and do not develop good relationshipswith their peers. Because of the lack of verbal interaction with adults, intellectual development isimpeded. However, this may not always be true. A study in Jimma conducted among community- based orphanage, did not confirm the above facts. The study showed that community-basedorphanages without institutional structure could adequately substitute for family caring; and that insome cases, families were unable to provide caring as much as it was in the orphanage.

Families contribute to child development through both the forces of nature and the forces of nurtureAt this point, researchers have not completely determined how much each factor contributes to the

outcome. For some behaviours of personality, nature predominates; for others the forces of nurturedominate.

The mother's education is the most important determinant of her children's health. For literacy andnumeracy to be well established and functional, the person must have completed 4 years of schooling The mother's education is one of the strongest predictors of her child's chances of survival. This is because maternal education is associated with many of healthy preventive and promotive behaviours.

Parenting styles refer to ways in which parents interact with, control, and discipline their children inthe process of socialisation. Parent's style of interaction affected the intellectual, emotional and socialdevelopment of the child, i.e., certain parenting styles are more likely to produce competentautonomous, and loving children. Three major parenting styles are discussed:




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1. The traditional parenting style places great emphasis on continuity with the past . Parents believethat children should uphold traditional values and behave in ways that have been worked out overtime and passed down from previous generations. Parents reward close ties with the extended family and punish attempts to be independent from the family and behaviours that are different from the traditional ways of doing things. The result is that children are very attached to their parents and conforming , but as adolescents and young adults may fear innovation, risk-taking andautonomy.

2.The authoritarian-restrictive parenting style places great emphasis on obedience to authorityParents believe that children need to be shaped, controlled and evaluated by fixed rules laid down by powerful people (such as elders and parents). Parents reward obedience to these rules andharshly punish disobedience and attempts to be autonomous. The result is that children are not strongly attached to their parents because of the restrictions and harsh discipline. As adolescentsthey do not know how to share responsibility or to be maturely autonomous or creative. If told totake responsibility or to change, they will, but it will not be self-motivated or self-initiated . Theymay be either very submissive and obedient or (else) impulsive and destructive.

3. Authoritative parenting style places great emphasis on rules and standards that are geared to the

child's age and personality. Parents believe that children need to have rules that are enforced, butthat these rules are not absolute or infallible but should be changed according to the child's

individual characteristics. Beginning at a certain age (6 - 8 years) children are expected to share inthe responsibility of setting and enforcing rules and can negotiate the nature of rules with parentsThe same holds true for emotional and intellectual interactions between parents and their childrenwhich are geared to the individual child and for which children share responsibility. The result isthat children are able to solve their problems, take responsibility, accept change and changing roles within and outside the family, and be autonomous. The responsibilities and changes may betoo taxing and confusing for some children, leaving them bewildered. As a result, children may beattached to or detached from their parents depending on the degree of responsibilities put on them.

Social capabilities

The most important social capability in the first year of life is the formation of an attachment Attachment is usually defined as a close emotional bond to a selected number of people, resulting in

security. A child needs attachment for survival, growth, and later for the development of other intimaterelationships. A mother needs attachment as an incentive to continue her effort to care for the childdespite the obstacles.There are many known functions of attachment for the child:

a. to feel secure (unthreatened and confident),

b. to feel secure enough to reduce one's fear of strange situations and strange people and to then beable to explore,

c. to internalise control over one's impulses; attached children show more self-controlled, persistentand enthusiastic problem solving,

d. to develop capabilities that later facilitate positive peer relationships and intimacy .

The family environment most conducive to developing a secure attachment is one where the adultresponds to the infant's cries, smiles, and gestures; and where the adult comforts and stimulates theinfant according to the infant's temperament and current state.

C. PSYCHOLOGICAL (PERSONALITY) DETERMINANTS

Personality refers to relatively enduring characteristics of a person that make him/her different fromothers, and that are psychological rather than biological, but may have developed as a result of biological or social factors (i.e., nature or nurture). Temperament is an example of a constitutionally based aspect of one's personality that is present from birth, though over time it may be modified by theenvironment.Three health related aspects of personality will be discussed here.




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a. HEALTH LOCUS OF CONTROL (HLC)

This concept refers to a person's generalised expectancy concerning what determines one's health andillness, internal factors within oneself or external factors outside oneself . In other words, HLC isgeneralised expectancies that either self (internal) or external or powerful others or chancedetermine one's health and illness. Practice of Preventive Behaviour is linked up with various personality variables such as the HLC.

It is assumed that people who expect to be able to affect their own state of health will seek more healthinformation, be more receptive to changing their health behaviours, and manifest more promotive, preventive, and curative activities. Yet, research works have not strongly supported all of theseassumptions. HLC has been measured by Multidimensional HLC developed by Wallstone andWallstone (1978), and also by using the modified scale by Leu & Wary 1981.

Using items for three dimensions, Wallstone and colleagues found that internal and chance itemscorrelated negatively and so could be subtracted to produce one score along an internal-externalcontinuum. The score for powerful others was sometimes positively correlated with chance butindependent of the internal score. Validation studies would have to be conducted in different set up tofind out how people view the control of powerful others and powerful spirits -- more in line withinternal control or with chance.

Concerning health education, some have advocated that educators try to teach people that they cancontrol their health and illness. Others have emphasized the need to alter education messages to fit thelocus of control of their listeners. For example, if health is thought to be under the control of God, then perhaps priests and other religious people should become involved in health education. If householdheads are thought to be powerful in influencing health and illness, then these men should be involvedmore in health education; giving it and receiving it.

b. Personality Types

Type A is characterized by easily aroused hostility, anger, a sense of time urgency, and competitiveachievement striving . Research suggest that the propensity for hostility may be the most lethalcomponent of Type A behaviour and the only one reliably associated with coronary heart diseasemorbidity and mortality. Type A behaviour is associated with hyperactivity to stressful situationsincluding a slow return to baseline. Some have suggested that these exaggerated cardiovascularresponses to stress may be genetically based and that Type-A behaviour may in, in part, result ofexcessive neuroendocrine reactivity to environmental stressors. Type-A behaviour can be identifiedearly in childhood and may be related to a parental style involving escalating performance standards,disapproval, and punitive or harsh methods of control. Research with children has not typicallytranslated into interventions because not all children who show Type A behaviour will become Type Aadults, nor will all Type A adults develop CHD.

The measurement of Type A personality or behaviour pattern is through a Structured Interview(Friedman & Rosen) or a structured questionnaire called the Jenkins Activity Survey. The later asksspecific questions such as: How would your wife rate you? Definitely hard-driving and competitive.

Definitely relaxed and easy going or anywhere in between. It is not as good at predicting disease asFriedman's interview which assesses verbal responses as well as the manner in which answers are given(nonverbal) such as explosive speech, interruptions, expressions of anger and impatience. According tothis measure, people are classified in four ways: Type A-1 characteristics include expressions ofvigour, energy, alertness, and confidence, and loud, rapid, tense or clipped speech, frequeninterruptions, explosive speech, hostility and impatience. Type A-2 people are not as extreme as A-1's. Thus A-2 people may be in a hurry but not be extremely impatient; they may be less hostile andaggressive.

Type A's need to control events and outcomes. When their control is threatened, they increase theirefforts to reassert control, thus appearing to be Internal. When exposed to loss of control or largeamount of uncontrollable stressors, however Type A's give up more easily than others, and appear




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helpless.

Type A's also experience the physiological stress response on most tasks. That is, when a task ischallenging, and requires accuracy, they show the typical sympathetic arousal of a person under stress(increased heart rate and blood pressure). This arousal is psychologically activated, and is not due toincreased physical activity. They also respond to the usual stressors with excessive sympatheticarousal. It is assumed that this leads to the higher rates of CHD found in such people.

Efforts to modify Type A behaviour through training in relaxation and stress management show promise in reducing not only cardiovascular reactivity to stressful situations but also morbidity andmortality due to CHD.

Type B people show little evidence of any of these characteristics; they are less competitive, lesshostile in their responses, and more relaxed. Type X people show A and B characteristics in almostequal proportions.

People with Type C (cancer-prone) personality are those who are easy going and acquiescent,repressing emotions that might interfere with smooth social and emotional functioning. The cancer- prone person is described as inhibited, over-socialized, conforming, compulsive, and depressive. He orshe is said to have particular trouble expressing tension, anger, or anxiety, instead presenting the self as pleasant, calm, compliant, and passive. The Type C or cancer-prone personality has been characterized

as responding to stress with depression and hopelessness, the muting of negative emotions, and the potential for learned helplessness. Yet, the association between personality and development of cancehas not been conclusively drawn through studies.

c. Stress, Stressors and Coping

Stress is the process of appraising events (as harmful, threatening, or challenging), of assessing potential responses, and of responding to those events; responses may include physiological, cognitive,emotional, and behavioral changes. Stress is used to refer to the internal state of tension ordisequilibrium resulting from a stressor. In other words stress is the process by which environmentalevents threaten or challenge an organism's well-being and by which that organism responds to thisthreat. The environmental events are called stressors. Some of the examples of stressors areunescapable pain, chronic illness, taking exams, increased responsibility at work, marital conflict, andthe evil eye. In the Ethiopian context some additional stressors can be: school problems, stressful new job, imprisonment, pregnancy, social stress from family or neighbours.The measurement of stressors includes Holmes and Rahe's Social Readjustment Scale which askshow many major life changes have taken place in the past year. Each change is assigned a score basedon the amount of adaptation or readjustment required by that event. Sarason included the samechanges but asked each respondent to indicate the intensity or the impact of the event on their livesCoyne, Kanner et al. developed a Hassles Scale to assess irritants that can range from minorannoyances to fairly major pressures, problems, or difficulties. They can occur few or many times, butit is their accumulation or repetition that creates stress. Lapore and others developed a measure ofchronic strains to assess recurring and major stressors in the life of a family living in a developingcountry like in India. Mesfin Samuel modified this scale for use in Ethiopia, and included stressorssuch as parental imprisonment, mental illness, chronic physical illness, overcrowding, andunemployment. These were strongly associated with mental disorders in the mothers, which in turnlead to behaviour problems in her children.

There are a number of factors that determine whether the stressors will lead to negative health outcomeOne concerns the stressors -- their number, duration and intensity. A second concerns whether acoping response is available in the situation for the person to use. If one is available and is used, theoutcome may not be as negative. A third factor concerns the characteristics of the personexperiencing the stressor. Type A people or withdrawn people, and anxious people respond morestrongly to stressors. Finally, someone with a large social network and strong social support fromrelatives, friends and spouse may be protected from negative outcome.




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Coping has been defined as the active utilization of biological, psychological, and social resourceswhich assist in controlling, mastering, and preventing the distress imposed by external and/or internaldemands (stressors) experienced by the person. Resources include one's health, energy, morale, problem-solving skills, defence mechanisms, and internal locus of control, as well as social support andsocial services.

Falkman and Lazarus classified 8 coping strategies. These include:♠ Confronting coping - aggressive efforts to alter situation♠ Distancing - cognitive efforts to detach oneself and minimize the importance of the situation♠ Self-controlling - efforts to regulate one's feelings and actions♠ Seeking social support - efforts to seek information, tangible support, and emotional support♠ Accepting responsibility - acknowledge one's own role in the problem and trying to put things

right♠ Escape-avoidance - wishful thinking and efforts to escape or avoid the problem♠ Painful problem solving - deliberate problem-focused efforts to alter the situation♠ Positive reappraisal - efforts to create positive meaning from the situation

Others have classified coping into two categories: active and passive.Active coping is associated with stressors that are controllable and for which there is available activeresponse. It is also associated with: activation of the Symapathetico-Adreno-Medullary (SAM) System; and increase in

epinephrine particularly when there is emotional arousal; and increase in norepinephrine particularly when there is physical exercise,

release of endogenous opiates such as enkephalines and endorphines; and a slight release ofcortisol.

When emotional arousal is not accompanied by vigorous physical activity, the free fatty acidsmobilized for energy are not used and become plaques leading to atherosclerosis. Active coping canlead to psychosomatic illnesses.

Passive coping is seen in highly aversive situations where one expects little control or ability tochange the situation, such as intense temperatures, surgery, death of a close relative, uncertainty about

the future. Passive coping is more closely associated with the Hypothalamic-Pituitary-Adreno-Cortical(HPAC) System and often leads to clinical depression, helplessness, hyper-vigilance, withdrawal, andsusceptibility to disease. One can characterize individual people in terms of whether they prefer andhabitually use active or passive coping.

Learned helplessness (Seligman)

What happens when control is not available - when we cannot, under any conditions, gain some senseof control over what happens to us? Work by Seligman (1975) and others suggests that if thisresponse-outcome independence is prolonged, we may learn that we cannot affect outcomes and ceasetrying to do. Repeated exposure to uncontrollable events "conditions" us to expect responses andoutcomes to be non-contingent, and the reaction that this produces has been called learnedhelplessness.

Psychologists have long been aware that when an individual repeatedly fails to accomplish a goal orexert control effectively over something, he or she not only may stop trying in that but also may becomeunresponsive in new environments where success might be more readily achieved. Beyond thehelplessness present in the setting where failure occurred, Seligman posited that people can learn to behelpless - that is learn that their attempts to control or succeed will not be successful.

According to Seligman, the primary cause of learned helplessness is the recognition that response andoutcome are independent - that the probability of achieving a given outcome is the same whether or notresponses are made. Once repeated exposure to uncontrollable events has caused the organism to learnthat the outcomes cannot be affected, responding ceases. One experience with uncontrollable eventsappears to affect motivation and cognitive ability in other settings as well as in the situation in which it




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was first learned.

Learned helplessness creates three deficits. 1. The first is motivational, in that the helpless person makes no effort to take the steps necessary

to change the outcome.2. The second is cognitive, in that helpless people fail to learn new responses that could help them

avoid the aversive outcomes.3. The third is emotional, in that learned helplessness can provide mild or severe depression.

Other psychological correlates of health behaviour

Emotional factors play an important role in the practice of some health habits. For exampleovereating is linked to stress for some obese people, and they are more likely to overeat when they areunder stress than when stress is absent. Positive health behaviours may also be under the control ofemotional factors. Self-esteem also relates to the practice of health behaviours. In both children andadults, those with higher self-esteem are more likely to practice a variety of good health habits thanthose with low self-esteem. Generally, good health behaviours are more likely to be practised by people with a sense of psychological well-being and a belief that their health is generally good. Health behaviours are similar to other aspects of life that require planful problem-solving activity.

Health behaviours are also integrally tied into people's personal goals. The overall goal of simply

staying healthy was only a partial predictor of these health habits.Some health habits are controlled by perceived symptoms.Cognitive factors, also determine whether or not individuals practice health behaviours. The beliefthat a particular health practice is beneficial and that it can help stave off a particular illness, as well asfeeling of vulnerability to that illness, may all contribute to the practice of a particular health behaviour(Health Belief Model).

D. GENETIC INFLUENCES ON HEALTH AND BEHAVIOUR (BEHAVIORALGENETICS)

Genetics have an effect on behaviour and health. The study of the observation of behaviours that could be transmitted from parents to offspring is termed behavioral genetics. Behaviour, in this usagerefers to numerous phenomena such as intelligence, aggression, emotionality, mental illness, andcriminality. The three major methods of genetic investigation of humans are family studies, twinstudies and studies of adopted children.

1. Family studies assess each member of a family in order to determine whether the prevalence of acertain characteristics exceeds that found in the general population. Of critical importance in suchstudies is the requirement that the considered characteristics be precisely defined. If thisrequirement is not met, then meaningful comparisons with a norm cannot be made.

Family studies are generally the weakest kind of evidence to support the presence of genetic predisposition to a certain personality characteristic. Since family members have not only the samegenes but also the same environment, it is impossible to determine whether the relationships found aredue to genetic or environmental factors.

2. Twin Studies can provide somewhat stronger test of the possible presence of genetic factors

because they compare persons raised in a highly similar environment who are either geneticallyidentical (monozygotic twins) or similar but not identical (dizygotic twins). Twin studies are themost popular method of evaluating human inheritance.

Twin studies, although strongly suggestive of the presence or absence of genetic factors, must beinterpreted with some caution. We can argue that monozygotic twins not only are alike genetically, butalso share a more nearly identical environment than dizygotic twins. They are of the same sex andcommonly tend to be dressed alike, treated alike, and usually confused with each other by other people.One way of overcoming this potential argument is to examine monozygotic twins who were separatedfrom each other very early in life and reared apart. But because of the time and expense involved in




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conducting such studies, only a small number of cases have been studied, primarily in the area of psychopathology. For example in the investigation of schizophrenia, such studies have suggested agenetic predisposition for this disorder. However, the small number of cases involved in these studies prevents any definitive conclusion.

Another point concerning twin studies is worthy of comment. Identical twins, in comparison withfraternal twins or normal siblings, have a great risk of retardation and pregnancy and birthcomplications. Such an observation raises some questions about identical twin studies and the

possibility of genetic involvement because it is possible that trauma to the central nervous system (birthcomplications for example), and not genetic factors, predisposes twins to develop certain forms of psychopathology and personality characteristics.3. Adopted Child Studies attempt to eliminate the possible developmental effect of being raised in a

similar environment. Such studies examine children who were adopted away from their origina biological family at birth and raised by another family. These persons have the genetic endowmentof one family and the environment learning experiences of another family. A number ofmeaningful comparisons can be made employing this method. For example, we can determinewhether the adopted child resembled his or her biological parents with regard to the psychologicalcharacteristics in question. Other comparisons are also helpful in determining the impact of geneticendowment in a different environment.

4. Convergence: The strongest support for the inheritance of a particular personality characteristics

or trait comes from the convergence of evidence from family studies, twin studies, and studies ofadopted children. If it is found that there is familial similarity in a trait, if monozygotic twins aresignificantly more similar than dizygotic twins on that trait, and if adopted children resemble theirnatural parents more than their adoptive parents, then some involvement of heredity for that trait is beyond dispute. In the field of personality, the only trait for which all three methods oinvestigation has been amassed is intelligence. The data strongly suggest that there is a significantinherited component in intelligence.

E. PSYCHOSOCIAL IMPACT ON HEALTH, DISEASE & DISABILITY

Disease and disability have an impact on all levels of society; they reduce the economic productivity ofa nation, demand a great deal of resources from the health system, affect the development of acommunity, place an extra burden on the family and on the healthy parent to take one the role of two parents, and cause a great deal of discomfort to the affected person.

Psychosomatic illness

According to one of Giel's reports, 20% of patients attending outpatient departments in rural Ethiopiawith a somatic complaint had a psychological problem. People with psychosomatic illness create a burden on the family and on the community. They cannot contribute fully to the economic and sociawell-being of the family and the community. Often they are incapacitated by their own pain. Theycontinue to seek health services because health workers are not able to identify the psychological problem and so treat only the somatic complaint, which recurs if the stressor continues. Example

headache.Mental Illness

The social impact of mental illness is probably more severe than psychosomatic illness. Psychotics aregenerally feared and expelled by the community to become beggars, prisoners, or seek help fromtraditional healers in the Zar cult. Those who function within the community seek relief from their pain from health workers who do not know how to identify or treat such patients. Consequently, these people continue to return for medical help or shop around. In addition, mental illness is known to bethe major cause of marital break down. Mesfin Samuel found that there was a correlation of 0.4 between maternal mental illness and child behaviour problems.

Mental problems are assessed using the WHO Self-Reporting Questionnaire for Adults and the




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Reporting Questionnaire for Children. Both were designed for use in developing countries. A newmeasure called Composite International Diagnostic Interview (CIDI) is on field tests, which may allowmore specific diagnosis of mental disorders.

Substance Abuse mainly: Alcoholism

Alcoholism was defined by a WHO Expert Committee in 1952 as the following: Alcoholics areexcessive drinkers who are so dependent on alcohol that they show interference with their bodily ormental health, their interpersonal relations, and their smooth social and economic functioning, or show

the signs of such developments.Disability

Disabilities include mental retardation, sensory disorders such as blindness and deafness, motordisabilities, and neurological diseases such as epilepsy and leprosy. Many of these disabilities have agreat impact on the community.

Because they are chronic and require special care, disabilities place an extra burden on familymembers. Because they are often unable to work, disabled people do not help support the familysometimes they leave and wander into towns to beg. Also there are many negative attitudes towardsdisabled people; even though their family may protect them to a certain extent, disabled people are lesslikely to marry and lead an independent life. Unfortunately, many people do not realize that blind

deaf, and epileptic people are as intelligent as others; they only need to have their intelligencedeveloped as all normal people do by using the senses that are still functioning.

F. ACCESS TO HEALTH CARE SYSTEM

Access to health care system also influences the practice of some health behaviours. Medically oriented preventive health behaviours are correlated with each other very well. The person who obtains aregular check-up is more likely to use a preventive screening service and is more likely to obtainimmunizations. The reason that medically oriented health behaviours are modestly related is that all ofthem are influenced by a common factor: access to medical services. Thus in predicting medicallyoriented health behaviours, we need to know who uses health services more generally. Individualswho are low in socioeconomic status (SES), who are female , who do not have a regular physician , andwho do not have convenient medical services are less likely to use health services generally and to practice health behaviours that require medical intervention. Research reveals that people with moreeducation and higher income are more likely to receive immunization, have regular physical checkupwhen they have no symptoms, obtain preventive dental care, get PAP tests, and respond to breastcancer screening programs. Even when screening programs or other preventive services arespecifically designed for low-SES groups, the more advantaged individuals within that group will usethe program more than the less advantaged. To summarize, then, access to medical care prompts the practice of a variety of medically oriented health behaviours. Unhappily, however, access to medical facilities does not necessarily improve nonmedical health behaviours such as smoking, overeating, and so on.

HEALTH EDUCATION I – PART 2

I. INTRODUCTION: DEFINITIONS OF HEALTH EDUCATION (HE)

Health education has been defined in many ways by different authors and experts. In a WHOTechnical Report Series (# 89 of 1954) it was defined as follows: "Health education, like general

education is concerned with changes in knowledge, feelings and behavior of people. In its mostusual forms it concentrates on developing such health practices as are believed to bring about the




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best possible of well beings."

The above definition shows that it is a process that aids people to find out their health needs andactivate them for suitable behavior. The education given for identifying the health need and matchingit with suitable behavior can be termed as health education. In other words, the entire process ofinvolving people in learning about health and disease and aiding them to act suitably for overcomingillness and preserving a positive health is health education. I.e. it is any combination of learningexperiences designed to facilitate voluntary adaptation of behavior conducive to health. It is required

for almost a very one in society and is required off and on, in a continuous manner. Health educationis needed for all ages, both sexes, all classes of community (rich or poor), literate or illiterate and in all parts of world.

