Health Education (C Med)

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Information, Education,
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29 Communication and
Training in Health
Preservation of good health depends upon adopting worth to him. Information affects the perspective of the
good health practices and avoiding practices that are recipient person. The facts and figures that are received
harmful to health. Out of the practices prevalent in a by humans have to be true and factual to be labeled
community, some are conducive to good health, some as information. Lies, falsehood or counterfactual
to bad health and some are inconsequential to health. ‘information’ is not information itself but is called
The aim of health education is to bring about a change ‘misinformation’. Information is therefore that
in health behavior of the people in such a manner that ‘intangible’ news and facts, which an individual uses to
the harmful health practices are given up while the good bridge discontinuities and gaps that are prevalent in his
ones are reinforced. Such change cannot come about mind. It is therefore a process of creating meaning from
simply because people are ordered to do so by the things that are seen or perceived by an individual.
authorities, exhorted to do so by leaders and politicians,
advised to do so by health professionals or rewarded
for doing so by the government or nongovernment
organizations. People, whether literate or illiterate, do
not change their behavior unless they understand and
feel the need for the same. To accomplish this is the
task for health education.
The importance of health education has been
increasingly realized during the last three decades, so
much so that health education has now emerged as Education
a speciality in itself. The reason why so much
It is the process by which behavioral change takes place
attention is being focussed on health education lies
in an individual as a result of experience which he has
in the realization that health care delivery systems,
undergone.1 Education is a learning process or a series
though elaborately planned and provided, remain
of learning experiences through which an individual
ineffective if unsupported by health education aimed
informs and orients himself to develop skills and intelli-
at motivating people to use these services and
gent action.2
cooperate with the concerned health programs. The
Webster defines, Education as the process of educa-
importance of health education has been strongly
ting or being educated; the knowledge or skill
highlighted by the Alma Ata conference. The
developed by a learning process; a program of
conference pointed out that community participation
instruction and an instructive or enlightening experience.
is crucial to ensure optimum utilization of the services
provided by a health care delivery system. It is
stressed that health is an individual responsibility and Communication
that it must be ensured that every individual is health Communication is the process of attempting to change
conscious, so that he may observe healthy living the behavior of others. The communicator’s job is
practices and seek appropriate medical help at
chiefly helping people learn to look at things in a new
appropriate time.
way by sharing ideas and information. When people
exchange ideas and information, they can work together
Definitions and Concepts better. Sharing entails parting with information that gives
power. Health secrets are the most closely guarded
Information secrets of the medical profession. Sharing this
knowledge helps overcome the imbalance in the power
One of the most common ways to define information of society over its health and promotes self-reliance.2a
is to describe it as one or more statements or facts that Communication is a general term for the flow of
are received by a human which have some form of information linking people or places. It is therefore the
XC e XC e
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facilitate this goal and conducts professional training
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PART IV: Health Care and Services process of exchanging news, facts, opinions and
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c u -tr ack c u -tr a c k
In communication, initially rapport or relationship is • Health education is the education for identifying
built up. Then information is provided and the final step health needs and matching them with suitable
is to promote ideas into action. behavior.5 The entire process of involving people in
learning about health and disease and aiding them
to act suitably for overcoming illness and preserving
a positive health is health education.3
• Health education is that part of health care that is
concerned with promoting healthy behavior.
Through health education we make people under-
stand their behavior and how it affects health. We
do not force people to change—Rather, we enco-
urage them to make their own choices for a healthy
life. Health education is also needed to promote the
proper use of health services.
• Health education is any combination of learning
experiences designed to facilitate voluntary actions
conducive to health (Green and Kreuter, 1991).
• Health education is a practical endeavor focused on
improved understanding about the determinants of
health and illness and helping people develop the
skills they need to bring about change (French,
1990).
Health • It is the process that assists individuals, small groups
and larger populations to identify their health needs
It is a state of complete physical, mental and social well- and priorities, obtain information and resources to
being and not merely the absence of disease or infirmity meet those needs and mobilize action aimed at
(WHO, 1948). achieving desired change. It focuses on creating an
The very definition of health encompasses the environment in which there are strong individual
essence of health education by making the individuals and structural supports for informed and voluntary
and communities equal partners in the process of decision making about personal health and
ensuring freedom from sickness and attaining the highest community well-being (Berkeley School of Public
plane of physical, mental and social health. Spreading Health, University of California).
the word that what people should do to remain healthy • It is the combination of planned social actions and
is important, but this is not sufficient to ensure health. learning experiences designed to enable people gain
In many situations, it is not only the individual who control over the determinants of health and health
needs to change because there are other things that behaviors, and the conditions that affect their health
influence the way people behave and react. The status and the health status of others (XIV World Health
physical surroundings, people with whom they live and Conference on Health Education, WHO, IUHE).
interact, the work they do and the resources available All definitions of health education emphasize the
to them must all be taken into consideration for central role of an individual and the community in
improving health. bringing about the desirable change.
Health education is not the same as health infor-
HEALTH EDUCATION mation. Correct information is certainly a basic part of
• Definition adopted by WHO: “Health education, like health education but health education must also
general education, is concerned with changes in address the other factors that affect health behavior
knowledge, feelings and behavior of people. In its such as the availability of resources, effectiveness of
most usual forms, it concentrates on developing such community leadership, social support from family
health practices as are believed to bring about the members and the levels of self-help groups. Health
best possible state of well-being”.3 education is therefore incomplete unless it encourages
• Definition adopted by the National Conference on involvement and choice by the people themselves.5a
Preventive Medicine in USA: “Health education is a
process that informs, motivates and helps people to HEALTH PROMOTION
556 adopt and maintain healthy practices and lifestyles, Health promotion is the combination of educational and
advocates environmental changes as needed to environmental supports for actions and conditions of
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living conducive to health (Green and Kreuter, 1991).
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CHAPTER 29: Information, Education, Communication and Training in Health
LEARNING
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c u - t r a cThe ‘educational component’ of health promotion
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It is the process of acquiring knowledge, attitudes or c u -tr a c k
provides individuals with the knowledge, skills and skills. Sometimes it may be merely passive or
critical awareness that enable them to make voluntary incidental, especially in relation to knowledge. For
and informed choices concerning personal or social example, an individual may read from a cigarette pack
changes to enhance their health. The ‘environmental’ or a hoarding that smoking is injurious to health. This
component of health promotion refers to the social, may be merely passive, incidental, cognitive learning,
political, economic, organizational, policy and regulatory without attitudinal or behavioral change. He may as
circumstances having a bearing on health related well continue to smoke throughout his life. In its fullest
behavior or more directly on health itself. sense, learning is complete when behavior changes.
Health promotion therefore is a planned combination As a matter of fact, learning, teaching, education and
of health education, preventive measures and policy training can be really said to have occurred only when
changes aimed at improving health status and creating behavior changes.
healthy environments and behaviors. Health promotion
provides knowledge, skills and capacity to assist indi-
PERCEPTION
viduals, groups and communities in identifying health
needs, obtaining information and resources and It is the act or faculty of receiving sensations and giving
mobilizing them to achieve change (Office of Health them a meaning in the intellect. Perception may be
Promotion, Washington State Department of Health). subjective or objective. Subjective perception may
Health promotion can also be defined as the science sometimes be faulty. Since perception is a component
and art of helping people change their lifestyle to move of knowledge, knowledge itself may or may not be
towards a state of optimal health, which can be defined correct, depending upon whether the perception is
as a balance of physical, emotional, social, spiritual and correct.
intellectual health. Lifestyle change can be facilitated
through a combination of efforts to enhance awareness,
KNOWLEDGE
change behavior and create environments that support
good health practices. Of all these, three supportive It is the collection and storage of information or experi-
environments will probably have the greatest impact in ence (i.e. knowledge = perception + storage of infor-
producing lasting changes. mation in the brain).
The WHO has utilized the broad definition of health Knowledge is not the same as information. It is the
to develop the concept of health promotion as the sense that people make of information. Thus people
process of enabling people to increase control over and create their own meaning, i.e. their own knowledge out
to improve their health. of the information they receive, according to their own
Increasingly health promotion is being recognized as
circumstances, their use for that information and their
an essential element of health development. During the
own prior knowledge. Only when information enables
1970’s there was a growing concern about the direction
people to communicate, participate and make informed
of the health system. Despite a rapid growth in inter-
national health gains, there were still some groups of choices does information become knowledge.
people who had not experienced any improvement in Knowledge often comes from experience.
their health status. More and more high technology
developments took place in medicine but there were ATTITUDE
some people who could not access even the most basic
An attitude is a predisposition to act in a certain way
health care. This concern resulted in reorientation of
health systems towards primary health care of which in response to a given stimulus. It has been defined as
health promotion was an integral part. “a relatively enduring organization of beliefs around an
object or situation, predisposing one to respond in some
preferential manner. In simple words, the combination
PRINCIPLES OF HEALTH PROMOTION
of knowing about a thing and forming a tendency to
• Health promotion involves the population as a whole react is the attitude of a person (Attitude = knowledge
in the context of everyday life, rather than focusing + feeling). It may be mentioned that some times we
on people at risk for specific diseases. may form attitudes even without knowing about a thing.
