HEALTH EDUCATION

AND COMMUNICATION

1
 Outline

 Objectives
 Introduction

 Improving health: a historical overview

 Health education and Health promotion

 Why health promotion and health

education
 Aims and principles of health education

 Responsibility of health educators

2
 Objectives

 Explain the historical background of disease

prevention and health promotion and related
concepts
 Capture the methods of understanding human
behaviour
 Describe communication process
 Acquainted and be able to use and explain the
various methods employed in health education
 Apply behavioural models to address hypothetical
health problems.
 Identify the challenges in behavioural change

3
 CHAPTER ONE
Introduction
Defining Health

– Different people may give different definition of

health based on their circumstances

– What does ‘being healthy’ mean to you?

 Reflect
!
– Lay and professional definition of health:

– To the general public, being healthy may

mean,
simply “ not being ill”
4
 Several researchers found different understanding of
health from different population (mothers, elderly,
youth, children ) in different settings.
 Summary of lay definition
– People’s idea of ‘health’ and ‘being healthy’ widely
vary
– They are shaped by their experiences, knowledge,
value and expectations as well as their view of what
they are expected to do in their lives and fitness level
they need to fulfil that role 5
 WHO definition of health

 Over half a century ago in 1948 WHO defined

health as ‘ a state of complete physical, mental,
and social well-being and not the absence of
disease or infirmity’

 Is this definition holistic?

 What other components you need to add?

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 Critics on WHO definition

 Health is dynamic, not a state

 The dimensions are inadequate.
 Well being is very subjective
 Measurement is difficult
 Idealistic rather than realistic
 Health is not an end but a means
 Lacks community orientation
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Perspectives of health

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 Determinants of health
Maintenance of good
health Diseases can be due to
 Proper nutrition  Genetic traits
 Safe drinking water  Congenital deformity
 Shelter (Ventilation or malformation
and illumination)  Traumatic
 Clothing, hygiene  Infection, infestation
 Proper work, exercise, and inflammation
rest and recreation  Malnutrition
 Proper social condition  Hormonal
 Proper sexual bhr
 Metabolic disorder
 Provision & utilization
 Poison
of health services 9
 Cont…
 The health field concept
 Human biology: genetically
 Environment: physical, chemical,
biological, psycho-social, economic..etc
 Life-style (Behavior): smoking, unsafe
sex, eating habit etc.
 Health organizations: availability,
accessibility, quality, affordability.

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 Improving health – Historical overview
 Emphasis of health promotion work has changed over
the decades
– whether on individual behaviour or socio-economic
factors

 Public health work on early 20th century concentrated on

environment reforms
– Improved sanitation and clear air

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 Improving health – Historical overview
cont...

 In the 1950 and 1960 the focus shifted to individual

health behaviour,
– Venereal disease (older name for STIs) accident
prevention, immunization, FP, cervical smear checks,
weight control, alcohol consumption, and smoking
– This emphasises on the ‘lifestyle approach’

– Meant a concentration of effort on health education

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 Historical overview cont...
 During 1970s, this emphasis was heavily criticised
(individualistic view)
 Because it distracted attention from the social and
economic determinants of health, and tended to blame
individuals for their own ill health, this was known as
“victim blaming”
 In the 1980s, the pendulum swung again, there emerged
the broader approach of health promotion and public
health we see now;
 At that time it was often called the new public health

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 International initiatives for improving
health
 The ‘Health for All’ movement of the 1977 by the WHO
 Emphasizes on:
– Reducing inequalities in health
– Positive health through health promotion and disease
prevention
– Community participation

– Cooperation between health and other local authorities

– A focus on primary health care as the main basis of
health care system

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 International initiatives for improving
health
 A further milestone was the publication in 1996 of the
Ottawa Charter which identified five key themes or
health promotion:
– Building a healthy public policy
– Creating supportive environment
– Developing personal skills through information and
education in health and life skills
– Strengthening community action
– Reorienting health services towards prevention and
health promotion

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 International initiatives for improving
health
 The Jakarta Conference in 1997, more recent one for
WHO
 The Jakarta Declaration reiterated the importance of the
Ottawa Charter principles and added priorities for health
promotion in the 21st century
– Promote social responsibility for health
– Increase investment for health development
– Expand partnership for health promotion
– Increase community capacity and empower the
individual
– Secure an infrastructure for health promotion

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 National initiatives

 Ethiopia adopted the declaration “health for all by the year

2000” PHC

 Ethiopia’s HSDPs I-III

 Where are we now?

 This will be related to assignments, from the point of view

of MDGs

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At the time of Alma Ata declaration of
Primary Health Care in 1978, health
education was put as one of the components
of PHC and it was recognized as a
fundamental tool to the attainment of health
for all.
 Adopting this declaration, Ethiopia utilizes
health education as a primary means of
prevention of diseases and promotion of
health.
 In view of this, the national health policy
and Health Sector Development Program of
Ethiopia have identified health education as a
major component of program services. 18
 Health education
 According to Griffiths (1972), “health
education attempts to close the gap
between what is known about optimum
health practice and that which is actually
practiced.”
 Simonds (1976) defined health education
as aimed at “bringing about behavioral
changes in individuals, groups, and larger
populations from behaviors that are
presumed to be detrimental to health, to
behaviors that are conducive to present
and future health.”
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 Cont…
 Based on scientific principles, health
education is any combination of learning
experiences designed to facilitate
voluntary actions conducive to health
(Green, 1991)
– Combination emphasises the
‘importance of matching the multiple
determinants of behaviour with multiple
learning experiences or educational
interventions’
– Design distinguishes HE from incidental
learning as a systematic planned activity
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 Health education cont...
– Facilitate: predispose, enable and reinforce

– Voluntary: is without coercion and full understanding

and acceptance of the purpose of the action
– Action: is behavioural steps taken to achieve an
intended health effect

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 Cont…

 Health education includes not only

instructional activities and other strategies
to change individual health behavior but also
organizational efforts, policy directives,
economic supports, environmental activities,
mass media, and community-level
programs.
 Two key ideas from an ecological perspective
help direct the identification of personal and
environmental leverage points for health
promotion and education interventions
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 Cont…
 First, behavior is viewed as being affected
by, and affecting, multiple levels of
influence.
 Five levels of influence for health-related
behaviors and conditions have been
identified:
 Intrapersonal, or individual factors;

 Interpersonal factors;

 Institutional, or organizational factors

 Community factors; and

 Public-policy factors 23
 Cont…

 The second key idea relates to the

possibility of reciprocal causation
between individuals and their
environments; that is, behavior both
influences and is influenced by the
social environment

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 Health Promotion
 Health promotion is the combination of educational and
environmental supports for actions and conditions of
living conducive to health

 In this definition:

– Combination refers to the importance of matching

the multiple determinants of health with multiple
interventions or sources of support

– Educational refers to health education

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 Health promotion cont....

 Environmental refers to the dynamic social forces than

the physical services.

– Such as: social, political, economic, organizational,

policy, and regulatory circumstances bearing on the
behaviour or more directly on the health

 Living conditions: referee to the complex web of culture,

norms and socioeconomic environment associated with
lifestyle

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 Health education Vs Promotion
 Both are systematic, planned application that
qualify as science.
 Health promotion entails methods beyond

mere education: community mobilization,

community organization, community participation,
community development, networking, policy
development, formulating legislation and developing
social norms.

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 Cont…
 Unlike health education, health promotion
does not endorse voluntary change in
behavior but utilizes measures that
compel an individual’s behavior change.
Ex. Increasing insurance premium for
smokers.
 Health promotion is done at the group or
community level.

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 Why health education and health
promotion:
 An estimated 40-70 percent of all premature deaths
 A third of all cases of acute disability
 Two thirds of all causes of chronic disability
– Are caused due to behavioural and lifestyle risk factors
 substance abuse;
 poor diet;
 sedentary work, and leisure;
 and stress related conditions (suicide, violence, and
reckless behaviour

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Why health education and health promotion

 Aim of health education and health promotion is to:

– Prevent premature deaths that are related to lifestyles

and behaviour

– By creating awareness, knowledge and necessary

environmental support for possible behavioural
change.