Health education should be an active process of learning and doing by one's self. The individual has toassimilate and internalize the information and ideas and adopt a behavior necessary for health. The HE process must result in a permanent change or sustained behavior. HE will stabilize the good pattern of behavior by providing necessary information and creating a positive attitude for the behavior that has been already formed.

In a more comprehensive way HE can be defined as a process with intellectual, psychological andsocial dimensions relating to activities that increase the abilities of people to make informeddecisions affecting their personal, family and community well being. This process, based on scientific principles, facilitates learning and behavioral change in both health personnel and consumers,including children and youth. This definition can be elaborated as follows:

Engage intellectual, psychological and social processes

The intellectual processes are usually engaged during learning and decision making. This dimensionincludes what is sometimes referred as knowledge, beliefs, awareness, perceptions, memory and problem solving, i.e., the cognitive or thinking component.

The psychological processes are particularly important for initiating health behavior and acting onone's decision. This dimension includes attitudes, motivations, values, as well as specific behaviors.

The social dimension is important throughout, because it includes all aspects of relating to other people such as the influence of others, joint decision making and community organization.

When discussing about these three dimensions of HE, COMMUNICATION plays the most vital role because it is the transmission of information from one person to another. It can be face-to-face andmass media, auditory and visual; it can be informative and emotional and persuasive; it can be positive(what to do and the benefits) and negative (what not to do and the disadvantages). Communication is acommon activity used to encourage learning, behavior change and decision making. It can engage inall the three dimension of a person, i.e., intellectual, psychological and social dimensions.Encourage learning and behavior change

What kinds of activities encourage learning and behavior change? A number of theories of healtheducation have been proposed, each attempts to identify what skills or knowledge must be learned andhow they are best learned and performed. A few of the models, which shall be discussed in very detail

in later sections, are:1. HEALTH BELIEF MODEL2. APPLIED BEHAVIOR ANALYSIS3. THEORY OF REASONED ACTION4. THEORY OF PLANNED BEHAVIOR, and

5. THE PRECEDE-PROCEED MODEL (HEALTH PROMOTION PLANNING MATRIX).

Foster making decisions and acting

The goal of HE is to possess the abilities necessary for making informed decisions about the health andacting on these decisions. These go beyond learning and performing specific health behaviors. Itrefers to having the abilities to make ongoing decisions about the health of oneself and others, as wellas being able to organize personal and social resources to act on these decisions. Decision making




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abilities include skills that were described as being intellectual, psychological and social in natureThese include:

1. seeking and evaluating information2. considering one's priorities3. comparing the costs and benefits of an action4. solving problems5. feeling confident about one's control

6. utilizing other's expertise and opinion, and7. coordinating the efforts of many people

Acting on these decisions requires even more in the way of skills, motivation, energy, and direction, aswell as the means to obtain physical and social resources.

Settings of health education can be any where including schools, communities, worksites, health caresites, homes & the consumer market place.

Health Promotion:

It is any combination of health education & related organizational, economic & environmentalsupports for behavior of individuals, groups, or communities conducive to health (has social context).It is the science and art of helping people change their life toward a state of optimum health.

Health Behavior:

These are actions of individuals, groups & organizations as well as their determinants, correlates, &consequences, including, social change, policy development and implementation, improved coppingskills, & enhanced quality of life.kasl & Cobb define three categories of health behavior:

i. Preventive health behavior : - any activity undertaken by an individual who believeshimself to be healthy, for the purpose of preventing or detecting illness in anasymptomatic state.

ii. Illness behavior : - any activity undertaken by an individual who perceives himself to be ill, to define the state of health, & to discover a suitable remedy.

iii. Sick role behavior : - any activity undertaken by an individual who considers himselfto be ill, for the purpose of getting well. It includes receiving treatment from medica providers, generally involves a whole range of dependent behaviors, and leads tosome degree of exemption from one’s usual responsibilities.




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II. AIMS & PRINCIPLES OF HEALTH EDUCATION

Essentials of HE

The following essential points are relevant and applicable to HE in all possible situations.

1. HE may be required for almost every one at some time or other.2. HE is not a one time affaire. It is a continuing education.3. HE can be organized as a self-learning process, and also can be a process of learning from

others.4. HE consists of proper communication of ideas.5. All the principles and theories of education and learning are fully applicable in health

education.6. Since HE has to do with health, correct knowledge about various aspects of health and disease

is highly essential for communicating or disseminating ideas for the purpose of producingnecessary attitude and behavior.

7. Any one who knows what is good for preservation of health can impart HE. Though peoplewho are trained for providing health care are much better fitted to give HE in the communitythan lay persons. This does not rule out the role of non-medical and non-health personnel ashealth educators but it only emphasizes the importance of acquisition of correct and complete

information and knowledge on relevant health problems and their application.8. Since HE aims at change of behavior a health educator has to acquire and develop skills toeducate, to communicate, to motivate and involve the client. He/she should have workingknowledge of social psychology and principles and theories of community organization.

9. HE is not like teaching of medical and health subjects to undergraduate medical, nurses and paramedical, etc. People in all walks of life have to be educated frequently on health practicesand health related behavior from time to time throughout life and as applicable to changingconditions.

10. It must be borne in mind that human behavior is governed by various influences and thereforeHE must take full cognizance of all the influencing factors in any given situation. A goodhealth educator has, therefore, to combine in himself knowledge and skills of behavioralsciences with sufficient rational understanding of the health problems and their solutions from ascientific and logical stand point.

Principles of HE

1. HE is primarily education and its purpose is to ensure a desired health related behavior. All HE

should be need-based. If the problem is severe or serious from the health person's point ofview but is not felt as much by the individual or the group then a proper diagnosis should bemade about the different influences (perceptions, beliefs, attitudes, prejudices, resources, etc.)

2. HE should not become an artificial situation or formal teaching-learning. One has to getinto the culture of the community and introduce novel ideas with a natural ease and

caution. It is better to start from where people are and slowly build up the talking points toavoid any clash of ideas and to allow for people's understanding, appreciation andinternalization of fresh ideas that the health educator wants to seed in the community.

3. It is necessary to discuss freely on the health problems and the solution and to ensure that allthe good and bad points, advantages and disadvantages, difficulties, etc., are thoroughly dealtwith.

4. Education is the process or act employed to develop the mind, character and body by planneddiscipline. It is a methodical socialization of an individual. Since education aims at change of behavior, the sciences of sociology, psychology and anthropology are essentially required in




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understanding human behavior. The educational process has to take into account the

learning process and the teaching process. For this the educational content has to bedeveloped based on the diagnosis of the socio-psychological factors. Methods of teaching or providing learning opportunities also form part of the educational process. Lastly the media ocommunication has to be considered carefully for effective propagation of ideas.

5. Patients should be made to appreciate the objective of treatment for diseases. There is agreat need for HE to make people understand curative aspects of many diseases but in timessickness people do resort to some care by and large. But in matter of preventive and promotivecare people are not by themselves sufficiently aware of the various things that they have to do.Generally, it is also difficult to demonstrate the beneficial effects of preventive and promotivecare to enable people to realize their importance. A continued education is necessary in everycommunity to help people to identify their health problems and to help them to understand whatsteps they have to take to prevent any sickness.

6. There should be a free flow of communication. The two way communication is particularlyof importance in health education to help in getting proper feedback and to get doubts cleared.For people to understand and appreciate ideas, messages, methods, procedures, etc., with properreasoning the communication should be simple, clear, brief and crisp. There are many

principles of effective communication which require to be carefully remembered and practiced by the health educator.

7. The health educator has to make himself acceptable. He should realize that he is an enablerand not a teacher. He has therefore, to win the confidence of his clients.

8. The health educator should not only have correct information with him on all matters that hehas to discuss but also should himself practice what he professes. Otherwise he will not

enjoy credibility.

9. The health educator has to adjust his talk and action to suit the group for whom he has to

give HE. This is particularly necessary when the health educator has to deal with illiterates and poor people.

10. A health educator has to employ all possible methods of education. He should also have abasic knowledge and should be fully familiar with all the learning principles. He shouldtherefore apply the teaching-learning methods appropriately to different groups and individuals by using judgement.

11. Since the ultimate aim of HE is to bring about desired health related behaviors, the healtheducator should as far as possible make every effort to reason out and rationalize , so thatthe client is able to internalize the relevant ideas.

12. To ensure a full understanding of the problems and its solution by the clients a well planned

program is necessary. The content of the program and the method of approach will have to be based on the educational diagnosis. Additionally care should be taken to include thimplementation and evaluation along with the clients.

13. The use of audio-visual aids for support and reinforcement is of particular significance inHE because of the different illiterate and literate groups that have to be involved also because ofthe technical nature of the subject matter. This is also particularly important to generate interesttowards lectures, talks and discussion. The aid provide not only a comfortable diversion buthelp in focussing attention on the essentials and giving the eye and ear a greater role in




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perception.

14. HE should be specific and relevant to the problems and the available solution. Thecontent should always aim at the focus or essence.

15. It is the essential function of any health educator to find out the existing behavioral patternsand their basis. If any change of behavior is required from a wrong practice to a supposedright practice the process of HE should aim at removing the wrong idea and its connectedattitude and then introducing correct ideas, attitude and practices.

16. It should be remembered that people are not absolutely without any information or ideasThere is always some perception or belief, etc., which should be studied first before HEcan be started. The health educator should remember that he his not merely passinginformation but he is giving an opportunity for the clients to analyze fresh ideas with old ideas,compare by past experience and take decisions which are found favorable and beneficial.

17. A grave danger with HE programs is the pumping of all bulk of information in one exposure orenthusiasm to give all possible information. Since it is essentially a learning process theprocess of education should be done step by step and with due attention to the different

principles of communication.

18. HE should be able to provide an opportunity for the client or clients to go through thestages of identification of problems, planning, implementation, evaluation and so on. Thisis of special importance in HE of the community. The principles of community organizationviz., the identification of opinion leaders, identification of problems and planningimplementing and evaluating are to be done with full involvement of the community to make itthe community's own program.

19. The health educator should use terms which can be immediately understood. Highlyscientific jargon should be avoided.

20. Any attempt of drastic or quick change of behavior may not only be difficult but may generallycause unnecessary mental conflict and resentment particularly because the expected behaviormay be much contrary to existing cultural pattern. HE should start from the existing cultureand gradually try at change of habit and practices . Moreover, the HE effort should aim atsmall changes in a graded fashion and not be too ambitious. People will learn step by step andnot everything together. For every change of behavior a personal trail is required and thereforethe HE should provide opportunities for trying out changed practices.




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III. COMMUNICATION

A. Purpose & Objectives of Communication

To communicate means (dictionary definition) "to impart, pass on or transmit a message, information,etc.; to exchange ideas or information with, be in touch with, to have access, to be connected with," andcommunication means "the act of communication, the things communicated, the means ofcommunicating."Essentially communication deals with transmission of information or ideas and sharing and exchangingof information.

It is needless to emphasize that in learning and education, communication gains great importance because education implies transfer of knowledge and skill and communication also means transfer ofinformation and exchange of ideas. In learning information has to be gathered and acquired; and skillshave to be observed, practiced and developed. Therefore, communication forms an indivisiblecomponent of the process of education and the process of learning.

B. COMMUNICATION PROCESS & COMMUNICATION MODELS

The process of communication is usually described by models with three distinct parts and theirelements. These are: (1) Sender or communicator; (2) the receiver of the message or thecommunicatee; (3) the message which lies between the communicator and the communicatee and getstransacted.

In other words, communication is a process by which an idea is transferred from a source to a receiver

with the intent to change his behavior. The purpose of communication is change. Many public health programs are connected with change and require communication intervention.

The most important thing is what happens when the message reaches the people it aims at. If they hearand understand it, and are inclined to believe it, good communication has taken place.

The six components of any communication process are:

1. Source (Encoder):

This is the originator of message, which can be an individual or groups; or it can also be institution ororganization.

The communicator has to arrange his thoughts and ideas in such a manner that he organizes hismessage for the benefit of the receiver. This process of arranging the ideas and preparing the messageis called encoding. Encoding is the transmission of ideas into a message by the source.

2. Message:

This is the idea that is communicated, something that is considered important for the people in thecommunity to know or do. Many messages are expressed in the form of language symbols. Since thismessage is likely to evoke a response in the communicatee, it can be considered as a stimulus. Thestimulation can be effected through any of the special sensory of the body.In a typical two-person conversation the verbal band carries one-third of the meaning; the non-verbalcarries two-third of the meaning.

Effectiveness of the message depends on:




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1. Psychological factors: intelligence, level of education, prior information, and selective perception.

2. Linguistic factors: vocabulary, grammar, etc.3. Receiver factors: culture, class, etc.

3. Channel: Physical means by which a message travels from source to receiver.

Classification of channels

(1) Interpersonal (face to face)(2) Mass media 4. Receiver:

This is the person for whom the communication is intended. The receiver of the message exercises notonly the sensory organs but also his brain and mind. The response to the message begins with thereceipt of the stimulus and the perception. The response of the brain and mind can be visualized likesomething than happens in the receiving set of telegraphic message. The brain analyses the messageand makes sense out of it. In social psychology this is referred to the same process as perception. It

consists of decoding the stimulus and interpreting it. Decoding is the mental process by which thestimuli that have been received through the sensory organs are given proper meaning according to theindividual's own way of thinking.

5. Effect: change in receiver's attitude, knowledge and practice.

6. Feedback:

This can be either positive when desired change in KAP occurs or negative when desired change inKAP does not occur. Feedback need not necessarily be a written message or written language, etc. Justlike the onward process of communication feedback can also be by gesture, symbols or signs.

MODELS OF COMMUNICATION

Various authors have given their models in communication. The different models have been evolvedaccording to the different situations and, therefore they will differ slightly from one another.

1. Aristotle model (1946)

It consists of three elements only: the speaker (source or communicator), the speech (message), andthe audience (receiver or communicatee). Since Aristotle has visualized a public meeting for thismodel, we have the speaker, the speech and the audience. There is no mention of the feedback as suchand we have to presume that this should be provided by suitable opportunity for questions and answers,etc. In a huge gathering it generally does not take place. It is possible in smaller groups.

Source Message Audience

2. Shannon and Weaver model

In this model the use and introduction of a medium for the transmission of message is distinctly seenas different from the Aristotle model. This consists of the following components: Source




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transmitter, Signal, Receiver; and Destination.

The parts of the medium are the transmitter and the receiver. The common application of this modeis the radio transmitter or telephone mouthpiece.

Communicatee is referred to in this model as destination.

3. Schramm model

This model has in addition to the previous model a process of coding the message at the source(communicator). The message is put in the form of code or encoded. It is then transmitted as a signalor energy form through a medium in the form of wires. This medium is called the channel. Thecommunicatee in this model is the receiver who decodes the message that has been received. For this purpose the communicator is to employ an encoder who converts the message into code. This is whathappens in the telegraph office when the telegram is handed.

4. Berlow model

This is not different from the previous model. The application is also seen in telegraph.

5. Leagans model (1963)

In this model the components are communicator, message, channel, treatment, audience andaudience response. In this model, feedback mechanism is provided in the communication processThere is also a special effort to treat the message so that it is suitable for the audience. In other wordsthis process ensures a proper formation of message with sufficient trial, pretesting, etc., and also provides for feedback for the purpose of monitoring and evaluation. This model will be ideal in the

class room situation where the public address system is arranged. It is also applicable in mass

communication or in group discussion where the message has been treated for the chosen channel ormedium of communication and a provision is carefully made for evaluation of effectiveness and impacton the audience. It is, therefore, applicable to cinema, television, posters, etc., where thecommunicator prepares the content with sufficient care and precision and simplicity, clarity, etc., andalso he elicits the response of the audience as and when necessary to ascertain his own effectiveness.

6. Fano model

The components of this model are source, source encoder, channel, encoder, channel, channeldecoder, user decoder, and users.This model is typically exemplified by the telegraph system in which the Morse code and any othercode for simplifying or abbreviating messages are used. This model applies also to the transmission ofwireless broadcast message particularly through secret codes in army operation or naval movements.


Sourceencode

Channeldecoder

SourcChanne

Users

DestinationReceiveSignaTransmitter Source

Communicator Messag Channel Treatmen

AudienceAudience



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7. Literer's model

The components in this model are selection, encoding, transmission, channel, noise, detectingdecoding, and selection.

The sender selects the content of the message to suit the need of the audience or receiver. This selectionis however based on the sender's perceptions or understanding of the receivers needs receptivity and power of understanding. The encoded message is transmitted through any medium, which is foundsuitable and available. The message is received by the receiving apparatus, which detects the signal.This is decoded into the original message selected or picked up by the receiver. ( Noise is anyobstruction or interference which prevents the message from being transmitted or carried over clearlyto the audience. Or it refers to any kind of obstruction or distortion or failure of transmission ofmessage.

8. Westly-Maclean's model

The components of the model are sender, encoding, channel, decoding, receiver, and feedback.

This is obviously a simple and comprehensive and ideal model; because it has the element of sourceencoding, channel and decoding and receiver and the feedback from the receiver to sender. Thereforeit enables a two-way communication, which is highly essential in mutual understanding in teaching-learning situation. The advantage of feedback, as already mentioned, is for the improvement of themessage by the sender in keeping with the need and power of understanding of the receiver. Themodel is applicable in the following situations: face to face communication, correspondencetelephonic conversation, wireless conversation, and lecture discussion, panel discussion forum.

┌──────┐ ┌────────┐ ┌───────┐ ┌────────┐ ┌────────┐│Sender├──>│Encoding├───>│Channel├────>│Decoding├─────>│Receiver│└──────┘ └────────┘ └───────┘ └────────┘ └───┬────┘

^ ┌────────┐ │└─────────────────────┤Feedback┤<───────────────────────┘

└────────┘

C. FACTORS AFFECTING THE COMMUNICATION PROCESS

1. Source or the sender or the communicator

The communicator has to be intelligent and understanding. He should know the need of the audienceHe should have proper judgment.

The communicator should possess the following characteristics:a. Skill in communicating - verbal, written. including treatment of message, etc. b. Knowledge of the channel and audience.c. Attitude towards the subject (topic), channel and audience.d. Source credibilitye. Skill in encoding and decodingf. Skill in utilizing the channel


ChannelEncoder

User decoder



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g. Confidence or attitude towards self.

2. Message

A message is the information, which a communicator wishes the audience to receive, understand,accept or act upon. Message will, therefore, consist of statements made verbally during conversation ortransmitted through any media.

The message has 3 dimensions or parts:1. The code2. The content3. The treatment

The message, if delivered directly as in a face to face conversation does not require any particularcoding normally. Words are merely uttered and are received directly by the receiver. But when themessage has to be fed through the channel it has to be properly encoded.

The content of the message refers to substance or the materials in the message for expressing theobjective or purpose of the particular communication.

The treatment of the message is the manner in which the message has to be prepared, processed anddelivered. Treatment of the message is the most important dimension. The success or failure incommunication depends to a large extent on the correctness or accuracy and essence or substance of themessage. The following are some of the necessary characteristics of a good message; should satisfy theobjective; should be clear; should be in level with the mental, social and economic capabilities of theaudience; should be significant; should be specific; should be simple; should be timely and appropriate;should be accurate; should be appealing and attractive; should be adequate; and should be applicable.

To ensure all the above qualities of a good message, the treatment is an essential prerequisite. It refersnot only to the technique and details of procedure but also to the actual content for its presentation.

Treatment of the message is directly connected with the technique employed, for presentation, and its purpose is to make the message clear, understandable and realistic to the audience and therefore, thecommunicator must have proper skill for treating the message. Treatment is the actual process of preparing the message for meaningful and purposeful assimilation by the audience. In generaltreatment may be understood as the choice of words, the organization of ideas, the proper sequence ofemphasis, repetitions, alterations of tempo, etc., which are required for ensuring clarity, simplicity,intelligibility and appeal to the message.

3. Channel

The sender and the receiver of the message have to be connected with each other through a medium orchannel of communication. In face to face communication there is no particular medium except theatmosphere. When message have to be transmitted to distant places we resort to various types of mediaor channels of communication. The physical bridges between the sender and the receiver of themessage are the channels.

In general, there are three aspects of communication:a. Encoding and decoding of message b. Message vehicle - sound waves, electrical wave, etc.c. Vehicle - air, wire, microphone, radio, etc.




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4. Selection of channels

It is very important for the communicator to find the proper channel for his message. The channemust be easily available and accessible to the receiver and also the receiver should be acquainted andaccustomed to utilize the message coming through the particular channel. While selecting the channethe communicator has to make sure that noise is kept to the minimum or eliminated. Anotherimportant precaution is that the medium should not become a barrier.

5. Audience or receiver

Audiences/ Recipients of HE are people who may be reached as individuals, in groups, throughorganizations, as communities or sociopolitical entities. In a good communication process the receivercan take the role of source or communicator for the purpose of giving feedback. Therefore, inteaching/learning situation the communicatee has to develop skills for proper communication. Thereceiver should be able to receive the message physically, mentally and psychologically. He/she should be confident and eager to receive. He must have faith in the source and must view the source with dueregard and cordially.

The level of intelligence or knowledge is of particular importance to the communicator. The position

or status of both the communicator and communicatee should also be considered. In certain situationsthe communicator will have the required credibility with the audience whereas in some other situations,he may be a 'persona non-grata'.

Understanding of the value of position or to and from communication is of great utility in learningsituations. This is of particular importance in communication in-groups for extension education. Thegreater the audience participation in the communication the greater the involvement and acceptanceThere are 4 dimensions of audiences:

1. Sociodemographic characteristics2. Ethnic & racial back ground3. Life cycle stage

4. Disease & at risk statusD. PRINCIPLES OF COMMUNICATION

1. The perception of the sender and receiver should be as close as possible to each otherThe sender or communicator should remember that the receiver has got his own individual perception. Individuals look at things in their own way and have likes and dislikes and attitudesdepending on what they understand and how much. The extent of understanding will dependon the extent to which the two minds come together. In a class room teaching or in groupdiscussion or in mass communication the sender must have some idea of the perception of thereceivers.

2. For effective communication there should be involvement of more than one sensor organ

for giving a cumulative effect. While transmitting any information the communicator is performing voluntary act or movements, either he speaks, writes or makes gestures or producesnoise or employs signals or symbols, etc. The receiver receives the message through thesensory organs. All the sense organs can perform the act of receipt of message depending on itsnature. A communication in which there is an opportunity for the different sensory organsto participate is much more effective than when there is a lesser number of sensoryorgans involved.