• Health promotion is directed towards action on the For purpose of understanding, attitude may also be
determinants or causes of health. described as a “State of readiness” of the individual to
• Health promotion combines diverse but comple- deal with an object or type of objects. Attitude has three
mentary methods or approaches. components: a cognitive component (knowing about
• Health promotion aims particularly at effective and something), a feeling about it and a tendency to take
concrete public participation. action. 557
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Core issues between the client and counselor
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PART IV: Health Care and Services MOTIVATION
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c u -tr ack
It has been defined by Lindsay as “a combination of c u -tr a c k
forces which initiate, direct and sustain behaviours ii. Counselor must respect the confidentiality and
toward a goal.”5 privacy of the client
iii. Counselor should be objective and nonjudgmental
iv. Client has the right to withdraw from the counseling
DECISION at any point to time
It is the commitment to carry out a specific task or to Elements of counseling (GATHER approach)
adhere to a particular course of action in the future. G — Greet the client (make them confortable, give
attention)
A — Ask/ascertain needs/problems or reasons for
BEHAVIOR coming
It refers to the “voluntary movements and purposive T — Tell client about merits, demirits, logistics and
acts arising out of decisions taken by the individual.” costs of different methods or options
Behavior is usually purposive. The purpose may be H — Help client to make voluntary decisions
of two types: E — Explain and educate about the chosen decision/
• Fulfiling a need or a want action/method
• Being accepted in the group or society to which the R — Return for follow-up visit.
person belongs.
Behavior is sometimes classified as covert and overt. PROPAGANDA
Overt behavior is an action outwardly done by the Propaganda is merely a publicity campaign aimed at
individual and is visible as such. presenting a particular thing or concept in a favorable
Covert behavior is a strong attitude which is most light in such a way that public may accept it without
likely to give rise to a particular action. In other words, thinking about it analytically. Health education, by
covert behavior is strong attitude. contrast, promotes active thinking and assessment of the
In all communities there are already many kinds problem by the people and encourages them to decide
for themselves whether they want to change and in what
of behavior that promote health, prevent illness and
manner.
help in the cure and rehabilitation of sick people. These
kinds of behavior should be identified and
encouraged. Our behavior changes all the time Role and Need of Health
because of natural events. When changes take place
in the community around us, we often change
Education and Promotion
ourselves without thinking much about it. This is a Man has a right to correct information. If such
natural change. Sometimes we make plans to improve information is not provided, the consequences can
our health. This is planned behavior change. In fact, be dangerous. Education means translation of
it is well known that most unhealthy behaviors are knowledge into practice by influencing the beliefs,
weeded out by people because of their bad attitudes, habits and practices; in simpler words, it
experiences with such behavior. However there is means practical training. Education helps in moulding
always a segment which is not able to change harmful a person for a particular purpose about which
behavior because of some specific personal knowledge has been imparted. Health education
characteristics. The health education and promotion would thus mean putting health knowledge into
process should identify such characteristics of people practice, i.e. training of an individual, group or
and concentrate on the difficulties such people have community in the ways of healthy living. Health
in changing behavior. education concerns all experiences of an individual,
group, or community that influence beliefs, attitudes,
and behavior with respect to health, as well as the
Counseling
processes and efforts of producing change when this
Counseling is face to face communication through which is necessary for optimum health. This all inclusive
a person is helped to make a decision or solve a concept of health education recognizes that many
problem. Here, choice is given to the clients from where experiences, both positive and negative, have an
the client himself makes his decision. There are many impact on what an individual, group, or community
areas of counseling in health care, e.g. family planning, thinks or feels, and does not restrict health education
genetic counseling, etc. But in advising, the client is to those situations in which planned or formal health
558 directly asked to carry out the order as advised. activities take place.
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It has been well realized that mere spreading of make available fresh drinking water. However, many
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health information of knowledge does not produce by people preferred to use muddy polluted water, w
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itself a lasting effect on health behaviors of the people. perceiving the clean, fresh water as “too thin.”5c This
Lessons imparted through lectures and talks are situation could have been avoided if the well-drilling
forgotten too soon. On the other hand, activities in program had an inbuilt component of appropriate
which people themselves participate are more enduring health education.5b
as means of education. This has been beautifully
expressed in the following Chinese aphorism. Objectives of Health Education
“If I hear it I forget it;
If I see it I remember it; and Promotion
If I do it I know it.” It may be recalled that according to the definition
Thus, to train the people in healthy living or to impart adopted by the National Conference on Preventive
health education, one has to motivate them to do things Medicine,4 “health education is a process that informs,
conducive to health or to adopt health practices. Health motivates and helps people to adopt and maintain
education is a translation of what is known about health healthy practices and lifestyles.” The three objectives of
into desirable individual and community behavior health education directly flow from this definition and
patterns by means of an education process. are described below.6
Health education, properly carried out, forms one
of the most effective tools in preventive medicine. It Informing People
forms the basis for potential success of various health
programs aimed at family planning, malaria eradication, Information is a basic right. It is also a prerequisite to
tuberculosis control, clean water supply, disposal of proper awareness and assessment of one’s duties and
wastes, early diagnosis of cancer, etc. It is a bridge rights. Health is basic right of all human beings and
between the people needing services and the institutions health information is necessarily so. Only an informed
providing the same. This bridge is the major approach community will aspire, work, demand and fight for its
to obtain people participation in any health program. right, i.e. health. Dissemination of information is certainly
Public health workers must realize that they have to easier when people are literate. However, education is
work with the people and not in a vacuum. No program not literacy and people can still be given adequate infor-
can be a success without people’s participation. mation in a community where the majority of people
People in villages are generally poor and are still illiterate.7 Health information helps people in
uneducated. They are not only ignorant of healthy becoming aware of their health problems, in developing
practices but are often apathetic towards them. The proper perceptions about them and in seeking appro-
messages coming from the experts, who are often out priate solutions for the same.
of contact with the people, may be understood easily
by educated persons with a technical background but Motivating People
not necessarily by the illiterate laymen for whom they
Mere information is not sufficient. The knowledge that
are really meant. If a health agency has not succeeded
tobacco and alcohol are harmful to health does not, in
in implementation of a public health program, a likely
itself, ensure that people will give them up. After infor-
reason is that the program has not adjusted to the felt
mation it is necessary to achieve the second objective,
needs of the people and has not procured their
i.e. motivation of the people to adopt a certain behavior.
participation. This motivation must be developed in them by a process
A recent example is that of Buddha Gaya Gama, of change of behaviors, as described later. For example,
a 100-house model village established in Bihar with Sri before people voluntarily practice family planning, they
Lankan initiative and aid. The two-room concrete must be motivated or mentally prepared and willing to
houses with attached indoor flush toilet, given to the adopt the small family norm.
people have not found favor with them. After six
months the houses were built, the toilets remain unused Guiding into Action
and the housewives cook in the open in preference to
indoor kitchen.5b This situation could have been avoided Motivation by itself does not automatically lead to actual
if the funds were spent to fulfill the felt needs of the practice or behavior. Along with motivation to drive a
people. Alternatively, if the aim was that people should car, a person must have help and guidance from an
use flush latrines, then it would have been preferable instructor before he can drive freely. Many smokers,
to educate and motivate them, so that they demand alcoholics and heroin addicts are motivated to give up
latrines on their own and use them when they have their habits, but need appropriate guidance. Young
them. Another example is from Liberia, where the mothers may be motivated to breastfeed their babies, 559
government launched a program for drilling of wells to but may need guidance and support.
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is motivated to perform an activity, i.e. to adopt a
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PART IV: Health Care and Services
The Process of Change in Behavior
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Information, motivation and guidance, the three objec- is performed, the tension is relieved and the person
tives of health education described above are, in fact, becomes quiet once more. This satisfaction-tension-
the components of the process of change in behavior. motivated tension-satisfaction cycle is explained in
The process of change must be well understood by an Figure 29.1. It is clear that in order to change
educator in order to succeed in his mission. Behavior behavior, the health educator has to create need in the
refers to purposive acts arising out of decisions taken mind of a person, motivate him to adopt a particular
by the individual. It is obvious that doing something behavior pattern and encourage and guide him while
under force is not behavior. Behavior is always he is trying to change, so that the change is successful
voluntary. Hence health behavior of a person can and permanent. Since motivation is the most important
change only when he decides to change it. task of the health educator, he must know what are the
A decision is a commitment to perform a task or to factors influencing motivation. These factors are:
adhere to a course of action in future. Psychologists have • Incentive (positive or negative)
identified three stages in the decision making process: • Cooperation
1. A predecisional phase in which the individual assesses • Competition
and compares the pros and cons of the recom- • Jealousy and rivalry.
mended behavior. The psychosociological basis of behavioral change
2. A decisional phase, in which the individual decides has been described above in detail. In more simple
that the particular course of action is not only words, the process of change of behavior can be
advantageous to him but is also an immediate must. described to occur in the following phases:
3. A postdecisional phase, in which the person, having
Awareness: The individual becomes aware of a new
decided to follow a course of action and having
idea or practice.
acted initially, judges the pros and cons again in the
light of the experience gained. The unfavorable and Interest: The individual evinces interest in the new idea
unpleasant component of the experience gives rise and wants to learn more about it.
to a postdecisional conflict in his mind, which is Evaluation: The individual weighs the pros and cons
resolved either by reversing the decision (i.e. giving- of the new idea.
up the new behavior), or by making suitable mental Trial: The individual puts the idea into practice on trial
adjustment to reconcile with the situation. basis and again assesses the pros and cons on the basis
What is implied in the third objective (guiding into
of initial experience.
action) mentioned in the previous section is that the
health educator guides and helps the client to stick to Adoption: The individual adopts the practice perma-
the new behavior by encouraging him to adjust to the nently.
new situation. Conviction: Once an individual is convinced and
Decision is an implicit component of motivation or accepts a new idea, he tries to convince others also to
the process of adoption. One cannot be motivated to adopt the new idea.
do something unless one has decided to do it.