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 The continued existence and spread of communicable
diseases.
 Increasing the tendency of chronic conditions.
E.g. Hypertension.
 Many people do not seek treatment until it is too late.
Ignorant, access, afraid of seeking treatment
 Increasing threats to the young from new and harmful
behaviors.
Eg. tobacco use, teen-age pregnancy, substance use etc.

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 Aims of health education
 The primary purpose of health education is,
to influence antecedents of behaviour so
that healthy behaviours developed in a
voluntary fashion.
 Motivating people to adopt health-promoting
behaviors by providing appropriate
knowledge and helping to develop positive
attitude.
 Helping people to make decisions about
their health and acquire the necessary
confidence and skills to put their decisions
into practice. 32
 Principles of health education
 All health education should be need based
 Aims at change of behavior

 Free flow of communication.

 The health educator has to adjust his talk

and action to suit the group.
 Provide an opportunity for the clients to go
through the stages of identification of
problems, planning, implementation and
evaluation.
 Health Education should start from the
existing indigenous knowledge
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 Cont…
 Based on scientific findings and current
knowledge.
 Should themselves practice what they
profess. Otherwise, they will not enjoy
credibility.
 The grave danger with health education
programs is the pumping of all bulk of
information in one exposure
 The health educator should use terms that
can be immediately understood.
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 Responsibility for health educators
I. Assess individual and community needs
for health education
II. Plan effective health education programs

III. Implement health education programs

IV. Evaluate the effectiveness

V. Coordinate the provision of health

education services
VI. Act as resource person in health
education
VII. Communicate health & health education
needs, concerns and resources 35
 The role of health education and
promotion in Primary Health Care
 Primary health care is a means of achieving
health for all.
 This is possible if all individuals, families,
communities, health professionals, government
and NGOS are involved in the programs.
 One of the core principles of primary health care
is community participation.
 To achieve effective community participation two
things need to be done.
– First: the political issues or government decision
– Second: educational issues (health education)

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 Health education settings

 Health education takes place in:

1. Schools
2. Worksites
3. Health care settings and
4. Community settings
5. Voluntary health agencies
6. Special communities(prisons and refugee)

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 Health education covers the
continuum from disease prevention
and promotion of optimal health to
the detection of illness to treatment,
rehabilitation, and long-term care.
 It includes infectious and chronic
diseases, as well as attention to
environmental issues.

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 Chapter Two: Health and Behavior

A behavior is any overt action, conscious or

unconscious, with a measurable
frequency, intensity, and duration.
Health Behavior is any activity undertaken
by an individual regardless of actual or
perceived health status, for the purpose of
promoting, protecting or maintaining
health, weather or not such behavior is
objectively effective toward that end.
(WHO, 1998)
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 Health behavior cont…d

 David Gochman defined as “ those personal

attributes such as beliefs, expectations,
motives, values, perceptions, and other
cognitive elements; personality
characteristics, including affective and
emotional states and traits; and behavioral
patterns, actions and habits that relate to
health maintenance, to health restoration
and to health improvements.”

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 Behavior components

 Basically our behavior has 3 domains

A) Cognitive domain- “stored information”
 Knowledge, Perception, Thinking

B) Affective domain-cognition +feeling

(connation)
 Attitude, Beliefs, Value

C) Psychomotor domain
 Psycho-mind, Motor – action

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 Role of human behaviour in prevention of
disease

 Healthy person early signs disease death

Primary HE Secondary HE Tertiary HE

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 The Role of Human Behavior in prevention of
Disease
• What is prevention?
• Prevention is defined as the planning for and the
measures taken to forestall the onset of a disease or
other health problem before the occurrence of
undesirable health events.

• There are three distinct levels of prevention: primary,

secondary, tertiary prevention.

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 The Role of Human Behavior in prevention of
Disease (cont…)

 Primary prevention
– Comprised of those activities carried out to keep
people healthy and prevent them getting disease.
– Examples, rubber gloves when there is a potential
for the spread of disease, immunizing against
specific diseases, exercise, and brushing teeth.
– any health education or promotion program aimed
specifically at prevention of the onset of illness or
health problems.

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 The Role of Human Behavior in prevention of
Disease (cont…)
 Secondary prevention
– includes preventive measures that lead to an early diagnosis and
prompt treatment of a problem before it become serious.
– It is important to ensure that the community can recognize early
signs of disease and go for treatment before the disease become
serious.
– The actions people take before consulting a health worker,
including recognition of symptoms, taking home remedies
(‘self-medication’), consulting family and healers are called
illness behaviors.
– Illness behaviors are important examples of behaviors for
secondary prevention.

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 The Role of Human Behavior in prevention of
Disease (cont…)

 Tertiary prevention
– Tertiary prevention seeks to limit disability or
complication arising from an irreversible
condition.
– The use of disability aids and rehabilitation
services help people from further deterioration and
loss of function.
– For example, a diabetic patient should take strictly
his daily insulin injection to prevent complications.

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 Factors affecting human behaviour

• Factors affecting behaviour are broadly classified in to

predisposing, enabling and reinforcing factors.
1. Predisposing factors: Provide the rationale or
motivation for the behavior to occur. Some of these are:
• Knowledge

• Belief

• Attitudes

• Values

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 Factors affecting human behaviour(cont…)

2. Enabling factors: these are characteristics of the

environment that facilitates healthy behavior and any
skill or resource required to attain the behavior.
• Enabling factors are required for a motivation to be
realized.
Examples of enabling factors include:
• Availability and or accessibility of health resources
• Government laws, priority and commitment to health
• Presence of health related skills

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 Factors affecting human behaviour(cont…)

E.g. Enabling factors for a mother to give oral rehydration

solution to her child with diarrhea would be:
• Time, container
• Knowledge of how to prepare and administer it.

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 Factors affecting human behaviour(cont…)

• In general, it is believed that enabling factors should be

available for an individual or community to perform
intended behavior.
 Behavioral intention Behavioral change

Enabling factors
(Time, money and materials, skills, accessibility to health
services)

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 Factors affecting human behaviour(cont…)

3. Reinforcing factors: these factors come subsequent to

the behavior.
– They are important for persistence or repetition
of the behavior.
– The most important reinforcing factors for a
behavior to occur or avoid include:
– Family
– Peers, teachers
– Employers, health providers
– Community leaders
– Decision makers

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 Stages of Behavior change

SUSTAINED BEHAVIOUR

TRIAL
READINESS
MOTIVATION
Acq. Know.& Skill
CONCERN
AWARENESS
UNAWARENESS
17
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 Basic vocabulary in health education

 Awareness: becoming conscious about an

action, idea, object, person or situation.
 Perception: interpretation of the meaning given
to sensory information.
 Information: the collection of facts related to an
action, idea, person, situation.(after awareness)
 Knowledge: is storage of information in the
brain. (learning facts & gaining insight)
 Skills: performing any action(ability to do well)

53
 Basic vocabulary cont…

 Beliefs: are convections that a phenomenon is

true or real. Neither correct nor incorrect!
 Attitudes: are relatively constant feelings,
predispositions, or sets of beliefs directed
toward an idea, object, person or situation. Put
another way attitudes are beliefs with an
evaluative component. (likes and dislikes)
 Values: are enduring beliefs or systems of beliefs
regarding whether a specific mode of conduct or
end state of behavior is personally or socially
preferable. (belief + attitude)

54
 Basic vocabulary cont…

 Motivation: is a combination of forces which

initiate, direct and sustain behaviour towards
goal. (intrinsic or extrinsic forces)
 Society: arises out of community.
– Unlike community, which refers to the
structure, location and size of the population,
society refers to the human relationship,
behavioural patterns, cultural traits,
institution, etc., in the community.
 Community mobilization: involves persuading
community members to attend or participate in
any activity planned by the health educator.
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Chapter Three: Theories and
Models in Health education

56
 A theory helps health education and health
promotion programs identify program
objectives, specify methods for facilitating
behavior change, provide guidance about
timing of methods, and select method of
intervention.
 Models are eclectic, creative, simplified
miniaturized applications of concepts for
addressing problems.

