Health Promotion and Education

MPH Ist Year

Health Promotion and Education

Prabesh Ghimire


MPH 1st Year

Table of Contents UNIT 1: INTRODUCTION................................................................................................................................................. 4 Concepts of Health Promotion and Education .......................................................................................................... 4 Philosophy of Health Promotion and Education ................................................................................................... 4 Scope/ Settings of Health Promotion and Education ........................................................................................... 7 Principles of Health Promotion and Education ......................................................................................................... 8 Responsibilities and competencies of health promotion and education professionals............................................ 9 Code of ethics and standard for health promotion and education professional .................................................... 10 Role of Theory in Health Promotion: ...................................................................................................................... 11 UNIT 2: National and International Disclosure in Health Promotion and Education .................................................. 12 Historical Developments- Milestones in Health Promotion and Education ............................................................ 12 Overview of International Declarations, Statements, Charter and Recommendations Supporting the Action Areas of Health Promotion................................................................................................................................................ 13 The Ottawa Charter for Health Promotion ......................................................................................................... 13 The Adelaide Recommendations on Healthy Public Policy ................................................................................. 15 The Sundsvall Statement on Supportive Environment ....................................................................................... 16 Jakarta Declaration on Health Promotion .......................................................................................................... 17 The Mexico Charter: Mexico Ministerial Statement for the Promotion of Health ............................................. 18 The Bangkok Charter for Health Promotion in a Globalized World .................................................................... 18 The Nairobi Declaration ...................................................................................................................................... 19 International Union for Health Promotion and Education (IUHPE) ........................................................................ 21 Victoria Health Promotion Foundation ................................................................................................................... 22 UNIT 3: FRAMEWORKS/ MODELS/THEORIES OF HEALTH PROMOTION AND EDUCATION ......................................... 23 Differences between Theories, Models and Frameworks of Behaviour Change (Q: 2072/12)............................... 23 PRECEDE/PROCEED MODEL ................................................................................................................................ 24 Health Belief Model ............................................................................................................................................ 29 Theory of Reasoned Action/ Theory of Planned Behaviour................................................................................ 30 Transtheoritical Model ....................................................................................................................................... 31 Social Cognitive Theory ....................................................................................................................................... 32 Diffusion of Innovation Theory ........................................................................................................................... 33 Roger’s Adoption Model ..................................................................................................................................... 34 Freire’s Model of Adult Education ...................................................................................................................... 35 Kurt Lewin’s Model of Planned Change .............................................................................................................. 36 Cognitive Dissonance Theory .............................................................................................................................. 37

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Theories of Stress and Coping............................................................................................................................. 38 Intervention Mapping ......................................................................................................................................... 39 Multilevel Approach to Community Health (MATCH) ........................................................................................ 40 UNIT4: VARIOUS APPROACHES TO HEALTH PROMOTION AND EDUCATION .............................................................. 41 UNIT 5: Fundamental Factors Involved in Health Education Process .......................................................................... 49 Learning in Health Education .................................................................................................................................. 49 Perception ............................................................................................................................................................... 49 Motivation ............................................................................................................................................................... 51 UNIT6: HEALTH COMMUNICATION ............................................................................................................................. 53 Meaning, Definition, Types, Process and Principles of Communication ................................................................. 53 Behaviour Change Communication and Application............................................................................................... 55 Meaning, Types, Importance and Selection Criteria of Health Education Methods ............................................... 56 Criteria for selecting appropriate methods and media of health education ...................................................... 56 Individual, Group and Mass Methods of Health Education .................................................................................... 57 Individual Methods of Health Education ............................................................................................................ 57 Group Methods of Health Education .................................................................................................................. 58 Mass Methods of Health Education.................................................................................................................... 63 Meaning, Types, Importance and Selection Criteria of Health Education Media ................................................... 64 Audio, Visual and Audiovisual Media ...................................................................................................................... 64 Audio Media........................................................................................................................................................ 64 Visual Media ....................................................................................................................................................... 65 Recent Advances in Use of Social Media (Internet) in Health Promotion and Education ....................................... 70 UNIT 7: SETTINGS IN HEALTH PROMOTION AND EDUCATION .................................................................................... 72 UNIT 8: Roles of Health Education and Promotion in Public Health Programmes ...................................................... 76 Role of Health Education in Primary Health care programs.................................................................................... 76 Role of Health Education and Promotion during emergencies (disasters) ............................................................. 76 UNIT 9: Community Health Development ................................................................................................................... 77 Community organization ......................................................................................................................................... 77 Community Development ....................................................................................................................................... 78 Group Dynamics ...................................................................................................................................................... 81 Miscellaneous.......................................................................................................................................................... 82

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UNIT 1: INTRODUCTION Concepts of Health Promotion and Education Health Promotion “The process of enabling people to increase control over, and to improve, their health”- WHO, 1986 “Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and environmental changes that will improve health” – Green 1980 Health Education Health Education is a process of growth in an individual by means of which he alters his behavior or change his attitude towards health practices as a result of new experiences he has had’. -Dorothy B Nyswander, 1949 Health education is defined as “any combination of learning experiences designed to facilitate voluntary actions conducive to health” (Green and Kreuter 2005). Philosophy of Health Promotion and Education A New Oxford American Dictionary, 2005 defines Philosophy as the study of the fundamental nature of knowledge, reality and existence. Education philosophy helps define views about learners, teachers, and schools. There are three branches of philosophy • Metaphysics: What is the nature of reality? • Epistemology: What is the nature of knowledge? • Axiology: What is the nature of values? Existing stand of health education philosophy/ Philosophical basis of health education (past question2072/3, 2068/7) There are five philosophies of health education. Philosophy Description 1

Cognitive-based

2

Decision-making

3

Behaviour change

4

Freeing/functioning

5

Social change

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Content focused Emphasizes factual information and the expansion of knowledge base of the individual Goal is to increase a person or group’s knowledge, enabling them to make better decisions about their health. Emphasizes critical thinking and lifelong learning Designed to teach systematic problem-solving skills and decision making processes that can be applied to health related decisions Emphasizes behavioural modification through such methods as self-monitoring, behavioural contacts and goal setting. Program objectives are quantifiable and measurable Focuses on freeing people to make best health decisions based on their needs and interests- not necessarily on the interests of society. Designed to help learners make self-directed and autonomous health decisions. Emphasizes concepts of freedom, individuality and lifelong learning Proposes education as a force for achieving social change. Emphasizes the role of health education in creating social, economic and political change that benefit all. Health education is closely connected with emphasis on raising awareness for responsible social action.

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Coherence of philosophy in theories, principle and practice (past question-2072/3, 2068/7) Philosophy - Health education and philosophy are fundamentally inseparable. - Philosophy within an educational context attempts to explain the means and ends of education in order to develop principles and guidelines for practice. - Philosophy results from the sum of knowledge, experience (practices) and principles and helps to address the purpose, parameters, and content of the health education discipline. - The health educator must answer the question, What are the appropriate ways and means of health education in order to receive guidance for educational action? The answer lies in the philosophical approach one chooses and its corresponding underpinnings of theories. Theory - Theory derives from philosophy. - In health education, we are often concerned with theories which describe various elements of human behaviour. Theories typically derive from various disciplines; however, theories from behavioural sciences and psychology have been commonly used to inform practice in health education. - Theories provide explanatory constructs that helps to structure action by identifying key relationships that can be used to explain, predict or change a phenomena. Philosophy and theory are perpetually linked; philosophy influences how one sees the world, theory shapes how one intentionally interacts with that world. A philosophy impacts the definition of important problems and theories provide strategies to arrive at solutions to those problems. Together, philosophy and theory guide principles and practice in health education. Principles and Practice Overall philosophy and theories determine the principles and ethics to be applied to health education and promotion practice. Some of the practical applications of health education theories and philosophy include: - Teaching and learning - Professional practice - Design, implementation and evaluation of educational programs - Conscientization - Research in health promotion and education - Selection and use of educational methods and media, etc.

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Ayurveda and Eastern Philosophy is appropriate to health promotion. Discuss with suitable examples (past question-2072/12) - Eastern philosophy follows the broad traditions which originated from, or were popular within India, China, Japan and South East Asia. There is a major differences between the Eastern (Asian) and Western philosophical approaches to health care and health promotion. In Eastern and Ayurvedic medicine, the emphasis is on health promotion or stabilization, as opposed to Western concepts of illness intervention and treatment of symptoms. - Methods of healing are drastically different, with Western medicine being much more ‘unnatural’ than Eastern. Eastern philosophy uses whole-food formulas to nourish the body’s natural healing abilities, while Western philosophy isolates and forces therapeutic actions to ‘treat’ disease. - Eastern examination works with the elements earth, fire, wood, metal, and water to interpret the relationship between the physiology and pathology of the human body and the natural environment. Western medicine uses vital signs like height, weight, and body temperate, and general appearance for health examination. Due to the harsh, ineffective, and dependency-driven aspects of Western medicine, Eastern medical philosophies are regaining popularity. - In Eastern philosophy, two forms of medicine are widely practiced, an Indian-Ayurvedic medicine and Traditional Chinese Medicine. In both Ayurveda and Chinese philosophies, preventive effect assumes a great importance. The philosophy of eastern medicine is similar to the philosophy of health promotion. - Through analysis of the Eastern medicine, one discovers that the Eastern philosophy is very similar to the theory of health promotion. Their principles fit the concept of health promotion. Ayurveda and TCM are historically of differing origin, but comprise common features. - It is important to note that while Eastern and Western medicine purport to achieve similar objectives – namely, the overall health of an individual – the perspectives and approaches are markedly different. The Western approach attempts to divide a person’s health from the disease, focusing on the elimination of the symptoms of an illness, rather than its root. Contrastingly, the Eastern approach to medicine considers a person’s health as a balanced state, and illness or disease creates

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MPH 1st Year

an imbalance. Eastern philosophy seeks to reestablish the natural, balanced state of the human body through channeling the body’s own healing mechanisms. The contrast in approach leads Western medicine to be reactive, fighting illness and disease after it strikes. Through harmonization, strength, and balance of the body’s natural state, Eastern medicine is preventative, thus helping individual’s avoid illness and disease, while still providing them the tools and combat illness, should it occur.

Scope/ Settings of Health Promotion and Education The settings for health education are important because they provide channels for delivering programs, provide access to specific populations and gatekeepers, usually have existing communication systems for diffusion of programs, and facilitate development of policies and organizational change to support positive health practices. Seven major settings are particularly relevant to contemporary health education: schools, communities, worksites, health care settings, homes, the consumer marketplace, and the communications environment. i. -

ii. -

Schools Health education in schools includes classroom teaching, teacher training, and changes in school environments that support healthy behaviour. To support long-term health enhancement initiatives, theories of organizational change can be used, for example to encourage adoption of comprehensive smoking control programs in schools. Communities Community-based health education draws on social relationships and organizations to reach large populations with media and interpersonal strategies. Community interventions in households, temples/churches, clubs, recreation centers, and neighborhoods can been used to encourage healthful nutrition, reduce risk of cardiovascular disease, and use peer influences to promote breast cancer detection among minority women.

iii. Worksites - Because people spend so much time at work, the workplace is both a source of stress and a source of social support. - Effective worksite health promotion programs can harness social support as a buffer to stress, with the goal of improving worker health and health practices. - Today, many businesses, particularly large corporations, provide health promotion programs for their employees. - Both high-risk and population wide strategies have been used in programs to reduce the risk of occupational diseases. Integrating health promotion with worker safety and occupational health may increase effectiveness. iv. Health Care Settings - Health education for high-risk individuals, patients, their families, and the surrounding community, as well as in-service training for health care providers, are all part of health care today. - The changing nature of health service delivery has stimulated greater emphasis on health education and provider-focused quality improvement strategies in health care organizations, public health clinics, and hospital. - Primary care settings, in particular, provide an opportunity to reach a substantial number of people. Health education in these settings focuses on preventing and detecting disease, helping people make decisions about primary health care, and managing acute and chronic illnesses.

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v. -

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Homes Health behavior change interventions are delivered to people in their homes, both through traditional public health means, like home visits, and through a variety of communication channels and media such as Internet, telephone, and mail.

vi. The Consumer Marketplace - The advent of home health and self-care products, as well as use of “health” appeals to sell consumer goods, has created new opportunities for health education but also can mislead consumers about the potential health effects of items they can purchase. - Social marketing is used increasingly by health educators to enhance the salience of health messages and to improve their persuasive impact vii. The Communications Environment - There have been rapid changes in the availability and use of new communications technologies, ranging from mass media changes to personalized and interactive media and a host of wireless tools in homes, businesses, and communities. - These channels are not settings and can be used in any of the settings described earlier. Yet they are unique and increasingly specialized, providing opportunities for intervention. Principles of Health Promotion and Education The World Health Organization identified seven key principles of health promotion as follows: SN

Principles

Description

1

Empowerment

2

Participative

3

Holistic

4 5

Inter-Sectoral Collaboration Equitable

6

Sustainable

7

Multi-strategy

Health promotion initiatives should enable individuals and communities to assume more power over the personal, socio-economic and environmental factors that affect their health. Health promotion initiatives should involve those concerned in all stages of planning, implementation and evaluation. Health promotion initiatives should foster physical, mental, social and spiritual health. Health promotion initiatives should involve the collaboration of agencies from relevant sectors. Health promotion initiatives should be guided by a concern for equity and social justice Health Promotion initiatives should bring about changes that individuals and communities can maintain once initial funding has ended Health promotion initiatives should use a variety of approaches in combination with one another, including policy development, organizational change, community development, legislation, advocacy, education and communication.

Principles of Health Promotion (Adapted from a Discussion Document on the Concept and Principles of Health Promotion, Copenhagen, 9-13 July 1984) i. Health promotion involves the population as a whole in the context of their everyday life, rather than focusing on people at risk for specific diseases. ii. Health promotion is directed towards action on the determinants or causes of health. Health promotion, therefore, requires a close cooperation of sectors beyond health services, reflecting the diversity of conditions which influence health.

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MPH 1st Year

iii. Health promotion combines diverse, but complementary, methods or approaches, including communication, education, legislation, fiscal measures, organizational change, community development and spontaneous local activities against health hazards. iv. Health promotion aims particularly at effective and concrete public participation. v. Health professionals should work towards developing their special contributions in education and health advocacy. Responsibilities and competencies of health promotion and education professionals Responsibility 1: Assessing individual and community needs for health education  Competency A: Obtain health-related data about social and cultural environments, growth and development factors, needs and interests.  Competency B: Distinguish between behaviour that fosters and that which hinders wellbeing.  Competency C: Infer needs for health education on the basis of obtained data. Responsibility 2: Planning effective health education programs  Competency A: Recruit community organizations, resource people and potential participants for support and assistance in program planning.  Competency B: Develop a logical scope and sequence plan for a health education program.  Competency C: Formulate appropriate and measurable program objectives.  Competency D: Design educational programs consistent with specified program objectives. Responsibility 3: Implementing health education programs  Competency A: Exhibit competence in carrying out planned educational programs.  Competency B: Infer enabling objectives as needed to implement instructional programs in specified settings.  Competency C: Select methods and media best suited to implement program plans for specific learners.  Competency D: Monitor educational programs, adjusting objectives and activities as necessary. Responsibility 4: Evaluating effectiveness of health education programs  Competency A: Develop plans to assess achievement of program objectives.  Competency B: Carry out evaluation plans.  Competency C: Interpret results of program evaluation.  Competency D: Infer implications from findings for future program planning. Responsibility 5: Coordinating provision of health education services  Competency A: Develop a plan for coordinating health education services.  Competency B: Facilitate cooperation between and among levels of program personnel.  Competency C: Formulate practical modes of collaboration among health agencies and organizations.  Competency D: Organize in-service training programs for teachers, volunteers and other interested personnel. Responsibility 6: Acting as a resource person in health education  Competency A: Use computerized health information retrieval systems effectively.  Competency B: Establish effective consultative relationships with those requesting assistance in solving health-related problems.  Competency C: Interpret and respond to requests for health information.  Competency D: Select effective educational resources materials for dissemination.

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Responsibility 7: Communicating health and health education needs, concerns and resources  Competency A: Interpret concepts, purposes and theories of health education.  Competency B: Predict the impact of societal value systems on health education programs.  Competency C: Select a range of communication methods and techniques in providing health information.  Competency D: Foster communication between health care providers and consumers. Code of ethics and standard for health promotion and education professional A code of ethics is a set of guidelines that is designed to set out acceptable behaviour for members of a particular group, association or profession. The Code of Ethics provides a framework of shared values within the professions in which Health Promotion and Education is practiced. Health educators’ work is directly concerned with communities and individuals. It is crucial that the rights and privacy of individuals and communities are respected, and that programmes are developed on an equitable basis, addressing the needs of the most vulnerable population groups and embracing the following principles:  respect for human dignity and rights  client full consent  confidentiality  non-discrimination or stigmatization  equity in access, coverage and service delivery  respect for cultural values and cultural diversity  refraining from conflict of interest, particularly commercial interest  integrity and good personal conduct Although there are no formal ethical codes and standards for health education and promotion in Nepal, ideally all health education professionals should abide by the following guidelines irrespective of job title, professional affiliation, work setting, or population served. i. -

ii. -

Responsibility to the Public Health Education and promotion professional support the right of individuals to make informed decisions regarding their health. Health Education and promotion professional accurately communicate the potential benefits, risks and/or consequences associated with the services and programs that they provide. Health Education and promotion professional are ethically bound to respect and protect the privacy, confidentiality, and dignity of individuals. Responsibility to the profession Health Educators maintain, improve, and expand their professional competence through continued study and education; membership, participation, and leadership in professional organizations. Health Educators contribute to the profession by refining existing and developing new practices, and by sharing the outcomes of their work. Health Educators are aware of real and perceived professional conflicts of interest, and promote transparency of conflicts.