Motivation initiates, directs and sustains behavior
towards a goal. Thus, there are three stages in the
process of motivation.
1. In the first stage of ‘initiation’, the mind starts thin-
king whether the proposed change of behavior is
of ultimate utility.
2. In the second stage of ‘direction’, the behavior is
directed towards attainment of the goal. The
individual is aware that a solution exists and he is
prepared to put that solution into practice.
3. In the third stage of sustained behavior, the
individual has tried the new behavior or practice and
is convinced of its benefit and the desirability of
continuing it in future. Fig. 29.1: Dynamics of behavioral change*
It is axiomatic that motivation for undertaking an
activity can occur only when the individual feels the need *An individual (or an organization) is basically quiet. He becomes tense
for something, i.e. when he is not fully satisfied with the when he feels a need. He becomes quiet again when tension is relieved.
560 present situation. In other words, the individual must Need causes tension while activity relieves it. Here behavior is viewed
have wants, desires, urges or needs, to fulfil which he as an activity which arises when there is a state of tension.
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People often consider the following before accepting would not change their behavior unless they feel the
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• Is the behavior simple to adopt or does it require ascertained before starting the health education
new skills? program. There may be a situation when the health
• Is the behavior similar to existing practices or is it problem is a serious one from the point of view of the
totally new? health professional but the people do not view it as such
• Is the new behavior that is desired, totally or parti- and hence do not feel any need for changing their
ally compatible with current practices and know- behavior. In such a situation, the health educator must
ledge? first create a need for changing their behavior. In such
• How much does the new behavior cost in terms of a situation, the health educator must first create a need
money, time and resources? in the minds of the people and also stimulate interest
• How much impact including economic does the new in them to fulfill that need. Only then will health
behavior have on individual/family? education succeed. Such a situation calls for a proper
• Are benefits seen immediately or in the long-term? educational diagnosis about the different factors
influencing the community, such as beliefs, prejudices,
resources, perceptions, attitudes, etc. Since education
Principles of Health Education5 aims at change in behaviour, the health educationist
should have a good understanding of the sciences of
The Challenge of Health Education psychology, sociology and anthropology. Also, in order
to bring about a change in behavior, the health
The words “Health Education” are very easily uttered.
educator should make all efforts to rationalize his ideas
If the deep significance of this term, as implicit in the real
and to reason them out properly, so that the audience
meaning of education, is not understood, even well mean-
may be able to internalize the relevant concepts.
ing doctors and health professionals may sincerely believe
they have “given” health education to people when, in Health education is not an artificial teaching
practice, they have merely lectured to them. No wonder learning exercise: The health educator has to be
they are surprised later when “health education” appears deeply interested in the community so that he should
to have been ineffective. Hence it is extremely important know the attitudes and practices and cultural values
that every member of the health team should know and prevalent in the community. He should start not by
understand the principles of health education. demolishing the present attitudes and values but by
The need for knowing the principles of health educa- building upon those that the community already has,
tion is clearly highlighted by the following real story.7a slowly trying to bring about a change by guiding
A team of health educators gave intensive health educa- people’s thinking towards the desired change.
tion to all the teachers in a particular taluk on all aspects
of leprosy. Some time later, they returned to evaluate Health education should involve free discussion:
their work. At first, they were delighted to find that the There should be a free flow of communication between
teachers remembered perfectly all they had been told: the people and the health educator. The health
leprosy is caused by Mycobacterium leprae; it is the least problems, their possible solutions, and the good and
infectious of diseases; it is completely curable; and so bad points of the solutions should be thoroughly and
on. But the evaluators’ delight turned to dismay when, honestly discussed, without trying to conceal anything.
on closer enquiry, they found that this new knowledge This helps in clearing all doubts in the minds of the
made no difference to the teachers’ old attitudes and people. The health educator should remember that his
practices. They still would not accept anything from the job is not to instruct people about certain do’s and do
hands of a leprosy sufferer, would not allow a leprosy- nots, but rather to let them assess and compare
affected child in the class and would not sit next to a themselves the new and old ideas on the basis of past
leprosy patient on the bus. The education they had experience, so that they may take their own decisions
received remained merely sterile knowledge; it did not that appear beneficial.
carry over into their daily lives.
This is the challenge of health education: that it Tell only what is needed: It is important that the
should give correct knowledge, leading to sensible health educator, especially if he is an expert, should not
attitudes, resulting in healthy practices, to bring about start telling all that he knows about the subject, including
a real change for the better, in the lives of the people.7a details of scientific research. He should clearly under-
stand the health problem, the possible solutions and the
The Thirteen Principles level of knowledge and general education of the people.
He should then limit the content of health education
The aim of health education is to bring about a to telling only that which is necessary, important and
change in health behavior: If behavioral change is relevant, using simple language. This does not, 561
not brought about, health education is wasted. People however, mean that he should be restrictive in his
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approach. As already mentioned, he should encourage • He should be friendly and sympathetic: The efficacy
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willing to answer in detail if specific questions are raised content and methodology of communication but also
by the audience during discussion. upon the personality of the health educator, the
Do not give conflicting information: The health interest he exhibits in the client and the respect he
educator should be consistent in what he tells the commands from the latter. A good example is that
of doctors and nurses, whom the patients give respect
people. What is even more important, different health
and whose interest in their welfare is unquestioned.
workers should not give contradictory message
Hence, it is essential that the health educator should
regarding a particular problem. Conflicting information
have a friendly attitude towards the people and
from different sources often prevents people from
should be sympathetic about their problems, no
following reliable health advice.8
matter how poor and primitive their lifestyle and how
Try to change only what needs to be changed: As peculiar their problems.
mentioned in the beginning of this chapter, all health • He should be knowledgeable: A person who does
behavior practices may be clarified into three categories not possess correct and sufficient knowledge and is
according to whether they are harmful, useful or unable to answer health related questions asked by
inconsequential to health. Health behavior falling in the people cannot be a good health educator.
the first category alone needs to be changed. An • He should practice what he teaches: It is an old
example of a practice inconsequential to health is saying that example is better than precept. The
giving honey to a newborn baby, Tulsi to a patient teaching of a health educator who does not practice
with fever and karela (bitter gourd) to a patient with what he professes would sound hollow to the
diabetes. people. For example, people cannot take a doctor
These practices may not be useful to the person to seriously who, while talking about the harmful
whom the stuff is administered, but there is no evidence effects of tobacco, himself keeps on smoking
that they are harmful. There is no point in criticising the throughout the lecture.
people for their beliefs and actions which they perceive • He should talk the language of the people: The health
to be beneficial, as long as they are not positively educator should adjust his talk to the individual or
detrimental. Health education should focus attention on the group to whom he is talking. The choice of words,
health behavior which is undoubtedly harmful. An phrases, examples, etc. should all conform to the
example of the latter is the practice of not giving leafy educational, social and cultural background of the
vegetables to pregnant women in some parts of India. client. Only then will meaningful exchange of ideas
Some other harmful beliefs and practices are listed be possible. The tendency on the part of the technical
below:9 experts to use difficult scientific terms in the interest
• For the first three days, the child should not be of accuracy should be curbed if simpler terms can be
breastfed and colostrum should be discarded. used to convey the meaning broadly.
• No liquids should be given to infants when they • He should employ all possible methods of education:
suffer from diarrhea. Different educational methods may be specially
• Weighing the children at young age will cast an evil suitable for different groups of people depending
eye on them. upon their age, sex, educational, background, etc.
• Eruptive fevers like measles, chickenpox and small- Also, some health messages may be more effectively
pox are due to the anger of some Goddess, who conveyed through certain methods. The health
needs to be appeased through prayers and offerings. educator should try to employ as many methods of
No doctor should be consulted. health education as possible. This not only facilitates
• Immunization induces high fever. proper understanding of the topic under discussion but
• Papaya is ‘hot’ food for babies. also makes it more interesting.
• Planting, growing papaya and drumstick trees is Use audio-visual aids whenever possible: Such aids
inauspicious. make the topic more lively, interesting and comprehensi-
The educator should make himself acceptable: The ble. They may be essential to explain certain technically
health educator should always remember that he is to complex messages. Knowledge depends upon percep-
assume the role not of a professor but of an enabler. tion while the degree of perception is directly
His task is to increase the ability of the people to under- proportional to the number of sense organs involved
stand their health problems, to find solutions for the in perception. Audio-visual methods involve the use of
same and to put those solutions into practice. In order two sense organs and are, therefore, better.
to play the role of an enabler, the health educator must Choose a proper medium of communication: The
win the confidence of his clients. The following medium will vary depending upon the nature of the
562 prerequisites are necessary for this: target clientele for the health message. When the
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number of target person is very large, mass media will • Builds on ideas, concepts and practices that people
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Communication must be good: The health educator • Repeats and reinforces information overtime, using
has to communicate with people so as to get his message different methods.
across to them. It is obvious that there cannot be good • Uses existing channels of communication such as
health education without good communication. The songs, drama and story-telling, and is adaptable.
qualities of good communication are that it should be • Entertains and attracts the attention of the community.
simple, clear and brief. The message should be delivered • Uses clear, simple language with local expressions
without any ambiguity. and emphasizes short-time benefits of action.
• Provides opportunities for dialogue and discussion
Health education should be planned properly: It to allow learner participation and feedback about
is always desirable to plan any activity or program understanding and implementation.
properly. This is especially so in case of health education.
• Uses demonstrations to show the benefits of
Unplanned health education may be as good as wasted.
adopting practices.