57
Comparison between a model and a theory

Theory Model
• Explains or predicts a o Simplified application

phenomena of concepts for

• Micro-level guidance addressing problems
o Macro level guidance
• Empirically tested
o Not enough empirical
• Based in previous
literature evidence
o Creative
• Usually parsimonious
o Usually tries to cover a
• Does not contain any
model lot
o May embody one or
• E.g. Social cognitive T
more theory 58
 A. The Health belief Model(HBM)
(Hochbaum, Rosenstock &Becker,1950-1974)

 Has been one of the most widely used conceptual

frameworks in health behavior.
 Has been used to explain change and
maintenance of health related behaviors and as
guiding framework for health behavior
interventions.
 The model focuses on two aspects of individual
representation of health and health behaviour:

1. Threat perception

2. Behavioural evaluation
59
 HBM cont..
 Threat perceptions are seen to depend upon two beliefs:
– perceived susceptibility to the illness and

– perceived severity of the consequence of such illness.

– together these two variables are believed to determine

the likelihood that the individual is following a health
related action,

 Although their effect is modified by individual differences

in demographic variables and psychological variables,
the particular action is believed to be determined
by the evaluation of available alternatives.

60
 HBM…
 HBM hypothesizes that health related action
depends on simultaneous occurrence of
three classes of factors
– Health concern that makes health issues
salient (health motivation)
– Perceived threat from health issue
– Belief that a particular health
recommendation would be beneficial in
reducing the threat at subjectively
acceptable cost
61
 Components of the HBM
Concept Definition Application

Perceived One’s belief regarding Define population(s) at risk, risk

susceptibility the chance of getting a levels.
condition Personalize risk based on a
person’s characteristics or
behavior.
Make perceived susceptibility
more consistent with an
individuals actual risk.
Perceived one’s belief of how Specify consequence of the risk
severity serious a condition and and the condition
its sequela are

Perceived One’s belief in the Define action to take: how,

benefits efficacy of the advised where, when; clarify the positive
action to reduce risk or effects to be expected
seriousness of impact 62
 Components of the HBM
Concept Definition Applications

Perceived One’s belief about the Identify and reduce perceived

barriers tangible and barriers through reassurance,
psychological costs of correction of misinformation,
the advised action incentives, assistance

Cues to Strategies to activate Provide how-to information,

action one’s “readiness” promote awareness, employ
reminder systems
Self-efficacy One’s confidence in Provide training, guidance in
one’s ability to take performing action.
action Use progressive goal setting.
Give verbal reinforcement.
Demonstrate desired behaviors.
Reduce anxiety.

63
 Example: Hypertension

 High blood pressure screening campaigns

often identify people who are at high risk
for heart disease and stroke, but who
say they have not experienced any
symptoms.
 Because they don’t feel sick, they may not
follow instructions to take prescribed
medicine or lose weight.
 Here, HBM can be useful for developing
strategies to deal with non-compliance in
such situations.
64
 Example…

 According to the HBM, asymptomatic people may

not follow a prescribed treatment regimen unless
they accept that, though they have no
symptoms, they do in fact have hypertension
(perceived susceptibility).
 They must understand that hypertension can lead
to heart attacks and strokes (perceived
severity).
 Taking prescribed medication or following a
recommended weight loss program will reduce
the risks (perceived benefits)without negative
side effects or excessive difficulty (perceived
barriers). 65
 Example…
Print materials, reminder letters, or pill
calendars might encourage people to
consistently follow recommendations
(cues to action).
 For those who have, in the past, had a
hard time losing weight or maintaining
weight loss, a behavioral contract might
help establish achievable, short-term goals
to build confidence (self-efficacy).

66
2.Theory of Reasoned Action(TRA) &
Theory of Planned Behavior (TPB)
 (Fishbein & Ajzen, 1970’s)

 TPB is newer and more evolved version of

TRA.

 Both emphasize the role of thought in

decision making about engaging in
behavior

67
 Cont..

 Basically rooted in cognitive theory in which

 Human beings are usually very rational &
make systematic decisions based on available
information.
 most behavior are under volitional control.

 TRA/TPB is concerned with individual motivational

factors as determinants of the likelihood of
performing a specific behavior.

68
 TRA and TPB both assume the best
predictor of a behavior is behavioral
intention.
 Behavioral intention (BI): is subjective
perception & report of the probability that one
will perform the behavior .
 NB: Different levels of intention for different actions
in different Context & time.
 TRA asserts, Direct determinants of individuals’
behavioral intention are their
– Attitude toward performing the behavior
and
– subjective norm (normative perceptions)
associated with the behavior.

69
 Constructs of TRA and TPB

Distal constructs Proximal

constructs

Behavioral
beliefs
Attitude toward
behavior
Outcome
evaluations

Normative
beliefs Subjective Behavioral Health
norm intention behavior
Motivation to
comply

Control beliefs
Perceived behavioral
control
Perceived
power
70
 Constructs of Theory of Reasoned action

1) Behavior: a single action performed by an

individual that is observed. Condom use.
2) Behavioral intention: the thought to perform the
behavior, which is an immediate determinant of a
given behavior.
3) Attitude toward the behavior: the overall feeling
of like or dislike toward any given behavior. The
more favorable attitude, more likely to perform.
4) Behavioral beliefs: beliefs that performing a given
behavior will lead to certain outcome.
5) Outcome evaluation: the value a person places
on each outcome resulting from performance of
the behavior.
71
 Constructs cont…

6) Subjective norm: person’s belief that most of the

significant others in his or her life think the person
should or should not perform the behavior.
7) Normative beliefs: how a person thinks others who
are significant in his/her life would like him/her to
behave.
8) Motivation to comply: the degree to which a
person wants to act in accordance with the
perceived wishes of those significant in his/her life.
 In subsequent research, Ajzen added the following
three constructs to create the TPB.

72
Additional Constructs of the Theory of Planned
Behavior

9) Perceived behavioral control: How much a

person feels he/she is in command of enacting
the given behavior.
10) Control beliefs: beliefs about the internal and
external factors that may inhabit or facilitate the
performance of the behavior.
11) Perceived power: perception about how easy or
difficult it is to perform the behavior in each
condition identified in the control beliefs.
 TRA/TPB can be applied in: condom use,
exercise, , healthy eating behavior, school based
intervention for HIV/AIDS prevention etc.
73
 3. The Trans-theoretical Model(TTM)

• By Prochaska & Diclemente, 1979

• Assumes that change is a process with
stages not just an event…so first look
the concern of stage theories.
• View behavior as habitual pattern that
requires gradual development rather than
event happening without process (e.g:
addictive b/rs
• As an event requiring deliberate steps
under individual conscious awareness.
74
 TTM…

 The model’s basic premise is that

behavior change is a process that
unfolds over time, not an event.
 It is one among stage theories.

 It uses stages of change to integrate

processes and principles of change
from across major theories of
intervention.
75
 Principles of change
 People change voluntarily only when they
– Become concerned about the need for change
– Become convinced that the change is in their
best interests or will benefit them more than cost
them
– Intend to take action in some context & time.
– Organize a plan of action that they are
committed to implementing
– Take the actions that are necessary to make the
change and sustain the change

76
 Constructs of TTM
 Stages of Change: temporal dimension

 Processes of Change: covert/experiential

and overt/ behavioral activities people use to
progress through the stages.

 Decisional Balance: weighing pros and cons

of changing.

 Self-Efficacy: temptation & confidence

77
 1st: Stages of change: integrative

1. Stages of change construct: spiral

than linear
– Pre-contemplation
– contemplation
– preparation
– action
– maintenance
– termination
78
 Stages of Change Model
Pre-contemplation
Awareness of need to change

Contemplation
Increasing the Pros for
Change and decreasing the
Cons

Preparation
Commitment &
Planning
Relapse and
Recycling
Maintenance
Integrating Action
Change into Implementing and
Lifestyle Revising the Plan

Termination 79
 Stages of change
Stage Definition Potential change
Strategies
Pre- Has no intention of taking Increase awareness of
contemplation action within the next six need for change;
months personalize information
about risks and benefits.
Contemplation Intends to take action in Motivate; encourage
the next six months making specific plans
Preparation Intends to take action Assist with developing
within the next 30 days and implementing
and has taken some concrete action plans;
behavioral steps in this help set gradual goals
direction
Action Has changed behavior for Assist with feedback,
less than six months problem solving, social
support, and
reinforcement
Maintenance Has changed behavior for Assist with coping
less than six months reminders, finding
alternatives, avoiding
slips/relapses (as 80
 4. Social Cognitive Theory (SCT)
 By Rotter & Bandura, 1954/86
 It is how individuals, behavior & environment
interact
 Social cognitive theory gives due attention
to the external environment which can
directly punish or reward the behaviors .
 In addition, it gives due attention to
human minds & qualities such as
expectation, values, confidence and self-
control.

