copc_manual_for_teaching.doc

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Community-OrientedPrimaryCare;A New Approach forTeachingHealth Care

(COPCTHC)

Teaching Manual

By:Prof. Dr. Amal Ahmed El-Badawy

Prof. of Community MedicineZagazig Faculty of Medicine

HEEPF, 1ST CYCLE

2004


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Table of Contents

Page

1- Basic Concepts 2

2-Define and Characterize Community 9

The Community Boundaries 9

The Community Characteristics 9

Health Agencies and implemented Health Programs 11

3-Identifying and Characterizing Community Health Status 14

Determinants of Health 14

Needs Assessment 16

Health Status Assessment 19

4-Identify and Prioritize health Problems of our Community 30

5-Develop Specific Intervention 32

Health Promotion 32

Health Education 38

Making the environment safe 56

Making Healthy Choices Easy 57

Community Partnership 57

6-Evaluation of the Intervention 58

7-Guidelines 61

8-Description of Teaching Activities 64

Dr. A.A.El Badawy COPC Manual2


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CHAPTER I

BASIC CONCEPTSIf Medicine is to be effective in maintaining peoples health and well-being, it must

be sensitive to the ways in which health and illness make sense within peoples lives.

Also how people understand their relationship with doctors and other health care

providers. Therefore, we need to understand, as best as possible, the meaning of some

terms which usually may overlap:

1-Health

What do we mean by health? Health as defined by the WHO is A state of completephysical mental and social well being and not merely absence of disease or

infirmity.

An operational definition of Health can be drawn out of this definition which

emphasizes that health is the ability of the human organism to function adequately

within his genetic and environmental conditions.

Therefore, health does not mean in its broader sense just being free of symptoms and

signs. It means being able to carry on a normal life, free of any physical or social or

mental abnormalities.

Nevertheless, over the past years, the concept of health has changed. The WHO

definition in 1984 has stated that: Health is the extent to which an individual or

group is able, on the one hand, to realize aspirations and satisfy needs; and on the

other hand, to change or cope with the environment.

Health is, therefore, seen as a resource for everyday life, not the object of living; it is a

positive concept emphasizing social and personal resources, as well as physical

capacities.

A spectrum of health divides it into stages:

- 100% Optimal Health

- Positive Health

- Negative Health

- Clinical Disease

-Complications



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- Death

2-Disease:

If we divide the word disease, it will be: dis-ease which means being not at ease, or in

other words it denotes a state of deviation from the normal status.

Thus, it is important to define: what is to be considered normal? Normality is

defined in different ways:

First, statistically i.e. the usual or the average for e.g. the systolic blood pressure isnormal when it is within the level of 120 which describes the level of 95% of the

population according to the normal distribution curve.

Second, socially which is what is usually accepted by the society as normal, for

example blood in urine, due to Schistosomiasis, was considered normal by Egyptian

since most of them have it.

Third, health may mean different things to different person according to their lifecycle (age) for example experiencing some bone ache may be considered normal in

old age.

3-Medicine is particularly concerned with identifying and treating disease. Thus,

Medicine by promoting health and preventing illness, endeavours to keep individuals

adjusted to their community. The model of disease is called biomedicine as it mainly

emphasizes on biological abnormalities. Nevertheless, biological abnormalities are

not found for all diseases and thus biomedicine is only one way of looking at the ill-

health that people experience.

Therefore, the part of medicine that deals with promoting health and preventing

diseases ispreventive medicine, the part of medicine that restores health and

rehabilitates patients is curative medicine, and finally addressing all aspects is theresponsibility ofcommunity medicine.

4-Public Health is the art and science of preventing diseases, prolonging life, and

promoting physical health and efficiency through organised community effort. Public

Health is best identified as social movement concerned with protecting and

promoting the collective health of the community. In public health, problems are

viewed within the context of the community as a whole rather than as simply

something occurring in a series of individuals.



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We will only consider three main aspects of Public Health:

A-Applied Epidemiology:

This will concentrate on the potential value of health data, whether previously

gathered or need to be gathered. It will help on identification of characteristics of the

community, its health problems and needs. Also, it will help on prioritization of health

problems and in developing and implementing interventions according to population

needs.

B-Population-based Health Care:

The value of care of population groups rather than individuals is introduced. The

health care provider adds to his practice a population-based view of community

needs. Therefore, he will consider:

-Access issue: why some patients utilize the service while others do not?

-Needs assessment issues: are patients seen reflect the community needs?

-Impact issue: are patients left out of the current system are in need of care?

C-Prevention:

The tremendous advances in reducing morbidities and mortalities are achieved by

simple approach involving the application of preventive measures such as healtheducation, improvement of sanitation, immunization etc rather than to expensive

intervention.

5-Primary Care:

Primary care practice is not defined as first-contact care nor according to specialtys

characteristics but on the definition that describes it as: the provision of an

integrated, accessible health care services by clinicians who are accountable for

addressing a large majority of personal health care needs, developing a sustained

partnership with patients, and practicing in the context of family and community.

The WHO has emphasized six characteristics that should be present:

1-Accessible: this will refer to the ability of the practice to eliminate some of

the common barriers such as cost, difficulty in reaching the primary care, etc.

2-Acceptable: it will refer to the acceptance by the community of the way the

service is being delivered. In order to insure it, peoples social, economic,

culture, tradition etc must be taken in consideration.



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3-Accountable: this represents the quality of care given and its cost

effectiveness. It includes the responsibility of monitoring and improving care

over time and the provision of care that ensures the least cost with the best

quality.

4-Comprehensive: it indicates the provision of a full range of primary care

service (preventive, curative and referral) to patients.

5-Coordinated: it describes the relationship between primary care practice and

others, especially the community, the non-governmental organization,

religious authorities, non-health authorities etc. In short it emphasizes

community participation with all its components.

6-Continuity: it emphasizes how the development of a patient-provider

relationship over time can improve the quality of care provided and enhances

the opportunity to offer the patient all recommended care especially the

preventive ones.

6- Community Oriented Primary Care (COPC):

Community Oriented Primary Care (COPC) , is a process by which a defined

populations health problems are systematically identified and addressed.

Define and Characterize

The community

Monitor Impact

of Intervention Involve Identify Community

the Community HealthProblems

Develop Intervention

Community Oriented Primary care (COPC) is the practice of primary care with a

focus on the community in which it is practiced. It requires knowledge of the

community, its demographics; the epidemiology of health problems, and sufficient

knowledge of the community belief systems and value to guide appropriate

interventions.

COPC requires five-step process to incorporate it into practice .



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1-Determining our community

2-Characterize our community in terms of health status,

3-Prioritizing the health needs of our community,

4-Developing specific interventions to address priority needs and,

5-Evaluating the effectiveness of the interventions.