To be effective, implementation of health education
should be preceded by making an educational diagnosis
and chalking out the details of the program in terms Communication in Health
of content, methodology, evaluation, etc. Educational
diagnosis is made by carrying out a study of the
Education and Training5
knowledge, attitudes and practices (KAP study) Communication deals with transmission of information
prevalent in the group or the community. or ideas and sharing and exchanging the same. Since
Health education should be provided in graded education implies transfer of knowledge, comm-
doses: It is futile to try to give too many health unication is an essential component of education. The
messages to the community at the same time. People three essential parts of a communication system are the
have limited power for comprehending what a technical communicator or sender, the communicatee or receiver
expert may think to be very simple themes. They and the message transacted between the two. The three
cannot understand and assimilate in their mind too dimensions of message are the code (the symbols, e.g.
many facts at a time. Moreover, they need time to the alphabet, in which it is transmitted), the content (the
internalize various concepts and to try out the concepts subject matter) and the treatment.
learned. The health educator must provide sufficient The treatment of a message refers to the manner
time and opportunities to the people to try out the new in which the message is prepared, processed and
practices advocated. He should thus aim at bringing delivered. Proper treatment of the message is most
about small changes in a graded fashion. important for effective communication. The
The health educator should put into practice the communicator has to use proper language, signs,
principles of community organization: Health symbols, examples, phrases, proverbs, anecdotes and
education ultimately aims at enabling the people to reinforcing techniques (repetition, etc.) to make the
identify their problems, think of solutions, decide upon message easily, fully and correctly understood by the
a course of action and implement the same. The health communicatee.
educator should identify the opinion leaders in the
community. He should involve the community in the Principles of Communication
process of identification of the problems and their
Though communication is an everday happening, it is
solution, as also in the process of program planning,
not a simple process. Even when two people are
implementation and evaluation.
communicating, there is no surety that they fully
understand each other. The uncertainties of communi-
Characteristics of Effective
cation multiply when a group of people or the whole
Health Education community is involved. A lot depends upon the abilities
• Promotes actions which are realistic and feasible of the communicator and the way he prepares and
within the constraints faced by the community. delivers his message.
The principles of communication given below should
*
There is often confusion regarding the terms educational materials and be kept in mind by all health professionals involved in
educational media. Media are needed to deliver the messages to target health education.
audiences. Thus, examples of media are TV stations, radio stations,
schools, newspapers and magazines, etc. Strictly speaking, walls on which The sender’s and receiver’s perceptions should be
posters are displayed and the health educators and extension workers as close as possible: Very often, two persons, though
who convey messages are also media. Cinemas and mobile film vans, intelligent, find it difficult to understand each other
likewise, are media.10 Examples of educational materials are films, slides,
posters, advertisements on television and radio and health articles in
because of their different perceptions. A good example 563
newspapers and magazines. of this is provided by comparing the communication a
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student may have with his parent and with his teacher or indirect. While both these are important, direct
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regarding some problem in physics or economics. It is communication skills are crucial to successful educationw
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often seen that while the parent, though knowledgeable and training in a class room situation. These will be
in the subject, is unable to explain the problem properly, described in the next section.
the teacher, a trained and experienced communicator, Three important skills are needed for communication:
can do so very easily. The difference is attributable to 1. Talking and presenting clearly: The goal of communi-
the difference in perceptions. While the teacher is able cation is to make sure that people hear, see and
to perceive the problem from the same angle as the understand the message (idea or feeling) that is being
student, the perception of the parent differs markedly shared with them. Therefore, it is important to talk,
from that of the student. write, or present the message clearly and simply. Use
The message should be of good quality: A good words people understand; use few words as possible;
message should be: Long lecture will bore people and they tend to
• Simple forget. A method that is strange to people may not
• Accurate communicate the right idea.
• Adequate 2. Listening and giving attention: In addition to
• Clear speaking clearly, educators must listen carefully in
• Specific order to understand peoples’ interests and ideas.
• Significant 3. Discussing and clarifying: It is important to find out
• Applicable if the audience has understood the educator
• Appropriate and timely correctly. Questioning can make communication
• Attractive or appealing between people more accurate. Summarizing at the
• In accordance with the laid down objectives end is very effective in communication.
• In tune with the mental and socioeconomic level of Nonverbal communication: Nonverbal comm-
the audience unication refers to all stimuli generated by individuals
• Practical. in a communicative set-up without the use of words or
Communication should involve as many sense voice. It involves body positioning, facial expressions,
organs as possible: As explained earlier, communi- gestures, etc. It supplements the verbal varity of
cation is more effective when more than one sense communication. This types of communication conveys
organ is involved. Thus when a message is delivered on inner meanings such as emotions, impulses and
the radio, only auditory sensation is involved. When it is conflicts.
on television, both auditory and visual senses are involved.
The use of senses of touch, smell and taste, wherever Education and Training
applicable, would further improve communication.
Methodology
Communication should be two-way: Unilateral
communication from the sender to the receiver is not Every doctor has to act as an educator and trainer, whe-
fully effective. It does not allow for any feedback from ther as a faculty member in a Medical College, Trainer
the receiver of the communication and hence it is not in a Training Institution, Lecturer in front of a group of
possible for the communicator to improve and modify laymen, Administrator responsible for Human Resource
his message and technique of communication according Development of his subordinates, Physician to his
to the needs of the receiver. From the point of view of patient or, even, a parent educating his child. Hence
education and training, communication is complete only it is essential for a doctor to have elementary knowledge
when feedback received by the communicator confirms of education and training methodology.
that the message has been correctly received by the
communicatee. Systems Approach
Direct communication is more effective: Communi- The training process is a system in itself, comprising the
cation is most effective when it is face to face. In this following subsystems:
situation, more sense organs are involved and constant,
immediate feedback is available, enabling the expert
TRAINING NEED ASSESSMENT (TNA)
communicator to modify his own perceptions and
message according to the needs of the communicate. Before undertaking a training program, the trainer
The efficacy of communication decreases as the must find out what the trainees need to learn. If the
communication becomes distant and indirect, (e.g. trainer decides the contents of training on his own, he
through the use of telephone, radio or print media). may regret because he may find later that the trainees
564 Depending upon the nature of communication, i.e. face already knew most of what was taught or that their
to face or distant, communication skills may be direct basal level of knowledge was too low to comprehend
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what was sought to be taught. He may even discover
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Formal Presentation Methods
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c u - t r a cthat the training program was not relevant to the job
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Lecture: This is the traditional method of teaching. It c u -tr a c k
functions carried out by the trainees. Hence it is

can be made more useful by using audio-visual aids and
essential that TNA must be carried out before a training
by including a question—answer session toward the
program is launched. This can be done by means of
end.
written questionnaire, by talking to prospective trainees
or their supervisors and by actually observing how Dialogue: This is a formal presentation in which two
they perform their tasks in the real job situation. experts carry on a dialogue amongst themselves for the
benefit of the audience.
FORMULATION OF OBJECTIVES Symposium: This is a modification of the lecture
method in which several experts are allotted different
Once the TNA has indicated what the trainees need to
aspects of a particular topic. Sometimes, they may even
be taught, the next step is to state the objectives of the
speak on similar topics. Each person tackles the subject
training course in clearcut terms. This is done at two
from his own point of view and thus provides variety
levels. First, the overall general objective of the training
to the audience in comparison to the monotony of a
is stated. Second, the specific objectives are spelled out.
single long lecture.
It is important to remember that “a good training
program should have its specific objectives in behavioral Panel discussion: This is an extension of the dialog
terms.” This means that the specific objectives should method. Here a small group of experts get in front of
be so stated that they pertain to an observable and the audience and discuss amongst themselves various
measureable change in behaviour. It is sometimes said aspects of the subject. A chairman or moderator guides
that the objectives should be SMART, i.e. they should and coordinates the discussion.
be specific, measurable, attainable, realistic and time Colloquium: Here a group of experts present them-
bound. This will be clear from the following example. selves before the audience and respond to questions
“The trainees should be able to appreciate the need for asked by the latter. This allows for sufficient interaction
checking population growth.” This objective is in non- between the two. A moderator is needed to conduct
behavioral terms. Appreciation is only at psychological the colloquium smoothly.
or mental level. It does not imply performance or
psychomotor behavior. It is better expressed in Group Methods
behavioral terms as follows:
These methods offer large scope for discussion and free
“At the end of the training the trainee will be able
exchange of views among the learners themselves and
to list five reasons why growth of population must be
among the learners and teachers, thereby facilitating
checked.”
learning. In the conventional method, a group of 5 to
15 persons discusses, a particular subject. In formal
CURRICULUM DESIGNING AND IMPLEMENTATION settings, such as in an academic or scientific institution,
The next step is chalking out day-to-day curriculum. This there is a chairman and a rapporteur and the subject
should be done in such a manner that: (a) All areas is critically analyzed regarding a particular problem, its
suggested by TNA are covered; (b) There is a natural solution and the program of implementation. In
sequence in the curriculum, proceeding from simple to informal settings, as in a roadside, street or village
difficult topics; (c) Sufficient time is given to trainees to gathering, or in a group of patients and their relatives,
practise the skills taught. the health educator follows an informal approach and
The following three aspects of implementation of stimulates the group members to respond to his
curriculum need detailed discussion: suggestions and to express their views freely.
Besides the above, there are other group methods
Teaching Methods of education described below.