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iii. Responsibility to employers - Health Educators use and apply current evidence-based standards, theories, and guidelines as criteria when carrying out their professional responsibilities. - Health Educators accurately represent potential and actual service and program outcomes to employers. - Health Educators maintain competence in their areas of professional practice. iv. Responsibility in the Delivery of Health Education - Health Educators are sensitive to social and cultural diversity and are in accord with the law, when planning and implementing programs. - Health Educators are committed to rigorous evaluation of both program effectiveness and the methods used to achieve results. - Health Educators communicate the potential outcomes of proposed services, strategies, and pending decisions to all individuals who will be affected. v. -

Responsibility in Research and Evaluation Health Educators adhere to principles and practices of research and evaluation that do no harm to individuals, groups, society, or the environment. Health Educators respect and protect the privacy, rights, and dignity of research participants, and honor commitments made to those participants. Health Educators report the results of their research and evaluation objectively, accurately, and in a timely fashion to effectively foster the translation of research into practice.

Role of Theory in Health Promotion: Various researches indicate that health promotion interventions that apply theoretical principles and associated constructs to their design are more effective than those that do not. This provides a powerful argument for the importance of theory in principles and practice of health education and promotion. One of the greater effectiveness of intervention based on the theoretical principles and associated constructs may be that theories help us understand behaviors and the process by which behavior change may occur. For example, the Theory of Reasoned Action postulates that attitudes and beliefs influence intentions and that positive intentions influence behaviours. Theories describe and explain how and why attitudes, beliefs, and social influences such as friends, family, and the media, as well as the environment, influence our health behaviours and ultimately our health. This information is used to create models that predict future health behaviours and thus are relevant to health promotion efforts in that they identify potential targets for change. A health promotion theory offers a number of benefits and its roles can be seen as the following  Theory serves as a toolbox for moving beyond intuition to designing and evaluating health education interventions that are based on understanding of why people engage in certain health behavior.  Theory also provides foundation for program planning and development that is consistent with the current emphasis on using evidence-based interventions.  It provides a road map for studying problems, developing appropriate interventions, identifying indicators and evaluating impacts.  It helps to explain the processes for changing health behavior and the influences of many forces that affect it, including social and physical environments.  Theory also plays a role in guiding planners identify the most suitable target audiences, methods for fostering change and outcomes for evaluation.

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UNIT 2: National and International Disclosure in Health Promotion and Education Historical Developments- Milestones in Health Promotion and Education SN 1

Year 1978

2

1981

3

1984

3 4

1986 1988

5

1991

6

1997

7

2000

8

2005

9

2009

10

2013

11

2016

Milestones Global meeting of WHO at Alma-Ata, Kazak with the Declaration of Alma-Ata formally adopted Primary Health Care. Health Education was identified as one of its principles WHO Global Strategy "Health for All by the Year 2000" provided the right environment for the concept of health promotion to foster WHO called a special meeting in Copenhagen Denmark to provide some clarity and direction which led to the first substantive document on health promotion First World Conference for Health Promotion (Ottawa Charter) Building healthy public policy was explored in greater depth at the Second International Conference on Health Promotion in Adelaide, Australia. Adelaide Recommendations on Healthy Public Policy was created Third International Conference on Health Promotion in Sundsvaal, Sweden, in 1991 was on creating supportive environments. Sundsvall Statement on Supportive Environments for Health stressed the importance of sustainable development The Fourth International Conference on Health Promotion held in Jakarta, Indonesia. Five priorities were identified in the Jakarta Declaration on Health Promotion into the 21st Century Fifth Global Conference on Health Promotion in Mexico focused on health inequalities both within and between countries. The Mexico Ministerial Statement for the Promotion of Health: from Ideas to Action. Sixth Global Conference on Health Promotion in Bangkok was organized; Bangkok Charter for Health Promotion in a Globalized World identified four new commitments were identified Seventh International Conference on Health Promotion in Kenya resulted in Nairobi Call to Action. Eight Global Conference on Health Promotion; Helsinki, Finland. Health in All Policies Ninth Global Conference on Health Promotion; Shanghai, China. “Healthy Cities, Good Governance and Health Literacy”

Factors that Necessitated the Changes in International Disclosures of Health Promotion International Factors that necessitated corresponding changes Disclosures Ottawa Charter for - This conference was primarily a response to growing expectations for a new Health Promotion public health movement around the world. - It built on the progress made through the Declaration on Primary Health Care at Alma-Ata, the World Health Organization’s Targets for Health for All document, and the recent debate at the World Health Assembly on intersectoral action for health. Adelaide - This conference was an outcome of the need to explore building healthy Recommendations public policy in greater depth.

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Sundsvall Statement on Supportive Environments for Health

-

Jakarta Declaration on Health Promotion into the 21st Century

-

Mexico Ministerial Statement for the Promotion of Health: from Ideas to Action Bangkok Charter for Health Promotion in a Globalized World

-

-

-

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Armed conflict, rapid population growth, inadequate food, lack of means of self determination and degradation of natural resources were among the environmental influences as being damaging to health Convened to allow health professionals from all over the world to consider how environments, whether physical, social, economic, or political, can be made more supportive for health. The evidence found that health promotion strategies can contribute to the improvement of health and the prevention of diseases in developing and developed countries alike. Convened to engaged new players including developing world to meet global challenges. To demonstrate and communicate more widely to developing countries that health promotion action can achieve greater equity in health and can close the health gap between population groups. To address opportunities and challenges of new millennium which were not thought of in 1986 such as the Internet, the human genome project, climate change, terrorism, geopolitical change, third world debt, and of course globalization of people, money, products and services.

Overview of International Declarations, Statements, Supporting the Action Areas of Health Promotion

Charter

and

Recommendations

The Ottawa Charter for Health Promotion The Ottawa Charter for Health Promotion is the name of an international agreement signed at the First International Conference on Health Promotion, organized by the World Health Organization (WHO) and held in Ottawa, Canada, in November 1986. The Charter defined health promotion as Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to wellbeing. The Charter is based on the belief that a secure foundation in society- the fundamental conditions of “peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity” - are prerequisites for health improvement. Strategies for Health Promotion (Q:2072/12) i. Advocacy - Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it. - Health promotion action aims at making these conditions favourable through advocacy for health.

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ii. -

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Enabling Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. This must apply equally to women and men.

iii. Mediating - The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media. - People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health. Areas of Action i. Building Healthy Public Policy - Health promotion puts health on the agenda of policy makers, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. - Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. - Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. - Example: Legislation on tobacco ii. -

-

Creating Supportive Environment The overall guiding principle for the world, nations, regions and communities is the need to encourage reciprocal maintenance - to take care of each other, our communities and our natural environment. Systematic assessment of the health impact of a rapidly changing environment - particularly in areas of technology, work, energy production and urbanization - is essential and must be addressed in any health promotion strategy Example: Development of healthy cities

iii. Strengthen Community Actions - Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities. - There should be flexible systems for strengthening public participation in and direction of health matters. This requires full and continuous access to information, learning opportunities for health, as well as funding support. iv. Develop Personal Skills - Health promotion supports personal and social development through providing information, education for health, and enhancing life skills. - Enabling people to learn, throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home, work and community settings.

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v. -

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Reorient Health Services The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services.

The Adelaide Recommendations on Healthy Public Policy Second International Conference on Health Promotion, Adelaide, South Australia, 5-9 April 1988. It generated a number of recommendations in the pursuit of healthy public policy commonly known as Adelaide Recommendations on Healthy Public Policy and identified four key areas of action. The conference called for a political commitment to health by all sectors. Policy-makers in diverse agencies working at various levels (international, national, regional and local) were urged to increase investments in health and to consider the impact of their decisions on health. Recommendations: Areas of Action The Conference identified four key areas as priorities for health public policy for immediate action: i. Supporting the health of women - Women’s networks should receive more recognition and support from policymakers and established institutions. For their effective participation in health promotion women require access to information, networks and funds. - This Conference proposed countries to start developing a national women’s healthy public policy in which women’s own health agendas are central. ii. -

Food and nutrition The elimination of hunger and malnutrition is a fundamental objective of healthy public policy. A food and nutrition policy that integrates agricultural, economic, and environmental factors to ensure a positive national and international health impact should be a priority for all governments. The Conference recommended governments to take immediate and direct action at all levels to use their purchasing power in the food market to ensure that the food-supply under their specific control gives consumers ready access to nutritious food.

iii. Tobacco and alcohol - The use of tobacco and the abuse of alcohol are two major health hazards that deserve immediate action through the development of healthy public policies. - This Conference called on all governments to commit themselves to the development of healthy public policy by setting nationally determined targets to reduce tobacco growing and alcohol production, marketing and consumption significantly. iv. Creating supportive environments - Policies promoting health can be achieved only in an environment that conserves resources through global, regional, and local ecological strategies. - The Conference advocated that, as a priority, the public health and ecological movements should join together to develop strategies in pursuit of socioeconomic development and the conservation of our earth’s limited resources.

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The Sundsvall Statement on Supportive Environment The Third International Conference on Health Promotion: Supportive Environments for Health with participants from 81 countries called upon people in all parts of the world to actively engage in making environments more supportive to health. The Sundsvall Conference identified many examples and approaches for creating supportive environments that can be used by policy-makers, decision-makers and community activists in the health and environment sectors. The Conference recognized that everyone has a role in creating supportive environments for health. In a health context the term supportive environments refers to both the physical and the social aspects of our surroundings. The action to create supportive environments has many dimensions: physical, social, spiritual, economic and political. Each of these dimensions is inextricably linked to the others in a dynamic interaction. Action must be coordinated at local, regional, national and global levels to achieve solutions that are truly sustainable. Proposals for action Sundsvall Conference believed that proposals to implement the Health for All strategies must reflect two basic principles: i. Equity must be a basic priority in creating supportive environments for health. All policies that aim at sustainable development must be subjected to new types of accountability procedures in order to achieve an equitable distribution of responsibilities and resources. All action and resource allocation must be based on a clear priority and commitment to the very poorest, alleviating the extra hardship borne by the marginalized, minority groups, and people with disabilities. ii. Public action for supportive environments for health must recognize the interdependence of all living beings, and must manage all natural resources, taking into account the needs of future generations. It is essential, that indigenous peoples be involved in sustainable development activities, and negotiations be conducted about their rights to land and cultural heritage. Action Strategies The Conference identified four key public health action strategies to promote the creation of supportive environments at community level. i. Strengthening advocacy through community action, particularly through groups organized by women. ii. Enabling communities and individuals to take control over their health and environment through education and empowerment. iii. Building alliances for health and supportive environments in order to strengthen the cooperation between health and environmental campaigns and strategies. iv. Mediating between conflicting interests in society in order to ensure equitable access to supportive environments for health.

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Jakarta Declaration on Health Promotion The Fourth International Conference on Health Promotion was held in Jakarta, Indonesia on 21-25 July 1997. It is the first to be held in a developing country, and the first to involve the private sector in supporting health promotion. It has provided an opportunity to re-examine the determinants of health, and to identify the directions and strategies that must be adopted to address the challenges of promoting health in the 21st century. Priorities for health promotion in the 21st Century i. Promote social responsibility for health - Decision-makers must be firmly committed to social responsibility. Both the public and private sectors should promote health by pursuing policies and practices that:  avoid harming the health of individuals  protect the environment and ensure sustainable use of resources  restrict production of and trade in inherently harmful goods and substances such as tobacco and armaments, as well as discourage unhealthy marketing practices  safeguard both the citizen in the marketplace and the individual in the workplace  include equity-focused health impact assessments. ii. -

-

Increase investments for health development In many countries, current investment in health is inadequate and often ineffective. Increasing investment for health development requires a truly multisectoral approach including, for example, additional resources for education and housing as well as for the health sector. Greater investment for health and reorientation of existing investments, both within and among countries, has the potential to achieve significant advances in human development, health and quality of life.

iii. Consolidate and expand partnerships for health - Health promotion requires partnerships for health and social development between the different sectors at all levels of governance and society. - Existing partnerships need to be strengthened and the potential for new partnerships must be explored. - Partnerships offer mutual benefit for health through the sharing of expertise, skills and resources. iv. Increase community capacity and empower the individual - Health promotion improves both the ability of individuals to take action, and the capacity of groups, organizations or communities to influence the determinants of health. - Improving the capacity of communities for health promotion requires practical education, leadership training, and access to resources. - Empowering individuals demands more consistent, reliable access to the decision-making process and the skills and knowledge essential to effect change. v. -

Secure an infrastructure for health promotion To secure an infrastructure for health promotion, new mechanisms for funding it locally, nationally and globally must be found. Incentives should be developed to influence the actions of governments, nongovernmental organizations, educational institutions and the private sector to make sure that resource mobilization for health promotion is maximized.

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The Mexico Charter: Mexico Ministerial Statement for the Promotion of Health The Fifth Global Conference on Health Promotion was organized at Mexico City on 5-9 June 2000. Areas of Action By acknowledging that the promotion of health is a central duty and responsibility of governments, the ministers of health present at the conference committed to the following: i. To position the promotion of health as a fundamental priority in local, regional, national and international policies and programs. ii. To take the leading role in ensuring the active participation of all sectors and civil society, in the implementation of health promoting actions. iii. To support the preparation of country-wide plans of action for promoting health. These plans will follow a basic framework agreed upon during the Fifth Global Conference on Health Promotion, and may include among others:  The identification of health priorities and the establishment of healthy public policies and programs to address these.  The support of research which advances knowledge on selected priorities.  The mobilization of financial and operational resources to build human and institutional capacity for the development, implementation, monitoring and evaluation of country-wide plans of action. iv. To establish or strengthen national and international networks which promote health. v. To advocate that UN agencies be accountable for the health impact of their development agenda. The Bangkok Charter for Health Promotion in a Globalized World The ‘Bangkok Charter for Health Promotion in a globalized world’ has been agreed to by participants at the 6th Global Conference on Health Promotion held in Thailand from 7-11 August, 2005. This charter identifies actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion. Strategies for health promotion in a globalized world Effective Interventions - Progress towards a healthier world requires strong political action, broad participation and sustained advocacy. - Health promotion has an established repertoire of proven effective strategies which need to be fully utilized. Required actions To make further advances in implementing these strategies, all sectors and settings must act to:  advocate for health based on human rights and solidarity  invest in sustainable policies, actions and infrastructure to address the determinants of health  build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy  regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people  partner and build alliances with public, private, nongovernmental and international organizations and civil society to create sustainable actions.

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Commitments for Health Promotion: i. Make the promotion of health central to the global development agenda - Strong intergovernmental agreements that increase health and collective health security are needed. Government and international bodies must act to close the health gap between rich and poor. - Effective mechanisms for global governance for health are required to address all the harmful effects of trade, products, services, and marketing strategies . - Health promotion must become an integral part of domestic and foreign policy and international relations, including in situations of war and conflict. ii. -

Make the promotion of health a core responsibility for all of government All governments at all levels must tackle poor health and inequalities as a matter of urgency because health is a major determinant of socioeconomic and political development. Local, regional and national governments must:  give priority to investments in health, within and outside the health sector  provide sustainable financing for health promotion

iii. Make the promotion of health a key focus of communities and civil society - Communities and civil society often lead in initiating, shaping and undertaking health promotion. - They need to have the rights, resources and opportunities to enable their contributions to be amplified and sustained. In less developed communities, support for capacity building is particularly important. iv. Make the promotion of health a requirement for good corporate practice - The corporate sector has a direct impact on the health of people and on the determinants of health through its influence on:  local settings  national cultures  environments, and  wealth distribution. - The private sector has a responsibility to ensure health and safety in the workplace, and to promote the health and well-being of their employees, their families and communities. The Nairobi Declaration The Nairobi Call to Action was developed by participants at the 7th Global Conference on Health Promotion, Nairobi, Kenya, in October 2009. The Nairobi Call to Action identifies key strategies and commitments urgently required for closing the implementation gap in health and development through health promotion. The following strategies and actions are presented under the five sub-themes of the Conference: i. -

Building capacity for health promotion Building sustainable health promotion infrastructure and capacity at all levels is fundamental to closing the implementation gap. Actions the make difference: • Strengthening leadership • Secure adequate financing • Grow practitioner skill base • Enhance system-wide approaches • Improve performance management

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ii. -

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Strengthening health systems To be sustainable, health promotion interventions must be embedded in health systems that support equity in health and meet high performance standards. Integrating health promotion in all health systems functions and at all levels improves the overall performance of health systems. Actions the make a difference: • Strengthen leadership • Enhance policy • Achieve universal access • Build and apply the evidence base

iii. Partnership and intersectoral action - Effectively addressing the determinants of health and achieving health equity requires actions and partnerships that extend beyond the health sector to implement forms of collaboration, cooperation and integration between sectors. - Actions that make a difference: • Strengthen leadership • Enhance policy • Enhance implementation • Build and apply the evidence base iv. Community empowerment - Communities must share the power, resources and decision-making to assure and sustain conditions for health equity. - Action that make a difference: • Enable community ownership • Develop sustainable resources • Build and apply the evidence base v. -

Health literacy and health behaviours Basic literacy is an essential building block for development and health promotion. Health literacy interventions need to be designed based on health, social and cultural needs. Actions that make a difference • Support empowerment • Enhance information and communication technologies • Build and apply the evidence base