1-Determine our community:

COPC focuses on a defined population within a community, it could focus on:

Geographically defined population such as a town or a village;

Specific population groups such as infants, mothers, elderly etc; or

People congregated at particular sites, such as workplace.

2-Characterize our community in terms of health status:

COPC broadens the perspective of health care providers to include the whole

community. It will focus on assessing the health status of the community as a whole.

This will require knowledge of the community, its demographics, the epidemiology of

health problems, and sufficient knowledge of the community belief systems and

values to guide appropriate interventions.

3-Identify and Prioritize the health needs of our community:

Setting priorities to address the different problems will be guided by different factors

such as possibility of control, resources, population perspective, its impact on the

community whether frequent or rare, whether it results on significant morbidities or

mortalities etc. Health problems can be isolated at any point of time during their

natural course, ranging from those at risk to those who eventually will succumb.

Therefore, a list of all community problems will be created, characteristics of each

will be identified, priorities will be set and the most feasible for intervention will be

selected.4-Develop specific interventions to address priority needs:

In order to ensure the success of intervention, involvement of the community is a

must. After identifying the problem that you are going to address, an intervention

program for its control must be planned and implemented. Some criteria have to be

present to ensure the success of this intervention. In short the selected intervention

should be feasible, accepted by the consumers, within the available resources, respect

previous successful interventions and rewards will be obvious within reasonable time.

5- Monitor and Evaluate the effectiveness of the interventions:



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The final step of the process is to monitor and evaluate what have been done. An

evaluation should be evaluated as rigorously as possible. The purpose of the

evaluation is to determine the effect of the intervention on the community. It will

provide feedback to planners, and thus assure credibility and allow the modification

and the improvement of the process. The evaluation is guided by the project

objectives, and must assess its structure, process and outcome as reflected by its

effectiveness.

1-Complementary functions of Clinical Care and COPC:

CLINICAL COPC

Individual Population

Examination of a patient CommunitySurvey

-Interview patient about history of -Collect data about community

the disease and carry out clinical health, using questionnaires

examination and laboratory tests secondary data sources etc

X-rays etc.

Diagnosis Community Diagnosis

1-Patients complaint 1-Usually problem-oriented.

2-Appraisal of a health status of Higher frequency of a

a well person such as pregnant women, condition in the community

examination of infants, children etc and its causes.

2-Health status of the

Community as a whole or

of a definite segment of it.

Treatment Treatment

1-According to diagnosis and available 1-Population intervention to

resources. prevent / treat specific

2-Intervention for patients seeking conditions prevailing in

advice about health and illness. the community or to reduce

risks.

Monitor Therapy Evaluation

1-Evaluation of patients progress 1-Evaluation of intervention of

and response to treatment. COPC process. Surveillance of

2-Ongoing treatment of chronic health indicators in the



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illness. community.

2-Incorporation of community

treatment into community

health care.

2-Parallel Between Clinical Care and COPC:

Clinical Care Step COPC

Who is the patient? 1 Define and characterize

The community

Engage the patient; 2 Involve the community;

Initiate practitioner- initiate the community-

Patient relationship professional partnership

Differential Diagnosis 3 Conduct a community

Diagnosis; rank issues in

priority order

Treatment 4 Develop and Implement

an intervention

Follow-up; is the patient 5 Monitor and evaluate

Improving?



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Chapter II

DEFINE AND CHARACTERIZE COMMUNITY

To define and characterize the community we need to identify the following:

1-Community Boundaries.

2-The community Characteristics.

3-Health Agencies and implemented Health program.

1-Community Boundaries

In conceptualizing a health problem and intervention, we may need to start with the

notion of a community as the residents of a geographic area . Therefore, the first

step will be to map the area and define its boundaries and important landmarks.

Maps are one of the types of graphic presentation that use location and geographic

coordinates to provide a clear and quick method for grasping information. In

epidemiology, maps may take different forms, among them we can state:

1-Density Maps:

It describes the population density, which is the average number of persons per square

kilometres (Km2 ). It is important in evaluating the success and coverage of different

health programs.2-Spot Maps:

A spot map is used to display the geographic distribution of an event, using a dot or a

symbol.

3-Chloropleth Maps:

Chloropleth maps are useful for depicting rates of health condition in specific areas

using different types of shading, hatching or colouring.

2-The Community Characteristics

A COPC team needs a complete quantitative and qualitative understanding of the

community in which an intervention is planned in order to measure health status

before and after the intervention.

1-Defining the Community Denominator:

In order to understand of the community in which we plan to measure the health

outcome, we need to have a solid definition of its population.

Denominators are determined differently for different measures of disease frequency.

The two most common measures are incidence andprevalence.



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1-Incidence measures the rate of occurrence of new cases (the number of new cases

during a period of time) divided by population at risk to develop the disease in the

same population over the same period time (denominator or population at risk). Thus,

the denominator for incidence rates includes both persons and time.

2-Prevalence is the number of cases existing in a defined population at a given point

of time, also requires knowledge of case numbers and persons in the population

denominator. Prevalence measures are not rates and therefore do not involve time in

the denominator. Their denominators include all the people at risk in a population.

Prevalence reflects the proportion which has the disease at a point of time.

Narrowing the Denominator toward Problem-Based Subpopulations

Certain aspects of the community will be important in the process of understanding

how to apply the COPC approach. Therefore, certain population may be chosen to be

targeted for the COPC for several reasons:

1-School Children:

School children are important subpopulation for several reasons:

Schools usually enrol most of children and a large part of adolescents.

Successful COPC interventions among school children offer many more years

of potential healthy life than among older groups.

Data can be collected easily.

COPC interventions can be easily integrated with school activities.

2-Vulnearable groups:

Mothers, preschool children, elderly etc can offer an excellent opportunity for the

COPC team to estimate the frequency of population risk factors or health conditions.

These groups place a substantial burden on the community health resources.

3-Work site:

Employee demographic and health data can be obtained from work places. They are

important because of risks they are exposed to, particularly accidents, exposures and

disability.

4-Hospitals and Health care units:

Hospitals and health centres databases can provide a good opportunity to characterize

our numerator and denominator populations for different health problems such as

trauma, infections, malignancies etc.



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2-Population Demography:

Demography describes the population characteristics (demos = people, graphos =

measure or describe).

A-Population Characteristics:

Some of the items that should be cover are:

a-Age: it is a basic variable that is closely related to disease patterns, but it is

difficult to ascertain its accuracy.

b-Sex: It is important since it reflects different physiological and behavioural

patterns in the two sexes.

c-Marital Status: It can be important as it may reflect an important social role

and life style.

d-Education and occupation: these variables will be responsible for people

behaviour, attitudes as well as their exposure to some health hazards.

e-Other Variables: such as parity for females, religion, social class etc may

help to explain the health status and problems prevailing in the community.