There are several methods by which education, Focus Group Discussion (FGD): Here participants
including health education, can be imparted. Broadly, talk with each other under the guidance of a facilitator.
the methods are of two types—formal presentation and Interaction among the participants stimulates each other.
group methods. In formal presentations, the speaker or Use of FGDs: (i) To secure background information,
communicator is on one side while the audience is on (ii) To generate ideas for project, (iii) To get feedback
the other. These methods have limited scope for discus- from project, (iv) To learn and develop vocabulary for
sion and interaction. In group methods, the teachers education program, (v) To formulate questions for the
and learners share the same platform and are thus able formal interview questionnaire/schedules and (vi) To
to indulge in free discussion. interpret the available data. 565
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Size and composition: Number of participants should Buzz group or session: Here the entire group is
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range between 6 and 12. Participants should be subdivided into smaller group of about 10 to 15 each.w
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representatives of the target population and must be Each small group discusses the problem during the time
homogeneous, i.e. having similar background and given. The problem allotted to different groups may be
experience. Those who have participated in an interview the same or may vary. After their deliberations, the
of similar subject previously are excluded from FGD. groups merge and their findings and recommendations
Team for conducting FGD comprises of a facilitator, two are pooled together and presented as the final document
recorders and a person drawing sociogram. of the whole group.
Conduction of FGD: At first participants are allowed Workshop: This is much like a buzz session except that
and encouraged to talk to each other to establish it is more elaborate. Thus there are advisers, experts
rapport, with general non-controversial subjects of and specialist speakers who guide the whole group. The
mutual interest. This will help the group to settle down workshop usually extends over several days.
to a comfortable relaxed beginning. At that time Conference and seminar: These are usually highly
dominant and reluctant participants can be identified. academic proceedings where several experts from
Then after introduction of the participants, the purpose different disciplines meet to deliberate on particular
and scope of the investigation/enquiry are explained. themes and to apprise others of the latest knowledge
Participants are told what is expected from them. Then and research in a particular field. These advanced
permission is sought to use a tape recorder/video methods do not find much applicability in the usual type
camera during the session (Fig. 29.2). of health education.
It should facilitate maximum interaction among Role play: This is a brief acting out of an actual situation
participants. Participants sit facing each other, so each for the benefit of the audience for better understanding.
of them can see all the other participants. Participants For example, a role play can be done to stress the
should feel physically and psychologically comfortable. importance of immunization or family planning and a
FGD can range from 1 to 2 hours, but it may be suitable conversation can be developed for the same.
continued beyond this time schedule.
Demonstration: This is the actual carrying out of an
Advantages: Here information can be collected rapidly activity in front of the audience or the group so that
and sometimes it is more accurate. It is economical and they may learn the concerned skill. For example, health
reduces individual inhibition. FGD permits interaction workers may be taught the technique of intradermal
between participants and facilitators, thus it provides BCG injection by actual demonstration.
considerable flexibility to the investigator to approach
Case method: Here a group of trainees is given an
further. FGD can raise issues and concerns that the
actual case in the form of a write up detailing the actual
facilitator might not have considered initially.
situation and problem. For example, an actual situation
Limitations: Information may not be generalizable in a primary health center may be described and the
concerning the whole population. It does not provide trainees may be asked to give their views and approach
quantitative information and sometimes participants do towards solving the problem presented. In the context
not give sensitive information. Some participants may of medical studies, the case history of a patient presented
dominate the session and some becomes reluctant. to a group for discussion, as in a clinicopathological
566 Not a good discussion Good discussion
Fig. 29.2: Sociogram showing examples of Not a good discussion and Good discussion
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conference, is an excellent example of the case method.
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TABLE 29.1: Classification of educational aids
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k . compilation of a number of cases for use in training
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• Audio aids
situations has been published by the National Institute – Megaphone
of Health and Family Welfare. – Microphone (public address system)
– Gramophone
Quiz: This is an excellent method because everybody
– Taperecorder
in the group is interested and full attention is ensured. – Radio
The answers given by the participants help to reinforce • Visual aids
knowledge of the entire audience. – Unprojected
i. Black-board
COMMUNICATIONS SKILLS ii. Pictures
iii. Cartoons
A mention was made earlier about direct and indirect iv. Photographs
communication skills. The direct communication skills are v. Posters, charts, graphs and maps
absolutely essential for a doctor in order to be an effective vi. Flash cards*
teacher, trainer or health educator. A detailed description vii. Flannel boards*
of these skills is not possible here due to lack of space. viii. Printed material: books, booklets, pamphlets, folders, etc.
ix. Three dimensional aids (actual specimens and models)
The more important skills are briefly described below. – Projected
• Eye contact: Speak to people. Look into their eyes i. Epidiascope*
(not through them, or away from them, towards the ii. Transparencies
walls or the ceiling). Maintain eye contact with the iii. Projection slides
audience. iv. Film strip*
• Audiovisual aids
• Body language: Make effective use of hand
– Television
movements, gestures and facial expressions to – Video
reinforce your speech. Do not be glued to your seat. – Tape slides*
Move freely. Do not keep too much distance – Cinema film
between yourself and the audience. Do not hide • Traditional media
– Puppet (string puppet, rod puppet, glove (hand) puppet, etc.
behind a desk or table.
– Folk songs
• Speech: Your voice should be loud, slow and clear. – Folk dances
Vary the volume, tone, and pitch of your voice. Do – Drama
not be monotonous. Use pauses to emphasise *It may be mentioned that cinema has the highest reach in lower
important points. income strata while the press has the highest penetration in the upper
• Questions: Ask questions to get confirmatory income group.
feedback that learning has occurred. Encourage the
audience to ask questions. Clarify their doubts
patiently and unambiguously. It would be noticed from Table 29.1 that a large
• Reinforcement: Whenever the trainees exhibit number of educational aids have a visual content, either
positive learning, reinforce it by an appreciative nod alone or in combination with the audio content. As such,
or statement. it is worthwhile considering the characteristics of a good
visual aid. These are brevity, simplicity, clear idea,
proper layout and the right colour combination. Words
EDUCATIONAL AIDS
should be bold and readable at a glance. For example,
Various educational aids available nowadays make the in case of a poster, it should be readable from a distance
process of education easier and more effective. The in a short-time. It should incorporate attractive words
educational aids act as facilitators of communication and dramatic illustrations. Size should generally be
between the sender and the receiver. The distinction 20"×30". A poster should essentially convey a single
between educational media and materials has already idea and a single message.
been clarified earlier. However, such distinction some-
times appears too theoretical. For example, a poster and EVALUATION
a gramophone record are educational materials, while
the wall or board on which the poster is displayed and Evaluation is a systematic process to assess how much
the gramphone on which the record is played are the of a predetermined objective of a plan has been
media. To avoid this confusion, it is more convenient achieved.
to use the world educational aid which may include
both the material and the media as convenient and
relevant, a classification of various educational aids is
567
given in Table 29.1.
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Measurement indicates a qualitative or quantitative 3. Sound planning will incorporate sound principles
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and methods of education.
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assessment about the desirability of the change. 4. Health and education need to march together,
Whenever teaching or training is carried out, its neither of the two encroaching on the other, but
effectiveness must be ascertained. In other words, the both providing mutually reinforcing services.
efficacy of training must be evaluated. Prolonged teaching 5. Full recognition needs to be given to people’s
by renowned experts is of no use of the students fail to needs and interests and to the social, cultural and
demonstrate any change in their knowledge, attitudes or economic setting in which they live.
practices. Such teaching must be termed a failure and 6. While developing programs, one must look at the
hierarchy of needs, both among the people and
must be improved for the next training course. This can
the professionals, and find ways of amalgamating
be done only when the change occurring as a result of
the two.
training is measured and quantified. Here lies the 7. People should be involved in the planning process.
importance of framing the training objectives in beha- 8. It is wise to start with simple things most likely to
vioral terms, so that they are measurable. Such measure- succeed and then move on.
ment can be done by a simple questionnaire for assessing 9. It is best to deal with those aspects first that are
knowledge, by a specially designed questionnaire or regarded as important problems by the people
interview for assessing attitudes and by observing the themselves.
trainees during task performance for assessing skills. An 10. All resources should be utilized to define problems,
identical evaluation should be carried out at the begin- collect facts, interpret the facts collected, draw
ning of training course (pre-evaluation) and at the end conclusions, apply the conclusions reached and
(postevaluation), using the identical evaluation tools. evaluate results.
When the comparison of pre- and postevaluation scores 11. Planning should be done with due regard to the
reveals statistically significant improvement, only then can ability to execute the plan.
one say that the training was successful. 12. There should be flexibility and continuity in planning.
Evaluation may be of different types. Outcome 13. Provision should be made for both short-term and
evaluation is carried out at a given point in time to long-term programs.
compare actual performance with that planned in terms 14. Ample time should be allowed while planning a
of both resource utilization and achievement of long-term program of education.
objectives. This is done to redirect efforts and resources. 15. There should be close cooperation between official
Impact evaluation based on the broader, long-term and voluntary bodies.
impact of a program or intervention. This is done some 16. Contributions of related disciplines should be
time after the program or intervention has been utilized to the fullest.
completed. Performance evaluation is the performance 17. All members of the health team should be involved.
of individual learners in a course or program. 18. Leadership is needed in the planning process.