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International Union for Health Promotion and Education (IUHPE) The International Union for Health Promotion and Education (IUHPE) is a unique worldwide, independent and professional association of individuals and organizations committed to improving the health and wellbeing of the people through education, community action and the development of healthy public policy. As a membership organization, the International Union for Health Promotion and Education (IUHPE) gathers people and institutions from all over the world, working in all areas that health promotion encompasses. The mission of the IUHPE is to promote global health and wellbeing and to contribute to the achievement of equity in health for all countries of the world. Goals The IUHPE aims to achieve the following goals:  Greater equity in the health of populations between and within countries of the world;  Effective alliances and partnerships to produce optimal health promotion outcomes;  Broadly accessible evidence-based knowledge and practical experience in health promotion;  Excellence in policy and practice for effective, quality health promotion; and  High levels of capacity in individuals, organizations and countries to undertake health promotion activities Objectives To achieve its goals the IUHPE will pursue the following objectives:  Increased investment in health promotion by governments, intergovernmental and non-governmental organizations, academic institutions and the private sector;  An increase in organizational, governmental and inter-governmental policies and practices that result in greater equity in health between and within countries;  Improvements in policy and practice of governments at all levels, organizations and sectors that influence the determinants of the health of populations;  Strong alliances and partnerships among all sectors based on agreed ethical principles, mutual understanding and respect;  Activities that contribute to the development, translation and exchange of knowledge and practice that advance the field of health promotion;  A strong and universally accessible knowledge base for effective, quality health promotion;  Capacity-building opportunities for individuals and institutions to better carry out health promotion initiatives and advocacy efforts. Activities/Projects i. Advocacy ii. Capacity building, education and training iii. Communications and marketing iv. Finance and internal control v. Partnership and institutional affairs vi. Strategy and governance

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Victoria Health Promotion Foundation The Victorian Health Promotion Foundation (Vic Health) was the world's first health promotion foundation established by the State Parliament of Victoria as a part of the Tobacco Act in 1987 with the funding from the state government collected tobacco tax. Vic health was provided an independent statutory authority and had a mandate to support health promotion activities with funds received from earmarked taxes. Vision: to support and enhance the wellbeing of all Victorians. Objectives The objectives of VicHealth as set out in the Act are to:  fund activity related to the promotion of good health, safety or the prevention and early detection of disease  increase awareness of programs for promoting good health in the community through the sponsorship of sports, the arts and popular culture  encourage healthy lifestyles in the community and support activities involving participation in healthy pursuits  fund research and development activities in support of these activities Strategies VicHealth's Action Agenda for Health Promotion 2013–2023 focuses on five strategic imperatives with associated goals and three-year priorities.  Promoting healthy eating  Encouraging regular physical activity  Preventing tobacco use  Preventing harm from alcohol  Improving mental wellbeing Examples of Activities of Vic Health  Anti-smoking campaigns  Buy out tobacco company sponsorship of sport and the arts -1988  Ban on all tobacco advertising in Victorian print media. Smoking bans in public places.  Food and Nutrition Program  Active for Life - in schools to teach children about making exercise a healthy lifetime habit to prevent heart disease.  Funding to various programs: o Cancer Council Victoria (Sun Smart, Quit) o Victorian Breast Cancer Screening Programs o Mental Health Research Institute Learning from Vic Health  The results of Vic Health's approach to tobacco control were very impressive. Prevalence of smoking in Victoria declined significantly. Over 17,000 premature deaths are being averted each year in Australia. This shows that tobacco control can be the best buy in terms of health care costs, health status improvements and longevity gains.  The dedicated (hypothecated) tax was the efficient way to raise funds to buy out the tobacco industry’s sponsorship of sport and the arts. This was possible due to the partnership between Vic Health and the Cancer Council Victoria’s Quit campaign and support of successive ministers and

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



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governments for legislative change. One of the major learning of Vic Health is that sustained funding, healthy public policy, political commitments and effective partnership are essential for better health impacts. Vic Health's partnership with unique stakeholders like sports and art provided an important message that health promotion is everyone's business including health agencies, political parties, sports, art, media, community and general public. Another important message relayed by Vic Health is that it was successful because it could sustain various political environments to secure continued funding. So, an important takeaway message is that Vic Health model may not be applicable to all countries. This is because finance ministries may not always be positive towards earmarked taxes. Also tobacco control and other non-communicable diseases may not be the country's priorities. If Health Promotion Foundation is to be modeled in any country, it needs to be established and run differently, according to respective cultural, political and economic contexts.

UNIT 3: FRAMEWORKS/ MODELS/THEORIES OF HEALTH PROMOTION AND EDUCATION Differences between Theories, Models and Frameworks of Behaviour Change (Q: 2072/12) When distinguishing among theory, model and framework, it is helpful to think of the term 'Theory'. Kerlinger (1973) defines theory as a set of interrelated constructs (concepts), definitions and propositions that presents a systematic view of phenomena by specifying relations among variables or constructs, with the purpose of explaining and predicting phenomena. Theories are used in health promotion to understand, guide and explain health promotion at the individual, family and community level. Several terms are important to understand when discussing about theories of behavior change. These includes: i) Construct ii) Models and iii) Frameworks i. -

ii. -

Constructs: Constructs are the main concepts of a theory. They are the elements of the theory used to describe, explain and predict behavior For example, the constructs of the Health Belief Model include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self efficacy. Models Models outline the structural components for a health promotion and hence present and explain relationships between constructs. If theory's goal is to determine how and why phenomena occur, the goal of modeling is to identify the structure or composition of the phenomenon under investigation. For example, the Health Belief Model explains how attitudes and beliefs influence behavior

iii. Framework - Framework provides a way of viewing the behavior but does not explain relationships between constructs. - For example, the Social Ecological Framework (SEF) describes different levels that influence behaviour but does not necessarily explain the specific constructs and how these interact.

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From the above classification, its been clear that Models and Frameworks can exist within theories, the former by outlining a specific set of constructs and how they are related to a behavior, while the latter by providing a general idea of what influences behavior. Despite differences in the terms theory, model and framework, they are often used interchangeably to describe the processes of behavior change. Some of the common theories, models and framework of behavior change have been summarized in the table below: Theories Theory of Planned Behaviour or Theory of Reasoned Action

Models

Framework

Health Belief Model

Social Ecological Framework

Diffusion of Innovation Theory

Precede-Proceed Model

Social Cognitive Theory

Transtheoritical Model (Stages of Change)

List of different behaviour change models and planning frameworks SN Models/Frameworks Developed by 1 PRECEDE/PROCEED Model LW Green, M. Kreuter 2 Health Belief Model Hochbaum, Rosenstock and Kegels 3 Transtheoritical Model Prochaska, DiClemente, & Norcross 4 Theory of Reasoned Action/ Theory of Planned Ajzen and Fishbein Behaviour 5 Social Cognitive Theory Albert Bandura 6 Cognitive Dissonance Theory Leon Festinger 7 Transactional Model of Stress and Coping Lazarus and Folkman 8 Diffusion of Innovation Theory E.M. Rogers 9 Force Field Analysis Kurt Lewin 10 Model of Adult Education/ Conscientization Paulo Freire Theory PRECEDE/PROCEED MODEL PRECEDE- PROCEED model is a nine steps planning process that begins at the end, focusing on the health related outcomes of interest and working backward to diagnose which combination of intervention strategies will best achieve the objectives. PRECEDE is the acronym for Predisposing, Reinforcing and Enabling Constructs in Educational/ Environmental Diagnosis and Evaluation. PROCEED stands for Policy, Regulatory and Organizational Constructs in Educational and Environmental Development. Phases of PRECEDE- PROCEED model: i. Social diagnosis - The social assessment determines people’s participation of their own needs and quality of life (Green and Kreuter). - In this phase, need assessment techniques are use to determine the quality of life by identifying the social problems in target populations. - These subjective quality of life social indicators could include illegitimacy welfare, discremination, happiness, self esteem, along with many other possibilities.

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ii. -

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Epidemiological diagnosis Epidemiological Assessment helps to determine which problems are most important for which groups in a community (Green and Kreuter, 1999). Epidemiological data is used to determine what specific problems are contributing to the social problems previously identified. This data might include mortality, morbidity, fertility, and disability and their dimensions such as incidence, prevalence, distribution, intensity and duration.

iii. Behavioural and Environmental Diagnosis - The behavioral and environmental diagnosis involves assessing factors that contribute to the health problems under consideration (Green and Kreuter). - Behavioral factors are those behaviors or lifestyles of the individuals at risk that contribute to the occurrence and severity of the health problems. - Environmental factors are those social and physical factors external to the individual often beyond his or her personal control that can be modified to support the behavior or influence the health outcome. - Modifying environmental factors usually requires strategies other than education. iv. Educational and organizational diagnosis - After selecting the appropriate behavioral and environmental factors for intervention, this step identifies the antecedent and reinforcing factors that must be in place to initiate and sustain the change process. These factors are classified as predisposing, re-enforcing and enabling and they collectively influence the likelihood that behavioral and environment change will occur. a. Predisposing factors • Pre-disposing factors are antecedents to behavior that provide the rationale or motivation for the behavior (Green and Kreuter, 1999). • This includes individual’s knowledge, attitudes, beliefs, personal preference, existing skills and self- efficacy beliefs. b. Reinforcing factors • Reinforcing factors are the factors following behaviour that provide continuing reward or incentive for the persistence or repetition of the behavior (Green and Kreuter). • Examples include social support, peer influence, significant others and vicarious awards. c. Enabling factors • Enabling factors are antecedents to behavior that allow a motivation to be realized (Green and Kreuter). • Enabling factors can affect behavior directly or indirectly through environmental factors. • They include programs, services and resources necessary for behaviour and environmental outcomes to be realized and in some cases, new skills that are needed to enable health behaviour change. v. -

Administrative and Policy diagnosis In this stage, determination is made if the capabilities and resources are available to develop and implement the program. Barriers to implementation, such as staff motivation or lack of space should be assessed and plans to address them put in place.

vi. Implementation - With the proper resources in hand, the appropriate methods and strategies of the intervention are selected.

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vii. Process Evaluation - At this level of evaluation, the main focus is upon professional practice. - Quality in health education programming is monitored by such methods as audit, peer review, accreditation, certification and government or administrative overview of contracts and grants. viii. Impact Evaluation - This level of evaluation assesses change in predisposing, reinforcing and enabling factors, as well as in the behavioural and environmental factors. - Cost effectiveness is one standard of acceptability in impact evaluation. ix. Outcome evaluation - It determines the effects of programs on health and quality of life.

PRECEDE PROCCED framework as a comprehensive framework The PRECEDE/PROCEED model is a comprehensive health promotion planning framework often used as theoretical framework from health program planning to implementation and evaluation. - PRECEDE/PROCEED model is multidimensional and is grounded in a variety of disciplines such as social/behavioural sciences, epidemiology, education and administration. - It is comprehensive also because it operates on the notion that health behaviours have multiple causations that must be evaluated in order to assure appropriate interventions

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Advantages of PRECEDE PROCEED framework over classical health belief and behavior frameworks - Health belief model and other classical frameworks are particularly useful for planning programs for disease avoidance and injury prevention but it does not lend itself very well to promotion of behaviours, particularly long-term behavior change. - These models lack consistent predictive power mainly because it focuses on limited factors. Cultural factors, socioeconomic status, and previous experiences also shapes behaviours, and those factors are not accounted for in the model. - In contrast, PRECEDE PROCEED model necessitates a systematic and comprehensive assessment of the social environment, the epidemiology of the problem, the behavior or behaviours that are affecting the health problem in question, educational and ecological factors and administrative and policy factors. - PRECEDE PROCEED framework also considers a wide range of potential outcome determinants at the needs assessment stage before the program is developed. - Unlike classical frameworks where behavior change interventions are imposed to target groups, this model emphasizes on community participation so as to foster community ownership in the process, the proposed solutions and the implementation of resulting programmatic interventions. - The ultimate benefit of the model is that appropriate interventions are likely to result and the likelihood of a rigorous evaluation design is enhanced. Key distinction between PRECEDE/PROCEED and classical frameworks PRECEDE/PROCEED

Health belief and other classical models

-

Considers variety of factors: social, epidemiological, ecological, administrative, behavioural, educational

-

-

Encourages community/ participation at all levels

group’s

-

Interventions are rather imposed by outsiders

-

-

Relatively less flexible

-

Encourages feedback and flexibility enough to fit the needs of a specific environment and community Focuses on outcome and impacts Introduces long-term behavior change

-

-

Comprehensive and scalable framework

-

Mainly focused on output only Influences but does not lend to long-term behavior change Rather specific with limited applications

-

Evidence based process with phased evaluation

-

Lack evaluation process

target

-

Limited to few considerations: beliefs and attitudes Factors like socio-economic factors, previous experiences etc. are not considered

Applications - PRECEDE/PROCEED model has a wide range of applications. Fewer examples are listed below: • Coalition building • Enhancing community participation • Cost-benefit evaluation of health education programs • Family planning studies • Immunization campaign • Combating domestic violence • Planning health programs in school settings • Ensuring compliance behaviours

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Limitations - This model is too comprehensive to be fully implemented in many situations - Health promotion and education funding may be allocated in specific area with no provision for social and epidemiological assessment - PRECEDE phase can take a long time, delaying the beginning of programs.

PRECEDE/PROCEED Framework for Malaria Prevention

PRECEDE/PROCEED Framework for Prevention of RTAs

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Health Belief Model The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals. The key phases and construct of Health Belief Model are: Concept Definition Perceived Belief about the chances of susceptibility experiencing a risk or getting a condition or disease

Perceived severity

Perceived benefits

Perceived barriers Cues to action

Self-efficacy

Belief in the extent of harm that can result from the acquired disease or harmful state as a result of particular behavior Belief in the advantages of the methods suggested for reducing the risk of seriousness of the disease or harmful state resulting from a particular behavior Belief about the tangible and psychological costs of the advised action Precipitating force that makes a person feel the need to take action Confidence in one’s ability to acquire the new behavior

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Application - Define population at risk - Personalize risk based on a person’s characteristics or behavior - Make perceived susceptibility more consistent with individual’s actual risk - Mention consequences of risks and conditions

- Define action to take; how, where, when; - Clarify the positive effects to be expected

- Identify and reduce perceived barriers through reassurance, correction of misinformation, incentives and assistance - Provide how to information, promote awareness, use appropriate remainder system - Provide training and guidance in performing recommended action - Use progressive goal setting - Give verbal reinforcement - Reduce anxiety

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Applications i. Applications in behavioural research - AIDS health belief scale - Factors associated with infant mortality - Modeling for physical activity behavior - Modeling of sexual behavior - Predictors of health behaviours in college students ii. -

Applications in primary prevention Condom use in female sex workers Dietary behavior Health counseling Pesticide safety Immunization Prevention of periodontal disease

iii. -

Applications in secondary prevention Adherence to malaria chemoprophylaxis Breast self-examination and mammography Cervical cancer screening Anxiety reduction in pregnant women HIV testing

Limitations - Cultural factors, socioeconomic status, and previous experiences that shape behaviours are not accounted for in this model. Theory of Reasoned Action/ Theory of Planned Behaviour The theory of planned behaviour asserts that achieving and maintaining behaviour change requires intent to adopt a positive behaviour or abandon a negative one. The theory holds that intent is influenced not only by the attitude toward the behaviour but also the perception of social norms (the strength of others’ opinions on the behaviour and the person’s own motivation to comply with those significant others) and the degree of perceived behavioural control. The constructs and phases of the theory of planned behavior are Concept Definition Example statements Behavioural intention Perceived likelihood of “I am going to quit performing behavior smoking this Monday” Attitude Personal evaluation of the “You know what? I think behavior smoking is dangerous for my health” Subjective norm Beliefs about whether key “I wonder if my friends people approve or would like me to quit disapprove of the smoking?” behaviour; motivation to behave in a way that gains their approval Perceived Belief that one has, and can “I can quit smoking, behavioural control exercise, control over even if I’m hooked on performing the behaviour cigarettes”

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How to modify? Brainstorming all possible outcomes By influencing behavioural beliefs and outcome evaluations By influencing normative beliefs and motivation to comply

By influencing control beliefs and perceived power

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Applications in health promotion and education - Colorectal cancer screening - Condom use - Modeling alcohol use - Promoting healthy diet - Violence prevention - HIV prevention program in adolescent mother - Exercise/ physical activity behavior Limitations: - This model predicts behavioural intention and behavior but do not provide detailed and specific guidance for behavior change. - They do not consider personality related factors, cultural factors and demographic variables, which also shape behavior - This theory assumes that perceived behavioural control predicts actual behavioural control, which may not always happen. - It does not take account of irrational thoughts and behavior Transtheoritical Model The Transtheoretical Model (TTM) uses stages of change to integrate processes and principles of change across major theories of intervention, Behaviour change is viewed as a progression through a series of five stages: Stages

Definition

Pre-contemplation

Has no intention of taking action within the next six months

Contemplation

Intends to take action in the next six months Intends to take action within the next 30 days and has taken some behavioural steps in this direction Has changed behaviour for less than six months

Preparation

Action

Maintenance

Has changed behaviour for more than six months

Example for physical activity promotion “It isn’t that I can’t see the solution, I just can’t see the problem

“I want to stop feeling so stuck” “I just took out a membership to a fitness facility”

“I’ve started exercising and while I enjoy it, sometimes I find it a chore” “Exercising three times a week has become a part of my lifestyle”

Potential change strategies Increase awareness of need for change; personalize information about risks and benefits Motivate; encourage making specific plans Assist with developing and implementing concrete action plans; help set gradual goals Assist with feedback, problem-solving, social support and reinforcement Assist with coping, reminders, finding alternatives, avoiding slips/relapses (as applicable)

Applications of transtheoritical model - Adherence to antiretroviral therapy in AIDS - STI screening

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Limitations - The stages in the model are arbitrary and classifying a population into different stages has little utility. - Validity of self-reported behaviour with regard to stage is questionable. - A significant number of people cannot be assigned to recognized stages. Social Cognitive Theory - Proposed by Albert Bandura - Social learning theory is based on the idea that people not only self-regulate their environments and actions, they are also acted upon by their environments. - This theory explains human behaviour as a triadic reciprocal causation among behaviour, environment and personal factors.