3. The more the communication takes place face-to-face the more is its effectiveness. In any




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situation it is needless to mention that the direct face-to-face communication surpasses all othermodes of communication. The face-to-face communication lends itself with out any specialeffort for a proper feedback mechanism. Further in the face-to-face communication there is oneed to employ any other medium than air. The only additional support that may be requiredwill be the use of suitable visual aids and demonstrations if found necessary. When face-to-face communication is not possible one has to resort to the use of suitable media or channels ofcommunication like the telephone, telegraph, mass media, etc.

4. Any communication without two way process is less effective because of the lack ofopportunity for concurrent, timely and appropriate feedback. Whether in face-to-facecommunication or in indirect communication through various media and channels, thecommunication can be made effective, if a provision is made for feedback. To make this possible the communication process should become a two way or to and from process. Thereshould be scope for a free exchange of ideas. A two-way communication not only helps ingetting feedback but also improves the climate and relationship between the communicator andthe communicatee. Since the two way communication is not always possible, such as in thecase of use of mass media, one has to utilize other methods of getting feedback either thoughaudience analysis, survey, etc (post-communication & feedback mechanism). Two waycommunication additionally brings together the perceptions, and subjective worlds so that they

start thinking and feeling together.

What are the pre-requisites for effective communication?

A. Communicator: The communicator should possess the following characteristics.

1. He/she should be knowledgeable and fully conversant with the subject under discussion.2. He/she should have credibility before the receiver, which is gained by sincerity, honesty and

intellectual capability.3. The communicator need to have proper communication skill and should have skill in selecting

and using the channel.

4. The communicator should have proper attitude towards the receiver and the subject matter.5. Feedback should be ensured.

B. Message: The message content should be brief and clear.

1. It should be need-based and timely and appropriate or relevant.2. It should be supported by factual material to give it proper authenticity.3. The channel should be manageable by the communicator and should be appropriate.4. Treatment of the message is also important. Its purpose is to make the message clear

understandable and realistic and specially situated for the channel or media that has beenselected.Some of the salient principles in treatment of message for effective communication are asfollows: (a) proper emphasis where required; (b) repetition for the sake of emphasis; (c)contrast of ideas and comparisons; (d) logical sequence; (e) redundancy for reduction of noise;and (f) no entropy, i.e., wastage or loss of information due to uncertainty or lack of clarityEntropy is the opposite of redundancy.

C. Channel

1. It should be familiar both to the communicator and communicatee.2. It should be appropriate to the message.3. It should be available and accessible.




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D. Receiver

1. Like the communicator the receiver also should have proper attitude and the desire to receivethe communication.

2. The receivers’ sensory organs should be intact and in good working conditions.

In general, effective communication can be considered from three important purposes. With regard tothe effect it should be able to answer specifically in the communicatee as well as the communicator, thethree aspects, i.e., (a) what a particular idea or thing is, (b) why it should be so, (c) how it can be done.The "what" portion gives the change in the knowledge level by supplying the necessary informationand ideas. The "why" gives the support for change of attitude and "how" provides the solution andtherefore, brings about the change in behavior.

E. INTERPERSONAL Vs MASS (GROUP) COMMUNICATION

In social interaction communication normally takes place between the individuals and among theindividuals in groups. When groups meet, apart from the multi-dimensional communication, that takes

place ordinarily, there can also be a two way process of communication between the speaker, lectureror educator and the group. For the individual approach and the group approach, the communication isusually face to face with or without the use of visual or auditory aids. When the entire community atlarge has to be contacted simultaneously, one has to resort to MASS MEDIA. The communicationthat is aimed to reach the masses or the people at large is called mass communication. In the presentday the commonly used mass media are microphones or public address systems, radio, cinema,television, newsprint, posters, exhibitions, etc.

INTERPERSONAL COMMUNICATION

Personal communication includes personal contact between doctor and patient, between teacher and

student, between health educator and client, etc. The decisive criterion for personal communication isthat communication happens at the same time and place. Personal communication means interaction between two or more people who are together at the same time and place.

Advantages

1. The transmitter speaks the receiver listens; then the receiver speaks, the transmitter listens; they both interact with each other.

2. Questions can be asked and answered, facts can be stated definitely and specifically. The participants can repeatedly make sure that they understood each other. It is a constant feedback process in which both parties are involved. The same applies to communication within a group;here the interchange takes place first of all between the leader and the members of the group,and secondly among the individual members of the group.

3. Multi-channel effect of personal communication. In mass communication one can either reador hear and see the information. At most two channels are used. On the other hand, in personalcommunication two or more people sit together in a room, where they can see, hear, smell,touch and feel each other. That is to say, they transmit and receive on both verbal and non-verbal channels; far more senses are involved than is possible in mass communication.

4. Useful in all stages of adoption of innovations.5. Useful when topic is a taboo or sensitive.




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Disadvantages

1. The fact that it calls for the use of many languages;2. Requires personal status;3. Needs professional preparation and knowledge.

Some important ideas regarding the use of personal communication

Education providers need:

- to develop a permanent exchange of ideas with clients, if not, " the health educator is no betteror even worse than a TV set";

- to realize the importance of the impression made when we meet a person for the first time;- to learn to observe the person we face and to derive from this observation useful information

for our work;- to keep in mind that the same words mean different things to different persons;- to pay attention to the body language of our partners and to our own: non-verbal behavior tells

often more words about people's feelings. USE OF MASS MEDIA OR MASS COMMUNICATION

The aim of mass communication in health education is to create awareness of a problem, totransmit knowledge, to set and change norms, and if possible to offer alternative of behavior.

Mass communication is one sided. The broadcaster transmits his message without knowingimmediately what is going on in the receiver's mind, whether he feels concerned or understood, orwhether he is unaffected by the message. Mass communication lacks direct contact.

The word media is used currently to refer not only to print media, radio and television but also coverstraditional means of communication such as puppet plays and folk art. In many countries health

messages may be communicated through traditional media such as art, town criers, songs, plays, puppet, shows and dance.

Combining with interpersonal approaches is very useful and may be critical to the success ofcommunication. Despite all efforts to create better educational tools, still the most effective meansremains the personal contact, with its one-to-one relationship where "teacher" and "student" changeroles continuously, each learning from the other. This is the dynamic, constructive communication.Hence, the importance for health service providers to recognize the importance of two-waycommunication and be technically prepared to perform this function as integral to their daily tasks.

Mass media have the greatest impact at the stage of awareness. Also on disseminating technologicaideas particularly to pass to early adopters (opinion leaders) and from there to late adopters. Massmedia is useful in increasing health knowledge. Mass media is also useful in increasing self-awarenessand influencing attitude change, decision making and behavior change. Mass media messageshowever, must be very carefully designed, so that the right message gets to the target audience in aform appropriate to their needs and lifestyles. It should be realized though that there is a poor feedbackwhen utilizing mass media. By and large, the purpose of mass communication is to sensitize the minds of people. Mass media helpin creating public opinion and public support. They can also help in giving an emotional appeal whenany particular propaganda is launched. During natural disasters, calamities, the mass media have vitaimportance because it is not only useful to flash the information and alert the people but also serve in




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bringing about the required behavior. Mass media also serve the big purpose of providinentertainment to the mass.The communicator should be able to select the correct media. However, depending on the resources itis generally the practice to employ as many media simultaneously in order to get the message across ina short time. Moreover, there are certain constraints with regard to the mass media like availabilityaccessibility, popularity, etc.

The information theory emphasizes on reduction of uncertainty or noise or disorganization of asituation at the receiving end. Apart from whether the information is reaching the receiving end or not,it is also subject to different kinds of mutations or interference. Distortion may occur due to barriersand other causes. Distortion is the twisting of the message and loss of clarity and certainty. Theinformation theory mainly focuses on the need for clarity and the reduction of uncertainty.

Advantages of a mass media:

1. They can reach many people quickly.2. They are believable. If people read something in a newspaper or hear it on the radio, they tend

to believe that it is not only true but also important. This is especially true if the "voice" is froma highly respected person (e.g. respected doctor).

3. They can provide continuing reminders and reinforcement. In order to promote breast-feedingrepeated radio messages help mothers to remember why it is important for their babies’ health.

Some of the disadvantages of mass media include the following:

a. Mass communication may create anxiety (as in the case of HIV/AIDS) or insecurity whencontradictory messages is transmitted.

b. The fact that "others", in large numbers, are exposed to the same appeal may create a sort of"this doesn't concern me" type of attitude.

c. The multitude of the stimuli emanating from this type of communication obliges the individualto develop a filtering mechanism in order to protect himself.

Three key principles in achieving successful mass campaigns, namely:

1. Clear definition of objectives based on reliable research findings, including public opinion;2. Co-ordination of the activities undertaken by all groups involved;3. Continuous evaluation and feedback.

F. Communication aids - projected Vs non-projected

Whether in the classroom situation or in a conference or in a community gathering or individualapproach, communication is facilitated and strengthened or reinforced by the use of suitable audio-

visual aids. Aids are facilitators of communication both for the sender and for the receiver. Audiovisual aids are various kinds and can be broadly classified as audio aids and visuals or projected andnon-projected aids (or graphic or picturesque aids).

The most essential principle of the use of aids is that the aid is so prepared and utilized that it facilitatescommunication rather than hinders. Since perception is at the base or the receipt of stimuli and theirinterpretation, aids will be useful if they can give meaningful message through the different sensoryorgans of the receiver.




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While discussing about media or aids in general, the principle underlying the proper selection of aids toensure its relative efficacy or utility will be understood in a rational manner by depicting a model,which is known as the "cone of experience". The cone is so prepared that at one extreme thesuggestion is the direct experience of the different senses, whereas in the other extreme is theabstraction or symbolization by words. The base of the cone represents the direct experience and whenwe move up we have different stages of decrease of direct experience ending up in mere visual andverbal symbols. However, the abstractness or the stimulus response through mere words, or gesture orvisual symbols need not necessarily be of poor effect as compared to direct experience.

Classification of Aids

1. PROJECTED AIDS: the film (cinema), filmstrip, slides and transparencies

Film or the Cinema

Advantages:

1. True-life situation is reproduced.2. A complete view of all physical aspects of anything is made possible.

3. Since the film is under motion an actual process of act or event is understood without having to be explained separately.4. It is self-explanatory.5. It adds a special interest in the audience to watch the film. It gets more attraction and attention

than listening to a talk.6. Many emotional effects can be brought about in the film, which will leave a lasting impression

in the mind.7. In the motion picture the coordination of sound and sight provides a realistic effect.

Limitations

1. Electricity or battery should be available.2. The place has to be darkened.3. Often a shelter is required to project special equipment.4. A technician to operate the projector is required.5. The equipment and the preparation of the film are both very costly.

Filmstrips

This is a film in its process and preparation but it is a much smaller affair. While the film runs intogreater length, a filmstrip is usually within a meter or two. The use of a filmstrip is especially suitablefor educational methods with small groups. It is not suitable for large groups or as a mass media. It isspecially used to tell things in a systematic and sequential manner with suitable illustration andnecessary pause for the group to see and learn. Filmstrips are exclusively used only for educationa purposes. Since it is done in a small group and since it is possible to manipulate it forward or backward there is plenty of scope for discussion, asking questions and repeating the same film ifnecessary for clarification. The filmstrip is relatively cheaper than the film. However, its use is limitedto the availability of a projector and dark room arrangement and electricity. It is quite easy to operateIt has been found a very useful aid for supplementing technical information.

Slides




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Slide is a transparency of any picture or write-up prepared on transparent materials. It can be projected by the use of a slide projector. Slides can both be used for smaller as well as larger audiences and alsofor educational purposes too.

Transparencies

Transparencies are large size slides. They are projected with the help of an overhead projectorTransparencies are meant specially for group situation. It can be easily prepared within a short timeTransparencies are of particular value in a classroom, seminars, and symposium, etc., where a group of people has to discuss a technical subject.

Television

This is a combination of wireless and cinema. TV is widely used in schools, airports, railway stationsexhibitions, etc. The advantages of TV are many. Many topics can be projected and can be conveyedIt can provide entertainment as well as educational materials. It can cater to all groups. Disadvantagesare the cost and accessibility. Electricity is required.

2. GRAPHIC OR PICTURESQUE AIDS

These aids essentially consist of drawings, sketches, cartoons, pictures, etc., and also graphs, chart,tables, etc. They are shown or displayed as such and do not necessarily depend on any projectedequipment.

Picture

The picture is drawn or painted and is the expression of ideas and feelings. A picture is drawnaccording to the perception of the mind.

Photograph

A photograph is the actual image of any object or person, taken by the application of the principle oflight devised in a photographic camera.

Poster

Poster is a picture with a message or caption or slogan written not only to explain but also to catch theattention of the passersby. Occasionally posters may have mere written matter and no picture ordrawing.Posters are generally used for mass education and are displayed in prominent places where peoplemove about in large numbers. Posters are also displayed in exhibitions.

To make a good poster the following points should be remembered:1. It size should be large enough to draw attention to the public from near and far.2. The message in the poster should be able to stimulate the thinking of the audience.3. Always put one single idea for each poster and not to bring in a number of ideas in the same

poster and make it unintelligible.4. The subject matter should be as short as possible, so as to fix and hold the attention of the

people.5. The letters and designs should be bold and big enough to seen from a distance.6. The lay out of the picture must be properly balanced to give a correct sense of proportion and




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inter-relationship between pictures.Posters are widely used in public places to catch and fix the attention of the public. They are cheap andcan be taken to distant places. But posters can also become monotonous and stale if not changedfrequently; moreover, because they are stuck up or displayed in public places they may be damagedeasily.

Cartoon

It is a design or sketch on paper or cloth usually of the nature of a caricature illustrating and makingfun of topical events. Cartoons are generally made in newspapers or magazines to give satirical or jocular commentary on any events.

Flash cards

A set of pictures with suitable captions or write-ups is prepared on any theme. Each one will represena particular idea, and the cards are arranged in proper sequence so as to send out the message to theaudience. The flash cards can be used by any educator and shown to the audience with necessaryverbal explanation.

Charts & Graphs

Chart is used to present numerical data as well as materials in abstract form. Graph is a chart form thatis used to present statistical data and present the relationship between variables. Charts and graphs areuseful to summarize, explain and interpret numerical facts by means of points, lines, areas, geometricforms and to facilitate comparison of values, trends, and relationships.

Charts are more effective in creating interest and eliciting the attention of readers. They help inunderstanding the meaning of the mass statistical data, which are visualized at a glance. The visualrelationships as portrayed by charts and graphs are more clearly grasped and can be easily remembered.

Map

Map is an accurate representation in the form of a diagram of the surface of the earth or of some partsof it, drawn to a scale.

Printed materials: books, pamphlets, booklets, brochures

Leaflets, folders, brochure; booklet and pamphletsA pamphlet is also called a brochure or booklet. Single sheet with one or more folds is often spoken ofas pamphlets. They are folders of leaflets. An unfolded sheet is a leaflet file or handbill.

A pamphlet must as brief as possible.

Display boards: Flannel Board, Bulletin (notice) Board, and ChalkBoard

3. THREE DIMENSIONAL AIDS

Here the actual specimen, objects, models, etc. are put up for demonstration. Models are prepared toimitate the actual objects or specimens. Diorama is a model with background and other objects in theenvironment, which give a three dimensional effect. It is prepared on cardboard or suitable materials insuch a way that the objects can be projected out for display and put back and folded when not in use.




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4. AUDIO AIDS

The common ones in use are megaphone, microphone or public address system; gramophone recordsand discs; tape recorder and the radio.

These serve very well to reproduce spoken words or any kind of noises made and help in repeating thesame a number of times. They are very useful in teaching and also for entertainment and masscommunication.

5. AUDIO-VISUAL AIDS

A combination of visual and auditory stimuli for communication can be more effective than eithervisual or auditory alone because of the involvement of two sensory organs.

6. OTHER AIDS: Folk songs, folk dances, drama, puppet show, puppet stage, puppet plays

These folk media are used to introduce sociological themes.

G. Counseling (Health Education with individuals)

1. PURPOSE OF COUNSELLING

Through counseling, an individual is encouraged to think about his problems and thus comes to agreater understanding of their causes. From this understanding that person will hopefully omit himselfto taking action that will solve the problems. The kink of action that a person takes, will also be that person's own decision although guided, if necessary, by the counselor.

Counseling means choice, not force, not advice. A health worker may think that his advice seemsreasonable, but it may not be appropriate to the situation in which the individual lives. Throughcounseling, the solutions are more likely to be appropriate. An appropriate solution will be one that the

person can follow with successful results.

2. RULES FOR COUNSELLING

The health worker in this example had obviously not learned the techniques of counseling, otherwisehe would have followed the simple rules below:

Relationships: A counselor shows concern and a caring attitude. He pays attention to building a goodrelationship with the person he is trying to help from the beginning. People are more likely to talkabout their problems with someone they trust.

Identifying needs: A counselor seeks to understand a problem as the person sees it himself. The people must identify their own problems for them. The use of opencomments will help here (see page 120). The counselor’s task is to listen carefully.

Feelings: The counselor develops empathy (understanding and acceptance) for a person's feelings, notsympathy (sorrow or pity). A counselor would never say, "you should not worry so much about that." people naturally have worries and fears about their problems. A good counselor helps people to become aware of their feelings and to cope with them.

Participation; A counselor never tries to persuade a person to accept his advice. If the advice turns




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out to be wrong, the person will be angry and no longer trust the counselor. If the advice is right, the person may become dependent on the counselor for solving all his problems.

A Counselor helps a person to think about all the things affecting the problem, and encourages him tochoose the solutions, which are the best for his particular situation.

Keeping secret: A counselor will hear many personal and possibly embarrassing problems. Thisinformation must be kept secret from all other people, even from the person's relatives. If someone youare counseling discovers that you have told other people about the counseling session, that person wilno longer trust you and will avoid you. A person may even get into trouble because of what thecounselor told others. A counselor always respects the privacy of the people he is helping. He neverreveals information unless he has been given specific permission.Information and resources: Although a counselor does not give advice, he should share informationand resource ideas which the person needs to have to make a resource ideas which the person needs tohave to make a sound decision. For example, many people do not realize the connection between their behavior and their health. A counselor does not lecture, but he should provide simple facts during thediscussion to help people have a clearer view of their problem.

All health or community workers can practice a counseling approach in their work. Parents and friends

can be counselors too. The important thing is friends can be counselors too. The important thing is thatthe health worker, teacher, father or friend be willing to listen carefully and encourage the person inneed of advice to take as much responsibility as possible for solving his or her own problem.

Now that you have read about the rules for counseling, think again about the mother's problems? Howcould the other relatives in the house have been involved? Can you think of possible alternativesolutions to the problem?

3. DIFFERENT TYPES OF COUNSELLING

Counseling with families

A person may need the help of his family to solve a problem. Counseling skills are useful whetherworking with one person or a whole family. When working with a family, we are dealing withMore than one person, therefore there may be more than one problem, more than one need and surlymore than one solution.

Also be aware that in families different people have different responsibilities and powers. The father,for example, may be the main decider on the types of food eaten. Grandparents influence the degree towhich families follow traditional customs. Find and talk to the right person for each problem. Alsoshow respect to the recognized head of the household.

Counseling with children

In a clinic, school or the community, you will find children with health, emotional or other problemsCounseling can be provided for them if they are old enough to talk.

It is better, to talk to the child alone. Background information can be obtained from the parents firstthen they can be politely asked to wait outside. Sometimes parents want to answer all the questions;they do not allow the child to speak for himself. The child may also fear saying certain things in frontof his parents. The counselor should explain to the parents that the child might speak more freelywithout others around.




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Begin by talking about happy things. Ask the child about his favorite games, for example. Once thechild is relaxed, begin talking about his problem. Let the child know that all he says will be kept secret.In this way he will trust you and speak freely. Always keep that promise. If parents, teachers, or othersfind out what the child said, he will fear the counselor and will never let him help again.

Follow the counseling rules with a child as you would with an adult. The child will be able to learnmuch about his health from a good counselor.

Home visits

Counseling can be done in the clinic or at school, but it is also helpful to visit the person at home. Ahealth worker should visit all homes in his community regularly. If the village is small, with 10-25houses, visits can be made at least once a fortnight. In larger villages or neighborhoods visits can bemade monthly.

Here are some reasons for home visits:- Keeping a good relationship with people and families;- Encouraging prevention of common diseases;- Detecting and improving troublesome situations early, before they become big problems;

- Checking on the progress of a sick person, or on progress towards solving other problems;- Educating the family on how to help a sick person;- Informing people about important community events in which their participation is needed.

Much can be learned from home visits. We can see how the environment and the family situation mightaffect a person's behavior. Does the family have resources such as a well? What relatives stay in thehouse? Do they help or hinder the person's progress?

When people are in their own home they usually feel happier and more secure. We often find that people are more willing to talk in their own home than when they are at the clinic. At the clinic theymay fear that other people will see them or overhear the discussion. They may tell more at home

because they feel safer there. Nutrition demonstrations, for example, may be more useful if done in a person's home. There thehealth worker will be able to use the exact materials and facilities that the person must use. This willmake the demonstration more realistic and make learning easier.

4. Education methods used in counseling

There are various education methods that can be used to help individuals and families solve their problems some help people understand the cause of their problem. Some help them see possiblesolutions, while other methods help them reach decisions for action.We have seen in chapters 1 and 3 how important it is for us to place ourselves in the position of other persons and understand why they behave as they do. But people themselves are not always aware oftheir motivations, or why there is a problem. Our role therefore is, first, to understand the problem andthen, to help the people understand it themselves and to find the solutions that are appropriate for theirsituations.

Sometimes a person may be reluctant to take the necessary action to solve his problem. He may not feelthat it is worth the time and effort. Encourage him to examine his values in order to take some decisionabout the importance to be placed on his health and welfare.

Another way to help people decide to act is the use of self-reward. People should decide on a reward




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that they will give themselves if they follow through with the necessary action.

It is important to help the people choose solutions that will fit in with their way of doing things, andwith their beliefs. Try to help people avoid solutions that are uncomfortable. Find workablealternatives.

Always remember that counseling calls essentially for a personal approach and for skills in listening, in providing information, and in helping people determine what is best for them.

H. HEALTH EDUCATION WITH GROUPS

THE VALUE OF GROUP EDUCATION

Using the group approach to educate people has a number of advantages.

1. It provides support and encouragement. Keeping to a healthy behavior is not always easy. In agroup one can find the support and encouragement needed to promote healthy actions and tomaintain them.