Performance evaluation might be carried out either by 19. There is need for administrative understanding,
formative or summative evaluation. Formative support and active participation.
evaluation is the continuous monitoring of learning 20. Assessment of results is essential.
activities for obtaining a feedback. Thus it helps to Most health programs planned nowadays have a
provide early insights into a program. Examples being component of health education, and rightly so.
unit test, item examination, part examination, etc. While However, in practice, not much importance is given to
summative evaluation is conducted at the end of the health education during program implementation. Since
course; some time after the program has been the success of a health program is closely interlinked with
completed. Examples—university exam. successful health education, it is imperative that at every
phase of health care program, equal importance should
be give to the corresponding health education counter-
Planning of Health Education part. This is clearly depicted in (Fig. 29.3) which shows
the inter-relationship between service and educational
It has been remarked earlier that unplanned health components of a health program.
education is almost a waste of effort. Proper planning
is, therefore, essential before launching a health
education program. Given below are twenty principles Levels of Health Education
of health education planning as suggested by the South Health education has to be imparted at various levels such
East Asia Regional Conference held in 1986.11
as the community, a group, a family or an individual.
1. Planning for health education should be an
integral part of all health planning.
COMMUNITY APPROACH
2. Sound planning will be rooted in sound health
568 facts and will apply these facts throughout the The most important step in community approach is to
planning process. encourage the people to find out their own needs and
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while utilizing a particular situation for health education,
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appropriate to the situation, whether it is an epidemic

or flood, and illness, pregnancy or delivery, etc. or
a social or religious fair. It is useful to remember that
people are highly responsive on such occasions.
• Contact a needy and suitable party to start with, such
as a rich person in a village who has no latrine but who
needs one and has space and money to build it. Create
a demand and then motivate him for action. The same
applies to construction of a sanitary well and soakpit.
• Immediate provision of services is essential once the
party is convinced about its need. Strike the iron
when it is hot. Fix up the time and date for
construction, provide the materials and follow the
project till it is finally completed.
• Mobilize community forces at this stage. Start a
campaign and competition for healthy living. The
person whose felt need has been fulfiled becomes
the best tool for propaganda, education and
Fig. 29.3: Inter-relationships between service and educational demonstration to others.
components of a health programme
• Form a health committee of interested people in the
village, who can be entrusted with the task of
then involve them in planning, execution and continuing the community health program.
evaluation of their schemes. The basic principle should The ultimate success of a health scheme would
be that of self help. depend on many factors such as the nature, extent and
In urban areas, there are many laws and bylaws related immediateness of the benefit which the villagers feel they
to health. For effective implementation, people must be would get from the scheme. It also depends on the
educated about the need for such laws and about the extent of their willing cooperation and active
desirability of abiding by them in the interest of their participation, on financial commitments expected from
own health and welfare. It is a common experience that them and on local conditions. Team spirit and tact on
most of these laws remain on the statute books only the part of health and other extension staff are vital to
because of the fear of unpopularity in case of enforce- the success of a program.
ment. A health education program should, therefore
include educational efforts aimed at making the people Group Approach
aware of their own responsibility in obeying the laws. The group approach saves time, induces acceptance of
From a practical point of view, the following prin- ideas, makes people more responsible about their own
ciples of community approach are important, especially health and lets them adopt preventive and curative
in a rural area: measures themselves to maintain or restore health.
• Contact the people that matter in the community Examples of groups are clubs, social organizations,
Such people may be: pregnant mothers (in an antenatal clinic), school children,
– Elected leaders, (Member of Parliament, factory workers, Mahila mandals, etc. This approach is
Member of Legislative Assembly, Panchayat more rewarding, especially when the problem affects the
Sarpanch), an influential man in business, a group directly, (such as family planning in married adults).
landlord, a politician or a priest. The steps for a group approach are:
– Local officers such as patwari, mamlatdar, BDO, • Introduction: Introduce yourself and talk about
police officer, etc. personal problems of the group members very
– Local medical practitioners. tactfully, using simple terms and language.
– Local voluntary and other health agencies. • Modification of attitude and behavior: These are
People readily listen to local leaders and an determined by social and cultural forces. Mere infor-
approach through them will produce quicker mation is not enough to change attitude and beha-
results. They should be taken into confidence and vior. Health education must seem to satisfy certain
should be involved in planning as well as social needs and fulfill some purpose before people
execution of the program. respond to it.
• Utilize all potential teaching opportunities provided • Communication: Didactic approach by tools such as 569
during real-life situations. However, it is crucial that a lecture, a film or a posters involves one-way traffic.
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Health education should be a two-way traffic or a transmitted diseases, including AIDS. This has
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two-way method (Socratic approach). Everyone in become crucial because of increasing permissiveness w
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the group should be encouraged to talk, ask in society allover the world. A recent WHO and
questions, express his ideas and take decisions UNFPA sponsored study on sexual behavior of
regarding a health practice. Group meetings may be young people has revealed the following facts about
more useful if they are arranged as health seminars, first sexual encounter of adolescents:
panel discussions, conferences, workshops, etc. in – The sexual relation develops over a period of time
which the group members are allowed to express their and does not take place between two strangers;
views or ask questions freely. In the two-way method, – The boy shows more interest than the girl;
there will be a feedback to the health workers as well. – Contraception is not used;
It is good to remember that information trickles – What substitutes for contraception is a little
downwards and experience moves upwards. assurance from the boy that the girl need not
worry about pregnancy;
Family Approach – One-third of respondents believe that contra-
ceptive methods cause infertility;
Health education should be imparted to all the family – No reference is made to the possibility of contrac-
members. The school child will be listened to at home ting sexually transmitted diseases, including AIDS;
for cleanliness and other health concepts learnt in the – One pregnancy is suspected, the boy resists
school if the parents have been already motivated. The responsibility;
mother is the centre for action but the father often plays – Self-induced abortion in unsafe circumstances is
the dominating role. If the mother, the father and the considered frequently, though not always acted
child, all are given the same health education message upon.12
through their respective channels (female MPW, male The above findings indicate the areas in which
MPW and school teacher respectively), the net effect sex education should be focussed for adolescents.
of the health education will be much more due to • Adults: There is need to create a desire to bring up
synergistic effect. the family in healthy conditions and to take part in
community health programs. Education about
Individual Approach family planning, antenatal care and child rearing is
• Infants: Health education is done by inculcating proper of importance.
habits (such as bladder and bowel evacuation), giving • Old age: Health education from childhood to
nutritious and wholesome foods and keeping the adulthood stresses upon promotion of health and
child clean at all times. Such training and activities prevention of disease. Old age poses some special
stimulate the development of healthy habits. problems. Here the aging individual has to be
• Toddler stage and early childhood: The watchful taught about how to cope with the inevitable
nature of the child at this age is specially suitable for disabilities associated with old age such as cataract,
educational purpose. The child watches his parents, loss of hearing, falling of teeth, menopause,
sibs or neighbors and copies them. Whatever habits osteoporosis, prostatic enlargement, etc.
they have (smoking, cleaning of hands, etc.), the Appropriate timely advice regarding these problems
child picks them very fast. goes a long way in reducing the anxiety and
• School age: Health education is imparted through: suffering of old people.
– Healthy school living in well-ventilated rooms
– Use of clean latrines and urinals Experience and Examples of
– School books and teaching curriculum
– Physical education and games
Health Education
– Personal examples set by the teachers and the Effectiveness of health programs can be markedly
advice and guidance given by them curtailed if appropriate health education is not included
– School meal programs which act as practical as a component. Underprivileged people may be over-
situation for nutrition and diet education. awed by those in authority and may not refuse outright
• Adolescent age: It is a delicate age because of something suggested by an official. They may carry out
important changes in sex and physique. Besides the suggested task even if they have to incur some
other things, sex education regarding anatomy and financial expenditure. However, this activity on their
physiology of sex organs has also to be given. part may be purely passive or involuntary, without any
Hygiene of sex organs (removal of smegma, change in attitude or behavior. A good example is the
menstrual hygiene) is also important. Special latrine construction carried out with 50% subsidy from
570 attention has to be paid to educate the adolescents the government as part of the community
about prevention of pregnancy and sexually development program. Even though many latrines
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were constructed, they largely remained unused Institute of Education, University of London in 1977.
to
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c u - t r a cbecause there was no motivation and hence no During the early years’ the major emphasis was on
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behavioral change on the part of the people. A real better care of younger sibs by a child. In its extended
good health education program would have averted form a major emphasis is now placed upon its health
this fiasco. educational aspect. With this end in view, the NCERT
Similarly, no special efforts were made to educate has successfully experimented with the child to child
the people or to involve them directly when the program in municipal primary schools, using an activity
National Malaria Control Program was launched. It was based approach. It is proposed to teach the children
thought that the act of DDT spray itself was sufficient the basic health and development concepts with the aim
to serve as means of education because people of improving their own knowledge, as well as using this
welcomed such spray. Things went on quite well in the child power to communicate relevant messages to
early stages and this was taken as the public younger children, parents and the community.14
approbation of the great value of DDT in malaria The child to child program is currently spread over
prevention. In reality, people were thankful because 75 countries. Its objectives are as follows (i) To improve
of the collateral benefits of DDT, such as reduction in the levels of health, nutrition and development of
the nuisance of flies, fleas, culex mosquitoes, bugs, school-going children through child to child activities;
ants, cockroaches and other insects. Very few persons (ii) To make learning a relevant, meaningful and
understood the role of DDT in preventing malaria enjoyable experience for children; (ii) To enable school-
through destruction of the vector species. It was not going children to make qualitative improvements in the
surprising, therefore, that the tremendous initial life of their younger sisters, brothers, parents and
response to DDT spray dwindled when DDT started neighbours, thus applying the facts learnt in school to
losing its effectiveness against insects other than the daily life; (iv) To improve the school and neighborhood
malaria vector. Malaria workers started facing large environment through organized activities.
scale refusal to DDT spray in most areas. There were The activities under the program may be of the
complaints about the quality of DDT and about following types:
malpractices of the staff, not because DDT had lost its • Child to child: The child may be involved in
effectiveness against the vector species but because the providing care for younger brother and sisters or
collateral benefits had disappeared. This brings home other younger children.