81
 SCT…
 Bandura stated that there are three factors
that interact dynamically to determine human
behavior. These factors are;
1. Environmental influence: there are three
major processes by which the environment
exert its influences on behaviors.
 Observational learning: role model compulsion

 Indirect reinforcement : observed but not

expressed
 Direct reinforcement: resulting from the
consequences for particular action
82
 SCT…

2. Personal factors: mainly related to prior

history in the form of skills, knowledge and
attitude pertaining to the issue at
hand, plus demographic, economic status
etc. (cognitive+ physical person)
3. Behavioral factors: mainly related to
individuals ability to exert self control as
they determine their response to the
situation. It includes factors such as self
efficacy, anxiety/emotions coping, goal
setting etc
83
 Main constructs of SCT
 Behavioral capability: Knowledge and skill
to perform a given behavior; (promote
mastery learning through skills training)

 Expectations: Anticipatory outcomes of a

behavior; (Model positive outcomes of
healthful behavior)

 Expectancies: The values that the person

places on a given outcome, incentives;
(Present outcomes of change that have
functional meaning) 84
 SCT constructs…
 Reciprocal determinism: The dynamic
interaction of the person, the behavior, and
the environment in which the behavior is
performed; (consider multiple avenues to
behavioral change, including environmental,
skill, and personal change) A b/r=a sustained
behavior

85
 SCT constructs…
 Observational learning: Behavioral
acquisition that occurs by watching the
actions -late majority in DOI) and outcomes of
others’ behavior (early majority in DOI);
(Include credible role models of the targeted
behavior)
– attention, retention, production & motivation
 Reinforcements: Responses to a person’s
behavior that increase the likelihood of
reoccurrence; (Promote self-initiated rewards,
vicarious and incentives)
 Vicarious, Self, &Direct

86
 …SCT constructs
 Self-control: Personal regulation of goal-
directed behavior or performance; (Provide
opportunities for self-monitoring, goal
setting, problem solving, and self-reward)

 Emotional coping responses: Strategies or

tactics that are used by a person to deal with
emotional stimuli; provide training in problem
solving and stress management

87
 SCT…
 Self-efficacy: The person’s confidence in
performing a particular behavior;
 Approach behavioral change in small steps to
ensure success (Goal setting)
 self efficacy increases through:
 through performance (personal mastery of
task)
 through vicarious experience (observing others
performance e.g use ordinary person
performance)
 verbal persuasion (receiving suggestions from
others)
88
 5. PRECEDE – PROCEED Model

 is one of the best models to develop comprehensive

program planning.
 Originated in the 1970s from applications in
hypertension trials (Green, Levine , Deeds, Wolle)

89
PRECEDE – PROCEED Model …
 PRECEDE – PROCEED Model …
The PRECEDE model is a framework for the
process of systematic development and evaluation
of health education programs.
 An underlying premise of this model is that
health education is dependent on voluntary
cooperation and participation of the client in a
process which allows personal determination of
behavioral practices; and that the degree of
change in knowledge and health practice is
directly related to the degree of active
participation of the client.
 PRECEDE – PROCEED Model …

 Therefore, in this model, appropriate health

education is considered to be the intervention
(treatment) for a properly diagnosed problem
in a target population.
 This model is multidimensional, founded in
the social/behavioral sciences, epidemiology,
administration and education.
 PRECEDE – PROCEED Model …

 As such, it recognizes that health and health

behaviors have multiple causations which
must be evaluated in order to assure
appropriate intervention.
 The comprehensive nature of PRECEDE
allows for application in a variety of settings
such as school health education, patient
education, community health education, and
direct patient care settings.
 PRECEDE – PROCEED Model …

PROCEED was added to the model in the late

1980s based on L. Green's experience with
Marshall Krueter
PROCEED was added to the framework in
recognition of the emergence of and need for
health promotion interventions that go beyond
traditional educational approaches to changing
unhealthy behaviors.
 PRECEDE – PROCEED Model …

The administrative diagnosis is the

final planning steps to "precede"
implementation. From there
"proceed" to promote the plan or
policy, regulate the environment,
and organize the resources and
services, as required by the plan or
policy
 PRECEDE – PROCEED Model …

 The components of PROCEED take

the practitioner beyond educational
interventions to the political,
managerial, and economic actions
necessary to make social systems
environments more conducive to
healthful lifestyles and a more
complete state of physical, mental
and social well-being for all.
 PRECEDE – PROCEED Model …

 The purpose of the PRECEDE/PROCEED

model is to direct initial attention to
outcomes rather than inputs.
 This forces planners to begin the planning
from the outcome point of view.
 In other words, you as a program planner
begin with the desired outcome and work
backwards to determine what causes it,
what precedes the outcome.
 Intervention is targeted at the preceding
factors that result in the outcome.
 PRECEDE – PROCEED Model …

 The planning process outline in the

model rests on two principles:
 The principle of participation, which
states that success in achieving change
is enhanced by the active participation
of members of the target audience in
defining their own high-priority
problems and goals and in developing
and implementing solutions.
 PRECEDE – PROCEED Model …

 The important role of the

environmental factors as
determinants of health and health
behavior such as media, industry,
politics, and social inequities
 6. DIFFUSION OF INNOVATION THEORY
(DOI)
 It is about how to deal with social systems in
communicating a new product to target audiences.
 It is one of the community models

 Developed by Everett M. Rogers (1962,2003)

 Diffusion of innovation theory is a theoretical

approach which provides an explanation of how

innovation, or ideas perceived as new are
communicated (diffused) through channels among
the members of the social system.

100
 Theory of Diffusion of Innovation (DOI)

 It is one of the community models

 Developed by Everett M. Rogers (1962, 2003)

 Diffusion of innovation theory is a theoretical

approach which provides an explanation of
how innovation, or ideas perceived as new are
communicated (diffused) through channels
among the members of the social system. 101
 Cont…
 Diffusion is the process by which an innovation
is communicated through certain channels over
time among the members of a social system
(Rogers, 2003).
 A key premise of the Diffusion of Innovations
model is;
 some innovations diffuse quickly and widely,
whereas others are weakly or never adopted, and
others are adopted but subsequently abandoned.
 innovations are adopted by different individuals and
spread at different rates in subgroups of individuals.

102
 Elements in the diffusion of innovation

 There are four main elements in the diffusion

of new ideas:
1. The innovation
2. Communication channels
3. The social system
4. Time

103
 Elements
1. Innovation: An idea, practice, or object that is
perceived as new by an individual or other unit
of adoption.(packed bundle of benefits for
consumers)
 Innovation could be ideas and practices-based;
– ideas based innovation-most difficult to implement
– Practice-based innovation-best chance of success
2. Communication Channels: Means by which
messages about innovation spread; including
mass media, interpersonal channels, electronic
communications and installment places.
104
 Elements…

3. Social System: Set of interrelated units that are

engaged in joint problem solving to accomplish a
common goal.
 Social systems have structure, including norms
and leadership.
 The social system constitutes a boundary within
which an innovation diffuses.
4. Time: time dimension is involved in diffusion in
three ways.
 The innovation-diffusion process, adopter
categorization/ innovativeness, and rate of
adoptions-all include a time dimension.
105
Characteristics of Individuals

106
 …CONT
 Rogers (1995, 2003) described the process of
innovation adoption by individuals as a normal,
bell-shaped distribution

Oct 10, 2022 By: Y.K.L. 107

Oct 10, 2022 By: Y.K.L. 109
 Cont…

 In each adopter category, individuals are similar

in terms of their innovativeness:
 Incomplete adoption and non-adoption do not
form this adopter classification.
 Only adopters of successful innovations generate
this curve over time.
 Identifying adopter categories could provide a
strong basis from which to design and implement
intervention strategies aimed at particular groups
of individuals.
110
1. Innovators
 Are first to adapt an innovation (they want to
be first to do something)
 Risk takers even if the innovation is
unprofitable.
 While an innovators may not be respected by
the other members of a social system, they
play an important role in the diffusion process
 They launch the new idea in the system by
importing the innovation from outside of the
system's boundaries.