2. It enables the sharing of experiences and skills. People learn from each other. A member mayhave tried a new idea and found it successful. Through that experience he gained skills whichhe can teach to other group members.

3. It makes it possible to pool resources. Group members can pool their resources. One farmermay not have enough money to buy a vehicle to transport his produce to market, but a group offarmers together could contribute enough money to meet that need. Members of a group cangive money, labor or materials to one of their members in times of personal or family crisisThey can also give support to the promotion of community health through projects such as safewater supply.

In summary, because some problems are difficult to solve by individuals alone, a group approach tohealth education is important. EDUCATION WITH INFORMAL GROUPS

The first thing when dealing with an informal group is to find out what the common interests and needsof its members may be. Women who attend market for example are concerned about good quality foodat reasonable prices. Health education with informal groups should be based on common interestswhatever these may be. A topic related to the interests of the women attending market might be"preparing inexpensive but nutritious meals."

As you often do not know who belongs to informal groups, you may have to find out their needsthrough indirect means such as clinic records. That is what was done in the sample program, which wewill describe.

Another concern in educating informal groups is that not all the members may know each other verywell. You will have to develop relationships and encourage participation. Try to make people in thegroup feel welcome. Point out their common interests and needs.

EDUCATION WITH FORMAL GROUPS




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It is possible to plan a greater number and variety of educational programs with formal groups. This is because formal groups have definite purposes and interests, specific leaders who can mobilize e thegroup, and commitments to meet regularly and carry out action. Since the members are known, it is possible to gain more participation from them in the planning and varying out of a program.

Health Education with Communities

Community health education is needed when a problem affects many or all people in the communityand when the cooperation of everyone is required to solve the problem. How can you develop healtheducation at community level? There are two points to keep in mind:

1. One should get the support of influential people in the community, those who are called"opinion leaders" or "key persons",

2. One should get a maximum number of people involved so that the community will reallystrengthen its capacity to do things for its health. This can be done through local communityorganizations, community health committees, interpersonal coordination groups, advisory or planning boards, etc.

Before starting a new structure - be it a health committee, an advisory board, local association or council to facilitate inter-sectoral coordination - investigate carefully the structures that alreadyexist in the community and see if they could serve for the purpose you envisage. It is oftentempting to create a new group but it may be wiser to extend an organization that has proven itsworth.

ORGANIZING A HEALTH CAMPAIGN

Campaigns can be planned to promote health knowledge, skills, attitudes and values on a particularhealth issue. They may also be used to accomplish a particular community improvement project.A health campaign is organized around one issue or problem. The campaign is said to have them participated. Examples are "Clean up the community", "Immunize your child", Good Food for HealthyBodies", "Clean water for Good Health".

The theme should be based on a real problem that has been identified by the community membersthemselves or is recognized as such. If there were a health committee in the community, it would beactive in identifying issues for such campaigns and planning the action to be taken.

The actual community activities of a campaign often take place during only one week or one month,

For this reason, campaigns are often called "Health weeks".

SPECIAL COMMUNITY EVENTS

Every community has festivals, celebrations and ceremonies. These may mark special seasons of theyear ceremonies. These may mark special seasons of the year such as harvest time, the planting seasonand the New Year. Some festivals are religious or political, others in remembrance of national eventsand heroes. There are usually many such events throughout the year.

Some festivals are a time for enjoyment and relaxation. Others call for serious thinking and quiet




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devotion. Whatever the purpose of the festival may be, the whole community usually participates.

I. Barriers of communication

The reasons for failures of HE programs can be separated into four overlapping groups, which aredescribed in detail below.

A. FAILURES IN THE PLANNING PROCESS TO APPLY EPIDEMIOLOGICAL ANDBEHAVIORAL SCIENCES TO THE SELECTION OF APPROPRIATE OBJECTIVES

1. Insufficient understanding of epidemiology so that the behaviors selected for the objectives ofhealth education is not linked to the disease in question.

2. Choosing inappropriate behavior objectives that are unrealistic for the community to change because of economic, social or cultural barriers and are low priority compared with other feltneeds.

3. Over-emphasis on behavior change as the path to good health without accompanying economicand social development, which tackles poverty and social inequalities.

4. Failure to ensure that all the required enabling factors is provided, e.g., adequate moneyresources, time and appropriate and accessible services.5. Health education programs in mother and child health which fail to take into account the

already heavy workload of the women in the home and agriculture.6. Putting the emphasis on traditional beliefs as the cause of a health problem without looking for

other possible explanations.7. Directing health education at the individual without taking into account the influence at the

family, community and national levels, e.g., pressure of other people, availability of servicesgovernment policies, unemployment, etc.

8. Ignoring influences at the national level, e.g., commercial advertising, powerful pressuregroups, government policies, etc.

9. Failure to carry out even simple research ("community diagnosis") on how the community viewtheir problems, the role of beliefs, pressure from others, and economic and social factors.10. Failure to develop community participation in the health education planning process.

B. COMMUNICATION FAILURE IN REACHING THE INTENDED AUDIENCE AND

PROMOTING UNDERSTANDING AND ACCEPTANCE OF MESSAGES

1. Using HE methods and channels of communication that only reach the better off and well-educated people and fail to reach those whose health is the poorest: the poor, mainly rural, loweducational level, low utilizers of health facilities.

2. HE messages not understood because of difficult and unfamiliar concepts, language, complexwording and confusing pictures.

3. Cultural and social distance between the health educator and the community resulting in poorlydesigned communications, which take little account of the way ordinary people, think and talk.

4. Use of HE materials produced abroad or from the national headquarters, which may not beappropriate for the local community.

5. Failure to test HE messages to see if they are correctly understood and will promote change.6. Over-emphasis on the "hardware" of communication, e.g., slides, films, leaflets, and visual aids

rather than the building up of understanding, empathy and trust between the health worker andthe community.

7.7. Too much emphasis on mass media such as radio. While efficient at promoting knowledge and




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awareness, mass media are poor at promoting behavior change compared with community level programs involving fact-to-face communication.

8. Ignoring the traditional methods of communication such as story telling, songs, and dramawhich may be a familiar part of the culture of the community and are both popular andunderstood.

9. Low credibility and respect of the health educator in the eyes of the community due to factorssuch as age, sex, training, personal behavior and perceived irrelevance of advice.

10. Too much reliance on formal teaching method such as lectures, and talks rather than those inwhich the learner actively participates and feedback and discussion are encouraged, e.g., groupdiscussions, problem-solving exercises and role plays.

C. FAILURE IN THE ORGANIZATION OF HEALTH EDUCATION SERVICES ANDTHE WEAK STATUS OF THE SPECIALIST HEALTH EDUCATOR

1. Lack of a clear government commitment and national policy for HE. Low priority for HE inhealth services compared to curative medicine.

2. Poor understanding of the role and importance of HE and prevention on the part of politiciansand the public.

3. Failure to develop the HE potential of different agencies outside the health services, e.g.

schools, community development, agriculture, adult education, radio and television services.4. Uncoordinated, conflicting and sometimes inaccurate advice on health from different fieldworkers and agencies.

5. HE is left to a small group of "HE specialists" only. Other health workers, teachers, etc., saythat it is not their job.

6. The weak position of the HE specialist e.g., low status, lack of training, low power, poor careerand promotion opportunities.

7. Frustration of the health educator because of isolation and lack of understandingencouragement, support and practical help from others, including national health educationservices.

8. The overall responsibility for health education in health services and the key decisions on the

content of HE programs are in the charge of medical personnel with little training in the behavioral sciences and communication.

D. FAILURE IN THE EVALUATION PROCESS AND THE DISSEMINATION OFRESEARCH INTO DECISION MAKING

1. Failure to evaluate even at a simple level.2. Evaluation based only on measurement of effort and activity and not impact and change in the

community.3. Failure to produce evidences that HE is effective and deserves funding.4. Reluctance to carry out evaluation of failures to determine the exact causes of failure and learn

from them.5. Demonstrating that change has taken place but providing no evidence that change has been the

result of the HE programs and not other factors.6. Insufficient description of programs making it difficult for others to assess special features of

programs and community that affect success and replicability.7. Not sharing with other health educators the evaluations of success or failure.8. Lack of opportunities, e.g., a magazine or regular meeting places where heath educators can

exchange experiences on their work and discuss wider issues on the organization and support ofHE activities.

9. Narrowly conceived concepts of research and evaluation, which allow no opportunity for participation of health workers and community in the evaluation process.




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IV. EDUCATION AND

EDUCATIONAL METHODS

Education is the basis of all learning. Learning is a totality of change of behavior through acquisitionof knowledge. A subtle difference between education and learning is that the learning can be passiveor incidental; whereas education is a deliberate effort. It is implied that education includes learning because when the process of education starts, learning also takes place; whereas learning can be purelyincidental sometimes merely due to circumstances and not through a definite effort to learn.

Both learning and education can take place through a teacher or instructor or by the individual self-alone. Learning is a process by which the individual acquires information and ideas, which may laterresult in change of attitude and behavior. Learning is the basis of behavior. Education is the process bywhich learning is facilitated. Or education is the process in which an individual or individuals or groupof people are given the facilities or opportunities by an agent or educator to learn. There can also bethe self-learning process or self-education.

With regard to HE the target group or audience will vary from situation to situation. The variation will be according to sex, age, literacy, caste, economic status, occupational status, health status, residentialstatus, location (hospital and community), etc. The educator must use his judgment and discretion to

choose a proper educational method and also proper aids, media, etc., to enable the group or individualto learn and benefit out of the experience.

EDUCATIONAL METHODS

a. FORMAL PRESENTATION METHODS

1. Lecture or speech

It is an oral presentation. The speaker has to be conversant with the subject. He has to organize his

thoughts and ideas. It is a simple and quick traditional way of presenting the materials. Lecturer orspeaker can prepare the talk in a logical fashion and can talk uninterruptedly. Nobody can normallyinterrupt or intervene. Nowadays lectures are supported by suitable visual aids.

As far as the audience is concerned lecture has advantages as well as disadvantages. They have to be passive listeners. So there is no need to read. They can take notes if they want. But if the speaker isnot impressive and effective the listeners will get bored, sleepy, distracted and so on. Since the speakeris would not like to be interrupted a good feedback is somewhat difficult.The lecture method is more advantageous to a mature group than to an immature group. The lecturemethod may prove ineffective if:

a. The speaker wanders from the subject; b. The speaker does not talk with proper introduction; emphasis, etc.,c. The speaker talks in a high flown language not understandable by the audience; andd. The speaker distorts facts for selfish purposes.

2. Dialogue

Instead of a single lecture, two persons with expertise carry out a discussion or dialogue betweenthemselves in front of the audience for the purpose of educating them. The dialogue as an educationamethod is easy to arrange and carry out. Since two persons take responsibilities there is likelihood ofgreater interest generated. However, care should be taken to see that the discussion does not deviate




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from the subject. Dialogue is also applicable to a more matured group.

3. Symposium

This is a lecture in one form but the difference is that different speakers are asked to give a lecture onthe same subject. The speakers prepare the talk in such a manner that each one of them presents a particular aspect of the subject. Ultimately the audience gets the benefit of the understanding of thesubject with its different aspects dealt separately by each speaker.

The symposium is of special use and relevance in any subject where a number of experts are availableto take up different issues and view points and thrash them out. Because of the variety of speakers thesymposium is more interesting than the lecture by one person alone.

The symposium does not allow or give any scope for audience participation and feedback. Symposiumis of particular application to a mature group who has the listening attitude and the capacity toappreciate the different aspects of the subject by listening. Needless to say expert members must beavailable to make symposium impressive and effective.

4. Panel discussion

In this educational method a small group of persons get around the table in the presence of the audienceand discuss among themselves the topic or subject which is relevant to the audience and in which the panel members have specialized knowledge. It is a to and from discussion among the panel membersto touch on all aspects of the topic and the audience appreciates the same by listening.

In a panel discussion also there is no scope for the audience to participate. However, if there is anarrangement by which the audience can be allowed to throw questions or comments towards the endthen it becomes panel discussion forum.

5. Colloquy

In this method a few members from the audience are made to stimulate discussion by presenting the problems or raising questions to a group of experts on the stage and the experts give their commentsand answers on the various aspects. A colloquy is especially useful when there are specific problems to be discussed for solution. One of the experts acts as a moderator and conducts the discussion. Theeffectiveness of the colloquy will depend on the efficiency of the moderator.

The advantage of colloquy is the direct audience representation and participation. It providesopportunities to extract information from experts. If the problems were controversial in nature theexperts would be able to pinpoint the solutions within the available time for discussion.

6. Forum

In the formal stage setting of lecture, symposium or panel, if it is desired to give opportunity to theaudience to participate by raising questions, doubts, etc., the forum is arranged for at the end of the panel discussion, symposium or lecture. It is otherwise question time for the audience. It is a goodfeedback mechanism.

b. GROUP DISCUSSIONS




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Among the "discussion-methods", group discussion is the most commonly employed method. It is avaluable educational method because the participants are given equal chance to express freely andexchange ideas. It is a collective thinking process to solve problems. Problems are also identifiedcollectively and the solution is worked out by pooling ideas and expertise. Group discussions have been found extremely useful because of the commonness of goal and collective planning andimplementation.

The group discussions can be formal and informal. In classroom situations and in the academicclimate, group discussion tends to be formal. The extension educator working in a community has ascope to organize both formal and informal group discussions.

There are specified types of groups, which have been evolved, and these are:

1. Buzz group or Buzz session

A large group is divided into small groups, or not more than 10 or 12 people in each small group andthey are given time to discuss a problem. The different groups are either allotted different specific problems or the same problem is allotted for all. The whole group is reconvened and the reports of the

large group will report their findings and recommendations. In the plenary session final documentationwill be made (This is very similar to a workshop).

2. Workshop

A large number of people belonging to a particular or discipline or allied disciplines collect together totake up specific issues and problems for making recommendation for future action. The methodologyof working is very similar to Buzz session but the workshop generally extends for the period of fewdays (usually a week's time). Moreover, experts, advisors, and speakers are employed to guide thegroup. In the buzz session there are no advisors except the guide of the entire group.

The workshop is a meeting of people to work together in small groups upon problems which are ofconcern to them and relevant to them in their own spheres of activity and to find suitable solutions.Therefore, it is a problem solving method.

Workshop is mostly applicable for people with previous experience on subjects and is more relevant todepartments and institutions, etc., than in community groups. Workshops help in evolving policies programs and methodologies.

3. Conference or Seminar

These are large groups convened amongst persons with common or allied discipline and interests. Thetechnique for the discussion may be around a big table or panel discussion, symposium, etc. Theconference can also be converted to a workshop if required. Seminars are generally with reference tolearning or academic institutions. The members or participants of the seminar come together toexchange views on current problems or to share with others their own experiences and new encounter,experiments, discoveries, etc.

The purpose of a seminar is to study the subject matter, by a group of persons under the leadership ofexperts in the field. Seminars very frequently are associated with research.

Another type of seminar is the so-called convention. This is with reference to the particularorganization or departments where groups from different administrative hierarchy come together to




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discuss about policy and ideas for strengthening the parent organization. Conventions are also spokenin connection with political and religious movements. They are merely conferences.

4. Brain storming

This is a modern method of eliciting from the participants their ideas and solution on debatable issuesor current problems. Instead of discussing a problem at great length the participants in brain stormingsessions are encouraged to make a list in a short period of time all the ideas that come to their mindregarding some problems without debating amongst themselves about the pros and cons of their ownideas.

All the ideas are pooled and ranked according to the number of times that they think have beensuggested by different individuals. Since the participants are allowed to think freely in sending theirideas in writing brain storming is also called ideation or image.

5. Role playing

Another educational method, which has gained importance and popularity particularly where skillshave to be demonstrated, is the role-playing. It is also known as Psychodrama. It is acting out of a

situation with natural ease and without any artificiality. Role play can be done by one individual or asmall group of people can stage a role play to bring out the actual way of behavior expected fromdifferent persons with different responsibilities. It generally lasts for a very short time. It isspontaneous in nature, and part of the overall teaching method. It should not be mistaken with dramaor play where the actors have specially practiced for the audience.

6. Demonstration

There are two educational methods of demonstration. One is called method demonstration and theother is called result demonstration. In the former the demonstrator demonstrates the actual process ofdoing a particular activity. In the later, the ultimate results or any useful procedure are shown to the

trainees. In between there can also be a method of learning by doing. To start with the teacher candemonstrate a method and later the learner or trainee can practice this method and appreciate for selfthe results.

Some method or result demonstration has got a special value in extension educator or communityeducation for introduction of innovative ideas and practice. Both the methods of demonstration of procedure and results help the learner not only to learn how things can be done but also to feel assuredor convinced about the result. The demonstration method or technique can be of great support tolecture or group discussion.




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V. HEALTH BEHAVIOUR MODELS

Why Modeling?

• Too many determinants and factors

• Factors / determinants differ by various characteristics – disease entity, demographic variabilityenvironmental context, etc.Modeling: Attempt to propose a working set of determinants which are thought to be the mostimportant factors or determinants affecting behaviors.Mitike 1: slides 2-14Various theories and models have been formulated and tested which are used to understand and predicthealth related human behavior. These theories attempt to analyze why people practice certain health behaviors. In other words, it is very important to know what kinds of activities encourage learning and behavior change. A number of theories of health education have been proposed, where each attemptsto identify what skills or knowledge must be learned and how they are best learned and performed.Some of such theories and models are discussed in detail in this chapter.

1. HEALTH BELIEF MODEL - ROSENSTOCK 1990

The most highly influential and widely researched theory of why people practice health behavior is thehealth belief model. The health belief model of Rosenstock (1990) and Backer (Janz & Backer, 1984)emphasize the intellectual dimension of health behavior. Recently it has added the psychologicadimension of Social Learning Theory (Bandura; Rotter), and we might also add the socialdimension from the Theory of Reasoned Action (Ajzen, 1988). The theory identifies the followingknowledge as relevant:

1. Perceived threat is made up of the perception that one is susceptible to the illness (i.e.,personal risk ) and the perception that the illness is serious. If these two perceptions are highthen the perceived threat is high, and one will be driven to act to avoid the threat. That is cuefor action is triggered by an individual's perception or by reading about health matters. The

perception of personal health threat is influenced by at least three factors: general healthvalues, which include interest and concern about health; specific beliefs about vulnerability toa particular disorder; and beliefs about the consequences of the disorder (i.e., whether or notthey are serious. Thus for example, a person may change his diet to include low-cholesterofoods if he values health, feels threatened by the possibility of heart disease, and perceives thatthe threat of heart disease is severe.

2. Outcome expectations are made up of the perceived benefits of the specified action (e.g.effective, inexpensive) minus the perceived barriers to the action (e.g., costly, timeconsuming). If the outcome expectations are high, they will specify exactly what action istaken. Behavior is evaluated from an estimate of the potential benefits of health seeking actionto reduce susceptibility or severity. The benefits are then weighed against perceptions of physical, psychological, financial and other costs of barriers inherent in the health-findingeffort. Demographic, social, structural and personality factors are included in some versions ofthe model as modifying factors since in theory they indirectly influence actual behavior. Forexample, the man who feels vulnerable to a heart attack and is considering changing his dietmay believe that dietary change alone would not reduce the risk of a heart attack and thatchanging his diet would interfere with his enjoyment of life too much to justify taking actionThus, although his belief in his personal vulnerability to heart disease may be great, his faiththat a change of diet would reduce his risk is low and he would probably not make any changes

3. Self-Efficacy is confidence that one has the skill and resources to perform the specified




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action. This comes from Bandura's social learning theory. If one has self-efficacy, one can perform the action with confidence and pride, though not necessarily with skill or expertisePractice enhances self-efficacy.

4. Subjective norm refers to one's perception that significant other people will approve of theaction. This comes from Fishbein and Ajzen's (1988) Theory of Reasoned Action. If you thinkthat most of the important people you know and live with will approve of the action, you arelikely to do it.

The theory does not specifically say how to learn or strengthen these ideas, other than throughcommunication where the message addresses perceptions of risk, benefits, confidence, and norms.

A large number of studies suggest that the health belief model explains people's practice of healthhabits well (for reviews, see Janz & Becker, 1984; Kirscht, 1983). For example, the health beliefmodel helps to predict who will make use of free health examinations, yearly medical checkups,vaccines, and disease specific screening programs. Participants in these disease-prevention programswere more likely to value their health highly, feel susceptible to the particular disorder in question, believe in the power of modern medicine to cure disease if detected early, and believe in the

importance of medical research. The health belief model has also been applied to participation in fluimmunization programs, preventive dental checkups, genetic screening, breast self-examination anddieting for obesity, among many others. Typically, results indicate that health beliefs are a modestdeterminant on intentions to practice these health measures.

Janz & Becker (1984) examined 46 studies using the health belief model to identify which components best predict the practice of health behaviors. Overall, perceived barriers to the practice of the health behavior was the most powerful dimension influencing whether or not people actually practiced a particular health behavior. Perceived susceptibility to a health problem was also a strong contributorSome components of the model predicted sick role (such as taking care of oneself or seeking medicalattention), but did not predict health behaviors very well. In particular, perceived benefits of a practice

and perceived severity of the problem were both associated with sick role behavior, but these factorswere less important in explaining preventive health behavior, such as not smoking or weight control.

Not all research supports the health belief model, however. One of the problems that has plagued testsof the health belief model is that different questions are used in different studies to tap the same beliefs;consequently, it is difficult both to design appropriate tests of the model and to compare results acrossstudies. Another reason why research does not always support this model is that factors other thanhealth beliefs also heavily influence the practice of health behaviors. These factors include socialinfluences, cultural factors, experience with a particular health behavior or symptoms, an socio-economic status (SES).

The health belief model appears to predict health behaviors best when other demographic factors, suchas SES and education, have already been considered.