The phases and constructs of social cognitive theory are: Concept Definition Reciprocal The dynamic interaction of the person, determinism behaviour, and the environment in which the behaviour is performed

Potential change strategies Consider multiple ways to promote behaviour change, including making adjustments to the environment or influencing personal attitudes

Behavioural capability

Knowledge and skill to perform a given behaviour

Promote mastery learning through skills training

Expectations

Anticipated outcomes of a behaviour

Model positive outcomes of healthful behaviour

Self-efficacy

Confidence in one’s ability to take action and overcome barriers

Approach behaviour change in small steps to ensure success; be specific about the desired change

Observational learning (modelling)

Behavioural acquisition that occurs by watching the actions and outcomes of others’ behaviour

Offer credible role models who perform the targeted behaviour

Reinforcements

Responses to a person’s behaviour that increase or decrease the likelihood of reoccurrence

Promote self-initiated incentives

rewards

and

Applications - HIV risk reduction program - Better walking performance in older adults - Smoking cessation - Understanding sexual behaviour - Studying children’s eating behaviour

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Limitations - Ignores the maturation throughout the life span - No considerations for biological and hormonal predispositions that could influence behaviors - It is not a unified theory—that the different aspects of the theory do not tie together to create a cohesive explanation of behavior. - It does not provide a full explanation or description of how social cognition, behavior, environment, and personality are related, although there are several hypothesis. Diffusion of Innovation Theory - Diffusion of innovations is the “process by which an innovation is communicated through certain channels over time among the members of a social system”. - Diffusion can be thought of as a special type of communication in which messages are about a new idea, product or service. - If a health education programme is viewed as an innovation, this theory could describe the pattern the target population would follow in adopting the programme. - The process of adoption is viewed as a classic bell curve, with five categories of people as adopters: innovators, early adopters, early majority adopters, late majority adopters, and laggards. - The categories are characterized as follows: • innovators are active information seekers of new ideas • early adopters are very interested in the innovation but not the first to sign up • early majority need external motivation to get involved • late majority are sceptics and will not adopt an innovation until most people in the social system have done so • laggards typically have limited communication networks and are the last to become involved, usually with the help of a mentoring programme or through constant exposure. - When an innovation is introduced, the majority of people will either be early majority adopters or late majority adopters; fewer will be early adopters or laggards, and very few will be innovators (the first people to use the innovation). - By identifying the characteristics of people in each adopter category, practitioners can more effectively plan and implement strategies that are customized to their needs.

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Four main elements for diffusion of innovation Elements Description 1 Innovation An innovation is an idea, practice, or object that is perceived as new by an individual or other unit of adoption. The rate at which the innovation get adopted by members of a social system depends on number of characteristics of innovation: relative advantage, compatibility , complexity, triability, observability 2

Communication channel

Communication channels are the carriers of the diffusion process, the road along which the innovation travels through the social system These channels can be mass media or interpersonal.

3

Time

The role of time in the diffusion process manifests itself as the point in time at which an individual decides to adopt the innovation. In addition, time plays a role in the speed with which an innovation is being diffused: rate of adoption

4

Adopters

Rogers identified five adopter categories based on their relative innovativeness: innovators, early adopters, early majority, later majority and laggards

5

Social System

The social system is the environment within which the diffusion process takes place It includes communication networks, values and culture, various roles of members of social system (e.g. opinion leaders), etc.

Roger’s Adoption Model Stages of Roger’s Adoption (Innovation-Decision) Process Earlier Roger had identified five stages of adoption as Awareness → Interest → Evaluation → Trial → Adoption In his later editions of Diffusion of Innovation, Roger changed his terminology of five stages to Knowledge → Persuasion → Decision → Implementation → Confirmation

1

Stage Knowledge

2

Persuasion

3

Decision

4

Implementation

5

Confirmation

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Description In this stage, the individual is first exposed to an innovation, but lacks information about the innovation. During this stage the individual has not yet been inspired to find out more information about the innovation The individual is interested in the innovation and actively seeks related information/details such as - Relative advantages - Social norms - Expected outcomes The individual takes the concept of change and weighs the advantages/ disadvantages of using the innovation. The individual employs the innovation to a varying degree depending on the situation. During this stage the individual also determines the usefulness of the innovation and may search for further information about it. Individual finalizes his/her decision to use, continue, or discontinue adoption

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Freire’s Model of Adult Education Paulo Freire was a Brazilian educator and philosopher who worked in the area of adult literacy. His book “Pedagogy of the Oppressed”, was first published in 1970 and is influential in the education field. Freire criticized the traditional “Banking concept” of education and focused on problematizing or problem posing education. Construct of Freire’s Model Constructs 1 Dialogue 2

Conscientization

3

Praxis

4

Transformation

5

Critical consciousness

Definition Two way exchange between learners and educator Identifying the underlying systemic forces of oppression

Reflective action (tying up theory to practice) Relationship that identifies one as a political and social being Political organization of those adversely affected

Methods of education Group discussions Online discussions Discussion Brainstorming Role play Simulation Team building exercise Pilot project Case study Field visit Group formation Coalition building Formation of organization

non-profit

Freire model of adult education uses a three-phase approach i. Naming phase (What is the problem?) - The facilitator is listening to the group talking about the issue at hand. - For example, when discussing underage drinking, rather than delivering a lecture, the facilitator would pose a question such as, “Is there a problem with underage drinking at our community?” - This initiates a critical dialogue among members.

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Reflection phase (How do we explain this situation?) The emphasis is on bringing out the inner emotions of the participants as much as possible. For example, the facilitator would pose a question such as “Why do people that are under age drink alcohol even though it is illegal? Facilitator is prepared with follow up questions to ensure all levels of the issue have been explored.

iii. Action phase (What can be done to change this situation?) - The goal here is to follow the approach advocate by the group. - For example, the facilitator’s goals is to decrease the prevalence of underage drinking, but the participants understanding the multiple levels of the issue, come up with the plans and strategies for accomplishing this. Applications of Freire’s Model i. General applications: • Adult education • Community organization • Health education • Social work

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Individual & community level behaviour change Breast cancer control Community organization HIV/AIDS prevention Oral health promotion Peer to peer approach in reproductive health

Limitations  Contorted manner of writing and his vagueness makes interpretation of concepts difficult and measurement complex  Complex terminologies: not very easy to understand and lends to multiple interpretations  Equal hierarchy of learners and educators is seldom achieved in real world settings  Difficult to differentiate the constructs so that they are mutually exclusive. Kurt Lewin’s Model of Planned Change -

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Kurt Lewin (1890-1947) is considered as the father of social psychology His field theory states that "one’s behavior is related both to one’s personal characteristics and to the social situation in which one finds oneself." Kurt Lewin theorized a three-stage model of change that is known as the unfreezing-freezing-refreezing model that requires prior learning to be rejected and replaced. Lewin's theory states behavior as a dynamic balance of forces working in opposing directions. These are driving and restraining forces. Driving forces Driving forces are forces that push in a direction that causes change to occur. Driving forces facilitate change because they push the person in the desired direction. E.g. knowledge about disease, perceived severity, economic progress, etc.

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Restraining forces Restraining forces are forces that counter driving forces. Restraining forces hinder change because they push the person in the opposite direction. E.g. superstition, lack of awareness, misconception, poverty, etc.

Lewin’s change model consists of three distinct phases i. Unfreezing - Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way. - Unfreezing is necessary to overcome the strains of individual resistance and group conformity. - Unfreezing can be achieved by the use of three methods. • First, increase the driving forces that direct behavior away from the existing situation or status quo. • Second, decrease the restraining forces that negatively affect the movement from the existing equilibrium. • Third, find a combination of the two methods listed above ii. -

Movement This stage involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive.

iii. Refreezing - Refreezing is establishing the change as a new habit, so that it now becomes the “standard operating procedure.” - Without this stage of refreezing, it is easy to go back to the old ways. Cognitive Dissonance Theory Cognitive dissonance theory was developed by Leon Festinger in 1957. Cognitive dissonance theory is based in three fundamental assumptions: i. ii.

Humans are sensitive to inconsistencies between actions and beliefs. Recognition of this inconsistency will cause dissonance and will motivate an individual to resolve the dissonance. iii. Dissonance will be resolved in one of the three basic ways a. Change beliefs b. Change actions c. Change perception of action

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Theories of Stress and Coping Transactional Model of Stress and Coping The Transactional Model of Stress and Coping is a framework for evaluating processes of coping with stressful events. Constructs

Definition

Primary Appraisal Secondary Appraisal

Evaluation of significance of a stressor or threatening event Evaluation of the controllability of the stressor and a person’s coping resources Actual strategies used to mediate primary and secondary appraisals  Problem management: active coping, problem solving and information seeking  Emotion regulation: venting feelings, avoidance, denial, and seeking social support Coping processes that induce positive emotion. Positive reappraisal, revised goals, spiritual beliefs, positive events

Coping efforts

Meaning based coping

Outcome coping

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Coping strategies may result in short and long term positive or negative adaptation

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Intervention Mapping - Intervention Mapping is a protocol for developing effective behavior change interventions. - Intervention Mapping is not a new theory or model; it is an additional tool for the planning and development of health promotion interventions - The Intervention Mapping (IM) protocol (Bartholomew et al., 2016) describes the iterative path from problem identification to problem solving or mitigation. - Each of the six steps of IM comprises several tasks each of which integrates theory and evidence. i.

Step 1: Logic Model of the Problem - Establish and work with a planning group - Conduct a needs assessment to create a logic model of the problem - Describe the context for the intervention including the population, setting, and community - State program goals

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Step 2: Program Outcomes and Objectives – Logic Model of Change - State expected outcomes for behavior and environment - Specify performance objectives for behavioral and environmental outcomes - Select determinants for behavioral and environmental outcomes - Construct matrices of change objectives - Create a logic model of change

iii. Step 3: Program Design - Generate program themes, components, scope, and sequence - Choose theory- and evidence-based change methods - Select or design practical applications to deliver change methods iv. Step 4: Program Production - Refine program structure and organization - Prepare plans for program materials - Draft messages, materials, and protocols - Pretest, refine, and produce materials v.

Step 5: Program Implementation Plan - Identify potential program users (implementers, adopters, and maintainers) - State outcomes and performance objectives for program use - Construct matrices of change objectives for program use - Design implementation interventions Implementation

vi. Step 6: Evaluation Plan - Write effect and process evaluation questions - Develop indicators and measures for assessment - Specify the evaluation design - Complete the evaluation plan

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Multilevel Approach to Community Health (MATCH) The Multilevel Approaches toward Community Health (MATCH) model provides a representation of the ecological levels in conjunction with the planning, implementation, and evaluation stages of a community organization process.

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UNIT4: VARIOUS APPROACHES TO HEALTH PROMOTION AND EDUCATION Pedagogy vs Andragogy According to Connor, Pedagogy literally means the art and science of educating children and is often used as a synonym for teaching. - More accurately pedagogy embodies teacher-focused education where teachers assume responsibility for making decisions about what will be learned, how it will be learned and when it will be learned. By contrast, Andragogy, a theory of adult learning, attempts to explain why adults learn differently to younger learners. - Andragogy is defined by Knowles as the art and science of helping adults learn. Distinction in the characteristics of the andragogical and pedagogical approaches to health education Features Pedagogy Andragogy The learner - The learner is dependent upon - The learner is self-directed the instructor for all learning - The learner is responsible for her own learning - The teacher/instructor assumes - Self-evaluation is characteristics of this approach full responsibility for what is taught and how it is learned - The teacher/instructor evaluates learning Role of - The learner comes to the activity - The learner brings a greater volume and quality learner’s with little experience that could of experience be tapped as a resource for - Adults are the richest resources or one another. experience learning - Different experiences assure diversity in groups - The experience of the instructor of adults. is most influential - Experience becomes the source of self-identity. Readiness - Students are told what they have - Any change is likely to trigger a readiness to To Learn to learn in order to advance to the learn. - The need to know in order to perform more next level of mastery. effectively in some aspect of one’s life. - Possesses the ability to assess gaps between where one is now and where one wants and needs to be. Orientation - learning is process of acquiring - Learners want to perform a task, solve a To Learning prescribed subject matter problem, and live in a more satisfying way. - Content units are sequenced - Learning must have relevance to these tasks. according to the logic of the - learning is organized around life/work situations subject matter. rather that subject matter units Motivation - Learners are motivated by - Learners are primarily motivated by internal external forces forces Importance and Applications of Andragogical Approach in Health Education - Most of the target groups in a community health education program are adults, theoretical foundations therefore must include an understanding of the principles of educating adults. - The central purpose of health education is to bring valid knowledge to bear on the decision that clients must make. In doing so, it is aimed at achieving the needs and goals that individuals specifies and, if possible, to satisfy the needs and goals of the community and society. The importance of a need assessment becomes instantly apparent to those subscribing to this approach

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In the process of health education, adults take part in the planning and assessment of their own education. Each lesson must be explained. Learners must be aware and understand the rationale behind certain procedures or information. Andragogy in practical terms means that adult education must concentrate more on the methods more than lessons. And the most useful of these applied in health education includes simulations, role playing, discussions, case-studies and self-evaluation.

Formal and Non-Formal Education Approach Formal education corresponds to a systematic, organized education model, structure and administered according to a given set of laws and norms, presenting a rather rigid curriculum as regards objectives, content and methodology. - It corresponds to the education process normally adopted by our schools and universities. - Various components of health issues have been a part of curriculum at each levels of formal education system in Nepal. Non-formal education approach Non formal education is an organized educational activity outside the established formal system- whether operating separately or as an important feature of some broader activity- that is intended to serve identifiable learning clients and learning objectives. - Non-formal approach to health education is an alternative way of providing educational opportunity to those who could not get education from formal systems. Characteristics of non-formal education approach (Fordham, 1993) - Non-formal education should be relevant to the needs of disadvantaged groups - It should concern with specific categories of person - Non-formal education should focus on clearly defined purposes. - There should be flexibility in organization and methods. Non-formal education approach in Nepal - NFEC under Ministry of Education has been extensively implementing various educational programs targeting adult men, women and children who have been deprived of getting access to and opportunity to formal education. - Basic (health) literacy, post-literacy, alternative schooling and life and livelihood skills training programs are the major initiatives being taken in Nepal. Features Purpose Timing Content Delivery system Control

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Formal education Long term and general Credential based Long cycle/ full time Standardized Academic Institution based External/hierarchical

Non-formal education Short-term and specific Non-credential based Short cycle/part time Individualized Practical Community based Self governing/ democratic

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Theory of Adult Learning According to Malcolm Knowles i. Learners need to know: - As one becomes mature, a person’s self-concept changes from being dependent into an independent one. - It is important that adult know the reason for learning something. Adults learn when they perceive a need to learn. - Learners can employ scientific, rational and critical thinking when making decisions. ii. -

Role of Experience As an individual becomes mature, he/she increases his/her experience which ultimately becomes a potent source for learning. To truly learn a thing, an adult must experience that thing. Learning takes place when the learner is able to relate a previous experience to the context of learning.

iii. Readiness to learn - As a person matures, his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles (Knowles et al., 1984). - Adults approach learning as problem-solving. iv. Orientation to learning - As one matures, the perspective of a person shifts from suspended use of knowledge to immediate use, likewise, his/her learning orientation changes from subject-oriented learning into one that focuses on problems. - If the lesson is of immediate importance, adults learn the fastest. v. -

Motivation to learn As one matures, the motivation of a person to learn is within him/her. Since motivation is the most important part of learning, appropriate motivation is imperative to support learning.

Conscientization Approach (Paulo Freire) Paulo Freire was a Brazilian educator and philosopher who worked in the area of adult literacy. He was a critic of the banking model of education, in which the elite own and construct the knowledge, and the poor are excluded. - According to Paulo Freire’s critical view of education, non-formal adult education should be viewed as conscientization. - Conscientization is the process of developing a critical awareness of one's social reality through reflection and action. - Freire maintains that adult education can be used to effect radical social change and liberate the oppressed. - Freire advocates for education that develops learners’ consciousness of their rights along with their critical presence in the real world. - In other words, for Freire, conscientization as a critical element of the field of adult education should help adult learners to examine the nature of their oppressive situation as well as their capacity to influence the situation.

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Consciousness implies that the oppressed will overcome the culture of silence and begin to apply pressure on those who oppress them so that they might attain their freedom. Conscientization enlightens people about the obstacles preventing them from attaining all sorts of freedom in a dialogical manner (through dialogue) as opposed to a prescriptive ways which is characteristic of a domesticating educational process. In conscientization, learners are not regarded as mere recipients of the educator’s wisdom. On the contrary, learners are invited to participate creatively in the process of their learning.

Process of conscientization:

Why the approach gained momentum in developing world? - Freire’s ‘Pegadogy of the Oppressed” and conscientization was developed in the late 1960s. It radically criticized the unjust social relations between South and North and advocated social transformations that included dismantling of powerful social institutions. This work of liberating education was widely used in Brazil, Chile and other Latin American countries. - The concept of conscientization was exported to South Africa around 1970s and was eagerly embraced by black consciousness activists. From 1970s to 1980s, South African activists used this term to describe the process of spreading political awareness. As such conscientization was linked to protest, and a community’s readiness to engage in struggle was seen as the degree to which it has been successfully conscientized. - This approach was adopted by Latin American CEBs (non-political, religious organizations) in the 1980s for engaged criticism towards the violations and injustices of politics. - This approach gained momentum around the world. The approach was also used in many South Asian countries. For example: After the independence of Bangladesh in 1971, one of the largest NGO of Bangladesh had developed a functional literacy programme based on Paulo Freire’s conscientization approach. This literacy intended to transform into political empowerment of the rural people. Social Marketing Approach -

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Social marketing applies commercial marketing strategies to promote public health. Andreasen defines social marketing as “the application of proven concepts and techniques drawn from the commercial sector to promote changes in diverse socially important behaviors such as drug use, smoking, sexual behavior. Social marketing is widely used to influence health behaviour. Social marketers use a wide range of health communication strategies based on mass media; they also use mediated (for example, through a healthcare provider, social mobilizer), interpersonal, and other modes of communication; and marketing methods such as message placement, promotion, dissemination, and community level outreach. They develop brands and market these products using socially appealing messages.