3-Health Agencies and Implemented Programs

1-Principle of Primary Care (PHC) in Egypt.

1-Areas of concern and components of Primary Health Care:

1-Education about prevalent health problems and methodsof prevention and control.

2-Proper healthy nutrition.

3-Environmental sanitation.

4-Maternal and child health careand Family planning.

5-Immunization and control of infectious diseases.

6-Control of endemic diseases.

7-Diagnosis and treatment of common diseases and hazards.

8-Availability of basic drugs.

9-Statistics.

2-PHC administrative Boundaries in Egypt:

Rural areas:

1-A rural health unit is established for every village with a population of 4000

individuals.



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2-A rural health unit, for a collection villages with a total population of 5000

individuals and at a distance of not more than three kilometres, is established in the

central village.

3-For separate village which cannot be gathered and with a population size less than

3000, an outpatient clinic is established where a doctor from the nearest PHC unit can

visited 2 to 3 times per week.

Urban areas:

1-Maternal and Child health care centres and Family Planning.

2-School health units

3-Control of infectious diseases and Food sanitation

4-Curative and dental care by a general practitioners.

5-Emergency services.

6-Health Education

These services are delivered through Urban centres. Later on the family doctor policy

is now implemented.

3-Duties in PHC Units:

Maternal and Child Health care

Reproductive Health:

-Premarital examination and genetic counselling

-Family Planning.

Nutrition Program

Immunization

Control of Communicable diseases

Control of endemic diseases

Laboratory Investigations

Environmental Sanitation

Curative and Emergency services

Registration

Health Education Programs

Empowerment Programs

Informatics, administration and quality assurance

Community Partnership



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Administrative duties

2-Expected Outcomes:

(Target Objectives to be reached by the year 2000)

1-Eradication of poliomyelitis and Tetanus neonatorum.2-Decrease Maternal Mortality ratio (MMR) by 50% out of the 174 per 100,000 in

year 1993.

3-Decrease Infant Mortality ratio due to dehydration and Acute respiratory Infection

as well as age specific mortality (1-5 years).

4-Keeep vaccination coverage to a least 90%.

5-Increase use of contraceptives to 55% and decrease general fertility rate from 3.9 to

2.9.

6-Increase use of Oral Rehydration Therapy from 60% to 80% in cases of diarrhea.

7-Promote breast feeding for two years duration.

8-Promote Maternal care during pregnancy and labour by trained personal to at least

60%.

3-Indicators for monitoring and evaluation:

1-Percentage of Coverage of Maternal care:

It will reflect the number of pregnant females that came for antenatal care (first visit)

compared to the number of live births in the same area and year per hundred.

2-Average Number of Antenatal periodic visits:

Total No of visits of pregnant females attending antenatal periodic visits in a year /

No of pregnant females in the same year.

3-Percentage of delivery under medical supervision:

-Total number of delivery under medical supervision / Total No of live births in the

same year * 100.

- Total number of delivery under medical supervision / Total No of females who came

for antenatal care in the same year * 100.

4-Disease specific prevalence rate:

Total number of cases of certain disease / No population at risk in the same year *

100.

Calculated for Diarrhea, Acute respiratory Infection etc.

5-Vaccination Coverage:



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Total Number of children (or pregnant females) completed the vaccine doses / Total

No of live births in the same year * 100.

Calculated for the third dose of polio, triple, tuberculosis and Measles and second

dose of tetanus for pregnant females.

Chapter III

IDENTIFY AND CHARACTERIZE COMMUNITY

HEALTH STATUS

1-Determinants of Health

Model of social and biological determinants of health

1- Community context:

The community context will comprise all factors at the community level that can

affect our health.


Community

Family

Use of Health Services

and

Self-care

Individual

Health status


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1 -Environmental factors: which will include all factors related to the environment

with its three components (biological, chemical and cultural). Several factors may

be seen as an example of the importance of the environment, in general, to our

health. Among them we can notice: the supply of safe water, the proper waste

disposal, the control of air pollution and finally the culture and traditions which

can have a great impact on our attitudes towards our health. Infection is caused a

large number of micro-organisms. Certain conditions must be present such as the

presence of vectors, suitable conditions as climate, bad environmental sanitation,

bad health habits etc. that will allow these micro-organisms to survive and

propagate.

Accidents: accidents occur due to causes either related to the environment such as

road construction, in the individuals such as drivers fault. Accidents in old age

are due to bad home conditions while accidents in factories can be attributed to

unsanitary working conditions.

2-Economic factors: this will include the different factors that are a reflection of

the economic status of the community as a whole. For example availability of

food, price of food, transportation, education etc.

3-Health services: this will represent the availability of health services in general

and for special groups such as maternal and child health care, occupational,

geriatric etc.

2-Family circumstances:

The family circumstances will reflect all conditions within the household that can

affect our health status.

1-Environmental factors: these will include the housing quality, the presence of

safe water and sanitary facilities within the house.

2-Economic factors: describing the household income, its way of allocation,

dependency burden etc.

3-Relationship and Care within the family: familial relationship such as domestic

violence, perception of needed care, children raising etc.

3-Individuals attributes:

The individuals attributes will have in its core thegenetic factors that will determine

the biological status of each particular individual. The other factors will reflect the

determinants of individual behaviour as regards his health status.Education is an

important determinant that will be shaped by schooling status and amount of



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knowledge acquired. Workor occupation with its impact on income and exposure to

hazards. Self-esteem and status and finallyperception of health needs as priorities in

his life.Dietary intake: dietary intake affects our health from birth to death. A lot of

deficiencies can affect growth and development, our level of resistance etc. Also,

overweight is responsible for a variety of diseases such as diabetes, C.V.D. etc. All

these conditions originate from conditions present due to community, family or

individuals conditions.

Life style: for example addictions, smoking etc are responsible for many health

conditions.

2-Needs Assessment

Health services are changing through alteration in demand, for example changing the

composition of the population (people lives longer), appearance of new diseases

(A.I.D.s) and changing preferences among consumers of health care. Therefore,

assessing of the different needs of the community is very important.

First we have to differentiate between

1-Need for health as defined by the WHO.

2-Need for health care: which is the ability to benefit from health care or

preventive services. Therefore, it is more specific and will depend on the health

care and preventive services available.

Therefore, what people actually want (perceived needs), might not necessary overlap

with what experts decide to be the needs (normative needs). Both types have to be

distinguished from that of the actual demands (expressed needs) and comparative

needs across similar communities or groups.