2. APPLIED BEHAVIOUR ANALYSIS - HEALTHCOM Group (Graeff, Elder & Booth1993)

This comes from operant learning theory. The analysis emphasizes behavior itself rather than perceptions or knowledge. A behavior analysis scale is provided to identify what health behaviorshould be changed. Criteria for choosing the target behavior include: high impact on health, observableconsequences of behavior, compatible with existing practices, behavior not too complex or costly or




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lengthy. The theory specifies that learning and behavior change take place as a result of reinforcingfeedback from the behavior. The consequences of an action determine whether it will be performed ornot. Positive consequences such as good health and approval ensure that the behavior will be performed. Consequences of the behavior most effectively strengthening it when they immediatelyfollow it are salient and relevant to the person. They need to be concrete but not necessarily materialPraise and social recognition from one's family, the school, health workers, and community leaders arevery effective. So is a certificate of merit, a symbol on one's house, a bar of soap, and a Litre cupThere are few natural consequences to preventive health behaviors other than the absence of diseaseFor example, child immunization leads to the absence of child diseases for the following 5 or 10 yearsThis is not observable. Without sophisticated knowledge of the cause-effect relation betweenimmunization and disease prevention, a mother would be unaware of the important consequences ofimmunizing her child. For this reason, planned artificial consequences must be given during the healtheducation project and then gradually substituted with other positive consequences that help maintainthe behavior. Although the theory deals mostly with behavior and its consequences, the antecedents of behavior must also be examined. Antecedents are things that trigger action; they do not force theaction to happen but they inform the person that an action is required. Examples are: seeing a healthworker demonstrate making ORS, seeing a handbill that pictures the substances and quantities formaking ORS, seeing the ARI or diarrhea symptoms of a child, talking about child spacing with one'sspouse, seeing a pictorial reminder on one's wall of the next immunization session, recalling what one

learned about weaning foods for one's infant, and deciding to dig a latrine. According to this theoryhealth education activities must encourage learning and performance of health behaviors by arrangingantecedents and consequences of the behaviors. It is called the A-B-C chain: antecedents, behaviorand consequences.

In summary

Antecedents: stimulate actionBehavior: skill and performanceConsequences: strengthen behavior

3. THEORY OF REASONED ACTION - FISCHBEIN & AJZEN (1977 - 1980)Another cognitive theory that attempts to integrate attitudinal and behavioral factors is Fishbein andAjzen’s Theory of Reasoned Action. According to this theory, a health behavior is a direct result of a behavioral intention - i.e., of whether or not one intends to perform a health behavior. Behavioralintentions are made up of two components: attitudes towards the action and subjective norms aboutthe appropriateness of the action.

Attitudes toward the action are based on beliefs about the likely outcomes of the action and evaluationsof those outcomes. Subjective norms derive from what one believes others think one should do(normative beliefs) and motivation to comply with those normative references. These factors combineto produce a behavioral intention and, ultimately, behavior change. To take an example, a smoker who believes that smoking causes serious health outcomes, who believes that other people think he or sheshould stop smoking, and who is motivated to comply with those normative beliefs will be more likelyto intend to stop smoking than an individual who does not have these attitudes and normative beliefs.

What is the value of thinking about health habits from the standpoint of this theory? A strong elementof this approach is that behavioral intentions are measured at a very specific rather than a general level.That is, when people are asked about very specific attitudes and normative beliefs, it is possible toobtain a fine-grained picture of their intentions with respect to a particular health habit.

Changes in behavior are seen first in individual beliefs, attitudes, and norms. Behavioral intention is




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pivotal, as a necessary but not sufficient immediate cause of behavior. As with the health belief modeldemography, personality and other social psychological variables are expected to influence intentiononly through the other components of the model. Fishbein/Ajzen is almost entirely rational and doesnot provide explicitly for emotional fear-arousal elements such as perceived susceptibility to illness.

By defining attitude and organizing other variables as causal processes that affect behavior in anattitude-behavior relationship, this model has strongly influenced attitude-behavior research in the pastdecade. Numerous applications of it to health related concerns include family planning, substanceabuse, weight loss, exercise, patient satisfaction, immunization, hypertension and use of child safetyrestraint devices.

Field studies found that behavioral intention often does predict behavior, particularly when the timeframe is short and the intent is clearly specified. From this and it seems that intention is a better predictor of behavior than attitude, but attitude's effect on behavior is not completely mediated byintent, perhaps because intention is less stable in a longer time frame. Behavioral intention takes intoaccount barriers and other `moderating variables' to the extent that the respondent is aware of them.Also, the more specifically attitudes and behavior are defined, the stronger the correspondence betweenthem, e.g., general attitudes toward birth control are weaker predictors of intent and behavior thanattitudes toward using birth control pills. The advantages of this specific assessment can be seen in

considering a college student's attitudes and practice regarding birth control. She might be favorabletowards birth control in general and have a general intention to practice contraception. At the sametime, however, she might be highly resistant to certain specific methods of birth control that areavailable to her. For example, she might be fearful of using birth control pills because of potential sideeffects, and she may not wish to use a barrier method, such as condoms, because she values spontaneityin her sexual relationships. Consequently, a general assessment of her intention to practice birthcontrol would suggest that she might engage in these behaviors, whereas, the specific assessment of herintention to use particular methods would highlight the sources of resistance to these specific methodsof making good on that general intention.

4. THEORY OF PLANNED BEHAVIOUR (TPB)

Recently, Ajzen his associates (Ajzen, 1985; Ajzen & Maden, 1986) undertook a revision of theFishbein and Ajzen's theory, which they called the Theory of Planned Behavior (TPB). They arguethat in addition to knowing a person's attitudes, subjective norms, and behavioral intentions withrespect to a given behavior, one needs to know his or her perceived behavioral control over thataction. In a test of the revised model, they found that people need not only hold a behavioral intentiontoward a particular attitude object but also feel that they are capable of performing the actioncontemplated and that the action undertaken will have the intended effect. Thus, feelings of perceivedcontrol and self-efficacy also appear to be important in demonstrating attitude-behavior consistency;even when there is a clear behavioral intention to act on the attitude.

The theory of reasoned action as originally formulated applies well to behaviors that are under personalcontrol. However, if a behavior is influenced by factors over which people have only limited controlthen their perceived self-efficacy, or ability to carry out the recommendations, becomes an important predictive factor. The TPB, then, adds this additional element to cover behaviors that may be only partially under personal control.

In summary, the TPB maintains that people will perform a health behavior if they believe that theadvantages of success outweigh the disadvantages of failure, if they believe that other people withwhom they are motivated to comply think they should perform the behavior and if they have sufficientcontrol over internal and external factors (Locus of Control) that influence the attainment of the




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behavioral goal. (Transparency: from 2, page 72)

5. HEALTH PROMOTION PLANNING MATRIX - PRECEDE-PROCEED MODEL

Health Promotion Programs operate either at primary (hygiene and health enhancement), secondary(early detection) or tertiary (therapeutic) stages of prevention, it may accurately be seen as anintervention whose purpose is to short-circuit illness or enhance quality of life through change ordevelopment of health related behavior and conditions of living. The PRECEDE framework( predisposing, r einforcing and enabling constructs in educational / environmental d iagnosis andevaluation) takes into account the multiple factors that shape health status and helps the planner arriveat a highly focused subset of those factors as targets for intervention. PRECEDE also generatesspecific objectives and criteria for evaluation. The PROCEED framework ( policy, regulatory andorganizational constructs in educational and environmental d evelopment) provides additional steps fordeveloping policy and initiating the implementation and evaluation process.

PRECEDE-PROCEED works in tandem, providing a continuous series of steps or phases in the planning, implementation, and evaluation process. The identification of priorities and the setting oobjectives in the PRECEDE phases provide the objects and criteria for policy, implementation, andevaluation in the PROCEED phases.

PRECEDE-PROCEED is a robust model that addresses a major acknowledged need in health promotion and health education: comprehensive planning. The PROCEED component of the model isof more recent inception and has head less exposure and testing. It is essentially an elaboration andextension of the administrative diagnosis step of PRECEDE, which was the final and least developedlink in the PRECEDE framework. There are eight phases of the PRECEDE-PROCEED model

PRECEDEPhase 1. Social diagnosis - quality of lifePhase 2. Epidemiological diagnosis - health status indicatorsPhase 3. Behavioral and environmental diagnosis

Phase 4. Educational and organizational diagnosis - predisposing, reinforcing and enablingfactorsPhase 5. Administrative and policy diagnosis - Health promotion, health education, policy

regulation organization

PROCEEDPhase 6. Implementation (Phases 4 & 5 of PRECEDE)Phase 7. Process evaluation (Phases 3 & 4 of PRECEDE)Phase 8. Impact evaluation (Phases 3 & 4 of PRECEDE)Phase 9. Outcome evaluation (Phases 1 & 2 of PRECEDE)

The concern for this chapter is Phase 4 of the PRECEDE which deals with Educational andorganizational diagnosis, which deals with predisposing, reinforcing and enabling factors influencinghealth behavior.

On the basis of cumulative research on health and social behavior, literally hundreds of factors could beidentified that have the potential to influence a given health behavior. The PRECEDE model groupsthem according to the educational and organizational strategies likely to be employed in a health promotion program to bring about behavioral and environmental change. The three broad groupingsare predisposing factors, reinforcing factors, and enabling factors.

Predisposing factors include a person's or population's knowledge, attitudes, beliefs, and perceptions




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that facilitate or hinder motivation for change. These are those antecedents to behavior that provide therationale or motivation for the behavior.

Enabling factors are those skills, resources or barriers that can help or hinder the desired behavioralchanges as well as environmental changes. They can be viewed as vehicles or barriers, created mainly by societal forces or systems. Facilities and health insurance, and laws and statutes may be supportiveor restrictive. The skills required for a desired behavior to occur also qualify as enabling factorsEnabling factors thus include all the factors that make possible a desired change in behavior or in theenvironment. Enabling factors are the antecedents to behavior that enable a motivation to be realized.

Reinforcing factors, the rewards received, and the feedback the learner receives from others followingadoption of the behavior, may encourage or discourage continuation of the behavior. Or in otherwords, reinforcing factors are factors subsequent to a behavior that provide the continuing reward orincentive for the behavior and contribute to its persistence or repetition.

The fourth phase of the PRECEDE consists of sorting and categorizing the factors that seem to havedirect impact on the target behavior and environment according to the three classes of factors just citedStudy of predisposing, enabling and reinforcing factors automatically takes the planner on to decideexactly which of the factors making up the three classes deserve highest priority as the focus of

intervention.

Any plan to influence behavior must consider all three sets of causal factors. For example, a programfor disseminating health information to increase awareness, interest, and knowledge (predisposingfactors) that does not recognize the influence of enabling and reinforcing factors, most likely will fail toinfluence behavior except in the segment of the population that has resources and rewards readily athand (usually the more affluent people).

Normally we expect the sequence to be as follows: A person has an initial reason, impulse, or motivation (predisposing factor) to pursue a given course of action. This first factor (arrow 1) in thecausal chain may be sufficient to start the behavior, but it will not be sufficient to complete it unless the

person has the resources or skills needed to carry out the behavior. The motivation is followed by(arrow 2) deployment or use of resources to enable the action (enabling factor). This usually results inthe behavior, followed by (3) a reaction to the behavior, which is emotional, physical, or social(reinforcing factor). Reinforcement strengthens behavior (4), future resources (5), and motivation (6).The ready availability of enabling factors provides cues and heightens awareness and other factors predisposing the behavior (6). An exercise in your home is more likely to prompt you to use it thanone at the YMCA. Similarly, rewards and satisfactions from behavior make that behavior moreattractive on the next occasion; today's reinforcing factor becomes tomorrow's predisposing factor (7)(transparency, page 153).




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VI. PLANNING BEHAVIOR CHANGE

During planning, communicators use primary and secondary research results to segment targetaudiences; select behaviors; plan strategies; develop messages; and design management, distribution,monitoring, and evaluation systems. This chapter focuses on how the communicator analyzes therelation ships between the environment and the desired behaviors and takes those relationships intoconsideration when selecting target behaviors, planning communication strategies, and selectingcommunication channels. Specifically, this chapter describes the behavioral approach to selectingtarget behaviors that are most amenable to change and have the greatest potential impact on the health problem and organizing them in order of priority; developing communication strategies that remedyskills and performance deficits by reinforcement of support for maintaining learned behaviors;selecting integrated interpersonal, print, and mass media channels to function as consequences as wellas antecedents to target behaviors.

Selecting Target Behaviors

The selection of target behaviors is one of the most difficult decisions made during planningTraditionally, communicators, in an effort to provide comprehensive information on the health

problem, have included too many behaviors and messages in their programs; the result is very littleimpact on behavior change. Communication programs that have achieved behavior change havefocused on a limited number of feasible behaviors.

There are several reasons why communicators should establish short list of behaviors to promote.1. Behaviors related to desired health practices are frequently too numerous and complex to

introduce, change and maintain all at one time.2. Some behaviors are more easily changed than others are; some behaviors are simply not

feasible for the target audience to perform, and others are incompatible with social and culturalnorms.

3. Some behaviors have more potential impact on the health problem. Communication programs

sometimes have promoted behaviors that have no clearly demonstrated relationship to thespecific health problem.

Steps in Selecting Behaviors

The following steps will help communicators select a few key behaviors to be targets for acommunication program.

Step 1: Review Assessment Research. The planning process begins with a review of the dataconcerning a target audience’s current beliefs, knowledge, and practices related to the health problemThis review will help planners understand existing behaviors and the consequences that maintain them,and to decide which behaviors are really feasible for the target audience to adopt.

Step 2: Review the list of "Ideal" Behaviors. Ideal behaviors are the medically prescribed behavioralsteps that the target audience should perform in order to prevent or treat the health problem. In theassessment stage, an interdisciplinary team initiates the definition of the ideal behavior. During the planning stage, the team reviews its list of "ideal" behaviors and adds steps that assessment research hasidentified as appropriate and necessary for the correct performance and maintenance of the health practice.

Step 3: Select Target Behaviors. Target behaviors are the minimum number of behavioral stepsessential for the health practice to be effective. All unnecessary and unfeasible behaviors list, so that the




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list is reduced to a manageable core, which will be the focus of the communication program.

The selection of target behaviors is a process of elimination. The planning team includes existingapproximations and excludes behaviors that have not demonstrated impact on the specific health problem and are not feasible for the target audience to adopt. The final target behaviors of thcommunication program will be a highly selective subset of the medically prescribed ideal behaviorsdefined during assessment.

This process of elimination is not necessarily either-or but, rather, a balancing of all the factors thatmight determine whether or not a behavior would be adopted. Sometimes the behaviors are notfeasible for the target audience to perform in their ideal form, but they are absolutely necessary to havean impact on the health problem.

If the list of target behaviors is still too numerous to be manageable, the team will need to determinewhich behaviors should be focused on initially and which can be introduced later in the program. Thisshortened list of essential target behaviors allows the team to select communication strategies,communication channels, training objectives, monitoring tools, and program evaluation criteria tofocus more explicitly and effectively on behavior change early in the program. Later, communicatorscan introduce target behaviors more critical to maintaining the health practice.

Tools for selecting Behaviors

To select the target behaviors, the interdisciplinary team first decides which behaviors on the ideal behavioral profile work sheet do not have any demonstrated impact on the selected health problem;these items are not considered as behaviors. Team members then compare ideal and existing behaviorsand analyze where they are the same where approximations exist, and where the two are completelydifferent. The behaviors on the two work sheets that are the same and are approximations are selectedas target behaviors. In situations where ideal behaviors are radically different from what the targetaudience is currently doing, but are necessary for impact on the health problem the team enters intonegotiation with a medical specialist to determine a more feasible intermediate target behavior. Again

this is not a scientifically rigorous methodology, but it assists the planning team in organizingdiscussions.

Selecting Communication Strategies

Communicators must consider many factors- medical, political, financial, logistical, and technical -when deciding on the "best" communication strategy. Behavioral factors also should play a part ininfluencing strategy selection. This section describes how communicators analyze the relationships between the environment and desired behaviors and takes those relationships into consideration whenselecting communication strategies.

Skills and performance deficits

In selecting communication strategies, communicators should consider whether the absence orincorrect performance of a target behavior is due to a lack of skills (Skills deficit) or the absence ofconditions favorable for performing it (performance deficit). When the person has a skills deficit,communicators will select strategies to introduce and teach these skills. If the audience is already performing approximations to the target behaviors, the communication strategy will require thoseapproximations and teach the skills necessary to shape them into target behaviors.

In other instances, people have significant knowledge and skills, but they are still not performing the behavior correctly or at all one reason may be that performing the behavior does not produce any




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immediately perceivable consequences or may actually produce unpleasant consequences. IN THIS

CASE, THE COMMUNICATION STRATEGY WILL FOCUS LESS ON TEACHING SKILLSAND SHAPING BEHAVIOR and more on developing an environment of support for continued

performance of the target behavior. For example, community- based primary health care volunteers,who are vital channels of interpersonal communication to mothers and other caretakers, generallyreceive some training and initially have an acceptable level of skills to provide basic health services andinformation at the community level. Despite a good beginning, however, attrition rates for thesevolunteers are high throughout the developing world, and their potential impact as conduits of healthinformation, skills and reinforcement to their communities is greatly diminished (Elder, et al., 1992)Frequently, program planners conclude that community health workers need more training to "keepthem motivated" The problem here however is more a performance than a skills deficit. An analysis ofthe situation form a behavioral perspective would lead to a strategy focusing less on retraining and skill building and more on increasing pleasant consequences and decreasing unpleasant consequences for thevolunteers work. Research would be used to determine which consequences would be most likely toincrease desired behaviors and which unpleasant consequences might be decreased. This informationwould be used in the design of a support system to help these workers continue to be effective andactive volunteers.

Performance deficits are also a common problem when mothers fail to perform target behaviors

correctly. Once again, a communication strategy would focus less on skill building and more oncreating an environment of support. Research could be used to identify what unpleasant consequencesmight be deterring this practice or whether it producers few, if any, pleasant consequences. Forexample, many mothers are convinced that breast-feeding is best for their infants and are taught how to breast- feed at the hospital. Breast-feeding can be extremely painful, however, particularly in the firstseveral weeks. May feel overwhelmed and frustrated by this pain. The communication strategy in thiscase could focus on increasing social support during the first month of breast-feeding. Communicationcould be used to teach fathers and other women how to support the first-time mother during this initialmonth.

Decisions for strategy selection

The flow chart shown as Figure 4.2 is a decision tree that can assist communicators in selectingcommunication strategies. It is divided into two general areas: skills deficit (on the left-hand side) and performance deficit (on the right). To use the flow chart, communicators first consider whether peopleknow about the target behavior. If they do not, communicators generally will select antecedenstrategies to introduce a behavior, provide information, and create awareness of and demand for newhealth technologies and behaviors. For example, in the early days of diarrhoeal disease control, mostORT communication strategies first focused on introducing the concept of dehydration and the need forORS to prevent deaths from dehydration.

If people were aware of the behavior, communicators would then consider whether "people are able to perform the behavior if they are asked. "If not, they have a skills deficit, and communicators wouldselect strategies to train and teach skills and to have approximations.

If, on the other hand, people know about the behavior and know how to do it correctly, but still are not performing it, they have a performance deficit. In this case, communicators would consider the right-hand side of the flow chart, which focuses more explicitly on how the consequences of the target behaviors function to support or deter these behaviors over time. In this case, communicators analyzethe consequences of the behavior and select the communication strategy to influence thoseconsequences, not the behavior itself.




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Strategies to Respond to Skills Deficits.

When the failure to perform the target behaviors is caused by a skills deficit, the target audience maynever have tried the target behaviors. In other cases, they are already performing approximations to thetarget behaviors. The flow chart illustrates the questions asked to decide whether one has more of askills or a performance deficit.

Does not know How to perform the Behavior. In this case, the target audience knows about the behavior but does not know how to perform it. For example, mothers know that they should use ORS but they may not have the skills to prepare and administer it correctly.

The communication strategy is to provide training and teach the skills necessary to perform the target behavior correctly.

Performs Approximations to the Behavior in this case, the target audience is performingapproximations to the target behavior, but not in sufficient frequency, duration, the correct form, or atthe right time.

The communication strategy is to reward approximations and teach correct frequency, duration,accuracy, and timing.

Strategies to Respond to Performance Deficits

In other instances, most people in the target audience can demonstrate how to perform the target behavior correctly, but still are not performing it in their daily lives. The communicator then looks tothe right side of the flow chart and begins to consider why this performance deficit exists.

When considering strategies to address performance deficit, the communicator needs to recognize thata behavior leads to more than one consequence. A behavior can actually produce a wide range of

consequences- from positive to negative, from immediate to delay, and from consequence - from positive to negative, from immediate to delayed, and from concrete too abstract. Communicators mightwant to start their strategy selection by listing all the consequences that, according to formativeresearch, occur when a person performs or does not perform the behavior. This list can helpcommunicators organize their discussion and select the most effective way to use those consequencesto support target behaviors. Consequences that are culturally relevant, individually salient, andimmediate will be the most powerful. Delayed or abstract consequences are much less so.

A communication program cannot eliminate some negative consequences, such as the pain caused by breast-feeding or side effects of medication; nevertheless, a creative communicator can develop waysto lessen the impact of this punishment by focusing on other consequences. The following sections provide examples of communication strategies that respond to performance deficits.

When performance is immediately punishing. In this case, a person actually receives perceptible punishment for performing a behavior. The punishment may come from individuals in his or her socianetwork. In other instances, punishment may come from the health system: doctors may scold mothersfor waiting too long to bring their children to the clinic when they are ill. Finally, punishment can comefrom performing the behavior itself: ORS, if administered too rapidly, can cause vomiting.

The communication strategy is to decrease unpleasant consequences and/or increase the saliency of positive ones. To decrease an unpleasant consequence, communicators must first determine where the punishment is coming from and then develop strategies to change or lower the impact of this




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punishment. If the punishment is coming from the behavior itself, communicators may want to developa strategy to incorporate or strengthen another salient source to provide positive consequences.When performance creates No Immediate Results. Because of their preventive nature, many target behaviors aimed at child survival have no immediate, salient consequences that the person performingthe behavior can easily perceive. For example, a mother may not be able to see that, because of newfeeding practices, her child is maintaining his weight during a diarrhea episode.

The communication strategy is to introduce new positive consequences for behavior. Thecommunication strategy might introduce planned consequences in order to support the behavior untilnaturally occurring consequences are perceived. Material consequences could be introduced.

If a communication program introduces planned consequences, communicators will also need todevelop antecedent strategies to increase the saliency of the new consequence.

As discussed, the choice of the most culturally appropriate, personally salient, and immediateconsequence to introduce should be guided by research with the specific target audience. Whatcommunicators may deem as the "best" consequence may not be the one perceived as "best" by thetarget audience.