• Child to family: In certain circumstances the child
very vividly the need and importance of talking the
may exert an influence on the health practices of
people into confidence and educating them about the
his parents and other family members.
program before implementing the same.
• Child to community: Children as a group may
Health education carried out well enough and long
influence the health practices of their community
enough, can be demonstrably effective. It is now well
through songs, plays, puppet shows, etc.
known that the prevalence of smoking is slowly declining
• Child to environment: The child may be involved
in the west and increasing in India. This reflects
in activities aimed at improving the quality of the
simultaneously the response to intensive health
environment, e.g. sanitation, tree planting, etc.14
education drive in the West and a lukewarm approach
in our own country. To give another specific example,
it has been reported that North Karelia, a country in Education and Training System
eastern Finland with the highest mortality from heart in Health and FW Institutions
disease throughout the world 20 years ago, has slashed
its death rates by half because of an all out program The Government of India established 47 Health and
to change the diets of the community and to persuade Family Welfare Training Centers in 1960’s in various
smokers to quit smoking. It is important to remember parts of the country. The HFWTCs are supposed to get
that it is easier to instil healthy lifestyles in the young guidance and support from the so called Central
than to change bad habits in adulthood. Based on this, Training Institutes, listed below:
Philippines has launched an all out program to teach • National Institute of Health and Family Welfare,
children how to have a healthy heart, right from their New Delhi.
kindergarten days.13 • Central Health Education Bureau, New Delhi.
An example of successful health education program • All India Institute of Hygiene and Public Health,
in prevention of cancer has been described earlier in Kolkata.
the chapter on noncommunicable diseases.13a • Family Welfare Training and Research Center,
Mumbai.
Rural Health and Family Welfare Training Center,
Child to Child Program •
Gandhigram, Tamil Nadu.
It was initially conceived and started by David Morley The training system in health and family welfare has 571
and his colleagues at the Institute of Child Health and proved to be grossly inadequate. Two major reasons
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for this are: (a) The number of HFWTCs initially To coordinate the activities relating to international
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population, has remained the same, though population The CHEB has established a Central Health Museum
has doubled; (b) The so called CTIs have not been able and organizes health exhibitions at various levels. It
to provide adequate guidance and support to HFWTCs; brings out several publications on health education. It
(c) The HFWTCs are starved of funds and facilities and organizes training of doctors, health visitors, nurses,
the HFWTC faculty has low morale due to poor health educators and school teachers, etc. It conducts
promotional avenues. a one year diploma course in health education under
Realizing the impor––tance of well-trained personnel the auspices of the University of Delhi. In addition, it
for effective health care delivery, the government of also conducts a three months certificate course, as well
India launched, with World Bank support, a National as short-term training courses suited to the needs of
Training Project, comprising India Population Project VI different categories of personnel.
and VII, in eight states (IPP VI in Andhra Pradesh, MP The Research Unit conducts studies in health habits,
and UP; IPP VII in J and K, Haryana, Punjab, Gujarat values and beliefs of people. It also encourages social
and Bihar). As a consequence the current pattern of sciences research on health subjects in the universities
training in health and family welfare is as follows.15-17 and other institutions.
Besides the CHEB, the DAVP (Directorate of Adver-
• National level: National Institute of Health and Family
tising and Visual Publicity) also carries out health
Welfare, New Delhi.
education activities.
• State level: State Institutes of Health and Family
Welfare. Eight SIHFWs have been established in the
8 IPP VI and VII states, besides Orissa, Karnataka, IEC Training Scheme
Assam and Rajasthan.
The Information, Education and Communication
• Regional level: HFWTCs. Regional Training Centers
Training Scheme was launched by the Ministry of Health
or RTCs, each serving about 10 million population,
and Family Welfare, with financial assistance from
have been established in the IPP states.
USAID, on 17th November, 1987, in 4 Hindi speaking
• District level: District Training Center and District
States of UP, MP, Rajasthan and Bihar in a phased
Training Team.
manner by covering during next 6 years a total of 68
As regards health education, the Central Health
Districts. There was general consensus that the scheme
Education Bureau (CHEB) is a part of the administrative
organization of the Director General of Health Services, had been useful. Though USAID assistance was no
Government of India. Similarly, states have a State longer available, the government decided not only to
Health Education Bureau (SHEB) in the Directorate of continue it beyond March 1993 but also to extend it
Health. Each District has a District Health Education Unit to the remaining Districts of the 4 Hindi speaking states
at District level as part of the District Health and other states of the country with poor demographical
Organization, and Block Health Unit at Block level as indicators. Thus, the Ministry of Health and Family
part of the Primary Health Unit. Welfare approved the Scheme to continue as a plan
The Central Health Education Bureau was scheme under the VIIIth Plan and made budgetary
established in 1956. Since then, it is engaged in provisions as part of the IEC Division of the Ministry.18
strengthening the concept of health education and The additional states included were West Bengal, Orissa
giving it a rightful place in the health programs. The and Assam.
Bureau coordinates and promotes health education
work in the country. It has six technical divisions, Rationale
namely, Training, Research and Evaluation, Field Study
and Demonstration Center (Urban and Rural), School Crucial to successful implementation of the Health and
Health Education, Health Education Services, and Family Welfare Programs is the performance of change
Media and Administrative Section. agents, i.e. male and female workers at the grassroot
The main function of the Bureau are: level. Some of the important variables that influence
• To train key health and community welfare workers performance at this level are the nature of workers’
in health education, transactions with villagers as well as their competence
• To prepare and produce health education material, in terms of the required knowledge and skills.
both printed and audiovisual, for the general public Predictability of workers’ visits to villages, and villagers’
and for training purposes, awareness of such visits, add to the reliability of services
• To coordinate and conduct research in health and contribute positively to establishment of rapport with
behavior and health education process, the villagers. Similarly, efforts to improve the skills of
• To help in implementing health education programs workers on a continual basis are also significantly
572 for school going population, for youth out of school beneficial to enable them to perform their job more
and for teacher trainees of different categories, and effectively. At present, though the workers are expected
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of workers are circulated to villagers. Similarly, the visits
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visit villages at regular intervals, nor improve villagers’ predictable pattern. It is difficult for health workers to
awareness of such visits. Training programs for workers contact each household on every visit. To establish a link
are largely institution-based and such programs mainly between villagers and workers, the village is divided into
concentrate on imparting knowledge rather, than skill units of twenty households. From each of these twenty
development and problem solving. Even for such households, one influential person, preferably a female,
training programs the worker gets opportunities for is identified, trained and involved in all health and family
getting orientation after long gaps. Presently, few welfare activities in the village. This approach not only
training programs provide opportunities for on the job ensures better coverage but also involves community
training. members in educational and service delivery activities.
The nature of supervision at various levels needs The health workers visit those households identified by
considerable improvement. Multiple levels of super- the link persons and requiring health and family welfare
vision, lack of regular supervisory visits and the fault education and services, on priority basis.
finding nature of supervision have to be changed to
supportive, innovative and problem solving type of TRAINING
supervision at various levels. Multiple supervisors also
Institution based training has its own relevance but its
often work in isolation, with little effort to share
ability to cover all workers at regular intervals is limited.
experiences with each other. As a result, more often than Training should not only cover technical aspects of
not, supervision becomes routine and ritualistic and loses programs but also focus on problem solving skills of
its potential as a supportive input in the organization. workers. This is possible only when the workers are
given training in the work situation by their immediate
Objectives supervisors at regular intervals. So the effort in this
project is to improve job performance of workers
The objectives of the project are to: (1) Increase the reach
through training by taking unique local level problems
of services by making visits of workers and supervisors
into account. Training in this project is conducted at
more predictable and regular; (2) Improve quality of
sector, PHC and district levels according to a
services through knowledge and skill development of predetermined schedule. Two types of training programs
workers; (3) Make supervision more oriented towards are contemplated at all levels: one, initial training of
problem solving; (4) Link supervision with training at longer duration; and the other, regular training of short
various levels; (5) Concentrate on local field problems, duration. While initial training is a one time activity to
both for development of training materials and their use; introduce the IEC project, the regular training is a
(6) Combine interpersonal communication strategy with continuous process and forms part of the system.
mass media approach; (7) Streamline supply systems to The contents of training programs concentrate on two
meet the local needs of health and family welfare units; aspects; one, on technical topics and problems based on
(8) Establish relationship between various levels and seasonal variations at the PHC level; and second, on
elements of the system; and (9) Improve performance problem solving and management aspects at sector and
levels through continuous interaction with village subcentre levels. In both cases, content is suitably modi-
community volunteers. fied to fit into local needs and requirements.