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Normative Needs Felt or perceived Needs

Level of services which What people want but not

Experts set versus desirable necessary expressed needs

Standard for individual

Or whole community

Expressed Needs Comparative Needs

Actual Number of people Comparing service

Using or demanding a provision across communities

Service or groups

Second, Providers of health care need to know:

1-What users need?

2-What is needed in a particular situation?

However, when we assess needs we have to consider , whose needs do we take into

consideration:

1-Present needs of people currently ill or

2-The potential future needs of the total population.


Health Care

Provision


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Therefore, the way a needs assessment is conducted, can have an influence on its

outcome. Conducting a needs assessment among people with specific conditions

will highlight needs which might be specific to them only, but not to the general

population or to people with other conditions. Directing assessment to non-users

will be lacking the experience and knowledge of the topic and will generally

select for provision of care for more common condition. Thus it is very important

to define:

1-How we define and measure needs?

2-Whose definition of needs is to be based on: lay people, professionals,

researchers, politicians, managers etc ?

We can notice from the previous figure, that it represents the needs, demands and

supply. Demand in this figure can be seen as the expressed needs

A potential problem that will arise is the problem of the unmet needs as well as un-

limited needs. The former issue refers to missing some needs, whilst the latter refers

to whether we will be able to fulfil the needs we identify. Asking people may lead toexpectations that health services can not fulfil (Unmet needs).

Dr. A.A.El Badawy COPC Manual

Needs

DemandforHealth Care

SupplyofHealth

Services

19


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The realization that health needs are far more than demands (expressed needs) gave

rise to the idea of clinical iceberg or iceberg of diseases. It is an indication that

perceived needs can lead to different reactions by different groups. Some will seek

medical help, others will use self-medication or they simply ignored.

Needs assessment should include the views of lay public, professionals, managers,

politicians and researchers.

3-Health Status Assessment

Gathering Information about the Community

The two basic methods that can be used to describe the population are primary and/or

secondary data.

1-Secondary data:

Each country has its own system of collecting routine health information and

reporting it. For the PHC, emphasis should on collecting the minimum amount of

necessary data in the simplest possible way and the most accurate one. National

census provides a wealth of demographic and economic data. Recorders such as

birth, death certificates and health care registries are another important source ofsecondary data. Surveillance refers to special reporting system which is set up for a

particular important health problem or disease.

2-Primary data:

When secondary data are simply not adequate to be used to define the health problems

in our community, we will need to collect primary data. Data collection can be either

qualitatively or quantitatively. Qualitative data will provide us with insight on

perspectives, opinions, attitudes and can be carried out by focus group. In-depth

interview can specially be used for health care providers to get a good insight of the

health status of the community. For quantitative data, they are best collected by

survey study.

The most suitable method of data collection in survey specially in our community will

bestructured interviewed, in which we need to develop a questionnaire.

In order to develop the needed questionnaire, we have to consider several issues:

1-Define the type of information that we need to collect; it can include demographics

data, attitudes, opinion etc.



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2-Make a complete list of variables, that we need to collect information about.

3-Include one or more questions for each variable, organize them by topics and the

topics by the flow of ideas that you want to present to the respondent.

4-All questions must be relevant to the studys goals as well as to the respondent i.e.

ensure that the respondent will be able to answer the questions easily and adequately.

5-A selection must be made between open ended and close ended questionnaires, each

type has its advantages:

-Advantages of close-ended questionnaires:

Answers are standard and can be compared from person to person.

Answers are easier to code and enter in computer.

Data are easier to analyze. All answers can be completed.

Respondents are clear about the meaning of the question.

Answers are simpler for respondents to complete.

-Advantages of open-ended questionnaires:

Can be used when all response categories are not known.

Allow the respondent to answer adequately and in great detail.

Can be used when there are too many potential answer categories to list.

Are preferable for complex issues.

Allow more opportunity for self-expression.

-Potentials pitfalls in asking questions:

Wording is too long or too complicated.

Two questions in one or double-barrelled questions.

Use of ambiguous terms.

Leading the respondents with non-neutral information.

Ask sensitive or threatening questions.

Categories of responses are not mutually sensitive.

Order of questions:

o Ask easy questions first.

o Put open ones last

o Ask information needed for subsequent questions first.

Vary questions in length and type to avoid boring.



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Do not make the questionnaire too long.

5-The sample as regards its size, type must be decided upon according to our

objectives. Accessible sample is a convenient way to get an overall idea of the

situation. Random sample can be used if we need to get a more representative sample.Sample Size can be calculated, but a size of 100 will be sufficient to fulfil the desired

objectives.

Primary and secondary data collection are usually used in a complementary way

to define our community health status.

3-Rapid Epidemiological Assessment:

Rapid Epidemiological Assessment (REA) allows the collection of epidemiological

data with the fewest resources possible in the shortest time. It can use the following

methods:

a-Cluster Sampling: it simplifies the random selection process. The areas under

study is divided into 30 or more clusters, from which after a random start, seven

or more individuals are included. Number of clusters and individuals will depend

on the number of factors under study. It is useful technique for the selection of a

representative sample.

b-Verbal Autopsy: It allows to get information about the cause of death. It collects

data from lay people using a questionnaire about the cause of death. Developing

of the questionnaire is the most important step as we need first to identify the

common causes of death and then after collecting demographic data we narrow

our questions to explore the cause of dearth.

Among other methods of REA we can state the sisterhood method and

questioning the key informants.

Health Indicators

1-Morbidity patterns:

Morbidity data will reflect the health status of the community, as it will reveal the

commonest health problems. Calculating different morbidity indices will help in

determining the types of health problems as well as the level of care delivered and

needed by the community.

The important morbidity indices are:



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-Incidence rates

-Prevalence

-Case Fatality rate.

2-Mortality Pattern:

Mortality data will reflect the common causes of health problems. We can calculated

out of death certificates, and /or records on health units.

The important mortality indices are:

-Crude death rate

-Age specific Mortality rates

-Cause specific Mortality rates.

Special Consideration:

Special consideration should be in our mind when handling information from PHC

units:

1-Mortality data are usually more accurate than morbidity data.

2-It is possible to estimate the number of cases of certain disease out of morbidity

data, such as disease specific incidence or prevalence, which can help very much in

assessing the magnitude of a problem and thus help in prioritization of health

problems in the community.

3-Interpretation of data from records must be carried out with caution regarding its

accuracy.

3-Other Vital rates:

Several vital rates can be of importance in assessing the health status of the

community:

-Crude Birth Rate which is can be used for assessing the population problem. How?

-Fertility rates, which are good indicators of the Family Planning program.