Communicators also must consider how the planned consequences they introduce will be phased outover time and what naturally occurring consequences will take their place. For the long-term performance of behavior, communicators cannot rely on planned consequences. The maintenance of behavior change is discussed further in chapter seven,

When non-performance is more rewarding than performance. In many in many instances, thehousehold responsibilities of children's caretakers compete with their performance of many health practices.The communication strategy is to increase rewards for the target behaviors. Caretakers often have notexperienced any positive consequences from performing a target behavior such as obtainingimmunizations several times over the first year of a child's life. In order to make the immunization

process more attractive to and feasible for a mother, the communication strategy would combine actualchanges in clinic practices with communication messages to promote clinic services. Clinics would tryto make visits more positive through better service (faster, more polite), better care and motivationalschemes (diplomas, lotteries). After experiencing more positive consequences from the behavior, themother is more likely to do rather than not to do.

When other Behaviors Are More Rewarding. In child survival programs, mothers frequently perform behaviors deemed counterproductive for the health of their children. For example, mothers bottle-feedrather than breast-feed.

The communication strategy is to increase rewards for the target behavior or increase punishment forundesired behaviors. Communicators generally prefer to develop strategies that increase rewards for thetarget behaviors. Rather than openly attacking mothers' existing practices, the communication strategy promotes a new practice that directly competes with it.

Communicators could also consider a strategy to increase negative consequences or punishment for acompeting or non-desired behavior, but this strategy generally has not been used in public health programs in developing countries.

When Behavior is too Complex, Difficult, or Costly. In this case,1. The interdisciplinary team has selected target behaviors that are not feasible because of high

cost, complexity, or difficulty; or




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2. The target audience still does not know how to perform the behavior correctly (a skills deficit).

If (1), the team must return to the step of selecting target behaviors. If (2), communicators must returnto the left-hand side of the flow chart to select their communication strategy.

Selecting Communication Channels

1. Interpersonal channels - such as face to face communication, community distribution, homevisits, training, group discussions, and counseling- are generally best for giving credibility tomessages, providing information, and teaching complex skills that need two -communication between the individual and a credible source of information. Interpersonal communicationfacilitates the discussion of information or messages that the target audience regards as"sensitive" or "personal." It is also important for providing positive feedback and immediatereinforcement to the people performing the target behaviors.

2. Broadcast channels generally provide broad coverage for communication messages, reachinga large number of the target audience quickly and frequently. In developing countries, radio has been a powerful channel to reach large numbers of people with communication messages, and

to model target behaviors and their consequences. In some countries, such as Egypt and thePhilippines television has also played an important role.

3. Print channels - such as pamphlets, flyers, and posters- are generally considered best for providing a timely reminder of key communication messages. Pamphlets and other graphicmaterials distributed at the individual or home level can provide complex information in adigestible form, so that the target audience can use that information when it most needs itAudio-visual materials - such as videos, slide-tape shows, and flip charts- visually portray keymessages during interpersonal communication sessions.

The rules for selecting channels are basic but very important:

1. Select channels that reflect the patterns of use of the specific target audience, not the tastes ofthe communication team or decision-makers. Almost all communicators have their 'favoritemedia, whether video, puppets, or radio In order to have an impact, however the channelsselected must be hose that "reach" their target audience with the greatest degree of frequencyeffectiveness, and credibility.

2. Recognize that the different channels play different roles.3. Use several channels simultaneously. The integrated use of multiple channels increases the

coverage, frequency, and effectiveness of communication messages.4. Select media that are within the program's human and financial resources.5. Select channels that are accessible and appropriate to the target audience. Radio messages

should be scheduled for those radio stations that the target audience actually listens to and at broadcast times when that audience listens. Print materials should be used only for literate orsemiliterate audiences who are accustomed to learning through written and visual materials.Materials should be distributed in accessible and visible places where the target audiencealready goes. Interpersonal communication should be provided reliably by credible sources(United States Department of Human Services, 1989).

The combination of these channels is called the media mix. The media mix selected should be one thatenables communicators to reach many people many times within the stipulated time frame, to supplythe appropriate information in an understandable form for each target audience, and to remain within a budget that can be maintained by the institution conducting the communication program.




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Summary

Communicators plan for a behaviorally focused communication program by analyzing the relationships between the environment and the desired behaviors. They take those relationships into considerationwhen selecting target behaviors, planning communication strategies, and defining the role ofcommunication channels. Specifically, this chapter provides a behavioral approach to selecting target behaviors that are most amenable to change and that have the most potential impact on the health problem; selecting and developing communication strategies that focus on skills development andcreating an environment of support to maintain learned behaviors; and selecting integratedinterpersonal, print, and broadcast channels to function as consequences as well as antecedents to target behavior.




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VII. THE TRAINING PROCESS

Training groups

Training is an organized program for teaching people new skills. Training is most often done withgroups of people, all of whom need to learn the same skills. Since training involves learning skillsthere must be many opportunities for participants to practice these new skills and participate in the planning and running of the program to make sure it meets their needs. A planning committee madeup of trainees and trainers is very useful.

Finding out training needs

We have already mentioned several groups in the community who could benefit from training programs that you might organize:

1. Community health workers need training in health care and health education skills:2. Teachers may need knowledge and skills in health and health education;3. Various groups of the community may want to develop specific skills: for instance, pregnant

mothers expecting their first babies may desire training in parenting and child care skillsworkers may want to train in first aid; and so on.

There are different ways of discovering what kind of training people would like to receive:

1. Talk to people in groups or during individual interviews: What skills do they want?2. Observe people at home, at work: do they seem to be performing well, or is there room for

improvement?3. Look at the duties given to the community health workers: have they been taught properly how

to carry out those duties?4. Think about the community: are there special problems for which the community health

workers need to learn new skills?5. Read reports or review progress made on programs organized by your agency: were the programs successful? If not, do the program managers feel that a lack of skills among staffmembers was a cause of failure? What so you think?

6. Read magazines or newsletters put out by professional groups such as nurses and healthinspectors; also talk to your supervisors: what are some of the latest ideas in health care? Whattraining is needed to practice the new skills?

Objectives and methods

a) Education objectives

Training, like any other health education program has an objective. The objective is the new behaviorthat people will practice by the end of the training program. The behavior in this case involves newskills.

An objective for a community health worker may be to know how to clean, treat and bandage a smallcut or wound. For a teacher it may be to know how to demonstrate to pupils how to clean their teeth.

b) Health objectives




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After community health workers, teachers and other local workers have learned new skills, they should be able to provide better services. Hopefully, services should result in improved health of thecommunity. For example, training staff to do an immunization program should result in the healthobjective of a marked reduction in the number of children who suffer form measles, polio and otherdiseases, and elimination of deaths from these diseases.

c) Involving people in setting the objectives

The people who are to receive the training should discuss their training needs and the educationobjectives. They should agree on what they want to learn. In this way, people will be more interestedin the training and will want to attend all training sessions.

d) Training methods

A training program should give people as much chance as possible to practice new skills. Thereforehealth education tools that encourage participation and practice should be used.

Audio- visual aids such as posters and projected materials can give background information and

knowledge. To learn the actual skills, tools such as demonstrations, case study, games and role-playshould be used (See chapter 7).

Planning the training session

At this stage, you have to keep in mind several important factors.

While you can certainly help people to acquire new knowledge and skills, you may not knoweverything the participants want to learn. You may need to bring in resource people who have speciaknowledge and skills to share with the others.

How long will it take for people to learn the new skills? Remember to allow enough time for everyoneto practice. Some training programs last a few days, others a week, a month or longer. This dependson how much need to be learned.

The time should be convenient for the participants the trainees. Discuss with the trainees how toarrange the best schedule. Can they take a week off from their work? Are they able to meet only once aweek? Is daytime or evening better?

Find a meeting place that is big enough to hold all the trainees. Make sure the place is comfortable andthose eating and toilet facilities are available. Find a place that is easy for all trainees to reach. Youmay be able to use a local hall or school without change.

Educational materials such as posters, projectors and photographs may be needed. Also trainees willneed materials with which to practice their new skills. These should be gathered well in advance. Useeducational materials that you can make yourself as far as possible. Try to plan training programs usinglocal materials and resources.

What about transport and housing? Are there problems that require your attention? Find out if there are people who would be willing to transport and hose your trainees.

If money is needed, contributions might come from the trainees or from various agencies. Money




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received for the program must be carefully and accurately accounted for so that one can see where itcame from and how it was spent. Also note that people may be glad to contribute again in the future ifthey are thanked for their donations. In any case, you must express appreciation for the support, whichyou have received.

Curriculum Planning

Any organized training requires to be done with proper planning with regard to what is to be taught andhow it is to be taught and by whom. All this will depend on the training needs. It is a common practiceto develop curriculum. Curriculum is a design for enabling the learning in a training situation. It is asystematic sequential arrangement of the objectives, the content, the methods of instruction to beadopted and the materials to be used in support of the educational methods.

Curriculum development entails the following steps.

1. Job analysis and study of job specification. This is done to know the training needs.2. The objective should be framed in keeping with the job description or expectation.3. Listing of subjects, topics or areas that is essential.4. The method of instruction for each area or unit should be discussed and evolved and time

allotment shall be made with regard to the method of instruction.5. Scheme of evaluation should be worked out to monitor the levels of comprehension and changeof attitude and behavior among the trainees, during the training and at the end of it.

A well-developed curriculum may require modification from time to time depending on the changingtraining needs for the job and also the feedback of the evaluation.

Running the training session

Pay attention to relationships by making sure that all the trainees and trainers know each other. In thisway they will work better together.

Even if you have involved the trainees in the planning, it is good to review with them the proposedobjectives and activities at the beginning of the session. Make sure that the plan is acceptable. Ask forsuggested changes. If time and other resources allow, make the desired changes but make sure firstthat all agree to these changes.

In order to encourage participation, trainees should lead sessions, demonstrate skills, share their ownideas and experiences and make suggestions for improving the program will be successful.

Evaluating the training

Evaluation occurs throughout the program. The following questions will help you think about how youwill evaluate training:

During the training sessions: are the learning of skills and the availability of resources going as planned?

At the end of the program: can all the trainees practice the skills they were taught?

After the program: are the trainees able to put their new skills to use?

Are there changes in the health behavior of the people in the community?




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Steps in evaluating a training program1. Ascertain the objectives2. Decide on the criteria for evaluation as against the objectives - qualitative and quantitative.3. Develop indicators or indices or measurement4. Decide the design of evaluation5. Data to be collected6. Analysis and interpretation

Skills Training

Training can then be based on responses to these questions or on tallies of direct observations. Forexample, all skills necessary for effective face-to face communication need to be included in training, but if evidence from assessment shows that trainees are already performing some skills fairly wellthese skills could be reviewed briefly in training. On the other hand, if assessment shows that certaincommunication skills are not being performed or not being performed well, this need to be introducedand practiced in training. The same goes for content areas. Scores from assessment will indicate whatinformation is accurately or inaccurately stated and what information is not mentioned at all in mosthealth talks the trainees give. This will guide the trainer in what health information needs correcting

and practice or simply needs reinforcement in training. In this way, training is customized to the needsof the trainees and makes the best use of precious training time.

Five Steps of Skills Training

Step 1;Instructions

Instructions are similar to didactic teaching, whereby knowledge about general skills and component behaviors is transmitted. This step, although necessary, should play only a minor introductory role inthe skill development process. Effective instructions serve only as preparation (an antecedent) for skillsdevelopment and cannot replace behavioral practice in the learning process. Instructions generally

include a description of the skill, specifying action to be taken rather than knowledge to convey orattitudes to portray.

Instructions also can include the rationale for using a skill. In the training of health workers, a rationalefor asking mothers about their current practices before giving instructions for home care is "You ask amother about her current practices first so that you can fit your messages to her demonstrated skill andknowledge level."

By using this type of instructional approach (in other words, setting up a dialogue about a topic), thetrainer establishes a more personalized type of communication and a feeling of openness about themessage. Through two-way communication trainers also gain direct evidence about their effectivenessas communicators. If a trainee is not able to state important parts of the message correctly, theinstructions themselves should be reexamined. Perhaps the vocabulary is inappropriate, too muchinformation was given too rapidly, more concrete examples should be given, and so on.

Step 2;DemonstrationIn the demonstration phase, the trainer demonstrates the target skill and further ensures that the participants fully understand the instructions that have been given. Demonstrations help clarify theverbal description of the component behaviors. Such clarification is especially important when thelanguage or manner of speech of the trainer and trainee is different-for example, when a health workerand mother are from different regions or ethnic groups. Demonstrations are also important when targetskills are relatively complex for example, when health workers are learning to fill out a child's




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immunization or growth- monitoring card or combining effective case management with counseling ina clinic visit.Step 3:Practice

Practice is performance of the behavior in the presence of the trainer. This is the only way to ensurethat those trainees really master the targeted squalls and are able to do them on their own after training.

In the practice sessions, as many of the trainees as possible try target skills. They may simply repeat thecomponent behaviors, or they may simulate real-life situations in a role-play. After the training sessionsare over, practice continues in the trainees' work place or home.

Practice in the training sessions should be set up to resemble the real-life situations participants willface later. In this way, the health worker will know for certain that the mother is capable of carryingout the prescribed task. When health workers are the trainees, they may take turns playing "mothers" inorder to make their practice of health talks or demonstrations as realistic as possible.

Practicing a skill once in training greatly helps trainees move from knowing about a skill to being ableto do it. Practicing the skill several times in training allows them to go further and become fluent in theskill. With repeated practice and feedback in training, trainees leave the session better able to perform

the task in their work place or home and are less likely to lose the skill level they achieved in trainingTraining sessions and workshops are often the first segments to be cut.

Step 4:Feedback and Reinforcement

Feedback is information given to individual participants about the quality of their performance. If properly given, feedback will function as reinforcement by encouraging the participant to try the new behavior again, with specific strategies on how to improve. To be effective as reinforcement, feedbackmust be specific, constructive, and pleasant. Positive feedback must be specific, constructive, and pleasant. Positive feedback must give the trainees a clear idea of what behaviors they were doingcorrectly, so that they can repeat those behaviors. Negative feedback must make clear how trainees can

correct behaviors they were performing incorrectly, and it should not overwhelm them by enumeratingtoo many expected changes at one time.

When selecting what skills or behaviors to reinforce, we need to remember that optimal skill levels aredeveloped through successive behavioral trials and feedback experiences. In other words, individualsenhance skills by actually performing them and receiving response-specific feedback in order toeliminate ineffective behaviors and repeat the effective ones. Practice does not "make perfect" unless itis combined with feedback. Thus, trainees must be given constructive and encouraging feedback for behaviors that get closer and closer to a desired skill; catch them doing something right and reinforcethem."

After the trainer has demonstrated the method of giving feed back participants themselves should usethe same feedback methods when they watch others do a role-play. The participants should statespecific strengths they observed and should give suggestions for what can be changed. Finally, thetrainer should give participants feedback on how well they gave feedback.

Step 5:Homework

Homework with feedback is critical to maintaining the skills learned in training. Homework constitutesadditional practice, similar to the practices done in training that the trainees must perform outside thetraining session. For homework to be most effective in strengthening and maintaining learned skills, itmust be checked by the trainer, and constructive feedback must be given; in other words, the behavior




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of carrying out a homework assignment (using new skills) must result in positive consequences, so thattrainees will continue to use the skill in their own clinics or homes. The trainer should seek outopportunities to check homework assignments through occasional visits to local clinics or, if travel islogistically impossible, come up with creative ways to provide feedback to health workers newlyemerging from training.

Homework with feedback is also effective at other levels of training. Health workers can assignmothers homework after a counseling session in the clinic. For example, the mother may be asked totry using two packets of ORS over the next forty-eight hours, after which the health worker will checkon progress during a home visit, give the mother constructive and encouraging feedback, and deliver aling-term supply of additional packets. If the mother is aware that someone cares enough to check upon her success or problems with this or any other health-related skill, she is much more likely to practice it.

To help mothers maintain the skills they have learned -especially if home visits are not possible- thehealth worker might ask the mother to demonstrate various aspects of the skill (for instance, thetreatment of diarrhea) during subsequent clinic visits. This practice session, with feedback from thehealth worker, can serve as a valuable refresher session, because a mother whose child has not had asignificant diarrhea episode for some time (for in stance, six months may have forgotten how to treat

the condition.

Training as Reinforcement Training, as it is typically designed, serves to prepare people for their work. In other words, it functionsas an antecedent in the A-B-C chain. In this position, Training can introduce new skills and begin thelearning process, but as an antecedent, it is in a relatively weak position to maintain long-lasting skilldevelopment and behavior change. One can, however, shift training's function in a program to that of aconsequence, so that it reinforces participants' learned behavior and contributes to skill enhancementand maintenance over the long term. These activities turn training into a tool for maintaining atrainee’s performance over the long term. Follow-up training sessions might be incorporated into an

already functioning general supervision or monitoring program if organizational structure, financial backing, and logistics are favorable. But whether called in-service training, continuing education, orgroup supervision, these follow-up sessions must be positive learning and motivational experiences for participants. In this way, training has become a positive consequence following behavior rather than anantecedent-triggering behavior.




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VIII. EVALUATION OF BEHAVIOR CHANGE

The aim and purpose of health education is to bring about health related behavior for maintenance ofgood health. The change of behavior or adoption of new practice and its sustenance marks the ultimateimpact of health education. Acquisition of proper information, change of ideas or knowledge fromwrong to right and internalization of useful ideas are as important as change of behavior. It has already been considered in an earlier chapter that there can be a desired change of behavior even withoutrequired change of knowledge and attitude. In such a situation health education has not had fullimpact.

The evaluation of any health education program is, therefore, to measure the change in the knowledge,change in the attitude and change in the behavior. A corresponding level of change in the threecomponents of knowledge, attitude and behavior will signify a successful impact, whereas the absenceof any change in one of the components will indicate only a partial impact which requires to be furtherreinforced.

The parameters or the criteria that have to be developed for evaluation of health education efforts will be the changes in the level of knowledge, attitude and behavior.

Evaluation may be directed to ward the health education program itself to find out to what extent it isin accord with sound educational principles. Practices that are in harmony with generally accepted policies can be expected to produce better results than those that are not. This approach is justifiedinasmuch as results in terms of changes in pupils and their environments often do not become evidentfor some time. As mentioned earlier, there is a lag between health education and its measurableapplication.

Evaluation is the process of determining to what extent a program has accomplished its objectives. Thetask of evaluation in health education, as in any other field, is much broader than finding out how muchfactual knowledge is retained by a group of people after their exposure to a specified amount of health

instruction.Evaluation serves the following purposes:1. It helps the educator to know where to place emphasis in a teaching program. It may show

which behavior patterns and which home, school, and community conditions have beenimproved as a result of the program, and which need further attention.

2. It helps to show strengths and weaknesses in teaching procedures. When a teaching program has produced results, evaluation may reveal which procedures have provedworthwhile. Conversely, when a program has failed, it may show which procedureshave been ineffective.

3. Evaluation aids health committees and other groups in curriculum planning. It givesinformation that should help to determine content and methods.

4. Evaluation gives data of value in "selling" a program to administrators and to thecitizens of the community.

Evaluation may be required in a health education program concurrently and terminally. For exampleif a health education program for control of tuberculosis is planned and it consists of a series of eventslike group discussion, lecture demonstration, cinema shows, display of exhibition and so on, there is aneed to evaluate each event then and there, to ascertain how many people participated, whethereffectively or not whether the message is clear to them and whether they found the messageadvantageous, etc. at every stage. If the community is the same, one should try to find out how muchthe different health education activities are having for the decided effect. Such evaluation on groups of




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people or individuals can be done by face to face questions or questionnaire or asking them to narrateor By observing whether there is any change in the knowledge, attitude and behavior. The change ofattitude is rather difficult to measure because it had to be done as measure of opinion and it is notalways reliable. One can be surer of measuring knowledge level and behavior and then attitude.A terminal evaluation takes into account the same parameters of knowledge, attitude and behavior butcomparison is done with levels before the program is commenced and after it ends.One has to be careful in the interpretation of the findings with regard to behavior. Behavior has to beobserved and confirmed and that too not once but many times to make sure that it is a sustained behavior.

Besides, a scientific evaluation of a health education program should enable one to find out whether thefollowing criteria are satisfied or not.

Relevance. It should be problem- oriented and need-based. It should also have relevance to theexisting culture of the community.

Coverage and progress of health education activities. The coverage refers to the community population or area to be covered and also the topics and subject matter and events that have been

planned for. Evaluation should find out if the target group has been covered or not.

Efficiency. The program has to be carried out by expending efforts in terms of people, time, money,materials and technologies. Evaluation should therefore, be done to find out the extent to which thefacilities are being used and whether the resources are used economically. This will further revealwhether the effort or purpose is economically feasible and worthwhile or a waste.

One of the by products of the evaluation process is the inevitable review of the objectives of the totalhealth education program, of the peoples' needs and interests, of the experiences provided in conditionsin the schools, homes and community. Another by product is the positive influence on humanrelationships that are involved in the co-operative teamwork of continuous evaluation.

Since a complete evaluation of health education covers all parts of the program, it is required that anattempt be made to measure the degree of success in accomplishing each of the evaluation is school-wide understanding of the health education program, and crystal-clear listing and describing of itsobjectives.

Evaluation instrumentsEven though he may not be particularly conscious of the fact, an educator is constantly evaluating hisaudience. When teaching plans are carefully made in advance, the teacher's purposes are clarified andhis choice of experiences or subject matter is more appropriate. By the same token, if the methods ofcollecting information for evaluation in health education are planned in advance, the collection of suchdata is more orderly, more complete, and probably will portray more accurately the situation as it reallyexists.Some of the more common procedures or methods of collecting evaluation information used byteachers are;1. Observations - of health behavior, of particular skills, or of events in the home or community.2. Surveys, Interviews3. Health records4. Case studies - Detailed study of individuals may show changes in health behavior in relation to

other factors that influences his total life.5. Health knowledge tests




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Each of these instruments or techniques can be used to good advantage. The resourceful teacher willnot limit himself to the use of only one, but will become skillful in using many of them.




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IX. RESISTANCE TO CHANGE IN HEALTH BEHAVIOUR

Given the compelling evidence that an individual's personal behaviors play such an important role indetermining his or her health, why is it that people still practice unhealthy habits? Unfortunatelyunhealthy behaviors are stubbornly resistant to change and highly subject to relapse. Two broad sets ofcauses are considered to be major obstacles to lifestyle modification. The first is the learning theorynotion called the gradient of reinforcement. This refers to the fact those immediate rewards and punishments are much more effective than delayed ones. Thus, if engaging in a behavior provideimmediate relief or gratification, or if failing to engage in this behavior provides immediate discomfort,the behavior should be easily acquired and difficult to extinguish. Furthermore, the health threats posed by the so called risky habits seem remote compared to the immediate pleasures of indulging, andthe inconvenience and effort involved in adopting more healthful preventive behaviors also acts as barriers to behavior change. The relative influence of remote or delayed reinforcement may also be areason why the strategy of prevention receives less attention from physicians, patients, and the healthcare system in general compared to that afforded treatment of diseases after they become problems.