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The social marketer must consider each of the four marketing elements: product, place, price and promotion • Price: What consumer must offer in order to receive benefits? • Product: What products are offered for behaviour change? • Promotion: What strategies are used for promotion (mass media, interpersonal communication)? • Place: where the behaviour is performed? Social marketing products/services are provided in substantial cost to the target groups. Successful examples of social marketing campaigns in Nepal are • Promotion of iodized salt • Promotion of family planning devices (condom, pills, depo and IUCDs) • Oral rehydration salt • Water purification (e.g Piyush)

Distance Learning Approach Distance education is any educational process in which all or most of the teaching is conducted by someone separated in space and/or time from the learner, with the effect that all or most of the communication between teachers and learners is through an artificial medium, either electronic or print. - Distance education can be used in general as well as professional education in all sectors Characteristics of distance learning - Teacher and learner are separated in time and space. - Distance learning requires the independent style of learning. - The principal means of communication is technology (print or electronic) - Distance learner may study at a time and place convenient to him/her - Learning materials are prepared and produced should be of very high quality. Forms of distance learning i. Synchronous: Telecourses, teleconferencing, telemedicine, etc. ii. Asynchronous: e-mails, audio cassette courses, videotape courses, correspondence courses, webbased courses. Advantages - Convenience - Flexibility - Effectiveness - Affordable - Saves time Disadvantages - Absence of live academic environment - Lack of instant feedback - Isolation - Difficult to monitor the learning process

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Child to Child Approach The Child to Child approach to health education was first introduced in 1978 by David Morley. Child-to-Child is a rights-based approach to children’s participation in health promotion and development. - It is based on the belief that children can be actively involved in their communities and in solving community problems. - Through participating in Child-to-Child activities the personal, physical, social, emotional, moral and intellectual development of children is enhanced. - The Child-to-Child approach is an educational process that links children’s learning with taking action to promote the health, well-being and development of themselves, their families and their communities. The child to child step approach Using a series of linked activities or steps, children think about health issues, make decision, develop their life-skills and take action to promote health in their communities, with the support of adults. i. Children identify and assess their problems and priorities ii. Children research and find out how these issues affect them and their communities iii. Based on their findings children plan action that they can take individually or together iv. Children take action based on what they planned v. Children evaluate the action they took: What went well? What was difficult? Has any change been achieved?

Risk Approach Risk Approach in health education involves appraisal of health risk among individual and communities and managing those issues from risk perspective. - It is a process of gathering, analyzing and comparing and individual’s prognostic characteristics of health with a standard age group, thereby predicting the likelihood that a person may develop prematurely a health problem associated with a high morbidity and mortality rate. - An assessment tool is used by health promoters to evaluate a person’s health. - The appraisal usually takes the form of an extended questionnaire that enquires into personal lifestyle, and personal and family medical history. - The appraisal may also include physical examinations, laboratory tests or environmental assessments. - The specific risks are identified in groups and strategies are developed to reduce such risks. - Major health risks in Nepal include, tobacco use, indoor smoke, deficiency of maro/micro nutrients, unsafe sexual behaviour, alsoholism etc. Steps in risk assessment and management i. Hazard assessment ii. Exposure assessment iii. Risk characterization iv. Risk communication v. Risk management

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Life Skill Approach Life skills are abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life. Life Skills-based health education is an approach to creating or maintaining healthy lifestyles and conditions through the development of knowledge, attitudes, and especially skills, using a variety of learning experiences, with an emphasis on participatory methods. Life skills based health education can be applicable in wide areas - Peer pressure, drug abuse and gender based violence - Sexual violence - Teenage pregnancy and unsafe abortion - HIV/AIDS prevention - Consumer education - Career opportunities Essential life skills for skills-base health education: i. Communication skills and interpersonal skills a. Interpersonal communication skills - Verbal/non-verbal communication - Active listening - Expressing feelings (asking parents not to smoke) - Giving feedback (without blaming) b. Negotiation/refusal skills - Negotiation and conflict management (e.g. condom negotiation) - Refusal skills (e.g. refusal of smoking requests) c. -

Empathy building Ability to listen, understand another’s need and circumstances

d. Co-operation and team work - Expressing respect for others’ contribution - Assessing one’s own abilities and contributing to groups e. Advocacy skills - Influencing skills and persuasion - Networking and motivation skills ii.

Decision-making and critical thinking a. Decision making skills/ problem solving skills - Information gathering skills - Evaluating future consequences - Determining alternative solutions to problems b. Critical thinking skills - Analyzing peer and media influences - Analyzing attitudes, values, beliefs and factors affecting them

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iii. Coping and management skills a. Skills for increasing personal confidence - Building self esteem and confidence - Creating self-awareness skills - Setting goals b. -

Skills for managing feelings Managing anger Dealing with grief and anxiety Coping with loss, abuse and trauma

c. -

Skills for managing stress Time management Positive thinking Relaxation techniques

Health education methods and techniques for promoting life skills - Class discussions - Role play - Demonstration - Case studies - Debates - Games and Simulations - Brainstorming, etc. Life skills education in Nepal UNICEF adopted three strategies to reach young people for improving life skills: i. Chatting with my best friend (sathi sanga mann ka kura) – radio program ii. Catmandu- TV program iii. Supplementary communication materials- life skills booklets, photo novels etc. BNMT has been providing life skills training to youths on HIV/AIDS and STIs Which approach will be appropriate in Nepalese Health Care System? (past question) The major challenge for health promotion in Nepal remains on which approach to chose and how best to apply the correct approach to the appropriate Nepalese context. In Nepal health promotion programs often cover a range of issues, target groups, settings and cultural contexts. Therefore when planning a program, it is necessary to choose a simple strategy or approach as the focus for the work. Health agendas of the Government of Nepal and other I/NGOs have been typically promoting healthy behavior approaches and are using interventions to change unhealthy individual behavior. This is probably because this approach offers easily quantifiable and achievable results within a short time frame. According to my viewpoint, ideally there is no approach which can function in isolation. Taking into considerations, the diversity in socio-cultural contexts, target groups and range of health promotion needs, the health planners and experts need to choose appropriate approaches, relevant to the particular context. Health promotion in Nepal can only operate with a mix of different approaches. For examples:  Risk approach is relevant for promotion against non-communicable disease.  Life skills approach seems relevant for educating youths on issues such as SRH.  Social Marketing is appropriate to increasing the uptake of modern family planning methods.

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UNIT 5: Fundamental Factors Involved in Health Education Process Learning in Health Education Meaning and definition Learning is defined as “any relatively permanent change in behaviour that occurs as a result of practice and experience”. This definition has three important elements. - Learning is a change in behaviour—better or worse. - It is a change that takes place through practice or experience, but changes due to growth or maturation are not learning. - This change in behaviour must be relatively permanent, and it must last a fairly long time. Principles of Learning Principles Description 1 Readiness - Individuals learn best when they are physically, mentally, and emotionally ready to learn, and do not learn if they see no reason for learning 2 Exercise - Those things most often repeated are best remembered. - It is the basis of drill and practice 3 Primacy - Things learned first create a string impression in the mind and that is difficult to erase. 4 Recency - The things that are learned most recently are best remembered. - Conversely, the further a student is removed time-wise from a new fact or understanding, the more difficult it is to remember. 5 Intensity - The more intense the material taught, the more likely it will be retained. - A student will learn more from the real thing than from a substitute. 6 Freedom - Things freely learned are best learned. - Conversely, the further a student is coerced, the more difficult is for him to learn. Perception This process of ‘interpretation of stimulus is known as perception’. So perception involves two processes: sensation and interpretation. But interpretation of any stimulus requires past experience also. Hence, perception may be defined as “a process of interpretation of a present stimulus on the basis of past experience”. In another words, perception is a process which involves seeing, receiving, selecting, organizing, interpreting and giving meaning to the environment.

Principles of perception: i. Figure ground relationship - According to this principle any figure can be perceived more meaningfully in a background and that figure cannot be separated from that background. - For example, letters written with a white chalk piece are perceived clearly in the background of a blackboard.

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Grouping of stimuli The objects can be perceived meaningfully when they are grouped together.

a. Proximity - The objects which are nearer to each other can be perceived meaningfully by grouping them. - For example, Stars which are nearer to each other are perceived together as giving particular shape. - In the figure, the objects in the left square are perceived as separate elements and objects in the right square are perceived as belonging to three groups. b. Similarity - The similarity principle states that object with similar shape, size, color, orientation and texture are perceived as belonging to the same group. - In the adjoining figure, the objects of same size are perceived as belonging to the same group. c. -

Closure The closure principle states that when an object is not complete, or the space is not completely enclosed, and enough elements are present, then the parts tend to be grouped together and we perceive the whole figure.

d. Continuity - The continuity principle states that if an object appears to form a continuation of another object, beyond the ending points, we perceive the pieces as part of a whole object. - In the figure, the viewer’s eye naturally follows the curved line, although it is interrupted and joined to another segment. Factors Affecting Perception i. Psychological Factors - Moods - Motives - Self-concept - Interest, attitudes, feelings, thoughts - Cognitive structure - Expectations - Level of intelligence - Emotional state (worries, fear, anxiety) ii. -

Socio-cultural factors Education level Level of understanding Customs, religions, and belief system Language variation

iii. Environmental factors - Invisibility, noise, congestion, etc.

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Motivation Motivation is a process by which a need or desire is aroused and a psychological force within our mind sets us in motion to fulfill our needs and desire. According to William G Scott, "Motivation means a process of stimulating people to action to accomplish desired goals". Characteristics of motivation - Motivation is an psychological phenomena - Motivation is related to needs - Motivation produces goal-directed behaviour - Motivation can be either positive or negative Motives and Drives Motives In general a motive is generally defined as a state of physiological or psychological arousal which influences how we behave. E.g. hunger motivates us to eat something. Drives - According to a drive reduction theory, any imbalances in homeostasis create needs, which are biological requirements for well-being. In responding to needs, the brain tries to restore homeostasis by creating a psychological state called drive - Drive is a feeling that prompts an organism to take action to fulfill the need and thus return to a balanced state. - There are two kinds of drives: i. Primary drives: - Primary drives stem from physiological or survival needs, such as the needs for food or water. - People do not have to learn these basic needs to satisfy them. iii. Secondary drives: - Secondary drives are those that are learned through experience or conditioning, such as the needs for money, social approval, or the need of recent former smoke to have something to put in their mouths. - E.g. having little money motivates many behaviours- from hard working to stealing. Theories of Motivation Maslow’s Need Hierarchy Theory According to Abraham Maslow, a U.S psychologist, man is a wanting animal. He has a variety of wants or needs. All motivated behaviour of man is directed towards the satisfaction of his needs. The theory postulated that people are motivated by multiple needs, which could be arranged in a hierarchy. The features of his theory are as follows:i. People have a wide range of needs which motivate them to strive for fulfillment. ii. Human needs can be definitely categorized into five types: a. Physical needs: e.g., food, water, shelter, etc. b. Safety or security needs: e.g. safety, security, protection against danger, etc c. Affiliation or social needs: e.g. Love, affection, acceptance, friendship, etc. d. Esteem needs: e.g. prestige, power, recognition, etc. e. Self-actualization needs: e.g. growth, achievement, advancement, etc.

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iii. These needs can be arranged into a hierarchy. Physical needs are at the base whereas selfactualization needs are at the apex. iv. People gratify their physical needs first, when the need is satisfied, they feel the urge for the next higher level need. v. Relative satisfaction of lower level need is necessary to activate the next higher level need. vi. A satisfied need does not motivate human behaviour. It only triggers or activates the urge for the next higher level of needs. Rosenstock’s Theory of Motivation Rosenstock’s Theory of Motivation includes three components that are necessary for an individual to get motivated. i. Perceived susceptibility - In order to get motivated, it is necessary that a person understand that he is susceptible or already under the influence of some disturbing force. - Unless somebody realizes that he is either susceptible or already undergoing the disease process, it is very unlikely that he will think of any treatment or preventive measures. ii. -

Perceived severity The perception of the person towards the severity of the condition is the key factor for motivation and hence called the trigger point of motivation. Motivating the persons to take necessary action to solve the problems becomes easier when the person becomes aware of the severity or intensity of discomfort that may result from the condition.

iii. Awareness of possible solution - For a person to get motivated to seek treatment or a solution to the problem, he should be aware of a possible solution within his reach. - Otherwise he may not be well motivates and not try to seek treatment. Bunchman’s Theory of Motivation Bunchman has given five principles of human motivation which are described below i. Motivation is based on one’s personal needs. Changes that satisfy his or her needs are likely to be accepted. The needs are in conformity with Maslow’s hierarchy of human needs. ii. Skill development is necessary for motivation. Meanwhile, appropriate environmental situation must be provided so that necessary action can be taken to solve the problem. Hence, motivation depends upon both person’s skill and appropriate environment. iii. Motivational efforts should be based on person’s interest and emphasize on those which he/she values more. iv. Motivation depends on individual’s perception of problems and solution. If a couple perceives overpopulation as a threat or risk to the welfare of the family and society, they may be easily motivated to adopt birth control measures. v. Motivation depends upon and individual’s perception of himself and his relation with others. A tuberculosis patient can be motivated to keep himself isolated if he is made to accept that and exposure to him may affect others.

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UNIT6: HEALTH COMMUNICATION Meaning, Definition, Types, Process and Principles of Communication According to Newman and Summer, "Communication is an exchange of fact, ideas, opinions or emotions by two or more persons". The process of communication generally involves five steps: i. Sender - The process of communication begins when the person with whom the message originates (sender) has an idea. - The form of idea will be influences by complex factors surrounding the sender: mood, background, culture, context of situation, frame of reference, etc. ii. -

Encoding The next step in the communication process involves encoding. This means converting the idea into words, gesture or symbols that will convey meaning. A major problem in communicating any message is that words, symbols have different meanings for different people.

iii. Channel - The medium over which the message is physically transmitted is the channel. - Messages may be delivered by different channels such as radio, telephone, letters, face to face discussions, presentations, etc. iv. Decoding - After the target person receives the message, it is broken down to a level that will enhance understanding. - Communication is successful only when the receiver successfully decodes and understands the meaning intended by the sender. v. -

Feedback The receiver’s response to the sender’s message is referred to as feedback. Without feedback, it is difficult to know whether a message has been received and clearly understood.

Types of communication One the basic of persons involved i. Intrapersonal communication - Intrapersonal communication occurs when an individual talks to himself/herself, pondering over an activity or examining self to assess something. ii. -

Inter-personal communication Inter-personal communication occurs in both a one to one and a group settings. It is an exchange of information, idea or facts between two or more people or groups of people eager of accomplishing some goals. In interpersonal communication there is face-to-face interaction between two persons, that is, both are sending and receiving messages.

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In interpersonal communication, it is possible to influence the other person and persuade him or her to accept our point of view. Since there is proximity between sender and receiver, interpersonal communication has emotional appeal too.

iii. Group communication - Group communication involves two or more people who come together to communicate. - The groups share some common attributes such as age, health status, educational background etc. (e.g. group of pregnant women). iv. Mass communication - Mass communication occurs when certain messages are sent to a large number of people through mass-media approaches. - Radio, television, newspapers, social media etc. are media that helps in mass communication. On the basis of direction of message flow i. One way communication ii. Two way communication On the basis of modes of communication i. Verbal communication: use of words ii. Non-verbal/ symbolic communication: facial expressions, gesture, body positions, eye contacts, symbols, etc On the basis of lines of authority i. Formal communication ii. Informal communication Principles of effective communication i. Completeness - The message is complete when it contains all facts the reader or listener needs for the desired reaction. - A message must be organized appropriately in the sense that it must include all the important ideals and its details. - All the aspects of the message must be grouped and brought together in logical sequence to prepare meaningful thought units. ii. -

Clarity The writing should be correctly planned and expressed in a logical way, and the writer should make sure that the ideas flow smoothly from beginning to end. Also, the communicator must be clear about the selection, suitability and usage of the medium.

iii. Coherence - Coherence means, tying together of several ideas, under one main topic in any paragraph. - Smooth flow, lucidity and transition aspects should be given effect to and there should not be any scope for the reader to misinterpret, mis-read or mis- spell the message.

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iv. -

Conciseness Conciseness refers to thoughts expressed in the fewest words consistent with writing. Unnecessary superlatives, exaggeration and indirect beginning should be avoided. Care should be taken to use adjectives judiciously, avoiding irrelevant details, unnecessary expression and mumbling sentences.

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Credibility Clarity in writing brings about credibility because it ensures that others understand the message easily and quickly. A clear and direct approach in writing makes it possible to achieve the principle of credibility in writing. Other essentials of writing like correctness and completeness add to the strength of credibility in the writing.

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vi. Correctness - Communication must be correct in tone and style of expression, spelling, grammar, format, contents, statistical information, etc. - There should not be any inaccurate statements in the message. - The subject matter of communication must be correct or accurate. Behaviour Change Communication and Application -

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Behaviour change communication or “BCC” is a set of organized communication interventions and processes aimed at influencing social and community norms and promote individual behavioural change or positive behaviour maintenance for a better quality of life. BCC is one of the strategic components of communication for health and development along with advocacy, social mobilization, community mobilization and social marketing.