111
2. Early adopters

 Are very interested in innovation, but they do

not want to be first to be involved.
 Opinion leaders/respected by peers

 Serve as role model for other members or

society
 More limited with the boundaries of the social
system

112
3. Early majority
 May be interested in innovation, but will need
some external motivation to get involved.
 Interact frequently with peers (sociable and
jockey)
 Deliberate (check and discuss) before adopting a
new idea.
4. Late majority
 Are skeptical and cautious and will not adopt an
innovation until most people adopt.
 Pressure from peers

 Interpersonal networks of close peers should

persuade the late majority to adopt it.

113
5. Laggards
Will be the last to get involved in an
innovation
tend to decide after looking at whether
the innovation is successfully adopted by
other members of the social system in
the past.
Posses no opinion leadership.

Isolated in the social systems

Point of reference is in the past.

 Suspicious of innovation
114
 Chapter Four: Communication
 A process by which an idea is transferred
from a source to a receiver with the intent
of establishing commonness or to change
behavior.
 The art and technique of informing, influencing,
and motivating individual, institutional, and
public audiences about important health issues.
 The ultimate goal of all communication is
to create behavioral change.

115
 Principles of communication
 Perception
 Sensory involvement

 Face to face

 Feedback

 Mutual understanding of the message is very

important for communication

116
 Components of communication

1. Source (Encoder)- Originator of message

- Individual or group; Institute
2. Message- the idea communicated

• In the form of words of the mouth or

symbols
3. Channel- physical means by which the
message travels from source to receiver

117
 Cont…

Channels include:
Verbal- most common
Written words- printed material
Picture

Music

Non-verbal communication/ Body

language
Any combination 118
 Cont…

4. Receiver/ Decoder: person or group for

whom the communication is intended
5. Feedback: the mechanism of assessing
what has happened on the receiver after
delivery of communication
- positive or negative
NB. Not all messages reach the receiver
(noise)

119
 Communication models
 Linear (One-way) Model
MESSAGE
Sender Receiver

– Messages from experts, educators and

mass media

– No feedback mechanism

120
 Communication models
 Systems (Two-way) Model
MESSAGE
Sender CHANNEL Receiver
FEEDBACK

– Bidirectional information flow

– Behaviour change via interactive
communication
 Eg.
patient counselling/ telephone
conversation/ discussion/ panel discussion 121
Factors affecting communication
process
 Source: Skill in communicating
Verbal or non verbal

– Knowledge about the audience

– Attitude towards the subject and audience
– Skill in decoding and encoding
– Skill in using the channel
– Selection of appropriate channel
– Confidence source credibility

122
 Cont…
 Message
– Code (signs and symbols, picture,
paintings)
Face to face, verbal

– Content
Substance of the message

– Treatment of the message

The way the message is prepared,
processed and delivered
Coherence and Clarity

123
 Cont…

 Channel:

– Inappropriate use of channels

 Receiver

– Literacy/ status difference with sender/

Time etc..

124
 Variables that need attention
SOURCE: attraction, age, sex, status,
attitude, credibility, skill. . .

MESSAGE: clarity, language, timing,

delivery, organization, content. . .

RECEIVER: attitude, age, sex, status,

perception of source. . .

CHANNEL: live, print, book, email. . .

125
 Types of communication
Interpersonal communication
– Between individuals or within groups
– Dynamic/Bidirectional
– Question and answer/ Multi-sensory
– Important in all stages of adoption of
innovations and for sensitive issues
– Limitation- Language/ Personality/
Professional knowledge

126
 Important points for effective interpersonal
communication
 Exchange of ideas with clients
 Importance of first impression
 Be observant
 A word or gesture might have different
meanings in different settings
 Pay attention to body language

127
 Mass Media communication

– Aimed at awareness creation, knowledge

transmission, changing norms and offer
alternatives of behaviour

– Print media/ Radio/ Television/ Traditional

means

– Traditional like proverbs, fables, stories

– Need to have careful design

– Poor feedback
128
 Cont…
Advantages
 Reaches many people quickly

 Believable

 Provides continuing reminders and

reinforcement
Disadvantages
 May create anxiety or insecurity when
contradictory messages are transmitted
 One sided

 Confusion on audience when messages are

inconsistent
 Creates “This doesn’t concern me” attitude
129
 Barriers of effective communication

 Physical

– Visual and hearing problem/ Clarity of

messages/ Appropriateness of physical facility
 Intellectual

– Schooling of sender as well as receiver/ Skill of

facilitator
 Language

– Language skill/ Different meanings

130
 Cont…

 Inconsistent verbal and non-verbal

communication

 Emotional
– Willingness of receiver/ status of sender

 Status of sender too high or low compared with

the receiver

131
 Appeal

 the way we organize the content of the

message to convince people.

132
 Types of appeals in health
communication
A/ Fear appeal
B/ Humour
C. Logical / factual appeal
D/ Emotional appeal
F/ One sided message
G/ Two sided message
H. Positive Appeals
I. Negative Appeals

133
Unit Five: Methods and Materials in
Health Education
 Methods refers to ways through which
messages are conveyed to achieve a
desired behavioral changes in a target
audience.

 In health education it is not enough to

decide what will be done; by whom
and when, we also need to decide how
it will be done (methods).
134
 Common health education methods

Informal methods Formal methods

1. Health talk 1. Symposium
2. Lecture 2. Seminar
3. Brainstorming 3. Workshop
4. Group discussion
4. Conference
5. Buzz group discussion
6. Demonstration
5. Panel discussion
7. Role play
8. Drama
9. Case studies
10. Traditional media
135
 1. Health Talks

 When talks are on health

agenda we call it health talks.
 It is the most natural way of
communicating with people
to share health knowledge
and facts.
 Can be conducted with one
person or with a family or
group of people or through
mass communication

136
 2. Lectures

 It is oral, simple, quick

and traditional way of
presentation of the
subject matter.
 Presents factual material
in direct, logical manner
 Economical

 In most cases audience

is passive
137
Forms of lecture

138
 3. Group Discussion
 The participants have equal
chance to express freely and
exchange ideas
 The subject of discussion is
taken up and shared equally
by all the members of the
group.
 It is collective thinking
process to solve problems.
 Extremely useful in health
education
139
 Cont…
Strengths
 Pools ideas and experiences from group

 Effective after a presentation, film or experience that

needs to be analyzed
 Allows everyone to participate in an active process

Limitations
 Not practical with more than 20 people

 Few people can dominate

 Others may not participate

 Time consuming

Groups can be stratified by different socio-

demographic factors (sex, age, educational status etc
140
 4. Buzz Group
A large group is divided into
small group, of not more than 10
or 12 people in each small group
and they have given a time to
discuss the problem.
 Then, the whole group is
reconvened and the reporters of
the small groups will report their
findings and recommendation

141
 5. Brain Storming
 Instead of discussing the problem at great length the
participants encouraged to make a list in a short
period of time all the ideas that come to their mind
regarding the problems without discussing among
themselves

 Is a means of eliciting from the participants their

ideas and solution on health issues.

142
 Cont…

Strengths
 Allows creative thinking for new ideas

 Encourages full participation because all ideas

equally recorded
 Draws on group's knowledge and experience

Limitations
 If not facilitated well, criticism and evaluation may
occur
143
 6. Demonstration

 “Showing how is better

than telling how.”
 Although basically focuses
on practice/skill it involves
theoretical teaching as well.
Chinese proverb;
 If I hear, I forget

 If I see, I remember

 If I do, I know
144
Note that,
 You remember 20% of what you hear
 You remember 50% of what you hear and see
 You remember 90% of what you hear, see and do
and with repetition close to 100% is remembered.