Forces in the social and physical environment comprise a second major set of barriers to lifestylemodification. Healthy or unhealthy habits are developed and maintained by social and culturalinfluences deriving from the family and society. In the last twenty years Americans have made

significant progress in changing their attitudes toward exercise and proper nutrition and have becomewell informed about the modifiable risk factors for cancers and cardiovascular disorders. Howeverthere are still powerful social pressures that lead teenagers to smoke and economic pressures such asthe lack of insurance reimbursement for helping patients prevent illness that lead physicians and otherhealth care providers to put less energy into prevention. Moreover, further economic and physical barriers are found in the higher cost and lower availability of healthier foods and in the lack of time andopportunity for exercise at many work sites.

In the Ethiopian context, health education is supposed to be given regularly in all health institutions andduring home visits throughout Ethiopia and is considered one of the major ways of changing health behaviors. The other less common way is to mobilize people by informing them they must participate

in an activity such as bringing their child for immunization on a specific day. In the case of healtheducation, people as a group are informed about certain diseases and what actions prevent thesediseases. The assumption is that the information will change people's knowledge and attitudes andthese in turn will change health behaviors. However, for a number of reasons, these changes do notusually take place. To evaluate the impact of health education, one must first determine whether newknowledge is acquired, then whether attitudes and behaviors change. Obviously, these changes take place gradually, if at all.

There are a number of reasons why it is hard to change people's habits, particularly those, which have been practiced for a long time. The following are some sources of resistance.1. Behaviors are often learned when very young, so that one acquires habits without knowing or

questioning their rationale.2. After performing the same action for a long time, the behavior is over learned and subsequently

performed automatically without thinking.3. People feel secure doing what is familiar; they feel insecure doing something new.4. Doing what everyone else does, at the same time and place, provides one with the opportunity

for social interaction.5. If one does what everyone else is doing, it implies that the behavior is correct, i.e., agreemen

implies validation.6. People may fear disapproval and rejection if they change to a new behavior.7. People find it hard to admit that their parents and other respected people and traditions are

wrong, especially if one is strongly attached to these people and traditions.




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In addition to these general sources of resistance, there are many reasons why health education as it istypically given at health institutions is unsuccessful. Some of these reasons concern characteristics ofthe communicator, the receiver, or the message itself. For example, the communicator should be well-liked (popular) and have a reputation for successfully treating patients in order to be credible and inorder to be identified with. A communicator who does not express respect for understanding of peoplewill not be listened to. Communicators who advocate new behaviors that are culturally unacceptableare dismissed as insulting and not credible. Listeners may believe that forces outside themselvescontrol their health and illness, e.g., change events, supernatural forces, or health professionals, andconsequently do not feel that their own behaviors make a difference. Listeners are not interested andtherefore do not attend to the talk if the topic is not the priority. Listeners have not usually attendedformal school and so are unused to acquiring new information through the lecture format. Thecommunication itself is usually in lecture format; it is too long in duration; it uses words rather than pictures or concrete demonstrations; the works are often abstract medical jargon; it is impersonal andaddressed to a large audience; it is only interested in informing, not in understanding the receiver's point of view.

To overcome some of these problems, one could try the following alternatives:

1. Concerning the COMMUNICATOR: To give health education, use most often a local

popular health worker who has some experience in curative work with the people. Ask peoplein the audience what are their health priorities among a list of topics that could be coveredCover these topics only. After each topic, ask if people want to know more about X Y or ZAsk the names of individuals, introduce oneself, and look at each person as if he/she mattered -- because they do. Offer something to each attendee, such as water to drink in case they arethirsty after walking, or water to wash their hands and the face and eyes of their children. Ifyou give the water to each person yourself, you will be able to meet and greet each individual.

2. Concerning the COMMUNICATION: It is very important that the communicator practicespeaking to improve their delivery. Focus on 2 or 3 topics at most, ones that are relevant to theaudience, e.g., for women, ask if they want to hear about EPI, nutrition, child diseases and

home treatment, or pregnancy. Within each topic, give 3 or 4 key items of information onlyThe book Facts for Life, produced by WHO and UNICEF and for which there is an Amharictranslation, provides the day information to communicate regarding health. The messageshould be short, repetitive, and use lay language. Alert people to integrate services andencourage them to ask for all the necessary services for themselves and their families while theyare now here. Give positive feedback to mothers by telling them something good that youknow about their health practices and concerns, e.g., I know that you are good mothers becauseyou breast feed your babies. Give positive to their children, which the mothers will feevicariously, such as weighing children in front of the audience and praising him/her for havinga healthy baby, or checking eyes and praising them for having clean bright eyes. Rather thanalways giving a lecture, show objects that you are talking about and demonstrate the activities.

3. Concerning the RECEIVER: Form smaller groups, say of 5 or 6 people, to give a talk to.Giving an 8-minute talk to 5 people rather than a 40-minute talk to 25 people will be muchmore effective. This way you can even have enough personal contact with your listeners to askthem if they have any questions and to answer their question in a more personal manner. Youcan at the same time give them more confidence that they can control their own health andillness rather than relying on external forces. This creates self-reliance. Target certain groupswho are similar in their priorities and education level.

Other settings besides health institutions can also be used for effective health education, partly becausegroups in these settings may have similar priorities. For example, CHAs can give health education to




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community meetings and during their home visits. Work places, military camps, prisons and schoolsare also good because places for health education because the people there have similar health problems and priorities. At schools, children are used to the lecture format; children are also moremalleable. They also look up to teachers, health professionals and police, who can teach them abouthealth and avoiding injuries. Children can also be involved in community health activities such asreminding parents and neighbors about the upcoming immunization session in their community,collecting materials for a latrine or planting a garden at their school, or cleaning up garbage in thetown.

When reading literature on health education, one must be aware that there are some importantdifferences between results of health education in developed and developing countries. For one, ruraluneducated people have more external locus of control, and so they need education on the fact that theycan control their health even before starting health education. Secondly, they are less concerned aboutapparent inconsistencies in their health beliefs. For example, they are not bothered by theinconsistency of believing in both bothering by the inconsistency of believing in both modern andtraditional cures for illness. Consequently, there may be little point in trying to eliminate theirtraditional beliefs unless they are harmful. Finally, they may respect or fear health professionals, butonly to the extent that they listen but not follow what to tell them. The respect that leads toidentification and adopting your suggested changes is based on liking and not fear. To be a good role

model you must gain their trust and also act in accordance with your words. It is not enough to simplytell people what to do.

The following are five strategies for learning new health behaviors and maintaining them:1. Observational learning and Imitation. One learns new behaviors by watching a role model

At a later appropriate time, one can imitate what one has learned. This is an important strategyfor acquiring new practices.

2. Rehearsal and Reward/Punishment. Practices will likely be perfected and maintained if one practices them often and is rewarded for the practice. If children practice cleaning theischoolyard and classrooms and using the school latrine, they may continue the practice at home

If children are given stars for good hygiene, they and their parents feel rewarded. Punishmentsuch as elimination of sugar rations can also be effective but should only be used whennegligence is the cause of noncompliance, such as when a mother has been informed and giventhe opportunity to immunize her children but has neglected to do so. This strategy is alsorelevant to changing practices.

3. Communication and Persuasion. This is the attempt to change knowledge and attitude byimparting information. The communication may arouse fear and then show the person how toreduce their fear by performing the health behavior. Fear about the consequences of smokingnot immunizing, having multiple sex partners can be aroused with the help of vivid pictures ofwhat can happen. Immediately after, one should provide the opportunity to reduce their fear bydescribing appropriate practice.

4. Dissonance Reduction. Dissonance is the state of tension aroused by performing practicesinconsistent with one's knowledge and attitudes. By getting mothers to immunize their children before they have the correct knowledge or attitude, they will be more receptive to the healtheducation you give them at this time about the reasons for immunization. By havingadolescents boys give a talk to their classmates or to other classes about AIDS and the use ofcondoms, they will begin to change their own attitudes about safe sex. This strategy is based onthe idea that a change in practice will lead to a change in knowledge and attitude if the correctknowledge is available when the new practice is being performed. It is the reverse of the usualhealth education strategy, which tries to change knowledge and attitude first and then, waits for




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the practice to change. It may also be quicker.

5. Social Pressure. Influence form respected leaders of the community can be brought to bear tomake sure people maintain the changes you have brought about through health education.Religious leaders or community elders can exert effective social pressure. Conformity is thetendency to go along with others because of social pressure.

6. Problem Solving. Focus groups and dyads of mothers or spouses are an excellent social

context to encourage people to identify obstacles that interfere with their practicing good health practices. They can then generate solutions and evaluate how well they could implement thesesolutions in their daily lives. This helps to develop skills at solving daily problems and givesthe participants the feeling of controlling their own lives. Very often they can do this withoutmuch input from an expert.




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X. SOCIAL MARKETING

(Getting and Keeping People Involved in a program)

After putting a great deal of work and energy into planning a health promotion program, plannersnaturally hope that the target population will want to participate in it. Then also hope that, onceinvolved in the program, the participants will want to continue with the program for its durationHoping is not enough, however. Planners must not just hope these things will occur, but work to makesure they occur. Planners need to have skills in marketing and psychology in order to get the target population involved and keep them involved. Only when the participants continue the behavior learnedin a health promotion program over a long period of time can the health goals of both the individualand the program be met.

MARKET AND MARKETING

For the purposes of program planning, the people in the target population make up the market. Kotlerand Clarke (1987,p.108) have defined market as "the set of all people who have an actual or potentialinterest in a product or service." A key to getting and keeping these people involved in a health

promotion program is to be able to market the program effectively. The process of marketingoperates on the underlying concept of the exchange theory.

"Marketing is the planned attempt to influence the characteristics of voluntary exchange transactions -exchanges of costs and benefits by buyers and sellers or providers and consumers. Marketing isconsiderably different from selling in that selling concentrates on the needs of the producer (to sellmore products), whereas marketing, which may have the same ultimate objective, concentratesnecessarily on the needs of the buyer or the public".

Applying the definition of marketing to health promotion suggests that program planners would like toexchange costs and benefits with those in the target population. That is to say, program planners would

like to exchange the benefits of population. That is to say, program planners would like to exchange the benefits of participation in health promotion programs (the objectives or outcomes of the programsthey planned), such as "a longer healthier life, looking and feeling better, and having fewer buthealthier children" for the costs of the program, which come from the participants, such as time,money, and effort.

Health promotion programs are social programs, as such; they do not have material objects to market, but instead must market awareness, knowledge, skills, and behavior. The marketing of healthpromotion programs falls into a special type of marketing called SOCIAL MARKETING. Socialmarketing is distinguished by its emphasis on so-called non-tangible products - ideas, attitudes, lifestylechanges - as opposed to the more tangible products and services that are the focus of marketing in business, health-care, and nonprofit service sectors.MARKETING AND THE DIFFUSION THEORY

One analytical tool that has been most useful in understanding the importance of marketing principlesis the diffusion theory (Rogers, 1962). The theory provides an explanation for the diffusion ofinnovations (something new) in populations; stated another way; it provides an explanation for the pattern of adoption of the innovations. If we think of a health promotion program as an innovation, thetheory describes a pattern the target population will follow in adopting the program.

The pattern of adoption can be represented by the normal bell-shaped curve (Rogers, 1983) (Figure11.1) Therefore, those individuals who fall in the portion of the curve to the left of minus 2 standard




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deviations from the mean (this would be between 2% and 3% of the target population) would probably become involved in the program just because they had heard about it an wanted to be first. These people are called innovators. They are venturesome, independent, risky, and daring. They want to bethe first to do things, and others may not respect them in the social system.

The second groups of people to become involved are those represented on the curve between minus 2and minus 1 standard deviations. This group would include about 14% of the target population; buthey are not the first to sign up. They wait until the innovators are already involved to make sure theinnovation is useful. Early adopters are respected by others in the social system and looked at asopinion leaders.

The next two groups are the early majority and the late majority. They fall between minus 1 standarddeviation and the mean and between the mean and plus 1 standard deviation on the curve, respectively.Each of these groups comprises about 34% of the target population. Those in the early majority may be interested in the health promotion program, but they will need external motivation to becomeinvolved. Those in the early majority will deliberate for some time before making a decision. It wiltake more work to get the late majority involved, for they are skeptical and will not adopt an innovationuntil most people in the social system have done so. Planners may be able to get them involvedthrough a peer or mentoring program, or through constant exposure about the innovation.

The last group, the laggards (16%) are represented by the part of the curve greater than plus I standarddeviation. They are not very interested in innovation and would be the last to become involved in newhealth promotion programs. Some would say that this group would not become involved in health promotion programs at all. They are very traditional and are suspicious of innovations. Laggards tendto have limited communicating networks, so they really do not know much about new things.

As time passes, the number of adopters of an innovation increases. Figure 11.2 presents an S-shapedcurve showing the cumulative prevalence of adopters at successive points in time.

The real plus of using the diffusion theory when trying to market a health promotion program is that

"the distinguishing characteristics of the people who fall into each category of adopters frominnovators to early adopters to middle majority categories to late adopters (laggard) tend to beconsistent across a wide range of innovations" (Green, 1989, March). Therefore, differentmarketing techniques can be used depending on the type of people the program planners are trying toattract to a program.

THE MARKETING PROCESS AND HEALTH PROMOTION PROGRAMS

If everyone in a given population were an innovator or early adopter there would be no need formarketing plans. Since that is not the case, there is a need for program planners to understand themarketing process and be able to apply its principles.

Syre and Wilson (1990) have identified five distinct functions of the marketing process as they relate tothe health care field. These include:

1. Using marketing research to determine the needs and desires of the present and prospectiveclients from the target population.

2. Developing a product that satisfies the needs and desires of the clients.3. Developing informative and persuasive communication flows between those offering the

program and the clients.4. Ensuring that the product is provided in the appropriate form, at the right time and place, and a

the best price.




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5. Keeping the clients satisfied and loyal after the exchange has taken place.

SUMMARY

An important aspect of any health promotion program is being able to attract participants initially andto keep them involved once they have begun the program. An understanding of the diffusion theory ishelpful in determining strategies for marketing a program. The actual marketing mix for a programshould take into account the four Ps of marketing: product, price, placement, and promotion. Speciaattention should be given to segmenting the target population. Once people are enrolled in a program,they need to be motivated to remain involved. Strategies of contracts, social support, mediarecognition, incentives, and competition can be most helpful in motivating people to continue their participation in a program.




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VI. RESEARCH METHODS IN BEHAVIORAL

SCIENCES: QUALITATIVE STUDIES

Qualitative research is a type of formative research that offers specialized techniques for obtaining in-depth responses about what people think and how they feel . It enables program management to gaininsight into attitudes, beliefs, motives and behaviours of the target population. When applied properlyqualitative techniques are used along with quantitative techniques in a manner that is interrelated ascomplementary. By its very nature, qualitative research deals with the emotional and contextual

aspects of human response rather than with objective, measurable behaviour and attitudes . Qualitativeresearch is conducted to answer the question "why" whereas quantitative research addresses questionsof "how many?" or "how often ?" The qualitative research process is one of discovery; the quantitativeresearch process pursues proof .

Additionally, qualitative research is not simply the qualitative techniques for eliciting responses but thequalitative nature of the analysis required to apply it. Qualitative research is interpretative rather thandescriptive. It involves small numbers of respondents who are not generally sampled on a probability basis. No attempt is made to draw firm conclusions or to generalize results to the population at large.

The two primary qualitative research techniques are:

1. individual depth interviews, and2. focus group discussions.

A. WHY USE QUALITATIVE RESEARCH ?

There are both conceptual and practical reasons for using qualitative research. The primary conceptuareason for using qualitative research is that it provides greater depth of response and, therefore, greaterconsequent understanding than can be acquired through quantitative techniques. In additionqualitative techniques, particularly one-on-one interviews, enable the researcher to tie together clustersof behaviour that relate to a given consumer decision or action--for instance, when a program mangerwants to know how the decisions were made to use an ORS product.

Another conceptual reason for using qualitative techniques has to do with the nature of qualitativeresearch itself and how it relates to the decision process in research. It can be argued that thequalitative research process and the broader formative process both retain major subjective or intuitiveelements. The initial steps in the formative research process-- that is, defining the problem andinformation needs, formulating hypotheses and defining variables-- are all essentially intuitive andtherefore qualitative in nature.

In addition to the above, there are many pragmatic reasons for using qualitative research methods.

1. Cost . In general, qualitative research is more economical than quantitative research.

2. Timing . Some qualitative techniques, particularly focus groups, can be executed and analyzedquickly without the necessity of data processing capabilities.

3. Flexibility. The study design can be modified while it's in progress.

4. Direct link with target public. Qualitative techniques give program management theopportunity to actually view and experience the target groups directly.

5. Lack of technical facilities. Qualitative research can be done in areas where no computer orother technical facilities are available.




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B. PROBLEMS WITH QUALITATIVE RESEARCH

One major problem exists with qualitative research; that is that it is often applied inappropriately. Inother words, qualitative research will sometimes be used when a quantitative technique is moreappropriate. Or, qualitative research will be analyzed as if it were a quantitative study, drawing hardand fast conclusions or projecting responses instead of developing hypotheses and gaining insights.

Another problem with qualitative research is related to its subjectivity. Since it is highly dependantupon insight and interpretation, qualitative research also is highly susceptible to subjective bias on the part of the researcher or observers. Because no hard data analysis is conducted, it is very difficult toverify whether the analysis of a qualitative research project is correct or not . And, because of thenature of qualitative techniques themselves, it is even difficult to determine if the research is beingconducted properly. Finally, because qualitative research has a high degree of flexibility and does notrequire a highly structured questionnaire format, it can allow the researcher or program manager to beundisciplined and not fully think through the research issue.

Much controversy has long been associated with qualitative research as a result of the potential pitfalls.A good deal of discussion in the research field centers on how to ensure the quality of qualitative

research, yet users and practitioners still do not agree on many of its aspects.

C. HOW IS QUALITATIVE RESEARCH USED ?

Qualitative research is used largely in the following four general ways.

1. An idea generation tool

♦ To stimulate ideas by providing program management with firsthand experience inobserving and hearing the target population, observing them interacting with the product and listening to their language about the issues. This behaviour and language

may be quite different from that used or imagined by the program manager.♦ To develop new ideas for the communications strategy, positioning and execution.

♦ To explore communications in order to learn what ideas and messages are perceivedfrom visual or verbal stimuli such as advertising, brand names, packaging and posters.

♦ To explore a category which is relatively unknown and for which the researcher isunable to provide the specifics required to develop a quantitative study.

2. A preliminary step to aid in the development of a quantitative study

♣ To develop hypotheses about the thought and decision making processes of the target population as they relate to the product or issue being researched.

♣ To specify particular information needs for the quantitative study.

♣ To help identify the types of people to be interviewed in the quantitative study--forexample, the primary and secondary target populations and the relevant decisionmakers.

♣ To aid in the development of question wording and sequencing--for example, to identify




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all of the attributes of a particular product which should be included in the quantitativequestionnaire.

♣ To assist in problem identification and definition--for example, to develop hypothesesabout the reasons for a sudden drop in usage of a particular product.

♣ To select and refine materials for a larger quantitative study - for example, qualitativeresearch can be used to reduce the number of concepts being evaluated or to refine theconcepts prior to going into the quantitative phase.

3. As follow-up to aid in the understanding of the results of a quantitative study

♠ Explain, expand and illuminate quantitative data--for example, to understand thereasons for an unexpected finding.

♠ To gain some understanding about the reasons for certain trends for example, tounderstand why mothers who have tried ORT are not reusing it.

♠ To describe the factors which are affecting an attitude change--for example, to

illuminate why one particular piece of advertising or promotion is more persuasive tothe target audience.

4. The primary data collection method

_ Some research problems do not lend themselves easily to a quantified approach andtherefore, qualitative research may be used as the primary data collection strategy.

Three Keys to Successful Qualitative Research

First, the research must develop the art of asking "why ?"

Second, the researcher must develop the art of listening.Third, the researcher must approach the research as a creative process of investigation.

The art of listening takes time and practice to develop fully. Qualitative researchers must be acutelyaware of the fact that accurate listening is extremely difficult and that listeners often make errors ofwhich they are not conscious. Truly creative listening requires a high degree of sensitivity, intuitionand reflection as well as accuracy.

Qualitative research, then, is very much like the investigatory process that would be carried out by adetective. Although there are some specific techniques and standard questions are almost alwaysapplied, the key to getting the right answer is to adapt and create the process to suit the specificresearch issue. It generally does not work to apply an "Off-the-shelf" approach. Just as no two crimesare alike, no two qualitative research projects are alike. A high level of creative thinking must beapplied to each new situation if the qualitative research process is to be truly successful.

Distinctions of qualitative and quantitative research

QUALITATIVE QUANTITATIVE

Depth of understanding ------------ Level of Occurrence




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"Why" ------------ "How Many?""How often?" etc.

Motivations ------------ Actions

Subjective ------------ Objective

Discovery ------------ Proof

Exploratory ------------ Definitive

Gains insights int. ------------ Measures level of...