Data Processing and Analysis

Descriptive statistics:

1-Types of data

The raw data of an investigation consist of observations made on individuals. Any

aspect of an individual that is measured, like blood pressure, age, sex is called

variable. Variables are either quantitative or qualitative.



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1- Quantitative data:

A quantitative variable is numerical and either discrete or continuous.

a) Discrete data: are usually whole numbers, such as number of cases of certain

disease (no decimal fraction).

b) Continuous data: Continuous data implies the measurement on a continuous scale

e.g. height, weight, age (a decimal fraction can be present).

2- Qualitative data:

It is a non numerical data and is subdivided into:

a) Categorical: data are purely descriptive and imply no ordering of any kind such

as sex, area of residence.

b) Ordinal data: are those which imply some kind of ordering like

-level of education: illiterate, read and write, primary.

-socio-economic status: low, middle and high

-response to drug either none, fair, good, very good.

-Degree of severity of disease: mild, moderate and severe.

2- Presentation Of Data:

The first step in statistical analysis is to present data in an easy way to be understood.

Therefore the use of tables and graphs are very important as a first step in data

manipulations.

The basic ways in which data are presented are:

(1) Tabular presentation.

(2) Graphical presentation.

1- Tabulation:

It is the basic form of presentation.

1- List: is the simplest form of presentation. A table consisting of two

columns, the first giving an identification of the observational unit and the

second giving the value of variable for that unit.



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2- Frequency Distribution tables: they provide the most convenient

format for summarizing and presenting data.

-For qualitative data, it is straightforward, the main task is to count the number of

observations in each category. These counts are called frequencies.

-For quantitative data, we have to form a frequency distribution which consists of

a series of predetermined classes together with counts of the number of

observations whose values fall within the interval of each class.

Some rules for the construction of the table:

1-The table must be self-explanatory.

2-Title heading: written at the top of table to define precisely the content, the place

and the time.

3-Clear heading of the columns and rows and units of measurements should be

indicated.

4-Decide on the number of classes. Usually lie between 2 and 10. Its selection

depending on the form of data and the requirement of the distribution. Too small may

obscure some information and too many will not differ from raw data.

5-Determine the width of the class intervals. It is convenient to maintain constant

width for all intervals. Choose the upper and lower limits of the class interval. List the

intervals in order. Consider each observation in turn and allocate it, to the interval into

which it falls. Indicate with a tally. Add the tally mark in each interval to obtain the

class frequencies.

3-Relative frequency: The proportion for given class is obtained by dividing the count

in each class by the total number of observation and multiply it by 100 (percent)

Age group Tally Frequency Percentage

25- 1l 2 2.0

35- 1lll 5 7.0

45- 1lll llll 1 11 18.0

55- 1lll llll 11 12 30.0

65- 1lll 1111 9 39.0



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75- 1 1 40.0

Total 40 100.0

2- Graphical Presentation:The diagram should be:

- Simple - Easy to understand

- Self explanatory - Fully labeled

- Save a lot of word:

1- Bar chart:

It is used for discrete or qualitative data. It is a graphical presentation of

magnitude by rectangles of constant width and lengths proportional to the

frequency and separated by gaps.

- Simple: different values of variable are given as vertical or horizontal bars.

- Multiple: Each observation has more than a value represented, by a group of bars.

- Component: subdivision of a single bar to indicate the composition of

total divided into sections according to their relative proportion.

This is an example of multiple Bar Chart.

2- Pie diagram:

Consist of a circle whose area represents the total frequency and which is


0

20

40

60

80

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North


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divided into segments. Each presents the proportional composition of the

total frequency.

3- Histogram:

It is very similar to the bar chart with the difference that the rectangles are

proportional in area to the class frequencies erected on the horizontal axis.

The width = class interval.

The highest = proportional are equal to the class frequencies.

4-Scatter diagram:

Useful to represent the relationship between two measurements, each

observation being represented by a point corresponding to its value on each

axis. When the points are joined by a line we call it a line graph.

5- Frequency polygon:

Derived from a histogram by connecting the mid points of the tops of the

rectangles in the histograms.

3-Data Summarization

To summarize data, we need to use one or two parameters that can describe the data.


1st Qtr

2nd Qtr

3rd Qtr

4th Qtr

0

1020

30

40

50

60

70

80

90

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North


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Usually we use the averages, which describes the center of the data and the

measures of dispersion which show how the data are scattered around its center.

1- Measures of central tendency:

One of the most important measure, used for data summary is the average. Variable

usually has a point (center) around which the observed values lie. These averages are

also called measures of central tendency.

The three most commonly used averages are:

1- The arithmetic mean:

Which is the sum of observation divided by the number of observations:

x = x

n

Where : x = mean

denotes the (sum of)

x the values of observation

n the number of observation

Example: In a study the age of 5 students were: 12 15 10 17 12

To calculate their mean = (12+15+10+17+13) / 5 =13.4 years

2- Median:

It is the middle observation in a series of observation after arranging them in an

ascending or descending manner.

The rank of median is (n+1)/2 if the number of observation is odd and n/2 if the

number is even (n = number of observation).

- If number of observation is odd, the median will be calculated as follow:

- e.g. 5, 6, 8, 9, 11 n = 5

- the rank of the median = (5+ 1)/ 2 = 3

- So median is 8



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- If the number of observation is even, the median will be calculated as follows:

e.g. 5, 6, 8, 9 n = 4

- The rank of median = 4 / 2 = 2

- The median will be the mean of observation 2 and 3 i.e.(6+8)/2 =7

3- Mode:

The most frequent occurring value in the data is the mode and is calculated

as follows:

Examples: 5, 6, 7, 5, 10. The mode in this data is 5

Sometimes, there is more than one modes and sometimes there is no

mode especially in small set of observations.

Advantages and disadvantages of the measure of central Tendency:

-Mean: is amenable to mathematical operation and it is usually preferred

since it takes into account each individual observation but its main

disadvantage is that it is affected by the value of extreme observations.

-Median: it is a useful descriptive measure if there are one or two

extremely high or low values.

-Mode: is seldom used.

2- Measures of dispersion

The measure of dispersion describes the degree of variations or scatter or

dispersion of the data around its central values(dispersion = variation =

spread = scatter).

1- Range:

It is the difference between the largest and smallest values. It is the

simplest measure of variation. Its disadvantages is that, it is based only on

two of the observations and gives no idea of how the other observations

are arranged between these two. Also, it tends to be large when the size of

the sample increases.

2-Variance:



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If we want to get the average of differences between the mean and each

observation in the data, we have to deduce each value from the mean

and then sum it and divided it by the number of observation.

i.e. = (mean x) / n

The value of this equation will be equal to zero. Therefore to overcome

this zero we square the difference. Mathematically it is better to divide by n-1.