Importance of behaviour change communication in health promotion - Increases knowledge - Stimulate community dialogue - Promote essential attitude change - Reduces stigma and discrimination - Creates a demand for product and services - Promotes services for prevention, care and support - Improves skills and sense of self-efficacy Behaviour Change Communication (BCC) Strategy BCC strategy is a coordinated and comprehensive plan for guiding multiple actions or activities that are aimed at achieving BCC goal and objectives. A well-designed BCC strategy should include: - Clearly defined BCC objectives - An overall concept or theme and key messages - Identification of channels of dissemination - Identification of partners for implementation (including capacity-building plan) - A monitoring and evaluation plan

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Applications of BCC Behavour Change Communication strategies have been widely used in numbers of public health programs in Nepal. Some of them are listed below: - Malaria control - Kala-azar elimination - Dengue & JE control - WASH behaviours - HIV/AIDS prevention and control - Family Planning - Birth preparedness and complication readiness Meaning, Types, Importance and Selection Criteria of Health Education Methods Methods of health education are the techniques or ways in which series of activities are carried out to communicate ideas, information and develops necessary skills and attitude. Types of health education methods Individual methods Group methods - Interview - Counseling

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Mini-lecture Demonstration Symposium Brain storming Role-playing Workshop Field trips Buzz-session Fishbowl session Puppet-show Group-discussion Panel discussion Forum

Mass methods -

Exhibition Lecture Health campaign Advertisement Drama

Criteria for selecting appropriate methods and media of health education - A particular method or media may get failure to achieve its educational objective simply because of its inappropriateness and impracticability in certain situation. - The appropriateness of particular method or media should be determined on the light of certain criteria. - These criteria should be well considered in choosing and applying a particular method or media. - The criteria are described below:

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Feasibility or practicability: A method or media should be feasible to apply from the point of view of transportation, economic factor, availability of necessary equipment and other facilities. For example, we cannot use electrical devices where there is no electricity

ii. Nature of the audience -

A method or media should be chosen to suit the educational status, culture etc of the target group.

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Teaching about the importance of eating meat will mean nothing to the vegetarian group who has taboo against taking meat. In the same way distributing pamphlets to illiterate people will not help to provide information to them.

iii. People’s attitude and belief on the method or media: -

People have different kinds of interest for different kinds of methods or media. - So, each method or media should be chosen according to the interest and belief of people on them. People take radio broadcasting, television telecast, government published pamphlets, etc as valid messages and tend to ignore individual lectures.

iv. Accessibility -

The method or media that a health educator chooses must be able to reach to the people concerned. In fact a health education program or message should be accessible to each member of the target group in the community.

v. Subject or purpose of health education: -

The purpose of health education also affects in the selection of particular method or media. The subject and purpose of the teaching will be based on audience need. If it is for conveying some health message or knowledge a lecture can help but when there is a need of skill and attitude development, demonstration method has to be applied.

Individual, Group and Mass Methods of Health Education Individual Methods of Health Education Interview - Interview is the process of asking questions to collect information and ideas. - It is a process or method of providing health education through the means of question and answer between the health educator and the learner. - In this process, interviewee’s, knowledge, attitude, feeling and health practices are studied and essential suggestions are given to bring about the positive change. Advantages of interview - Helps to assess knowledge, attitude and practice - Helps for intensive and systematic teaching with exchange of ideas and feelings - Help to reach a better conclusion for solution of a problem. - Easy to conduct with less cost and limited facilities. - Even illiterate persons can be interviewed and taught - Easy to make follow-up - It is a two way communication - The expression and gestures can be observed. Disadvantages of interview - Time consuming - Difficult to cover wide range of target people - Tedious if has to be repeated to many people.

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Counseling Counseling is a process of encouraging and helping an individual in identifying his or her health problem, the cause of the problem, the ways of its solution and also encourages taking necessary actions to solve it. - The decision of actions strategies is made on his own choice with least of advice from the counselor. - A counselor will have to play a serious role of helping the client in identifying the actual problems and the appropriate method to solve it. So he/she must encourage adequate interaction between client and counselor. Techniques of counseling - Building rapport - Identifying clients needs or problems - Encouraging discussion and providing appropriate information - Maintaining patience - Keeping secret Advantage of counseling - It is helpful in dealing with individual clients and motivate him/her to take necessary action to solve health problem - Provides maximum opportunity for feedback. - Helps to maintain two way communications. - Illiterate people can be taught by this method. - Easy to make follow up studies on the basis of counseling records. Disadvantage of Counseling - Counseling takes long period of time. - Counseling is a difficult process and requires experienced counselor - It is difficult to cover wide range of people through counseling method. Group Methods of Health Education Demonstration Demonstration is the process of providing knowledge and skills as well as developing attitude of a small group of people through the manipulation of appropriate teaching devices or materials. - Teaching by demonstration involves verbal and visual explanation. - It is a mixture of theoretical and practical teaching. - It is organized to teach about the specific topics and it should take less than 45 minutes to complete the demonstration but it slightly varies according to the topic. - The numbers of learners in the group may be about 15 to the maximum. - The learners are given opportunity to see and manipulate the device or materials used in demonstration and also give opportunity to practice the process and questions and answers to clarify doubts. Advantages of Demonstration - It is the effective teaching method which involves varied learning experiences like seeing, hearing, feeling, testing and smelling depending upon the subject of demonstration. - It is interesting and draws attention of the learners because of the active learning process. - It helps to develop not only knowledge and attitude but also skills for required work performance. - Student’s achievement could be immediately assessed through verbal expression and skill practice.

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Provides concrete and realistic visual picture of what is being taught resulting in a more lasting impression. It is cheap, practicable, accessible and useful for different categories of learners. It needs only limited materials and object. It can be used at different teaching-learning situations at different places.

Disadvantages of Demonstration - Sometimes it may be difficult to get necessary equipment and materials for certain demonstration. - May not be appropriate to conduct demonstrative teaching on certain topics especially when there will be only cognitive gain. Mini lecture Minilecture is the method of giving information about any subject matter with the help of short lecture or speech, maintaining the exchange of ideas between the speaker and the audience, as well as evaluating about what the audience perceived in between the speech. Advantages of Mini lecture - Two way communication is maintained between the speaker and audience - The audience gives maximum concentration on the speech. - Since there is quick evaluation in between the speech , the mini-lecture can be changed according to fit to the knowledge condition of the audience - It can be effective in small groups within short time interval Disadvantages of Mini Lecture - It will be difficult for the speaker to present mini-lecture in short time, as well as to evaluate and change the mini-lecture according to the perception of the audience. - The audience feels shy and embarrassed when they cannot answer the questions asked by the speaker. - It can be applicable only for small groups. Brain Storming Brain storming is also called ‘Creative Ideation’. This is a modern method of eliciting from the participants, their ideas and solutions on debatable issues or current problems. Instead of discussing a problem at great length the participants in brain storming session are encouraged to make a list in a short period of time all the ideas that come to their mind regarding some problems without debating amongst themselves about the pros and cons of their own ideas. Advantages of brain storming - Provides varieties of useful ideas in short time for quick group decision - Enables individuals to think and respond quickly - Decision made by group thinking is better than by individual thinking. Disadvantages of brain storming - Ideas pulled out may not always be relevant and helpful to make group decision. It may happen especially with the new learners. - It might take some longer time and may not be appropriate for packed programmes.

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Role Playing Role play is a socio drama which can be carried out by individual or a group of people taking different roles and acting out problem situation similar to that they encounter in their real life situation. - They enact roles as they have observed or experienced and act or pretend to be a sick. Person, as a mother, child, health worker etc. - In a role playing there will be about 5 to 6 characters and 15-20 audience but the number may be slightly vary according to situation. Advantages - Gives learners opportunity to express their ideas based on real life situation and can learn from each other. - Enables the learners to see things through the eyes of others. Start learning how knowledge and attitude affect health behaviour. - Develops the power of quick thinking and expression .Helps the characters to explore their potentialities and come to a better decision. They can apply those skills in their real life situation while dealing with health problems. - Develop careful listening habit. - Makes people think in a more constructive way. - It interesting and provides active learning opportunity in a realistic way. - It simple and inexpensive and can easily be conducted at different situation. - The best way to teach people about health in order to make them understand it. Disadvantages - It may lead to only a recreational activity not educational. - Everybody cannot successfully act due to shyness, lack of experience, lack of confidence and expression skills. - Every learner may not get opportunity to participate as role player. Group Discussion It is a method of teaching through the direct share of knowledge, ideas and experiences among small group of persons about a particular subject or problem within a limited period of time with a view to solve the problem. - Any discussion should take only an hour or less to avoid boredom. - An ideal group may consist of Six to Twelve members depending upon the situation so that each person is able to communicate with all the others face to face to reach to a decision and achieve the common goal. - There are three types of members in a group discussion. They are Leader or moderator, Recorder or Note-taker and Participants. Advantages - Develops creativity, confidence and ability of judgment in the members or learners. - Helps learners to come to a group decision and solve their common problem. Group decision is better than individual decision. - Helps members to become active learners and learn new knowledge, ideas and experiences about their subject of concern through a cooperative process. - Provides adequate communication among all the members with exchange of ideas and experiences. - The health educator can make a closer study of the members of target group regarding their need, interest, attitude, ability and other potentialities.

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Disadvantages - Some self-conscious members may not venture to bring forth their valid idea "for fear of disapproval by other members. - Sometimes discussion may be prolonged without any fruitful result, or it may take longer time to come to the conclusion or decision. - Somebody may not feel personally responsible for the result of discussion. So, they may not participate well. Fish Bowl Session - The fishbowl is a method to organize presentations and group discussions that offers the benefits of small group discussions within large group settings. - This is done by arranging the room so that the speakers are seated in the centre of the room with other participants sitting around them in a circle watching their conversation ‘in the fishbowl. - Best used in conferences, workshops and town hall-type meetings, the Fishbowl focuses the entire group’s attention on a discussion among 3 - 6 people. Other people present become observers, active listeners, and potential participants through a rotation process which reduces the distance between speakers and audience. - A fish-bowl session may include 12-30 participants and take place for 45-90 minutes Rationale of use Fishbowl can be used to - Foster dynamic group interactions and active participation. - Discuss or introduce controversial health topics - Showcase expert panel discussion - Avoid power point presentation Process of fishbowl session - An engaging health education topic that is compelling to the audience is chosen - 3-6 experts or noteworthy participants who can initiate fishbowl conversations are identified. - The chairs are arranged in two circles. The inner circle (fishbowl) consists of 6-7 chairs for experts and outer circle of chairs are arranged for remaining participants, leaving enough space for movement in between two circles. One or two chairs in the inner circles are left empty. - The moderator describes the topic for discussion and fishbowl participants are invited for discussion. The participants in outer circle observe the discussion as active listeners. - After about 10-15 minutes, a participant from outer circle is invited to join the fishbowl. Only the inner circle can speak or contribute to discussion. - The discussion is continued in a rotation process - In order to keep the discussion lively and informative, the participants from fishbowl are encourage to step away once they have contributed their thoughts so that other participants from outer circle can join the discussion. Panel discussion Panel discussion is one of the methods of group teaching. It can be adopted both for school students and community people in order to provide health education. - The panel members will be a group of experts normally 3 or 4 persons who themselves enter into question and answer process regarding a specific topic of discussion. - The health educator can manage to identify and bring the experts. He can work as a coordinator to introduce topic and the experts, and also help conduct the discussion.

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Advantages - Provides varied knowledge, ideas and experiences about the subject of concern to the learners. - Interesting and .can draw attention of the audience or learners. - Learners get opportunity to ask questions and pass comments, which help, in teaching learning process. Disadvantages - Sometimes it is difficult to get the appropriate experts. - Difficult to set definite time to suit the experts. Buzz Session (past question- 2070/3) A buzz session consists in dividing large group of audience into small groups of 2 to 15 people to discuss for specified time on specific question, problem or issue. - The groups work simultaneously in the same room (the word buzz comes from the resulting noise). - The task is brief and relatively simple. Steps of conducting a buzz session - The session is incorporated into a large group activity, such as a conference. - Groups may be set up in advance or on the spot. For example, in a banquet-style room, participants sit at round tables with each table constituting a discussion group. This is most appropriate arrangement - The leader introduces the issue or problem to be discussed. The issue can be the same for all groups, or each group can have a different phase or sub-problem to discuss. - Once the problem or issue is clarified and understood by each group, the groups should be asked to choose their leaders and recorders. - The groups are left for discussion to no more than 20 minutes. Leader tries to get all the members of the group to participate. - The recorder takes notes and prepares a summary to be presented when all the groups come together. - The summaries are submitted in writing and reported at the plenary session in the form of synthesis. Rationale for use of buzz session - To create an opportunity for discussion even in a large group. A buzz session gets more people to participate and is less intimidating than a forum. - To identify an audience’s needs and points of interest. - To encourage the contribution of participants who would be reluctant in a large group. - To obtain participants’ feedback on the conduct of the activity. Advantages - A large number of ideas, issues and recommendations can be collected in a short time. - Each participant has an opportunity to share their point of concerns. - Because members are expressing opinions, it is good for dealing with controversial subjects. Disadvantages - Effectiveness of the group may be lowered by the immature behaviour of the few participants. - It may not be effective for young groups or groups that know each other well to take each other’s opinions seriously.

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Workshop - The workshop is the name given to a novel experiment in education. - It consists of a series of meetings; usually four or more, with emphasis on individual work, within the group, with the help of consultants and resource person. Workshop group may consists of about fifteen participants. Steps of conducting workshop - In the beginning of the workshop, the organizers give opportunity for the participants to introduce each other. - The purpose and schedule of the workshop is discussed. - Workshop session is begun. There may be one or two sessions a day. Chairperson is selected for each session or for the entire day by the participants. - The workshop organizer may throw some light on the objectives of the workshop. The experts may also express their opinion and provide necessary information during the discussion period. Such need may arise at the time of confusion, misunderstanding and conflicts of opinion among the participants. - Sometimes a full discussion on specific topics may be needed and it will be done through small group discussions. - The decision made by the small groups will be reported to the chairperson of the respective group to the plenary session. - After conduction of the workshop, it is necessary to prepare a workshop report. Advantages - Helps to provide up-to-date knowledge and skills as well as to develop appropriate attitude. - Provides opportunity for participatory learning. - Provides varied learning experiences like listening, speaking,, seeing, discussing, etc. Disadvantages - Takes long time to organize the workshop. It might take weeks or even months. - Sometimes it is difficult to get appropriate experts (resource person. Mass Methods of Health Education Exhibition Exhibition is the systematic and meaningful display of educational materials with an intention to educate large number of people within a limited period of time and at a particular place. - Exhibition can sometimes be organized to provide health education to the community people. - Exhibition consists of the use of different teaching materials and methods to illustrate and explain the points of teaching. - They are posters, charts, graphs, models, real objects, cassette playing with some health message, demonstration, puppet show, videocassette, etc. Advantages - Provides better learning through varieties of experiences like hearing, seeing, touching, feeling and tasting. - Opportunity may be provided for practical learning through demonstration, manipulation of objects and through practice. - Interesting and attractive because of decorations, good setting, and other lively displays. - Helps students to develop creativity. - Organizing exhibition can also help learn some new knowledge and skills.

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Disadvantages - Difficult to organize in terms of money, materials and manpower. - Difficult to organize to suit different kinds of people w ith different needs, background, interest, etc. - Difficult to get appropriate place and adjust to the available time due to lack of resources, unfavorable weather, etc.

Meaning, Types, Importance and Selection Criteria of Health Education Media Media refers to those aids or teaching materials using sight or sound to present information. Media includes audio-visual aids like film show, documentary show, television, etc. Objectives of using media in health education - To increase the effectiveness of the health education programs - To hold the attention span of the learner for the duration of instruction - To save time - To use all the relevant information available from different sources - To make learning experiences last longer In order to employ the audiovisual aids, user should be aware of - Different audio, visual and audio-visual teaching aids - Criteria of selection of the aids - Methods of preparing aids - Using suitable aid at appropriate time. Types of media for health education (Q: 2072/12) Audio Media Visual Media -

Radio Cassette player/ Tape recorder

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Posters/Pamphlets Flip charts Flash cards Photographs Charts, maps Silent motion pictures Bulletin boards, Flex charts, etc.

Audio-Visual Media -

Projector Motion pictures Television Internet & Social media

Audio, Visual and Audiovisual Media Audio Media Radio Radio is the audio aids through which messages are relayed to a heterogeneous and large number of people at one time, who are not physically present before the communicator. - It is a mass media, which provides one-way communication. - The concerned audience are informed and asked to attend the broadcast at the particular time and place. Advantages - It is very much helpful for illiterate people; the message should be simple to understand. - It leaps the barriers of distance and space.

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Radio transmitter can be carried with and attend the radio health programme anywhere the individual goes. One can give up to date information to a large number of people in a very short period of time.