Types
– Method demonstration: procedure is shown

– Result demonstration : results are shown

145
 7. Role Play
A type of drama in a simplified manner. It portrays
expected behavior of people.
 A role-play is a spontaneous and/or unrehearsed
acting out of real-life situations. A script is not
necessary.
 It is a very direct way of learning; some are given a
role or character and have to think and speak
immediately with out detailed planning.
 Few minutes for instruction and 5-10 minutes for them
to plan & think
 A role play should last about 20' and 20-30'discussion.
146
 8. Drama

 Drama is a presentation, in which the subject matter

or topic is studied well either written or in words, and
then presented in educative and recreating manner.

 Needs detail planning, script development and

practicing

147
 9. Case Study

 Case Study: is an in-depth analysis of real or

simulated problems that help audiences to identify
problems and suggest solutions according to their
own contexts.

148
 10. Traditional media
1) Poems
2) Songs
3) Proverbs
4) Dances with songs
5) Fable
6) Games
7) Stories
8) Town criers etc.

149
 Selection methods for health education
1. How ready and able are people to change?
2. Your ‘learning’ objectives.
3. How many people are involved?
4. Is the method appropriate to the local culture?
5. What resources are available?
6. What mixture of methods is needed?
7. Subject matter
8. Limitations  of  time
9. What methods fit the characteristics of the target
group?
150
 Formal methods-Scientific methods
1. Seminar:
 A seminar is a lecture or presentation delivered to
an audience on a particular topic or set of topics that
are educational in nature.
 Seminars are educational events

 It is usually held for groups of 10-50 individuals for

about an hour though usually not in practice.

151
2. Workshop
 is a period of discussion and practical work on
a particular subject in which a group of people
share their knowledge and experiences.
 It is a series of educational and work sessions
(where manual work is done).
 Small groups of people meet together over a
short period of time to concentrate on a defined
area of concern.
 Workshops tend to be more intense than
seminars. 152
3. Symposium
 is typically a more formal or academic
gathering, featuring multiple experts
delivering short presentations on a particular
topic.

 It is an academic in nature where experts

(academicians ) present their views on a
particular theme.
 eg. annual research symposium in a university

153
4. Conference: Conference refers to meeting for
lectures of discussion where representative of
various stakeholders participate.

 Conference has a far broader spectrum of

meaning than the other three (seminar,
workshop, symposium ).

 Not limited to academic activities only;

beyond academic where many diverse
participants participate 154
5. Panel discussion: is a meeting where experts
(two or more) are invited to make short
presentation or speak on different aspect of the
same subject area or theme.

 Eg. Theme-mental health in Ethiopia.

Expert1: history of mental health in Ethiopia
Exeprt2: Mental health and health policy
Expert3 :Future of mental health

155
 Health learning materials: are those teaching
aids which give information and instruction
about health specifically directed to a clearly
defined group of audience.

156
 Role of IEC materials in behavior change
communication
 Can speak to the people without the presence of
communicator.
 It serves as transferring of health message or acts as channel
to carry a message to target audiences.
 Can enhance the understanding, the credibility and the
believability of health message.
 It can remind the public the message they can received from
different sources.
 It can motivate the public to seek for further information.

 Some IEC materials serve as means of delivering health

message on very sensitive issues. For example, leaflets 157
 Health Learning Materials (HLMs)

There are four types of health learning materials:

1. Printed HLMs
2. Visual HLMs
3. Audio HLMs
4. Audio-visual HLMs

158
 Print IEC materials

 Example of print IEC materials

1. Poster
2. flipcharts

3. leaflets

4. booklets

5. cards

6. News paper etc.

159
2. Visual health learning materials
• Include something seen, for example models, real
objects, and photographs. Written words are not
included under visuals.
• Visuals are one of the strongest methods of
communicating messages, especially where literacy
status is low.

160
Real objects
 Are just that-real. If your display is on
‘family planning methods’, you would display
real IUDs, pills, condoms, diaphragms, and
foams.
Models
 Are three dimensional objects which look like
the real objects.
 Models might be used for 3 reasons:

1. If the real objects are not available

2. If the real object is too big to display.
3. If the real object is too small to be seen easily.
161
 3. Audio Health Learning Materials

 Includes any thing heard such as spoken word,

health talk, music, sound, etc.

 Radio and audio cassettes are common audio

aids.

 They are easily forgotten.

162
 Audio visual Health Learning Material

 Audio visuals are multi-sensory materials-

combine both seeing and listening

 They convey messages with high motivational

appeals.
 It show real life situation and entertaining
 These materials include TV, projected
materials, films or videos,
163
 Chapter Six
Group dynamics/process
 It is the aspect of the group which tells us
what is happening among the group
members or in the group itself.
 We usually concentrate on the task or
work to be done and not how things are
proceeding.
 But the group dynamics keeps the group
together and serves as glue for members
of a group.
164
 In order to determine the effectiveness of
group functioning /dynamic the following
features are important:
I. Characteristics of the group: sum of the
individuals
II.Size of the group: depends on the aim
(most common 8-12)
III.Background of the group members:
reason for attending the group

165
 Cont…
IV. Nature of the task: Task or process
oriented
V. Group decision making: depends on the
complexity of the decisions required the range
of skills / expertise in the group the amount of
relevant information available to the members.
VI. Individual roles of members: some are
helpful; others are unhelpful.
VII. Pattern of leadership: Authoritarian,
Democratic or Laissez-faire
166
 The type, characteristics and hints how to deal
with individuals group members.

Types Characteristics How to deal with them

1. The Always they create Keep cool. Don’t allow yourself to

quarre- hostile reaction when become involved in an argument ask
lsome their idea is rejected them questions and they will
type probably make some foolish or far-
fetched statements that can be dealt
with by other group members. Don’t
allow anyone to become personal.

2. The They are always in the Use them frequently but don’t let
positive side of the leader. And them monopolize the conversation.
type they can be of great help
to the chair person,
particularly when the
decision gets bogged
down. 167
3. The They may be When they give an opinion ask them to
know-all bluffing give reason. If the reasons seem faulty
type and not really ask other members of the group to
know the answer. comment. This helps to build up
confidence in the group so
they will not be imposed on.

4. The They talk too Don’t discourage them interrupt them

talkative much to get the tactfully and ask direct question.
type attention of the Because if they talk too much they can
other group bore others.
members.
5. The shy They may know a When suitable opportunities arise, call
type great upon them by name to give an opinion
deal but be shy to but be sure that the question is an
speak easy one to build up confidence to
out. contribute more to the group.

168
6. The They have no Be patient and try to win their
Uncooper- suggestion friendship. Acknowledge their
ative and also don’t accept experience and let them feel
rejecting or that you depend up on their
type reject others idea. help for the success of the
meeting.

7. The They are more Be patient and keep to the

highbrow intellectual and use point; if necessary, rephrase
Intellectu-al difficult technical their statements for the
type words benefit of other members. Ask
them to help the group with
difficult technical points.

8. The They often out to Pass their questions back to the

persistent trap the group and
questioner chair person. get the questioner’s view.
169
 Obstacles to Group Decision Making

1. Fear of consequences: fear that employers or

other influential people will criticize them
2. Conflicting loyalties: there can be divided
loyalties among the different members
3. Disagreements and personalities: personal
behavior and disagreements between group
members can interfere with decision making
4. Hidden agenda: individual group members may
try to influence the whole group to follow their
particular interests.
5. Inadequate information: the decision may be
based on the personal opinions of the group
members rather than the facts of the situation.
170
 Type of groups
Formal groups Informal groups
A well organized kind Not well organized
of group
Characterized by:
Characterized by:
 No special purpose or
 Has purpose or goal
goal
 A set of membership
 No special membership
 Recognized leaders
 No special leader
 Have rules
within the group
 Sense of belongingness
 No special rule apply
 Longer activities
 Short term

10/10/22 171
 Health Team
 What is a team?
 A team is a special type of group.
 Like other groups the team has also purpose or
goal.
 In a team each member has special skills or
responsibilities.
 It is necessary for every member of the team to
work together for the team to be effective.
 There should be interdependence effect.
 A health team contains different categories of
health professionals like nurses, sanitarians,
health educators, medical doctors and health
officers.
172
 Each of the above members of the team has
special responsibilities.
 If each member of the team does not handle
his/her responsibility, it is difficult to improve
and maintain the health of the community it
serves.
 Even though they have different
responsibilities, all the team members are
equally important to solve health problem of
the community.