Interpretive ------------ Descriptive




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Summary of Qualitative research applications

┌──────────────────────────┐│EARLY EXPLORATION FOR DEA ││GENERATION AND DIRECT EXP-││ERIENCE OF TARGET POPUL- ││ATION │└────────────┬─────────────┘

││

┌───────────────────────────┐ │┌──────────────────────────┐│PILOT FOR QUANTITATIVE │ │ │ EXPLAIN,UNDERSTAND AND ││STUDY: │ │ │ ILLUMINATE QUANTITATIVE ││EXPLORATION,HYPOTHESIS │ │ │ BEHAVIORAL AND ATTITUDE ││DEVELOPMENT,LANGUAGE │ │ │ DATA │

└────────────┬──────────────┘ │└─────────────┬────────────┘

│ │ │ │ │ │

└──────────────┐ │ ┌────────────┘│ │ │┌───────────────┐ │ │ │ ┌────────────┐│IDENTIFY INFO- │ ┌───────┴───┴──┴─────────┐ │ ││MATION NEEDS │ │ │ │UNDERSTAND ││OF POTENTIAL │ │ QUALITATIVE │ │TRENDS ││TARGET SEGMENTS├───┤ RESEARCH ├────┤IN BEHAVIOUR││ │ │ APPLICATIONS │ │OR ATTITUDE ││ │ │ │ │SHIFTS │└───────────────┘ │ │ │ │

│ │ └────────────┘

└────────┬──┬┬───┬───────┘│ ││ │┌──────────────┘ ││ └─────────┐

┌────────────┴───┐ ││ ┌───────────┴──────────┐│PROBLEM IDENTI- │ ││ │HELP DEVELOP COMMUNI- ││FICATION AND │ ││ │CATION STRATEGIES, ││DEFINITION │ ││ │CONCEPTS AND ││ │ ││ │TREATMENTS ││ │ ││ │ │└────────────────┘ ││ └──────────────────────┘

┌──────────────┘│┌─────────────────┴───────────┐ └──────┐│ TIE TOGETHER CLUSTERS OF │ ┌────────┴──────────────────────┐│ BEHAVIOUR ON AN INDIVIDUAL │ │OBTAIN INFORMATION FROM SMALL, ││ BASIS │ │"ELITE"SAMPLES ││ │ │ │└─────────────────────────────┘└───────────────────────────────┘ D. THE TWO MAJOR QUALITATIVE METHODS

Two leading qualitative research techniques are individual depth interviews and focus groups




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discussions. Focus groups capitalize on group dynamics and allow a small group of respondents to be guided by a skilled moderator into increasing levels of focus and depth on the key issues of theresearch topic. They are by far the most widely used qualitative technique. Individual depthinterviews, like focus groups, are characterized by extensive probing and open-ended questions, butthey are conducted on a one -on-one basis between the respondent and a highly skilled interviewer .

When to use individual in-depth interviews

Although individual depth interviews are less widely used, there are specific circumstances for whichthey are particularly appropriate. These includes and practices regarding the treatment of diarrhoeadisease.

Highly sensitive subject matter . Conducting a study among women who have had an abortionregarding their feelings about sexuality and family planning.

Geographically dispersed respondents. Conducting a study among population by policy makersregarding their reactions to a document on child spacing and maternal health.

Peer pressure. Conducting a study among consumers to obtain their reactions to a potentially

controversial advertisement where a "social desirability" response might cloud the real persuasive power of the message.

When individual depth interviews are being considered as the research technique, it is important tokeep several potential pitfalls or problems in mind.

_ There may be substantial variations in the interview setting . Depth interviews generally take place in a wide range of settings and therefore limit the interviewer control over theenvironment. Interviews conducted in a hospital or at a store may have to contend with manydisruptions, all of which inhibit the acquisition of information and limit the comparability ofinterviews.

_ There may be a large gap between the respondent's knowledge level and that of the interviewer Individual depth interviews are often conducted with knowledgeable respondents (Such as physicians) yet administered by less knowledgable interviewers. Therefore, some of thresponses may not be correctly understood or reported. This type of "elite" respondentgenerally also has a greater desire to speak beyond the limits imposed by the interviewer and toseek more interaction with the interviewer, compounding the problem even further.

_ The potential for sponsor observation and feedback is limited . As there generally is no sponsorobserving the interviews, the feedback procedure either does not exist or takes considerablylonger to conduct. Debriefing the interviewers after each of the initial interviews is conducted(So that changes can be made) is a time-consuming process.

Additionally, there also are some key interviewer behaviours which are important to the success ofconducting depth interviews and which should be kept in mind. It is important that the interviewer beable to:

1. accurately receive the information;2. accurately recall the information;3. critically evaluate the information; and4. act upon the information as it is received to regulate the interview process.




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Accurately receiving the information can be inhibited by interviewer fatigue, interviewer boredom,interviewer bias or expectation of answers, interviewer preoccupation with taking notes, and bytechnical language foreign to interviewer. Steps should be taken to avoid these problems if possible.

Accurately recalling the information can be inhibited by a confusion of content between interviews,selective retention on the part of the interviewer, and by the interviewer's attempt to retain too muchinformation.

Critically evaluating information during the interview is a function of the interviewer's ability toidentify the actual level of richness of the content being provided. It is important that the interviewersteer the respondent away from irrelevant information and induce richness when superficial answersare being provided.

Acting upon the information being received and altering the interview process as it occurs is important both within a given interview as well as across the series of interviews. The ability of the interviewerto regulate the interview within a given interview is really an issue of probing, focusing and staying ontrack with respect to the interview objective. Regulating or altering the process across a series ofinterviews is a matter of assessing information that has been accumulated from one interview to the

next in order to refine the interview guide and make it more responsive to the overall objectives of theresearch.

When to use Focus groups ?

Focus groups are far more widely used than individual depth interviews. The key reasons why focusgroups are selected more often as the qualitative technique include:

Group interaction. Interaction of respondents will generally stimulate richer responses and allow newand valuable thoughts to emerge.

Observation. The sponsor can observe the discussion and gain "first hand" insights into the behaviours,attitudes, language and feelings of respondents. This is particularly important in the early, "creative"stages of program development.

Cost and timing . Focus groups can be done more quickly and generally less expensively than a series ofdepth interviews.

Specific applications of focus group research:

Idea generation. A group discussion is conducted among pharmacists or physicians to generate newideas for an improved ORS product (food additives, vitamin A additives, flavour additives, etc.) Agroup works best to build on ideas generated.

Package design screening . Alternative package designs, either in concept or in prototype form, are presented to potential user groups to reduce the number of concepts to a smaller amount for aquantitative test. A group works best because design personnel can be present to view the group.

Evaluation of message concepts. Messages in some rough, pre-production form are presented to potential target audience groups for evaluation and refinement. A group works best because creative personnel can be present to view the group.

Problem identification and definition. A group discussion is conducted among condom users to




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generate hypotheses about why a successful condom brand failed when introduced into a new region.groups work best to get a quick reading before planning a quantitative study.




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WHICH TO USE: FOCUS GROUPS OR INDIVIDUAL DEPTH INTERVIEWS ?

Issue to Consider Use focus groups when.. Use individual depth interviews when..

Group Interaction ...interaction of respondents ...group interactionmay stimulate a richer is likely to be limitedresponse or new and valuable or non-productive.thoughts.

Group/Peer ... group/peer pressure ..group/peer Pressure pressure will be valuable in would inhibit responses

challenging the thinking and cloud theof respondents and meaning of results.illuminating conflictingopinions.

Sensitivity of ...Subject matter is not ...subject matter issubject Matter so sensitive that so sensitive that

respondents will temper respondents would be

responses or withhold unwilling to talkinformation. openly in a group.

Depth of individual ...the topic is such ...the topic is suchResponses that most respondent that a greater depth

can say all that is of responses per relevant or all that individual is desirable;they know in less as with complexthan 10 minutes subject matter and

very knowledgeable respondents.

Interviewer ...it is desirable to ...it is desirablefatigue have one interviewer to have numerousconduct the research; interviews on theseveral groups will project. One interviewer not create interviewer would become fatigued or boredfatigue or boredom. conducting the interviews.




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TABLE Continued

Issue to consider Use focus groups ... Use individual depth

interviews when...

Stimulus ...the volume of ...a larger amountmaterials stimulus material of stimulus material

is not extensive. must be evaluated.

Continuity of ... a single subject ...It is necessaryInformation area is being examined to understand how

in depth and strings attitudes and behaviorsof behaviours are less link together relevant. on an individual

pattern basis.

Experimentation ...enough is known to ... it may be necessarywith interview establish a meaningful to develop the interview guide byguide topic guide. altering it after each of the initial

interviews.

Observation ...it is possible and ..."first hand" consumer desirable for key information isdecision makers to not critical or whenobserve "first hand" observation is notconsumer information. logistically possible.

Logistics ...an acceptable number ...respondents aretarget respondents can geographically be assembled in one dispersed or not

location. easily assembledfor other reasons.

Cost and ...quick turnaround ...quick turnaroundTiming is critical, and funds is not critical and

are limited. budget will permit higher cost.




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A Summary of specific applications

Individual Depth Interview Focus Groups

Complex subject matter and Idea generation.knowledgeable respondents.

Highly sensitive subject matter. Package design screening.

Geographically dispersed Evaluation of messagerespondents. Concepts.

Peer pressure. Problem identificationand definition.

E. GROUP DISCUSSION TECHNIQUES

Many focus group techniques have evolved over time. Broadly, the difference between those

techniques relate to:1. different moderating approaches;2. functional group differences;3. structural group differences; and4. the variety of processes which have emerged to address specific marketing or informational

need.

Moderating approaches to focus groups

There are two primary aspects of the moderating approach. First, the questioning technique can beeither directive or non-directive. Second, the flow of the focus group can be either structured or non-

structured.1. Questioning Technique

A directive moderating approach uses questions which are very pointed and which specifically restrictthe range of responses which might arrive. This questioning technique is used only when the objectiveof the focus group is very narrowly defined.

A non-directive moderating approach uses questions which are open ended and non-biasing. This typeof question permits respondents' honest feelings to emerge, minimizes the moderator's influence andhelps to eliminate later confusion in separating fact from fiction of what was said in the group. Thistype of questioning is almost always the best style to use when conducting focus groups.

2. Focus Group Flow

In a structured focus group the moderator works from a prepared topic guide which contains the issuesto be addressed and the specific areas for probing . The topic guide ensures that all areas relevant to theresearch objectives are covered. The probing outline ensures that the specific information needs ofmanagement are met in each topic area. Structured focus groups are readily compared across a seriesof groups.

A non-structured focus group is conducted using a very sketchy topic guide. The group participants




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themselves largely determine the content and flow of the group. The rationale for conducting this kindof group is that it eliminates moderator-management judgment as to what issues are salient. This styleis rarely used as it often misses many important information needs of program management. It issometimes used in the early problem-definition stage of a project when no prior research has beenconducted and when management has little experience with the subject and has no hypothesesregarding the relevant issues of the subject.

Except in unusual situations, focus groups should use the non-directive, structured moderatingapproach. In practice, most effective groups are actually semi-structured --the moderator is skilledenough to cover all of the issues in the structured topic guide while maintaining a flexible flow ofconversation; a conversation which pursues issues as they are mentioned by respondents and relevantnew topics as they arise.

2. Functional group differences

The type of focus group being conducted is determined by the group's purpose-- what it is intended toaccomplish. Traditionally, groups have been divided into three broad categories:

Exploratory groups. The purpose of the group is to generate ideas or to stimulate a rich level of

respondent thinking on specific topics. the moderator generally plays an active role, encouragingrespondents to build on each others ideas. It is often used to help design a quantitative study.

Clinical . The purpose of the group is to uncover the psychological and sociological motivations forattitudes and behaviour . Projective techniques are often used, and analysis relies on clinical judgement. Clinical groups have limited use in marketing; however, the approach may be very usefulto enhance and expand the understanding of previous research findings.

Phenomenological . The purpose of the group is to provide researchers with a direct link to the target population as they describe in detail and in their own language, their thinking and behaviour in real-lifesituations and decision making. Such a group is generally more focused and generates more concrete

specific responses such as reactions to products, packaging concept statements, communication andother stimuli.

3. Specialised Group Processes

Over time, special qualitative techniques have been developed or modified to suit the needs ofresearchers in the field of marketing. These include:

a. The Laddering Technique

In this technique, the line of questioning proceeds from product characteristics to user characteristicsFor example, the method might begin by asking respondents to indicate how one product or behaviourdiffers from another to identify key variables such as "easier to use". That reason is then probed todetermine what is important about it--what its benefit to the user is. For example, "Doesn't take timeaway form household chores". That answer is then probed until multiple layers of underlying benefitsare elicited. This is often referred to as "tapping into the user's network of meanings," and is meant touncover deeper levels of benefits and barriers.

b. Hidden Issue Questioning

This technique focuses on individual respondents' feelings about sensitive issues in their lives




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Common themes which surround a particular topic such as child care or sexual intimacy are drawn outso that intimate personal issues are developed into widely shared, sensitive life themes. The procedurecalls for individuals to construct specific "best case" and "worst case" scenarios about topic areas sothat their daydreams, anxieties and hopes are brought to the surface-- for example "what was thehappiest time in your life?" or "what would you do with your time if you were given 5 milliondollars?"-- with probing the answer to these questions represent significant leverage points formotivating behaviour.

c. Symbolic Analysis

This technique calls for researchers to examine how consumers perceive the opposites to the behaviouror product under study. For example , in order to learn about diseases, medical researchers often studyhealth and well-being. There are three ways to study such opposites. The first is to investigate non-usage. For example, the research might ask "what is someone like who never uses this?" or "Whawould it be like if you could no longer use this?" The second way is to imagine a "non-product" or anon-version of the existing one, like "nonfattening" or"nonalcoholic." A third way to study opposites isto investigate perceptions regarding opposite types of products. For example, the opposite of ice creammight be yogurt because it is less fattening, or it might be soup because "a good meal begins withsoup." Understanding how respondents determine opposites unlocks keys as to the real meaning of the

product or issue.

4. Projectable techniques

A projectable technique is an instrument which obtains responses in an extremely indirect manner These instruments were devised to overcome the inability or unwillingness of individuals to expresstheir true interests, opinions or motivations in response to more direct questioning . It can reduce the bias of approval-seeking because the respondent does not know exactly what the moderator is goingafter. The most common techniques used by marketing and communications specialists include theThematic Apperception Tests (TAT). Visual stimuli depicting a situation are presented, and therespondent is asked to comment on the situation by explaining it and tell what might have gone on

before and what is going to happen next.Role playing. The respondent is asked to give the opinions and attitudes of other people.

Cartoon Completion. The respondent is asked to complete a cartoon caption which fits the sketch provided or which responds to what another cartoon character has said.

Association. This includes word association and sentence completion techniques where the respondentis asked to give the first word or phrase that comes into his/her head in response to those given by theinterviewer.

5. Structural group differences

In order to meet the objectives of the research, many different focus group formats have evolved.While the application of these new formats is limited, they are worth mentioning briefly.

♣ Traditional groups. An interactive, focused discussion of 8-10 people.

♣ Mini-groups. An interactive, focused discussion of about six people.

♣ Dyadic groups. An intense discussion between two people such as husband and wife or a product user vs.a non-user.




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♣ Family unit, cross-generational groups. An interactive, focused discussion on a topic which ishighly influenced by family ties and values (e.g., child bearing or rearing). The entire family,including the grandparents participate.

♣ Ad labs. Groups designed specifically to create and refine advertising.

♣ Repeat focus groups. Respondents are generally asked to do something between groups such as buy or use a product so that responses can be tied together.

♣ Qualitative panels. These are similar to the above but generally consist of more respondentsare repeated over a longer period of time and are often connected to quantitative studies.

F. THE FOCUS GROUP MODERATOR

The focus group moderator's role is critical to conducting an effective focus group. In selecting themoderator it is important to evaluate:a. personal characteristics;

b. moderating style; andc. experience and background.

1. Personal characteristics

Some individuals simply have the right combination of personal traits and "raw talent" to makeeffective moderators. Things to look for in a potential moderator include:

♦ The ability to feel at ease and comfortable with other people: someone who is relaxed, and un-threatened by personal interaction with others.

♦

The ability to put others at ease: someone others just naturally "open up" too quickly.♦ The ability to project unconditional regard and acceptance of others: someone who is

genuinely non-judgemental or who can appear to be.

♦ The ability to convey warmth and empathy.

♦ Good verbal and interpersonal skills: someone who gets along well in many different situationsand with many different kinds of people and who can use language to seem like "one of them."

♦ Good listening skills: someone who pays close attention to what others say and does not feelcompelled to always inject his/her own thoughts and comments into the conversation.

♦ The ability to project enthusiasm: someone who seems genuinely interested in others andwhose general enthusiasm stimulates heightened interest among others.

♦ An awareness of his/her non-verbal reactions: someone who is capable of maintaining bodylanguage and facial expressions which project the above traits and do not convey annoyance orfrustration.

♦ Someone whose physical characteristics are not threatening, intimidating or off-putting toothers.




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♦ Someone who matches the focus group respondents as closely as possible to facilitate rapport.

2. Moderating style

Styles of group moderating vary greatly. Some moderators facilitate the group discussion by being friendly and involved , others by being more "laid-back". Still other moderators are challenging , almostargumentative in their style. An extremely experienced moderator often can vary his/her style to suit

the type of respondents and the objectives of a group. In selecting a moderator, it is important to beaware that such differences in style exist and to match the moderator style with the needs of the groupif possible.

3. Moderator experience and background

Moderators who have specialized moderating experience dealing with the subject matter to bediscussed (i.e., specific health issues, a specific product) or with the type of respondents (i.e., teens, professionals) generally will be more effective.

The academic background of moderators tends to vary widely. Many are psychologists trained in

group dynamics. In dealing with marketing issues, a moderator with some marketing or social sciencebackground may be useful. In some cases (for example, dealing with underlying motivations on a particular subject) it may be most useful to select a moderator with skill in using projective techniquesor with experience in one of the qualitative approaches develop for that purpose, such as laddering orhidden issue questioning.

Occasionally circumstances are such that an experienced moderator is not available and someone withexperience in the field such as a nurse or other health provider must conduct the group discussions. Inthis case, it may be necessary to stress certain key points to the acting moderator :

A moderator is not a teacher

A moderator is not a judge A moderator does not look down on respondents A moderator does not agree or disagree with what is said A moderator does not put words in the respondents' mouths

Also

The focus group is not a text-- there are no right answers The focus group is not a time to inform The focus group is not a time to persuade

4. Briefing the moderator

Once a moderator is selected, he/she must be thoroughly briefed on the project. This generally occursas the moderator works together with the sponsor to develop the topic guide. If the moderator isworking form an independently prepared topic guide, it will be necessary to brief him/her as to why theresearch is being done, what is to be achieved from the research, and the specific application of theresearch findings.

In order for the interviewer to be adequately briefed for the study, the sponsor of the project should familiarize the moderator with prior research findings, important issues, hypotheses and opinions




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Anything that helps to inform the moderator about the subject area or the sponsor's thinking isimportant and enables a skilled moderator to listen better and to ask meaningful, follow-up questions.Prior information reduces the possibility of exploring directions that have been previously researchedor that are irrelevant to the study objectives.

5. Evaluating the moderators' work

Focus groups are commonly evaluated by the volume of respondent output produced --that is, by themoderator's ability to keep the group actively talking for 60 to 90 minutes. While this is a simple andeasy way of determining if the group was productive, it is far from inclusive or "correct." The quantityof the focus group is,of course, far less relevant than the quality or "richness"of the group. Richnessrefers to findings that are thought-provoking and that communicate much relevant information in a parsimonious fashion. Additionally, the following key points deserve consideration in evaluating afocus group:

Did respondents feel comfortable enough to openly discuss their attitudes ? Were respondents mode aware of the task at hand ? Level of interaction among group members: a true group or ten individual interviews? Did moderator ask questions in an unbiasing manner?

Is the viewer able to tell how the group felt about an issue? Is a substantial amount of post-hoc analysis necessary to separate true respondent feelings from

those expressed due to moderator demands? During the course of a single group, did the moderator demonstrate enough flexibility to pursue

new directions? Across a series of sessions, was each group conducted identically, or did the moderator permit

the discussions to evolve ? Did the moderator exercise the proper amount of control-- loose enough to permit expression

among respondents, yet tight enough to avoid chaos and interruptions ?

G. K.A.P. SURVEYS

Knowledge, attitude and practice are thought to be important determinants of health, in addition to biological and health service factors. Practice refers to health behaviours. The practice may promotehealth and prevent diseases or the opposite. Because favourable health practices contribute to healthand prevent illness, they are of interest to health professionals and may have to be learned or changed ifthey are not already present. Many health educators believe that the best way to teach or change practices is to teach correct knowledge and favourable attitudes, and that good practices will followGenerally, it is assumed that Correct knowledge + Positive Attitudes = Health Practices. Because ofthe importance attributed to knowledge, attitudes and practices in health, researchers want to find outwhat people know, feel, and practice. For these purposes they develop and use KAP questionnairesK.A.P. questionnaires are designed usually in order of P.A.K.

Practice is assessed by asking what the person currently does and giving an exhaustive list of options,to each of which the person responds yes or no. It is possible for a person to report doing several of theoptions in the course of a day or week. Some important guidelines on such questions are: be specificabout behaviour; ask about most recent practice, include all practices not only good ones, and verifythrough observation or questioning. If you include an open-ended question, follow it up with specificresponse alternatives in case the person has not provided you with a complete description.

Attitude is assessed in terms of what the person prefers to do, what they would do if they had thechoice, or how favourable - unfavourable or positive - negative they are to the object.





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Knowledge is assessed in terms of what the person knows about the item and whether this knowledgeis true or false. A good way to do this is to have some open-ended questions, which are respondenmust answer as in a short-answer test, e.g., What is a germ ? This would be followed by a series ofTrue-False Statements or Yes-No-Don't questions to test recognition knowledge. Correct and incorrectstatements must be included in the latter and the respondent is asked to indicate whether a statement istrue or false, or whether the question should be answered Yes or No. The number of correctlyanswered statements is their knowledge score. Some hints: include all relevant knowledge, a pilot testmay be required first and mix correct and incorrect items.

How to develop a KAP questionnaire:1. Define conceptually what is meant by Knowledge, Attitude and Practice. Keep to these

definitions when you make up the items.2. Develop items systematically to include all the relevant ones. This may first require a probing

pilot test with personal or group interviews to elicit the respondents' KAP spontaneously. Thecontent must be complete and include all important practices, attitudes and knowledge.

3. Phrase items in lay terms not in professional terms.4. Combine items that bear on the same practice.5. To improve reliability, include at least 10 items for each K, A, and P. Reduce data by summing

across items. Make sure scoring is appropriate for summing, e.g., 1 point each for each correc

item on the K test, 1 point for each healthy practice, and 1 point for each healthful attitude.6. Order items as follows - PAK - to minimize contaminating P answers with K items.

Critique of KAP studies:

The KAP questionnaire is useful for finding out the Knowledge, Attitude and Practices of a group of people, and identifying those that require change. It is often assumed that K+A=P and that to changeP, one must first change K and A. However, this equation is faulty. Changing K and A does notalways lead to a change in P. Also other variables enter the equation, such as access and socia pressure. Another problem with the KAP questionnaire is that the respondents' answers are often biased by their limited recall and their desire to please the interviewer. Finally, the questionnaires are

limited to KAP that are being questioned; items must be continuously improved to reflect the newsituation. Add items that are found to be predictive of practices, even though they do not fit thecategories of K and A. Ask the respondent to keep a daily record of their practices, rather thanreporting on them from memory.

Lecture Notes on HE

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