3- Standard deviation:

The main disadvantage of the variance is that it is the square of the units

used. So, it is more convenient to express the variation in the original

units by taking the square root of the variance. This is called the standard

deviation (SD).


1

)X(SD

2

=

n

X


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CHAPTER IV

IDENTIFY AND PRIORITIZE HEALTH PROBLEMS

OF OUR COMMUNITY

Health problems can be isolated at any point of time during their natural course; at

each point, different subpopulations are affected, ranging from those at risk to those

who eventually succumb. These subpopulations can be represented quantitatively as

the numerator or denominator in measures of the incidence or prevalence of a

particular health problem.

Any health problem may take many forms and have different components that can be

addressed in an intervention.

A health problem may be viewed in the form of:

-Risk factor before the disease actually occurs.

-A screening finding after the disease occurs but before symptoms develop.

-A symptom of disease such as headache.

-A complication or consequence of the disease: diabetic foot ulcer.

Therefore, it is very important to realize that health problem can be isolated at any

point during its natural history.

1- Disease

No disease Disease Onset Symptoms Cure, Complications or death

2-Symptoms

Asymptomatic Symptomatic3-Preventive Stage

Primary Secondary Tertiary



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Health Problems and Subpopulations

Each level of a health problem corresponds to a segment of the overall population.

Identifying the levels of the problem will determine the subpopulation that we need to

consider. We can start with the whole population then we can narrow it to those who

have the risk factors, then to those with the disease / condition, and finally to those

who die from the problem.

Developing Health priorities:

Analysis of the community health profile should cover:

1-Main Health Problems

2-High risk groups

3-Level of available health services.

4-Deficiency that we need to overcome.

At this stage we need to prioritize our problems and select the problem amenable for

the intervention. The following guidelines will help:

1-Develop a Priority Chart, in which each health problem is given a simple

score for its relative importance. The score will be based on:

-Frequency of the condition

-Level of morbidity (severity)

-Level of mortality (fatality)

-Effectiveness and feasibility of intervention

-Cost of intervention.

-Time constraint.

2-Another important issue that should be considered, while setting priority for

intervention, is the identification of groups at risk and the possibility of

reaching them.

CHAPTER V



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DEVELOP SPECIFIC INTERVENTION

The type of intervention will be decided upon not only according to the type of health

problem, but also according to the stage of the health status whether we are dealing

with risk factors or actual disease or complications etc.

HEALTH PROMOTION

Health promotion is one of the basic activities, which are carried out very early in

order to control most of the community health problems before appearance of any

manifestation.

1-Definition:

Health promotion is all activities that are intended to prevent diseases and ill health

and increase well being in the community.2-Health promotion activities:

include:

1-Making environment safe.

2-Individual protection.

3-Health education.

4-Making healthy choices easy: community development

Therefore, in order to intervene at the community level, usually one or more of

the previously mentioned activities should be considered. Nevertheless, before

proceeding to discuss the previously mentioned activities, certain basic ideas

should be discussed.

Composite Model of health promotion

Governmental and social action Health education

Physical environ. Cultural environ.

Positive Health


A


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From the previous composite model, it is evident that two models can act together in

an interactive way in order to accomplish the state of health promotion:

1-Empowerment Model:

This implies to increase individuals ability to choose and influence their environment.

It aims to equip individuals with the skills and information that will give them the

power to take control over their own health.

2-Community Model:

It seeks to encourage individual to act together as a community to demand changes in

their environment to make it healthier.

Life Style and Perception of risk and risk taking behaviour

Life style refers to those individual and/or societal behavior patterns that are at least

partly under individual control and that demonstrably influence personal health.

Linking health and life style can be summarized in the fact that the major causes of

deaths are due to chronic diseases such as heart, accidents etc. These conditions are in

its majority related to personal behavior and the perception of risk and thus potentially

amenable to prevention. Also, most of morbidity causes have in its etiological factors,

causes that can be linked to life style.

Adopting specific health-enhancing(e.g. exercise) and health-promotingbehavior

(e.g. screening) and changing health-damaging behaviors (e.g. smoking) are ways in

which people realize their potential to enhance their health status.

Ignorance is often considered to be a major barrier to following lifestyle advice.

However, ignorance was not found to be always present among lay people and

therefore knowledge is not always a good predictor of behavior.

Perception of risk is better understood when knowledge is viewed as a part of much

broader consideration of peoples life and experiences.The identification of risk factors for disease is important for prevention of ill-health

and the promotion of good health. Therefore, there is increasing emphasis on the

importance of life style and the role of health related behavior for certain diseases.

These behaviors are termed risk-related behavior. People are responsible for their

behavior and therefore can be considered responsible for their health. Nevertheless,

individuals ability to control their lives and their health is limited by the social

circumstances that shape peoples lives.



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If we consider for example heart diseases, we will find out that although people are

aware of how to prevent it, yet they continue to act in a risky way: become fat, no

exercise and they continue smoking. Another problem such as Schistosomiasis, where

people continue to get in contact with canal water, for different social and economic

reasons, although they know they can get the infection through this behavior.

Nevertheless, people have different way to justify their risky behaviour: They smoke

because this is the way to overcome stressful situation, to socialize or to get few

minutes for stop working and relaxes. As for Schistosomiasis, they do not to get

different from colleagues or they need to do so to get their wok done.

Therefore, it is very important to recognize the social context of risk perception and

risk taking behaviour.

Health Belief Model

A health Belief Model can explain much of this perception and behavior. In this

model, we perceive that we can become susceptible and can suffer from certain

illness. Following this perception, we start to realize that this illness can be severe

enough to lead to serious illness. We start to adopt certain health motivation that is

affected by demographic and psychological variables. This motivation will be

affected by our perceptions of benefits and barriers to adopt certain health behavior.

Finally, certain cues to action such as advice from a doctor or friends or propaganda

will initiate our action to adopt this healthy behaviour.


Perceived

Susceptibility

Demographic

Variables Perceived Severity


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Health Belief Model

If we consider again the example of heart conditions, the situation following the

health belief model will be:

1- 1- Most people experience some chest

pain and it sometimes it affects their performance: perception of the risk and

its seriousness

2- Males in middle age, living in stressful situation will be motivated to consider

changing their risky behaviours: demographic and psychological variables

motivating their behaviour.

3-They realize that if they adopt a healthy behaviour they will be able to carry

their work, enjoy their lives and not to get ill: perceptions of benefits

4- Their commitment to work does not allow them much time to practice sport or

their social events force them to eat much: perception of barriers.