173
The goal of a health team
 To improve and maintain health of the
community it serves.
Why health team?
 Many health problems are difficult to deal
with alone.
 To share experiences.

174
 Groups’ and Teams’ Contributions to
Effectiveness

10/10/22 175
 Stages of team development

 Teams move through five stages to develop

a. Forming: during the initial stage the team forms
and learns the behavior acceptable by the group
b. Storming: as the group becomes more
comfortable with one another they begin to
assert their individual personalities
c. Norming: the conflicts that arose in the previous
stages are addressed and hopefully resolved.
Group unity emerges as members establish
common goals, norms and ground rules.
d. Performing: it is a stage by which a group
begins to operate as a unit
e. Adjourning: it is a time for a temporary group
to wrap up activities
 Chapter Seven: Patient
education
 In the present day context, patient's rights
constitute an important aspect of everyday
hospital practice.
 The right to be informed about one's health, the
right to take an active part in the process of
treatment and rehabilitation, the right to be
educated and counseled in managing a chronic
disease and copying with everyday life, the right
for a better quality of life – these are issues that
have emerged in patient oriented activities
during the recent years.

177
 Patient Education is defined as "a
planned learning experience using a
combination of methods such as teaching,
counseling and behavior modification
techniques which improve patients'
knowledge and influence health and illness
behavior".

178
 Patient Education (PE) = Therapeutic
Education and Health Education.
 PE is an integrated part of treatment and care
especially for long-term care patients.
 It is multiprofessional and intersectoral teamwork,
and includes networking. It is a life-long learning
process.
 Therapeutic patient education should enable
patients to acquire and maintain abilities that allow
them to optimally manage their lives with disease.
 It is patient-centred and includes organized
awareness, information, self-care learning and
psychosocial support regarding disease, prescribed
treatment, care, hospital and other health care
settings, organizational information and behavior
related to health and illness. 179
 Patient Counseling is defined as
"an individualized process involving
guidance and collaborative problem
solving to help the patient to better
manage the health problem".
 Empowerment of patients and the
responsibility of patients are
important parts of health care.

180
 Patient is a co-operator in treatment and
care and producer of his/her own health.
 Provider-patient interaction is changing
from paternalistic, provider-centered
approach into a more co-operative,
patient-centered and relationship-oriented
approach aimed at shared responsibility
and shared decision-making.
 The physician's communication has direct
and strong relationship to quality of care.
 The quality of provider-patient
communication has an impact of patient
satisfaction.
181
 The purpose of patient education and
counseling is to help patients manage their
chronic disease by using available health,
social and economic resources.
 Patients need to develop their own
understanding of the problem and what
can be done about it.
 A well trained patient obtains a higher
quality of life, the disease remains under
control, the treatment is consistent and
hospital costs are smaller for both the
individual and the state.
182
 Counseling
 The meaning of counselling: To counsel means ‘to
advise, to recommend, to advocate, to exhort, to
suggest, to urge’ (Oxford Dictionary 1996:131).
 However, counselling as a concept, has many
interpretations.
 Whatever its goals, counselling is directed towards
assisting people to take decisions, to effect a change,
to prevent problems or crises or to manage them
when they arise.
 Hopson (1981) thus, from a problem-solving
perspective, saw counselling as helping people to
explore problems and clarify conflicting issues, and to
discover alternative ways of dealing with the problems
by taking appropriate decisions and action.
183
 Counselling for general health promotion, the
avoidance of diseases, is both individualistic and
group-oriented and usually considered an
essential component of public health.
 The emphasis is on adopting what are considered
good ‘health habits’.
 Issues considered include good personal and
environmental hygiene, good nutrition and safe
drinking water, adequate exercise, relaxation and
rest, and avoiding high levels of stress and
health-risk behaviours such as smoking and
excess alcohol consumption.
 These issues can be discussed openly and without
fear of isolation or stigmatization.
184
 AIDS Counselling

 According to the World Health Organization, AIDS

counselling is a confidential dialogue between a
patient and the counsellor or care provider aimed
at enabling the patient to cope with the stress and
to take personal decisions relating to HIV infection
and AIDS morbidity and mortality (WHO 1995).
 Counselling in HIV/AIDS care is an interaction of
information exchange, skill acquisition and
emotional support between the counsellor, the
person infected with HIV and others significant to
the client who include family members, friends,
health practitioners, employers and people who
give spiritual support. 185
 The evolution of HIV counseling and testing:
where are we now?
 Now more than ever, the benefit of knowing one’s
HIV status is apparent.
 Increasingly, people can take advantage of a
variety of prevention, treatment, care, and
support options when they are aware of their HIV
status.
 However, alarmingly few people who need to
know their HIV status have access to such
services.
 Voluntary Counseling and Testing (VCT) has been
a major strategy for increasing access to knowing
one’s serostatus.
186
 Benefits of knowing one’s HIV status

 At Individual level
• Creates more realistic self-perception of client’s
vulnerability to HIV
• Promotes or maintains behaviors to prevent
acquisition or further transmission of HIV
• Alleviates anxiety, and facilitates understanding
and coping
• Facilitates entry to interventions to prevent
mother to child transmission of HIV
• Helps client to plan and make informed choices for
the future
• Leads to early referral to HIV specific clinical care,
treatment, and support 187
At community level
• Creates peer educators, and mobilizes
support for appropriate responses
• Reduces denial, stigma and discrimination;
and normalizes HIV/AIDS.

188
 The World Health Organization (WHO) and major
international public health organizations have
drawn urgent attention to the need to rapidly
increase access to knowing one’s HIV status.
 They have advocated the requirement to
increasingly implement innovative strategies to
delivering HIV counseling and testing in more
settings and on a much larger scale so that more
individuals can make use of the above benefits.
 All such innovations need to satisfy the minimum
requirements of ensuring the voluntary nature of
HIV testing, informed consent, confidentiality,
and access to high quality supportive counseling

189
 Different outcomes (e.g. clinical care or HIV
prevention goals) require different approaches to
delivering HIV testing and counseling in different
settings, of which counselors should be aware.
 However, all innovations or adaptations must
satisfy those recommended and internationally
required standards of care to be effective and
ethically sound.

190
 Core Principles for HIV counseling and
testing

• HIV testing should be voluntary (mandatory

testing is neither effective nor ethical)
• Informed consent should be obtained although it
may vary in different context and settings.
 Elements to ensure true informed consent for HIV
testing include: Providing pre-test information on
purpose of testing and offering information on
treatment and support available once results are
known; ensuring understanding; and respecting
individual autonomy
• Confidentiality must be protected
• Post-test support and service are crucial
191
 Theories of Counselling

1. CLIENT-CENTRED OR PERSON-CENTRED THEORY

 The core of the theory is that humans have an

inherent self-actualizing tendency, a movement
towards developing capacities in ways which
serve to maintain and enhance the individual.
 Client-centred counseling attempts to enact
Rogers' facilitative conditions.
 The counsellor genuinely accepts the person
counseled, whatever his thoughts, feelings and
behavior.

192
2. RATIONAL-EMOTIVE THEORY

 At the centre of these hypotheses is the concept

that events do not force people to have emotional
behavioural reactions.
 It is rather their interpretation or thoughts about
events that precipitate emotion and behaviour.
 Therefore, the target for change in psychotherapy
is those thoughts, attitudes, beliefs and
meanings, that create emotional-behavioural
disturbance.

193
 3. BEHAVIOURAL COUNSELLING
 This definition is perhaps too general to portray
fully the character and colour of behavioural
counselling, but it highlights two important facts:
(1) there is no end to the variety of methods,
used in behavioural counselling, and (2) the goals
of counselling - to resolve the client's
problems - can be stated in behavioural terms.
 The methods and procedures of behavioural
counselling are based on social-learning theories
- theories about how people learn and change
their behaviour.