Major Components SUPERVISION

To achieve the above mentioned objectives, efforts are There are multiple supervisors for each worker. Given,
concentrated mainly on four components. These are: this, the importance of immediate first line supervisors
(i) Visit schedules; (ii) Training; (iii) Supervision; and has often been neglected. At present, the nature of
(iv) Monitoring and evaluation. supervision has become almost routine. Each supervisor,
during brief visits to subcentres and PHCs, concentrates
VISIT SCHEDULES only on three aspects. These include: (1) records;
(2) target achievement; and (3) new instructions. To
Villagers mainly follow the days rather than dates. make supervision more effective, it is necessary to
Therefore, under the IEC scheme, the tour programs introduce the concept of teaching in supervision and
of health workers are drawn as a weekly schedule rather convert the present nature of supervision into
than a datewise calender schedule. The new system supportive and skill development type. This project
attempts to make the visits regular and predictable by envisages giving equal importance to all supervisory
assigning a particular week-day in a fortnight to a particular levels, constituting supervisory teams, and finally
village. To make villagers aware of visits, Weekly schedules integrating supervision with training and visit systems. 573
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Commercial marketing, in contrast, simply tries to
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PART IV: Health Care and Services MONITORING AND EVALUATION
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Success of any program depends on ability to monitor
certain direction-convincing consumers that a certain
and evaluate programs adequately and accurately and
brand of toothpaste is superior, for instance, rather than
to take corrective action, if necessary.
that it is important to brush the teeth regularly.
The project aims at designing simple information
Social marketing’s products are ideas and practices.
system to identify the local health and family welfare
Social marketing is distinguished by its emphasis on
needs and to pinpoint local problems and issues. These
so-called nontangible products ideas and practices as
provide a major input into the training programs.
opposed to the tangible products and services that are
the focus of commercial marketing.
Role of HFWTCs
The HFWTCs play an important role in the IEC scheme. Elements of Social Marketing
Their specific functions in this context are: (i) To
organize training program; (ii) To provide assistance to UNDERSTAND “CUSTOMER NEEDS”
district supervisory-cum-training teams; (iii) To develop
locally relevant or adapt centrally developed training Social marketing aims to “reach” one or a number of
material; (iv) Providing additional skills to health target groups in order to initiate and effect changes in
workers, specially in the area of interpersonal their ideas and behavior. The starting point of social
communication. marketing, therefore, is getting to know the target audience
thoroughly through market research: its social and
demographic makeup (economic status, education, age
Social Marketing structure, and so on), its psychosocial features (attitudes,
Social Marketing (SM) is merely the application of motivations, values, behavioral patterns), and its needs.
commercial marketing principles to advance a social
cause, issue, behavior, product, or service. Advertising and DISTRIBUTION CHANNELS: MAKING THE
other communications are central to social marketing. “PRODUCT” AVAILABLE
Social marketing is a cyclical process involving six steps: Mass media are undoubtedly the most important
Analysis; Planning; Development; Testing and refining “vehicles” for creating awareness of social products as
elements of the plan; Implementation; Assessment of in- well as for distributing nontangible products. But their
market effectiveness; and Feedback. effectiveness varies greatly. In urban areas, depending
Kotler and Gerald Zaitman in 1971, first presented on the target group, television, cinema, and radio (with
the idea of social marketing. This concept combines due attention to the right broadcasting time) as well as
traditional approaches to social change with commercial magazines, newspapers, posters, and other print media
marketing and advertising techniques. Its originators can be effective. In rural areas, often only radio plus
defined social marketing as “the design, implementation traditional “media” such as folk theater, puppet shows,
and control of programs aimed at increasing the accep- and song and dance performances are appropriate.
tability of a social idea or practice in one or more group As a rule, the communication channels selected
of target adopters”. should be ones the target audience comes into contact
Social marketing makes use of methods from the with on a regular basis as well as perceives as being
commercial sector: setting measurable objectives, doing credible, since familiarity with a medium and with the
market research, developing products and services that performers makes it easier to get the message accepted.
correspond to genuine needs, creating demand for them Tangible products (such as condoms for family
through advertising, and finally marketing through a planning), which may form part of a social marketing
network of outlets at prices that make it possible to campaign, can be provided through various channels:
house-to-house or a local distribution center, by post,
achieve the sales objectives.
direct sale, and so on. They can be given for a fee or
The difference between commercial and social
free of charge. The decision on the marketing channels
marketing thus lies not in the methods they use but in to be selected how many, what kind, and where
their content and objectives. Social marketing is a some- depends on many factors such as nature of the product,
what more complex concept, however, and sometimes costs, the size and location of the target population, and
also less effective than its commercial counterpart, since its consumption habits.
it aims to influence people’s ideas and behavior (for
example, to make them give up smoking). Moreover,
PRICING
marketing social products with a tangible base is even
more complex, as demand has to be created for the Prices fulfill various marketing functions. For one thing,
574 idea or product concept, such as family planning, as well they regulate the target groups’ access to products.
as for the tools or product itself, such as condoms. Particularly in poor countries, higher prices impede
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access whereas lower prices facilitate it. For another, Mexico, and Egypt. In India, Nirodh has become
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viewed as an indicator of quality and attendant prestige understood by people. Mala-D and Saheli are other
value. High price is often equated with high quality. examples of social marketing of contraceptives in
India.
OPPORTUNITY COSTS—THE COST OF ADOPTION Social marketing has proved successful despite
significant obstacles like cultural and religious resistance,
The total cost of adopting a social idea or practice often lack of knowledge about the topic, illiteracy, and pricing
goes beyond the monetary price alone, as further cost- constraints. But SM is no shortcut for success; it requires
related factors are typically involved: the time lost or both experience and sensitivity to local conditions.
spent (in traveling and waiting, for example, and the
outlay this entails) together with perceived barriers to
adoption-be they psychological, social, or physical. References
Reducing such costs and creating incentives to adopt 1. Pounds RL, Garretson RL. Principles of Modern Education.
and maintain the new idea or practice overtime is thus New York: MacMillan, 1962.
another central task of social marketing. 2. Grout E. Health Teaching in Schools (5th edn):
Philadelphia: Saunders, 1968.
2a. Anonymous: Health for the Millions. 12(5-6):1(Oct-Dec
Examples of Social Marketing 1986 issue). VHAI.
3. WHO: Tech Rep Ser No. 89.
Social marketing techniques have been particularly 4. Somers, Anne R. Prev Med 1977;6:406.
successful in the health field. Examples are given below. 5. Ramachandran L, Dharmalingam T. Health Education: A
New Approach. Delhi: Vikas Publishing House Pvt Ltd
1990;59,165,169-75,195-97.
IN DEVELOPED COUNTRIES
5a. WHO: Education for Health: A Manual for Health
• The National Cancer Institute used marketing Education. Primary Health Care. Geneva: WHO, 1988.
techniques to change the behaviors of US women 5b. Times of India, 8.9.93.
5c. Development Forum. Jan-Feb issue. United Nations
and health professionals regarding breast cancer
University. 6,1983.
detection; 6. WHO: World Health. 23,1979.
• The National High Blood Pressure Education 7. Gupta MC, Mehrotra M, Arora S, et al. Indian J Ped
Program, using these techniques, has increased 1991;58:269-74.
patient compliance with antihypertensive regimens; 7a. Action News India. Issue No 11. Action Aid India: Delhi,
• The American Cancer Society developed a sound 1986.
marketing program to convey the benefits of giving 8. Pisharoti KA. Guide to the Interaction of Health Education
up smoking, especially for teenage girls.19 in Environmental Health Programs. WHO Offset
Publication No. 20: WHO: Geneva, 1975.
9. Xero India. International Vitamin A Consultative Group
IN DEVELOPING COUNTRIES (IVACG) Special Issues. 8, 1985.
10. Manoff KR. Mothers and Children 2(3), 2. American Public
• In Honduras, oral rehydration salts (ORS) were first
Health Association, 1982.
marketed in 1980 under the brand name Litrosol. 11. First South East Asia Regional Conference on “Eduation
Litrosol was heavily advertised on television and for better health of mother and child in Primary Health
radio, and widely distributed through the existing Care”. Madras, 1986.
health care system and by local village volunteers. 12. Population Headliners: Issue No 219. ESCAP: Bangkok,
By the end of the first year of the ORT campaign, 1993.
49% of the mothers had actually used Litrosol and 13. Times of India, 1992.
71% could recite the radio jingle composed for this 13a. Sankara Narayanan R, et al, Cancer 2000;88:664-73.
14. Muralidharan R, Tolani S, Jain S. Child to Child: A Manual
campaign. More importantly, during the two-year
for Teachers. Delhi: NCERT.
campaign period, diarrhea-related mortality in 15. Gupta JP, Gupta MC, Sood AK. Functions of HFWTCs and
children under the age of five dropped from 48 to Proposals for Their Strengthening. Delhi: NIHFW, 1992.
25%. 16. Gupta JP, et al. Macrostrategy for Inservice Training of
• Similar ORS marketing results have been achieved Health and FW Personnel. Delhi: NIHFW, 1992.
in Egypt and Gambia. About 50% of Egyptian 17. Gupta JP, et al. Macrostrategy for Implementation of
mothers had used ORT after one year of the National Training Project (IPP VI and VII). Delhi: NIHFW,
program and over 50% of cases for the second year 1992.
18. Department of Family Welfare: IEC Training Plan: Revised
of the campaign in Gambia used ORT.
Operational Strategy. Delhi: Min of H and FW.
• Contraceptive Social Marketing (CSM) programs are 19. Lucaire LD. Development Communication Report. Issue
well-established in India, Bangladesh, Sri Lanka, No 51. Washington: Clearinghouse on Development 575
Thailand, Nepal, Colombia, EI Salvador, Jamaica, Communication, 6,1985.
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Health Education (C Med)

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Health Education (C Med)

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h a n g e Vi h a n g e Vi

functions carried out by the trainees. Hence it is

566 Not a good discussion Good discussion

and methods of education.

appropriate to the situation, whether it is an epidemic

CHAPTER 29: Information, Education, Communication and Training in Health

Major Components SUPERVISION

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