5- A friend got the condition and/or the doctor warned him that he is at

increasing risk to become ill: cues to action.

Illness behaviour and the doctor-patient encounter

1-Deciding to consultDr. A.A.El Badawy COPC Manual36

Health Motivation

Perceived

Benefits

Psychological

variables

Action

Cues to

Action

Perceived Barriers


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People act differently in front of symptoms, some fail to go to the doctor or went late

although the symptoms are serious, while others can go to the doctor on trivial or

minor symptoms. Understanding why people do or do not consult, is important

because some doctors behave badly about inappropriate or trivial complaints and

patients feel frustrated about their doctors who seem to be uninterested by their

conditions. Both types of feelings will influence subsequent consulting behavior,

medical treatment adherence and health.

Over a two weeks period about 75% of the population will experience one or more

symptoms of ill health. About one third will do nothing about their symptoms, one

third will self-medicated and one third will consult their doctors.

Therefore, it seems that there are more people with serious diseases and who are not

seeking medical care than those asking for medical help.

2-Symptoms:

Experiencing symptoms might be presented as follows:

1-Being aware of his body functions and able to monitor the way it

functions thus be able to perceive any changes.

2-Once perceived it may be interpreted as indicators of ill health i.e.

Symptoms.

Three features of symptoms are important for peoples perceptions of their

seriousness: -intensity or severity,

-their familiarity with the symptoms and

-the duration of frequency of the symptom.

3-These symptoms may be evaluated as requiring further action i.e. Illness behavior.

3-Illness Behavior:

Patients may experience symptoms several times a week but they go to see their

doctor on average only 3 or 4 times a year.

The most important variables known to influence illness behavior are:

1-Visibility, recognition of signs and symptoms

2-The extent to which they are perceived as serious.

3-The extent to which symptoms disrupt personal life.

4-The persistence and frequency of signs and symptoms.

5-The personal tolerance of symptoms by different individuals.

6-Available knowledge and cultural assumption of the symptoms.

7-Needs for denial and needs to compete with illness.



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8-Interpretations of symptoms once recognized (Stigma).

9-Understanding of health providers.

10-Availability of suitable health services.

4- Patient Compliance:Patients compliance or adherence refers to following the advice of health care

professionals. It includes:

-Preventive health behaviors.

-Keeping medical appointment

-Self-care actions

-Taking medicated as directed.

However, non-adherence was found among about 40-45% of patients. This suggests

that:

-Almost half of all prescribed medications has a reduced health impact.

-Doctors may be only effective with about 55-60% of their patients.

-Patients are becoming ill unnecessary due to non-adherence.

It is estimated that 10-25% of hospital admissions are due to non-adherence.

Review of adherence research has revealed that several factors are associated with

adherence:

First: Patient has to understand what they are being asked to do.

Second: They must also remember what they are told.

Third: They must be satisfied with the doctor and the consultation.

HEALTH EDUCATION

A- Principles of Health Education

Definition:

Health education is planned opportunities for people to learn about health and

make changes in their behavior.



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Therefore, it includes:

1- Raising awareness

2- Providing information

3- Motivation and persuasion to make changes

4- Equipping people with the skills and confidence to make those changes.

Basic Reasons for Health Education:

1- Health Knowledge is a basic human right:

People need to know the potential to affect their health. However, in some

circumstances they do not want to know as for example in the diagnosis of a

terminal illness.

2- Health Education is the basis for health promotion:

Decisions about the prevention of ill-health, recovery from illness and coping

with chronic ill-health and disability should be made on the basis of a sound

understanding and knowledge about health.

Health education is a tool which enables people to take more control over their

own health, and over the factors which affect their health.

3- Health education gets results:

No professional practice can claim 100% success, but it is clear that in theory a

great deal of our health problems are preventable and that there is considerable

scope for prevention and health promotion.

Health Education Goals:

1-Health consciousness goal:

Increase awareness of health issues Knowing

2-Knowledge goal:

Give information Knowing

3-Self-awareness goal:

It involves clarifying values about health, i.e. helping people to identify what is

really important to them Feeling

4-Attitude change goal:

Change what people feel, what they believe and what their opinion is about

Feeling

5-Decision making goal:

Decide what to do in the future about health in general or a particular health

problem Knowing and Feeling



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6-Behaviour changegoal:

Do something about health Doing

7-Social change goal:

Complex goal of making Healthy choices easier choices

Changing social, physical environment so that people are encouraged to adopt

healthier behavior.

Example:

The example that we are going to exam is the effect of physical exercise on our

health.

1- Conscious I know that exercise is healthy.

2- Knowledge Physical exercise strengths my

body and heart

3-Self awareness I feel unfit, not healthy

4- Attitude Change I use to believe that exercise was only for

young people but now I believe I would benefit from exercise.

5- Decision making I will join a sport club

6- Behavior Change I go to the club, I walk to work, I climb rather

than use elevators.

7- Social change Sports facilities are cheaper, schools had play

ground etc..

1 and 2 Know

3 and 4 Feel

5 Know and Feel

6 Do

7 Healthy choices are easier

B- Concept of Health Education:

The concept of health education comprises three levels:

1-Primary: it aims to prevent illness and to improve the quality of health and life.

It is directed for e.g. to improve the health of children and adults.



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2-Secondary: it help the person to restore his former state of health whenever he

gets ill. For example: improve his compliance with treatment, educate people

about their health status or change a harmful practice.

3-Tertiary: it is directed towards how to make the best of the remaining health

potentials i.e. Rehabilitation.

C- Dimensions of Health Education:

1-Health Education is concerned with the whole person: physical, mental, social

etc.

2-Health Education is a life long process.

3-Health Education is concerned with people at all points of health and illness i.e.

primary, secondary and tertiary.

4-Health Education is directed towards person, families, groups and

communities.

5-Health Education is concerned with helping people to help themselves and help

others i.e. making healthy choices, easier choices.

6-Health Education involves formal and informal teaching using several

methods.

7-Health Education is concerned with a wide range of goals such as information,

attitude change, behavior change and social change.

D-Planning for Health Education

Therefore, in order to implement a health education program several steps have to be

considered, they will start from identifying of consumers till implementation of the

program and evaluate its impact.

They comprises:

I-Planning: A-Situation Analysis:

-Identify the consumers -Identify the needs and priorities

-Decide on the goals and objectives -Identify resources.

B-Planning of the program:

-Plan content and methods -Plan evaluation methods

II-Implementation: Take action and Carry out the program

III-Evaluation: Evaluate the structure, the process and the outcome


Identify Consumers

Identify Needs and

PrioritiesDecide GoalsFormulate Specific

ObjectivesIdentify Resources Plan ContentPlan EvaluationImplement (Action)

Carry out


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I-Planning:

A-Situation Analysis:

The situation analysis will be concerned mainly with the collection of information

that will allow us to analyze and identify the basis for the development of the health

education program. In all situations, we have to bear in mind the link between the

knowledge, attitude and behavior.