194
 Unit Eight: Research Methods in
Health Education

 Research is a systematic search for new information

and knowledge.
Two types of Researches:
1. Basic : generating new knowledge &
technologies to solve problems.
2. Applied research: identifying priority problems,
and designing and evaluating policies & programs
using the existing knowledge.

195
 Research in Health Education (cont..)
Two types of research methods –
 Quantitative & Qualitative
– Quantitative research involves measurement of
events using numerical data that will be analyzed
& reported in the form of percentages, frequencies,
proportions etc. E.g. Surveys, experiments etc.
– Qualitative research is a type of formative research
that offers specialized techniques for obtaining in-
depth responses about what people think & how
they feel.
 Research in Health Education (cont..)

 In health education, mostly we use qualitative

technique. This is because, qualitative
research, by its very nature, deals with the
emotional & contextual aspects of human
response rather than with objective,
measurable behaviour & attitude.
 Qualitative Research (QR) - appropriate for
understanding the experiences and behavior of
individuals.
 Qualitative research designs
 Four major types of qualitative
research design are ;
1) phenomenology
2) ethnography
3) grounded theory
4) case study
Phenomenology: It is a way of describing something
that exists as part of the world in which we live.
 Phenomena may be events, situations, experiences
or concepts.
 We are surrounded by many phenomena, which we
are aware of but not fully understand.
Ethnography : has a background in anthropology.
The term means “portrait of a people” and it is a
methodology for descriptive studies of cultures and
peoples.
 The cultural parameter is that the people under
investigation have something in common.
 Grounded theory
 The main feature is the development of new
theory through the collection and analysis of
data about a phenomenon.
 It goes beyond phenomenology because the
explanations that emerge are genuinely new
knowledge and are used to develop new
theories about a phenomenon.
 In health care settings, the new theories can
be applied enabling us to approach existing
problems in a new way.
 For example, our approaches to health
promotion or the provision of care.
 Case study
 Can take a qualitative or quantitative
stance.
 Case study research is used to describe an
entity that forms a single unit such as a
person, an organization or an institution.
Some research studies describe a series of
cases
 Qualitative Research
Strength & Weakness
Strength:
– Cost-effective
– Addresses health belief, perceptions and behaviour of
illness
– Gives meaning to symptoms and their treatment
– Looks at religion, world views as explanation of
misfortunes
– Health needs of the community
– Relationship between human behaviour and certain
forms of illness / sickness
– Organisation of medical institutions
– Compare different healing systems
– Doctor-patient relationship
 Qualitative Research
Strength & Weakness (cont…)
Weakness:
– Labour intensive
– Training of researchers
– Population sample not random and difficult
– Small group studies / difficult for generalisation
because lack of replication
– Observer error disagreement i.e. low reliability
– Unsuitable for large scale studies or for measuring
physiological phenomena etc.
 Qualitative Sampling Methods

 Purposive sampling technique is commonly used in

selecting the study participants.
 Purposive sampling in contrast to probabilistic
sampling, is selecting study subjects for their ability
to generate rich information.
 Purposive sampling in qualitative research can be
achieved through different techniques:
1. Snowball or chain sampling
• Locating participants by asking others to identify
individuals or groups with rich information on the
phenomenon under study.
 Qualitative Sampling Methods (cont…)

2. Homogenous sampling
• People with basically similar characteristics to
study the group in-depth.
• The selection of participants is usually done within
certain strata: participants with similar.
demographic or social characteristics being
included in the same strata.
• It focuses on a similar type of respondents thereby
simplifying analysis and group interviewing.
 Qualitative Sampling Methods (cont…)

3.Extreme or deviant
 Chooses extreme cases of outstanding

successes or crises events after knowing the

typical case in order to highlight and understand
the situation.
E.g.. Two health centers, one whose family
planning clients are highly satisfied and another
whose clients are not satisfied.
Valuable to test emerging theories by learning
from highly unusual manifestations.
 Qualitative Sampling Methods (cont…)

4. Maximum Variation Sampling

 Heterogeneous sampling
Useful for obtaining maximum differences
among information rich informants or groups.
The subjects included in the study are different
from each other based on predetermined
criteria.
This type of sampling used for to identify issues
that cut across individuals
E.g. a study of rural, urban and sub urban
 Qualitative Sampling Methods (cont…)

5. Convenience sampling
Study participants are selected based on their
ease, accessibility and availability.
The researcher selects those individuals who are
most readily available.
This may help to save time, money and effort.

However, it may be the weakest sampling

scheme due to its low credibility.
 Data collection techniques in Qualitative Research

The most common ones:

 Interviews - Group interview / FGD

- In depth interview
 Observation

 Ethnographic methods - to analyze how specific

health practices relate to the larger cultural context.
 Focus group discussion (FGD)

 The most widely used technique

 It is a group discussion of 6-12 persons guided by a
facilitator/ moderator, during which group members
talk freely & spontaneously about a certain topic /
issue.
 Purpose - to obtain in-depth information on
concepts, perceptions, ideas, and views of the group
FGD techniques can be used to
 Focus research & develop relevant research
hypothesis E.g. explore why malnutrition rate is
higher in one village than others?
 Formulate appropriate questions in a larger survey
 E.g. bouts of diarrhoea for <1year are not reported
 Focus group discussion (cont…)

 Supplement information on community knowledge,

beliefs, attitudes, & behaviours already available but
unclear
 Develop appropriate messages for health education
programs
 Explore controversial topics.

 E.g. contradictory answers by the husband & wife.

 Focus group discussion (cont…)
How to conduct an FGD
 Participants should be roughly of the same socio-economic
group
 Conduct in a quiet, well-illuminated & neutral place, & sit in a
circle.
 Use a semi –structured questionnaire guide for all.
 There should be a moderator (skilled), note taker, tape
recorder, & observer (if need be).
 Each session should not last for more than 1 ½ hrs.
 Number of session would depend on the project needs,
resources, & whether new information are still coming from
the sessions.
 Focus group discussion (cont…)

Functions of the Facilitator/ Moderator

 Introduce the session
 Encourage discussion

 Build rapport, emphasize

 Avoid being placed in the role of expert.

 Control the rhythm of the meeting, but in an

unobtrusive way.
 In-depth Interview

 Involves use of key informants to obtain in-depth of

information mostly using open–ended questions.
 Highly sensitive subject matter E.g. Abortion,
sexuality
 Geographically dispersed respondents

 Presence of peer pressure - behaviours happening to

satisfy social desirability
 In-depth Interview (cont…)

Pitfalls / Drawbacks
 Substantial variations in the interview settings

 There may be gaps between the respondents’

knowledge and that of the interviewer.
 The potential of sponsor observation & feedback is
limited.
 Time taking (90-120minutes for one respondent)
 Sample Size

 No hard and fast rules.

 Sample size depends on:

 Purpose of the research.
 Specific research questions.

 What will be useful, and what will have credibility.

 Available time and resources.

 Selection continues to the point of

redundancy (Saturation point).
 Qualitative Data Analysis

Reading Coding

Field

Interpreting

Office
Reducing Displaying
 Qualitative Data Analysis(cont…)
Process Purpose

Reading/Data immersion Familiarization oneself: transcripts,

audios, field notes, memos, journals

Coding •Theme developing

•Coding
•Attaching labels/code

Displaying •Verifications;
•Evidence search
•Text filing by themes/category

Reducing Core category; core meaning

Text filing by main themes

interpretation Relations; pattern; deviant cases analysis;

differences; consistency; gaps; contextual
& theoretical formulations
 Presentation

Results of QR can be presented as

 a book,

 journal article or

 as a report submitted to a funding agencies.

 A summery of findings may be presented at conferences

or published by the media
 The styles of writing also varies significantly from
narrative style to a format with tables , graphs and
picture
219
 Presentation cont…

A more structured format is suggested to be composed of 6

major sections
I. Introduction
II. Setting
III. Design
IV. Finding
V. Discussion
VI. References

220
Many Thanks!

221