Disadvantages - It is one-way communication system. - The communicator cannot be sure of it people sure listening to and understanding his message. - There may be electricity and batteries problems & broadcasting facilities are available only in the limited area. - It is difficult to evaluate the impact of radio teaching. - Sometimes there may be language barrier to certain group of people. - Message received only through verbal teaching so it is easy to forget. - Difficult in timing to fit the convenience of the specific target people. Cassette Player/Tape Recorder Cassette player is a small portable audio machine or equipment, which can be operated with the help of the electricity or batteries. - It is useful for providing health education (message) to a group of audience. - These days cassette player or tape recorder is commonly used media. - Different cassettes can be recorded with different health messages and be used according to the need and interest of the audience group. Advantages - Useful for group teaching session and make discussion. - It can be recorded and played easily at various place. - The recorded message can be pre -tested before using for actual teaching session - It can be played at learner 's speed of learning by stopping in between or by playing over. - It can be played with the help of batteries where there is on electricity supply. - It is portable and easy to carry at different places of teaching Disadvantages - Some people become confused about the operation of equipment - Break of electricity supply or lack of batteries might pose problem. - Learning by hearing only is not effective. Visual Media Poster - Poster is a pictorial and graphical non-projected visual combination of bold design, color and message, which is intended to catch attention of learners from long distance to implant a significant idea in his/her mind. - Sometime, poster is made even without picture, such poster is not useful for the illiterates, and a perfect poster should be good for both literate and illiterate. Steps of preparing a poster i. The headline or verbal message - Must be concise and direct to the point - A catchy phrase that sticks to people’s mind is used. - Headline consists of not more than 7 words. - Lettering should be simple, clear, large and evenly spread

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Image or pictorial content Images visualize the idea or message clearly and directly. It should be appealing and attractive

iii. Composition/ layout or visual organization - Dynamic arrangements of verbal and pictorial content to direct the viewer’s attention - Verbal and pictorial contents must complement each other to create a pleasing effect. iv. Colours - The colours can be used to focus the main idea/message - Colour combinations should be appealing. Not more than 2-3 colours should be used. Qualities of poster - A good poster should carry only one unit of message - Colored poster is more natural, attractive and clear - An ideal size of the poster is (60×60) cm but it may be different in size. - The picture and letters should be big enough to be seen clearly from a distance of about five meters. - Message should be based on the need of target of people and should confirm the existing culture of the community concerned. Advantages - Pictorial and colored posters are attractive and effective. - It can be carried easily from one place to another. - Can be locally prepared in limited number to meet immediate and local health education needs - Many People can learn something from limited number of posters on display. - Even illiterate people can learn something by looking at the picture of the poster. - Helps to develop creativity of in the learners by involving them in designing and making posters - Can be saved for future use. Disadvantages - It provides one-way communication. - Color printing of poster is very expensive and printing services may not be available in rural area or place. - It can damage easily. - Difficult to make sure that intended group have seen or read the displayed posters. Pamphlet Pamphlet is a visual media. It is considered as mass media of health education. - The message can be written in the form of poem, song, and diagram. It can also be written in the form of dialogue. - It can also be introduced in the form of leaflets, folders to convey health related message. - A pamphlet should be as brief as possible, it should be not exceed mote that four pages Advantages - Helps in propagating messages rapidly in mass scale through wide distribution. - Pamphlets are very easy to carry from place to place. - The first reader can pass the read pamphlets to others. - It covers the large number of people place through wide distributions for the purpose of propaganda

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It is easy to prepare and not costly People can read them at them free time and understand the message well. It can be kept safely to read again and again, which helps remainder of the information.

Disadvantages - Provides only one-way communication. - Not useful for illiterates. - There is no sure either the people have read and understood the distributed pamphlets. - Printing service may not be available everywhere especially in remote or back ward areas. Flash Card - Flash card is a set of visual aid that consists of messages in series or steps by consecutive pictures, which convey certain message about a specific topic. Steps of preparing a Flash card - Plan the units of message to be conveyed through each card. Each card should contain only one unit of message. - Normally eight to twelve cards can make a set. However, the number may vary according to the nature of subject or content. - Obtain few sheets of drawing paper or cardboard paper. The paper should be thick enough to keep the individual cards rigid while showing the audience by holding on its side. - Cut the cardboard paper to the desired number and size. The good size of the card is 12 x 10 cm. The size may vary according to the size of the learner’s group. Size of the flash card No. of audience Distance 8 cm x 12 cm 4 to 8 60-80 cm 12 cm x 18 cm 9 to 12 80-100 cm 18 cm x 18 cm 13 to 19 100 cm to 125 cm 18 cm x 25 cm 20 to 25 125 cm to 150 cm -

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Two cover cards can be kept either of the same paper or of different thick paper. Write down the title of the set on the front cover to make it easier to identify the set for use. Appropriate drawing or picture is drawn on one side of each card. Appropriate pictures can also be cut from magazines and paste rightly on the card. The units of message should be numbered serially which will be accompanied by appropriate pictures on the cards. The number should be written on the back of the cards. The caption of the first card should be written on the back of the front cover card. The caption of second card should be written on the back of the first card and so on. The set of flash cards can be wrapped up with the help of rubber band or a piece of strong thread to keep it safe. The cards can even be hinged together at the top loosely so that they can be easily flipped over when using.

Use of flash card - Keep the cards together in a sequential order by keeping one on the top of the other with the pictures face up. First card should be on the top of the second, and so on. - Prepare the audience by letting them sit properly. Give an introduction on the topic of teaching. - Hold the set of flash cards at appropriate height so that all the learners can see the picture while teaching.

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Show the title page and introduce the topic. Put it on the back and show the first card. Explain the picture by looking at the caption written on the back of the title page. Be sure the picture is not covered by the fingers while holding or showing the card. Put the first card behind the package and explain the second by looking its caption on the back of the first card. Continue changing all the cards in this way until all of them have been explained. A question and answer session should be held on the spot to address confusion and misunderstandings. Necessary corrections or explanations should be given for better learning. Store the flash card set properly for future use.

Flip Chart A flip chart is a visual teaching aid, which is just like photo album. It is the series of related charts or poster assembled in a booklet form. - It is also called flipbook or turnover chart. - A set of flip chart normally consists of 6-8 charts the size of individual sheet of chart should be approximately 50cm×70cm is normal size. But it may also vary depending upon the available paper size. - A flip chart is mainly used in classroom teaching, training program, Group teaching in community etc. Steps of preparing flip chart - Plan for health education messages to be conveyed through individual charts in a logical order. - Get appropriate and required number of paper sheets to write down the units of message. - Write down the units of messages. Each unit of message should be brief. The pictures and letters should be bold enough to be seen clearly from a short distance. - Two or three colours may be used to make the pictures and captions look attractive. - Individual charts are hinged together at the top. - The title of flip chart is written in the front side of the cover. Techniques of using flip chart - A group is seated in front of the health educator in such way that no one blocks the other in looking at the chart - The flip chart is placed high enough so that it can be seen clearly. - The topic of presentation is introduced - Each chart is explained well before going the next. - Participants are encouraged to ask questions - Care should be taken so that any part the picture or message is not blocked during presentation. Advantages of flip charts - It helps to show abstract information visually. Pictorial explanation is better and more effective. - It is portable and easy to carry from place to place for providing health education at different situations- clinics, classroom, community group, etc. - It is helpful to make systematic presentation. Helps the educator to explain points clearly and comfortably within the limited period of time. - A health educator can make flip chart by himself by utilization of local resources and materials. - Flip charts are economical. They do not require us to use any special films or printers to produce them. - It can be used repeatedly whenever needed. - It can be used to illustrate information so that the audience can follow the sequence. - It is helpful for both literate and illiterate person to learn.

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Disadvantages - Flip chart is expensive to produce in large scale. - There may be difficult to draw the appropriate picture. - Ready-made flip chart may not achieve education goals. - It doesn't cover the large number of people at once. Flannel-graph A flannel-graph consists of flannel board and a series of cut pieces or cut-outs. The use of flannel-graph helps the health educator to illustrate the points of teaching and reinforce the message presented. The edges should be fixed on the board with the help of thumb-pins or appropriate nails. Steps in preparing flannel board and graph (Q:2072/12) - A plyboard, cardboard or similar material is cut into desired size - The board is covered with a flannel cloth - The cloth is folded over one edge of board and fastened using a stapler. - Graphic materials are illustrated; lettering can be done by freehand or with the help of lettering guides. - Strips of sandpaper are attached irregularly at the back of the graphic materials. - For a successful display and to avoid districting “drop-offs” (falling of flannel graph), the adhering power of the graphic materials are tested in advance. Using a flannel graph - The flannel board is tilted slightly backward at the top so that materials are less likely to fall. - Windy locations such as near the window or an electric fan are avoided. - The sequence of the presentation is carefully planned. - Health educator is stood beside the board to avoid blocking the presented graphs. - Graphs or materials are left on the board only for as long as they are needed. - The presentation is kept simple. Advantages - The pictorial explanation is interesting and attractive. - Organized and systematic display of cut pieces can make the teaching impressive and effective. - Could be used at different teaching situations — in the classroom, community group, group of mothers attending Family Planning /Maternal and Child Health clinic etc. - It is easy to carry the sets of cut pieces to distant places. - It is durable and can be preserved well for future use. - It is not expensive to make a flannel graph. Bulletin Board Bulletin board is a non-projected visual aid, which health education message and any other information is displayed with view to informing people. - The board is made of sheet of light plank or plywood, card -board sheet or similar rigid material usually set within a frame. - Different education material like cuttings, picture, graphs, chart, leaflets and other appropriate teaching aids are displayed with the help of thumb pin or sellotape. - Bulletin board can be kept in library section, waiting hall, offices, hospitals, health post, nursing home etc. - The normal size of the bulletin board is 60cm×40cm.

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Advantages - It is attractive, simple and economical way of providing information and message - Stimulate learners' thoughts when they are involved in the preparation of display. - People get opportunity to learn something while waiting in the hall, passing through corridors, etc. - Students learn through share of knowledge and skills among fellow learners while preparing for the displays - Helps to provide up -to date information - Learners learn through share of knowledge and skills among learners while preparing for the display. Recent Advances in Use of Social Media (Internet) in Health Promotion and Education The term social media generally refers to Internet-based tools that allow individuals and communities to gather and communicate; to share information, ideas, personal messages, and in some cases, to collaborate with other users in real time. This may include - Social networking (facebook, twitter, google plus) - Professional networking (linkedIn) - Media sharing (Youtube, Flickr) - Content production (blogs) - Knowledge aggregation (Wikipedia) By its unique nature, social media is a tool for - Interaction with individual audiences - Multi-way interactions with sizable group of audiences - Mass message dissemination Advantages of social media in health education and promotion The following advantages make social media viable channels for public health education and communication: i. Through social media, we can target and reach diverse audiences - Just as some audiences may prefer to receive health information via print materials, or from their peers, there are increasing numbers of audiences who prefer to receive health information online. - With the number of social media users growing so rapidly, social media present an opportunity to reach diverse group audiences in a very short period of time. ii. -

-

Social media allows to share health information in new spaces Social media allow us to share relevant content in new and emerging channels, test how our messages resonate in different spaces, and provide opportunities for multiple exposures to messages. Through the use of social media channels, public health organizations can share relevant content where users are already spending their time. Sharing health content in new spaces allows public health educators to potentially tap into the large audiences of social media channels relatively at a very cheaper cost.

iii. Feedback can be listened to and collected in real time - Social media give us insights into what health information may be important and interesting to users, in the moment. - This real-time aspect of social media is a key component to ensuring that our communication efforts are relevant, meaningful, and useful to our audiences.

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iv. Social media permits direct engagement - Due to the multi-way, interactive functionality that is inherent to these platforms, social media can allow us to increase direct engagement to maintain and increase trust and credibility. Challenges of social media to health education and promotion in present context (past question: 2072/3) i. Poor quality of information - The main limitation of health information found on social media and other online sources is a lack of quality and reliability. - Authors of health information found on social media sites are often unknown or are identified by limited information. - In addition, the health information may be unreferenced, incomplete, or informal. - While evidence-based public healrh de-emphasizes anecdotal reports, social media tend to emphasize them, relying on individual patient stories for collective health knowledge. ii. -

Loss of message control Potential risks of and fears related to social media engagement for health education includes loss of control of the message, giving credibility to junk science and reputational concerns. There are large concerns about negative comments misdirecting and reshaping the message and conversations. The tendency of messages being shared to numbers of users is very rapid and the health educator loses control to correct or withdraw messages if misguided or shared with distorted meanings.

iii. Breaches of client privacy - Concerns regarding the use of social media by health education professional frequently center on the potential for negative repercussions resulting from the breach of client confidentiality. - Such infractions may expose health educators and health care entities to liability under privacy laws. iv. Damage to professional image - A major risk associated with the use of social media is the posting of unprofessional content that can reflect unfavorably on health education professional. - Behavior that could be taken as unprofessional includes violations of client privacy; the use of profanity or discriminatory language; posting photos without consent; negative messaging, etc. v. -

Overlooking disadvantaged groups Social media users usually represent groups that are relatively affluent, literate and more or less aware of particular health concerns. While most of the health education campaigns intend to target disadvantaged groups, use of social media typically tends to overlook these groups.

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UNIT 7: SETTINGS IN HEALTH PROMOTION AND EDUCATION Historical Evolution of Setting Approach - The setting approach has its origin within the World Health Organization (WHO) Health for All movement, which was instrumental in the development of new public health, with its focus on how physical, social, economic and political environments affect health and well being. - Within this context, the Ottawa Charter presented a framework for health promotion with explicit focus on setting. - The charter stated: “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.” - The Ottawa Charter stimulated WHO to prioritize the settings approach in its health promotion programmes. - From the late 1980s, the settings approach emerged across Europe and globally launched by WHO in 1987 as a Healthy City initiative. - Drawing on this experience, developments took place within settings such as schools, prisons, hospitals and universities. - Subsequent international health promotion conference served to legitimize further the settings approach. Concept of Setting Approach in Health Promotion and Education (Q: 2072/12) - Healthy settings or the setting based approach to health promotion is a holistic and multidisciplinary method which integrates action across risk factors. - The setting approach for health promotion provides an opportunity for a more comprehensive and organized approach through integration of health promotion activities and interventions into all areas of the setting. - The setting approach is a whole system approach and recognizes that health is multifaceted and it determined by a complex interaction of factors operating at a personal organizational and environmental levels. - A setting based approach has roots in the WHO health for all strategy and more specifically, the Ottawa Charter for Health Promotion. - The key principles of healthy setting include community participation, partnership, empowerment and equity. Advantages: - A significant advantage of working through a setting approach is that it provides a more integrated and cohesive mechanism for addressing multiple health issues and their determinants. - The setting approach enables whole system planning for health across the relevant sectors. Types of healthy settings A setting based approach has been implemented in multiple areas such as: i. Health City/Village approach ii. Health Promoting Schools Approach iii. Healthy Workplace Approach iv. Health Promoting Hospitals v. Health Promoting Universities vi. Healthy Aging Approach vii. Health Promoting Correctional Centres (prisons)

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Elemental and Contextual settings - Contextual settings are larger units that hold smaller elemental settings. Elemental settings are contained within a broader contextual setting. - For example, city may contain important elements such as schools, hospitals, markets and workplaces. - Elemental settings directly affect the life of people that live within them i. -

-

-

ii. -

Healthy City Healthy Cities are arguably the best-known and largest of the settings approaches. A healthy city seeks to promote policies and action for health and sustainable development, with an emphasis on determinants of health, on people living in poverty and the needs of vulnerable groups. A healthy city provides communities with a framework for multi sectoral planning for health. In essence, the healthy city is not just a place in which health promoting activities take place but one in which all sectors of society place a priority on improving health and plan together, in a coordinated way to meet community and population health needs. A Healthy City aims to: • to create a health-supportive environment, • to achieve a good quality of life, • to provide basic sanitation & hygiene needs, • to supply access to health care. Being a Healthy City depends not on current health infrastructure, rather upon, a commitment to improve a city's environs and a willingness to forge the necessary connections in political, economic, and social arenas. Healthy Village Healthy village includes a community with low rates of infectious diseases, access to basic healthcare services, and a stable, peaceful social environment. Programmes attempt to foster a holistic approach to health management through fostering communication among community leaders and members. Communication throughout the various social ranks of the village and a village health plan are necessary components of all programmes. Countries like Egypt, Nepal, Pakistan, and Sudan have Healthy Village initiatives.

iii. Health Promoting Schools - A Health-Promoting School views “health” as physical, social and emotional wellbeing. It strives to build health into all aspects of life at school and in the community. Characteristics of health promoting schools - Fosters health and learning with all the measures at its disposal. - Engages health and education officials, teachers, teachers' unions, students, parents, health providers and community leaders in efforts to make the school a healthy place. - Strives to provide a healthy environment, school health education, and school health services along with school/community projects and outreach, social support and mental health promotion. - Strives to improve the health of school personnel, families and community members as well as pupils; and works with community leaders to help them understand how the community contributes to, or undermines, health and education.

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Components of health promoting schools - Healthy school policies - School physical environment - School social environment - Individual health skills and action competencies - Community links - Health services Health Promoting School vs School Health Program (Q:2072/12) School Health Program

Health Promoting Schools

- School health program are traditionally considered the exclusive responsibility of health sector

- Health promoting schools are the responsibility of the school family with inputs from health sector and communities

- Schools are regarded as passive receptors of interventions implemented by health sector - Vertical, medicalized and care-oriented programs

- Schools are active components determining interventions through participatory process - Horizontal, socialized and system oriented programs - Characterized by need based educational process with regard to affective processes and emotional intelligence

- Basically characterized by the cognitive and didactical transmission of health information on isolated subjects - Strives to improve the health of students only - Does not consider actively the health and well-being of staffs in the school - Sporadic in nature particularly focusing on vaccination campaigns, health campaigns, vision screening, health talks etc. - Generally related to specific diseases or physical aspects of health

- Whole of school approach - Strives to improve the health of school personnel, families and community members as well as pupils - Continuous in nature incorporating overall issues from policy development to provision of wider school health services. - Also related to development of abilities and skills to live a full and healthy life.

- Carried out by external agents - Neither of the members of the educational community nor local health teams or other members of community have much influence on decisions with regard of or the approach to such interventions

- Carried out by school community - Promotes interaction among the school, community, parents and local health services.

- Components of school health program • Health instruction • School health services • Healthful school environment • School Community Joint Activities

- Components of health promoting schools • Healthy school policies • School physical environment • School social environment • Individual health skills and action competencies • Community links • Health services

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iv. Healthy Workplaces - Workplace health promotion can be defined as the combined efforts of employers, employees and society to improve the health and well-being of people at work. - This vision of workplace health promotion places particular emphasis on improving the work organization and working environment, increasing workers' participation in shaping the working environment, and encouraging personal skills and professional development. - Workplace health promotion focuses on a number of factors that may not be sufficiently covered in the legislation and practice of occupational health programmes, such as • the organizational environment, • the promotion of healthy lifestyles, • and non-occupational factors in the general environment. - Non-occupational factors include family welfare, home and commuting conditions, and community factors which affect workers' health. - Workplace health promotion supports a participatory process to help promote a stronger implementation of occupational and environmental health legislation - To be successful, workplace health promotion has to involve the participation of employees, management and other stakeholders in the implementation of jointly agreed initiatives and should help employers and employees at all levels to increase control over and improve their health. v. Health Promoting Hospitals A health promoting hospital (HPH) is defined as one that ‘incorporates the concept of health promotion into its organizational structure and culture by means of organizational development. (WHO, 2005) - The goal is to improve the quality of health care, the relationship between the hospital and community, and the conditions for and satisfaction patients, staff and relatives. - Based on Health for all strategy, Ottawa Charter for Health Promotion and the Budapest Declaration on Health Promoting Hospitals, a health promoting hospitals should: • Promote human dignity, equity and solidarity and professional ethics, acknowledging differences in the needs, values and culture of different population groups. • Be oriented toward quality improvement, the well-being of patients, relatives and staffs and protection of environment. • Focus on health with a holistic approach and not only on curative services • Be centered on people providing health services in the best way possible to patients and relatives. • Use resources efficiently and cost-effectively and allocate resources on the basis of the contribution to health improvements. • Maintain close links as possible with other levels of the health care system and community. -

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UNIT 8: Roles of Health Education and Promotion in Public Health Programmes Role of Health Education in Primary Health care programs Primary Health Care Programs Family Planning

Nutrition

Maternal and child health

Infectious diseases

Water sanitation

and

Role of Health Education and Promotion with Examples - FP demand generation through interpersonal communication (IPC) and home visits (e.g. BCC campaigns by MSI/SPN, HC3, PSI) - Promoting informed choice of contraceptives through counseling services. (eg. By HFs, MSI, FPAN) - Promotion of women's control over family planning, men's involvement, and the importance of long-acting methods through radio, television and print media with targeted family planning messages (for e.g. smart dampati campaign by USAID, OK campaign by PSI) - Promotion of contraceptive access and use through social marketing approaches (for e.g. social marketing of condom, pills and sangini (depo) by Nepal CRS company) - Promotion of homestead food production as a way to promote balanced and healthy diet through SBCC. - Delivering nutritional information including promotion of exclusive breastfeeding through radio programs (e.g. Bhanchhin aama radio program by Suaahara) - Education on danger signs of pregnancy, neonatal care, immunization schedules, etc. through use of IEC materials. - Promotion of birth preparedness and complication readiness - Promotion of oral rehydration and zinc supplementation (radio jingles on nawa jeevan and baby zinc) - Awareness on navi care after delivery (BCC by chlorhexidine care program) - Promoting LLIN use for malaria control through IPC and mass media (Global fund). - Awareness for prevention and control of infectious diseases like influenza, dengue, scrub typhus, cholera, etc. - Promotion of effective hand-washing techniques (by UNICEF) - Promotion of water disinfection through social marketing (e.g.piyush) - Promotion of toilet use and sanitation through SBCC. (e.g Global Sanitation programme by UN habitat)

Role of Health Education and Promotion during emergencies (disasters) Public health education and promotion play an essential role in reducing disaster vulnerability by: - increasing public awareness of environmental health hazards; - informing people how future risks of epidemics can be prevented or how their impact can be reduced; - increasing people’s awareness of the threats to health and safety that may result from a disaster, or that may exist and intensify during an emergency; - encouraging people to participate in protecting themselves, their environment and their health services from disaster and the effects of disaster. Role of health education and promotion during emergencies i. In some cases, there may be a good deal of misinformation and rumour regarding disease and outbreaks, and it is essential that people have access to authoritative information through means of health education. ii. There may be many unfamiliar arrangements for water and food supply, excreta disposal, etc., especially when people are forced to evacuate their homes. Health education helps to provide rapidly, the information about the new arrangements and the importance of complying with them (e.g. the importance of using designated defecation fields).

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UNIT 9: Community Health Development Community organization MURRAY G. ROSS in 1955 defined community organization as, A process by which community identifies its needs or objectives, orders (or ranks) these needs or objectives, develops the confidence and will to work at these needs or objectives, finds the resources (internal and/or external) to deal with these needs or objectives takes action in respect to them and in so doing extends and develops co-operative and collaborative attitudes and practices in the community. Characteristics of community organization - Community organization is a process of achieving community needs. - Community organization helps to identify the needs and resources - In the process of community organization, entire community is considered as a client. - Community organization is a means not an end. Objectives of community organization - To organize the community scientifically - To help the community to identify its needs and to work on it - To empower the community to identify the resources within and outside the community for development. - To equip the community to plan, implement, monitor and evaluate development initiatives. Role of community organization in health promotion and education (past question 2072/3 MHP&E) Roles of CO Description 1 Build capacity - Build capacity of members and groups to work together to identify community health problems and well-being needs 2 Involve people - Involve people in designing, developing and implementing health promotion collectively interventions against issues affecting health of communities 3 Build awareness - Build awareness of community members on health contexts and availability of services. 4 Enable groups - Enabling groups to analyze those health relates issues or problems that are neither their responsibility nor within their ability to solve. - It enables groups to consider and agree on how they will activate and get those with responsibility to move and focus on the problem and get the problems addressed. 5 Build confidence, - Build knowledge, skills and confidence of marginalized groups to advance knowledge and from an experience of powerlessness to state of health promotion. skills

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Community Development Community Development is a process designed to create a condition of economic and social progress for the whole community with its active participation and the fullest possible reliance upon the community initiative. (UN Bureau o Social Affairs, 1955) Characteristics of community development - It focuses on the whole community rather than on any one area or a group or a segment or of population. - It concentrates on the overall development of the community and attends the needs of the whole community. - It promotes problem-solving approach - It is always concerned with bringing social change - The foundation of community development is self-help and participation of local people, in whatever manner they can. - Community development usually involves utilization of local resources. Process of community development

Ways of Viewing Community Development Sanders (1958) presents community development in four different typologies i. Community Development as a process - Community development as a process moves by stages from one condition or state to the next. - It involves a progression of changes in terms of specific criteria. For example, a change from state where one or two people or a small elite group make decisions for the rest of the people to the state where people themselves make these decisions about matters of common concern. - The emphasis of community development as a process is upon what happens to people, socially and psychologically.

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ii. -

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Community Development as a method Community development as a method puts the emphasis on both the process and objectives. It is a means to an end; a way of working so that some goal is attained. Those who subscribe to community development as a method applies centrally advised programs which are inevitably less attentive to the needs of each community.

iii. Community development as a program - Community development can also be viewed as a program consisting of a set of procedures and activities. - It is as a program that community development comes into contact with subject-matter specialties such as health, welfare, agriculture, education, etc. - Community development as a program emphasizes on activities. iv. -

Community development as a movement Community development is a crusade, a course to which people become committed. It is not neutral, but carries an emotional charge; one is either for it or against it. Community development as a movement is dedicated to progress of the community.

Techniques of Community Development and their application in public health programs Murray G. Ross identifies three techniques/ approaches of community development i. Single Function Approach (External Agent Technique) - In this technique, community health development programmes are implemented by the external agents. - The external agent convinces the people through his personal skills and experience and motivate them to work for the development of community health. - He identifies various health problems and seeks suitable solutions for it. - He organizes the people to discuss the situation, arrange meetings, forms committee to highlight the hindrances in the developmental procedures. - Al last this agent presents a policy for the community and the whole community adopt it for development. - This technique neglects the attitudes of community members to the innovation towards winning the support of the community for the subject. ii. -

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Multiple Agent Technique In this technique, the community development experts try to provide various facilities including health, education, sanitation, recreation etc. to control the causative factors in the way of community development. The basic philosophy of multiple agent technique is to convert centuries into decades. In this technique, some members are selected from the whole community. They try to make a combined policy for the improvement and betterment of people. This approach is also called representative because these people work in the community as representative of the whole locality.

iii. Internal Resource Mobilization Technique - In this technique, stress is laid on the needs to encourage people to identify their own needs and work cooperatively for satisfying them. - The community members are encouraged and motivated to use their resources for the improvement of the areas.

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Differences between community organization and development (past question- 2072/3) Community Organization Community organization is a method of social work In community organization, emphasis is on process It is a continuous process, without any time bounds and it is achieved as per the pace and participation of people Community organization emphasizes people’s participation Assistance of government and/or other agencies does not matter in community organization In community organization, people are involved in planning and executing the programmes to solve their problem Community organization is universal to all community Community organizers are usually people who bring social change (social change agents)

Community Development Community development is a programme planned to bring social change Community development focuses on end/goals Community development is time-bound and one has to take action within a stipulated time to achieve the goals Community development focuses on people’s development In community development, external assistance is sought and considered as important In community development, external agencies plan the programme. People’s participation is optimal Community development differs from community to community, people to people, according to the nature of the problems, needs, situations, etc. Community development personnel can be from any professional field other than social work such as public health, livelihood, agriculture, technology, etc.

Role of community organization for post-disaster re-construction work (past question- 2072/3) Reconstruction begins at community level. A good re-construction strategy promotes community organization to bring about rapid and sustainable solutions. Roles of community organization can range from assessment to implementation and evaluation of reconstruction works. Reconstruction Roles of community organization activities 1 Assessment - Conducting • Housing assessments and census • Community-led need assessments • Local environmental and health assessments • Mapping of affected areas, damages and changes • Stakeholder analysis 2

Planning and design

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Prioritizing and planning re-construction projects Carrying out participatory site planning and site evaluations Identifying targeting criteria and qualifying households Participating in training (DRR and re-construction methods) Assisting with grievance procedures

3

Project development and implementation

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Carrying out/or overseeing Housing reconstruction, including housing of vulnerable households Infrastructure reconstruction Reconstruction of public facilities (health centres, schools, community buildings, etc) Managing community warehouses

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Supervising reconstruction Participating in monitoring and social audit committees Conducting participatory evaluations

4

Monitoring evaluation

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Group Dynamics Group Dynamics - A group can be defined as several individuals who come together to accomplish a particular task or goal. Group dynamics means the study of forces within a group. The social process by which people interact with each other in small groups can be called group dynamics. - Group dynamics refers to the attitudinal and behavioural characteristics of a group. - It concerns how groups form, their structures and process, and how they function. - Group dynamics are relevant in both formal and informal setting and therefore it is an important area of study in both professional teaching-learning (e.g. training programs) as well as community health education processes. Importance of group dynamics - The members are always influenced by the interactions of other members in the group. Understanding group dynamics can help influence the thinking of members in health education process. - A well functional group can give the effect of synergy. - Even the attitude, perceptions and behaviour of members depend on group dynamism. For example, person with negative attitude can be converted to positive attitude with the help of appropriate interaction in the group. Group dynamics is primarily concerned with the following: 1. Process of group formation 2. Structure of group 1. Process of group formation - According to Tuckman, there are five stages of group development. i. Forming: Team acquaints and establishes ground rules. Members treat each others as strangers. ii. Storming: Members start to communicate their feelings but still view themselves as individual rather than a part of team. They resist control by group leaders. iii. Norming: People feel part of the team and realize that they can achieve work if they accept each other’s viewpoint. iv. Performing: The team works in an open and trusting atmosphere where flexibility is the key. v. Adjourning: A team conducts an assessment and implements a plan for transitioning roles and recognizing members’ contributions. 2. Structure of Group - Group structure is a pattern of relationship among members that hold group together. - Group structure is concerned with group size, group roles, group norms, and group cohesiveness. i. Group size - Group size varies from 2 people to a very large number. - Small groups of 2-12 are thought to be more effective with ample opportunities of participation. - Increasing size of group beyond 10-12 members results in decreased satisfaction among group members.

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ii. -

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Group roles Group roles can be classified into task roles, maintenance roles and individual roles. Task Roles Roles Building & Maintenance Roles Individual (Blocking) Roles • Coordinator • Compromiser • Aggressor • Elaborator • Encourager • Arguer • Energizer • Follower • Blocker • Evaluator/ Critic • Gatekeeper • Dominator • Information Giver/ • Harmonizer • Player Seeker • Observer • Recognition Seeker • Opinion Giver/ Seeker • Standard Setter • Self-confessor • Orienteer • Recorder

iii. Group norms - Each group creates its own norms defining group standards, boundaries of acceptable and unacceptable behaviour. - Norms often should reflect the level of commitment, motivation and performance of the group. iv. Group Cohesiveness - Cohesiveness refers to the bonding of group members or unity, feelings of attraction for each other and desire to remain part of the group. - Many factors influence the amount of group cohesiveness – agreement on group goals, frequency of interaction, inter-group competition, favourable evaluation, etc. Miscellaneous Evaluation of health education program Evaluation is a systematic way of learning from experience and using the lesson learnt to improve current activities and promote better planning by careful selection of alternatives for future action. (WHO) Evaluation is the process of determining the amount of success in achieving the predetermined objectives. (American Public Health Association) Types of health education program evaluation i. Process Evaluation - Process evaluation can be defined as “the assessment of policies, materials, personnel, performance, quality of practice or services, and other inputs and implementation experiences.” (Green & Kreuter,2000) - At this level of evaluation, the main focus is upon professional practice. - This is the time to experiment with methods, to pilot new programs components, and to solve problems in new materials such as their readability, cultural sensitivity and/or acceptability to target population. - Quality in health education programming is evaluated by such methods as adult, peer review, accreditation, certification and government and administrative overview of contracts and grants. ii. -

Outcome Evaluation Outcome evaluation can be defined as “assessment of the effects of a program on the ultimate objectives, including changes in health and social benefits or quality of life.” (Green & Kreuter, 2000)

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Outcome evaluation is centered upon mortality and morbidity, such as the incidence and prevalence of the condition(s) affected by the program. The information gathered in outcome evaluation determines whether a program has had an impact on health status and quality of life. Outcome evaluation is a long term consideration requiring large population samples.

iii. Impact Evaluation - Impact evaluation assesses the immediate effect a program has on the behaviors of the program participants. - This level of evaluation assesses change in pre-disposing, reinforcing and enabling factors, as well as in the behavioural and environmental factors. - Cost-effectiveness is one standard of acceptability in impact evaluation. Evaluation can also be classified into following types i. Formative Evaluation - Formative evaluation is done during the planning and implementing processes to improve or refine the program. - For example, validating the needs assessment and pilot testing are both the forms of formative evaluation. - Possible evaluation measures: number of sessions held, attendance, participation, staff performance, adequacy of resources, etc. ii. -

Summative evaluation Summative evaluation begins with the development of goals and objectives and is conducted after implementation to determine the program’s impact on the priority population. Possible evaluation measures include: increase in knowledge, awareness and skills, quality of life improved, morbidity and mortality, etc.

Criteria for Evaluation While evaluating a health education program, four criteria or components of evaluation should be considered as recommended by WHO. i. Adequacy - The evaluation should try to get adequate information about methods and media used, resources utilized, objectives fulfilled, target population covered, subjects or contents dealt, peoples response to health education program etc. - Attention should be given on the adequacy of implementation strategies applied. ii. -

Relevancy The evaluation should also consider the relevancy of activities against set objectives, relevancy of contents with objectives, relevancy of objectives with the needs etc.

iii. Efficiency - Evaluation should also emphasized to know how efficiently the health education workers have worked, how economically the progress is made etc. - Attention should also be given on if the goals and objectives are achieved in scheduled time or not. iv. Appropriateness

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The evaluation should also study the appropriateness of health education program to the need of target group, to the time the program is implemented etc.

Supervisory system of Health Education Activities in Nepal - Supervision of health education activities in Nepal is done in integration with other national health programs. Integrated supervision has been followed as one of the priority programs of Ministry of Health. - In District Health System, it has been recognized as a key management practice and the tool for effective implementation of health service interventions. - In district, supervision schedule should be planned at all levels before the program implementation for upcoming fiscal year. - Staffs from district to HP levels have, as a part of their responsibility, a significant supervisory role to perform. - It includes preparation of supervision checklists, its use during supervisory visit to its proper recording and reporting, its review by the concerned higher authorities and appropriate feedback system, all at appropriate time period. - Necessary supervision trainings are provided to all staffs from time to time for maintaining effective supervision system. Routine supervisory system at National Level Supervising Organization Organization to be supervised Department of Health Services (Including its Divisions and Centres)

Regional (RHD)

Health

Directorate

District (Public) Health Office Primary Health Health Post

Centre

and

Regional Health Directorate District (Public) Health Office

Primary Health Centre Health Post District (Public) Health Office District Hospital Primary Health Centre Health Post Primary Health Centre Health Post EPI Clinic, PHC-ORC, FCHVs Other community based health activities

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Frequency of Supervision Three times a year Mountain/ Hilly Region: at least once a year Terai: At least two times a year As per need As per need At least three times a year At least three times a year At least two once a year As per need At least three times a year At least two times a year Monthly (for VDC based) Once a year (for HP based) As per need

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Health Promotion and Education

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