The relationship between knowledge, Attitude and Behavior:

Knowledge and experience

Age

Social and

Class Sex

Education

Beliefs Attitudes Intention Behavior

Peer Culture

Pressure Norms

Expectations of others

1-Identifying consumers and their characteristics:

The first question that we needs to answer is : WHO is our client? In other words we

need to identify the different characteristics of our target audience:1-Numbers:

we need to know to whom we are directing our effort: to individuals, to

special groups or to communities. Our message and methods will differ

according to the numbers of our recipients.

2-Age and Sex:

The age and sex of our recipients will shape our message and methods.

For example young age needs that we target problems that interest

them such as hazards of mobile phones while targeting the problem of

Dr. A .A. El Badawy, Teaching Manual 42


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diarrhea will not interest them. Females will be interested about

nutrition and childbearing, problems which are of no interest to male

audiences.

3-Knowledge, culture, experience and language:

The culture, the past experience, the level and type of knowledge and

the type of language that the clients can use to address the educator and

that the educator can use to address them. It is well known that wrong

knowledge can make health educators job a difficult one. The culture

of any community shapes the communitys believes attitudes and

therefore can predict the behavior, what is accepted in one society may

be not accepted in another one. The past experience can form a barrier

to change ones attitude towards certain problem since they are more

convinced by their past experiences. Finally, it is always difficult to

beat and overcome wrong information and convince them with new

different ones.

4-Attitudes and Motivation:

Attitudes are the result of some knowledge. It is always important to

develop attitudes that favor the practice of a healthy behavior. If we

fail to influence someone attitude towards certain problem it will be

difficult to motivate them to change their behavior.

5-Expectations and receptiveness:

Recipients of the health education program have some expectations

that they expect to get from the program. If these expectations are not

met, their reception of the message delivered by the health education

program will not be accomplished. Another aspect that needs to be

considered is their abilities to receive, understand and be convinced of

what is delivered to them.

6-Health problems:

The type of health problems that are prevailing, will affect the success

of the program. Trivial problem as well as very serious problem (has

no cure for example) can undermine their acceptance of the program. It

is always difficult to convince people about healthy behvior that is

related to an unclear health problem. For example, it is difficult to

convinve people to practice family planning while it will be easier to



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convinve them about the importance of oral rehydration therapy for

the treatment of their children.

2-Identifying Health education Needs and Priorities:

Needs:

A-Concepts of needs:

Needs are several types, they may be Normative (expert opinion), felt

(what the consumers want), expressed (reflect their demands, felt that

are turned into demands), orcomparative (similarity with others).

B-Identifying Health education needs:

In order to identify the educational needs we have to cover different

areas that can formulate ones needs.

1)Scope:

The scope may be well defined as in the case of a dentist who wants to

inform his patient on oral hygiene, in contrast to a community health

worker who has a wide scope for example he is concerned with the

prevention of disease and with health promotion.

2)Reactive or Proactive:

-Reactive: (client-directed approach)

it means responding to needs and demands which other people make.

-Proactive: (medical and behavior approach)

it means taking the initiatives and decide oneself on the area of work to

be done.

3)Health Information:

a-Epidemiological data:

It provides information on the health of the population, causes, risk

factors and the potential for prevention and health education.

b-Social and Environmental Indicators:

Social and environmental factors such as housing, employment,

income etc may indicate the needs for health education.

c-Professional and Public views:



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the views of professional and the public reflect experience and

perception accumulated over the years. Therefore it is necessary to

consider these views. Obtaining these views can be from informal

discussion and or interviews.

C-Assessing Health Education Needs:

It can be approached by asking a series of questions:

a-What sort of need is it?

Normative, felt, expressed or comparitive.

b-Who decide that there is a need?

Who decide: professional, consumers or both.

The best is both: Professionals rase awarness to make consumers

perceive the problems.

c-What are the grounds for deciding that there is a need?

Is there an evidence in the form of hard data, facts, figures? If not

could we collect such data?

d-Is health education the answer to the need?

Health education cannot solve all the problems, it may not always even

be a partial answer.

Setting Health Education Priorities:

Due to limited time, resources and energy, priorities have to be defined.

There is no straight forwards method, but the following may be considered:

1-Health issue type:

Is it a health promotion issue, a problem or related to social factors?

2-Effectiveness:

It is going to be effective in the prevention of the conditions and can be

more effective than other measures (for e.g. cholera control)?

3-Feasibility:

It can be done and be successful with this group? We have the

necessary resources, knowledge, relevance, skills and materials.

4-Ethics:

We have to determine if it is acceptable to the expert and to the

consumers. We have to find out how the outcome will affect their

lives:



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-Do we have the means for prevention?

-If we can do nothing on the problem, why produce

worries?

5-Consumers type:

Policy makers, individuals, families, selected groups or whole

communities.

6-Age groups, gender:

Children, young, parents or elderly. Males or females.

7-At risk groups:

They are susceptible to hazards: smokers, have high pressure,

unemployed, low income etc.

8-Working with others:

We need to know what was done by others, do we need to continue or

not?

We have to be careful not to duplicate or interfere with the work of

others.

So Setting needs and priorities have to be specified very carefully because it will

determine the objectives and the outcome of the health education program.

3-Decide on the goals and objectives

Goals are the broader aims of the health education program. The goals will describe

what is intended to reach by the end of the program. Objectives have to be specified.

Three main characteristics of the objectives that need to be considered, are:

1-It has to stated in the learners terms i.e. understandable by the learner.

2-Describing specifically the learners terminal behavior i.e. quantitative and

qualitative measure of what the learner will be able to do.

3-It has to be realistic.

4-The evaluation be build in.

4-Identify Resources:

To identify resources, certain items have to be covered:

1-The educator characteristics and their roles.

2-The client capabilities so that we can build on.

3-People that can influence your client.



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4-Existing policies and or plans.

5-Facilities and materials that can be used.

1)The educator Characteristics and their roles:

To some extent, every one is a health educator, because at some time or another we all

discuss questions of health with somebody else.

However, some agencies may be responsible formally:

1-Ministries of: environment, education, health, agriculture, social

affaires etc.

2-Mass Media: TV, Radio

3-Local Health Authorities.

4-Health professionals, teachers, social workers, pharmacists, etc.

5-Non Governmental Organizations.

The role of health professionals in health education has several constraints:

1-Lack of identification of the health education element in the health

professionals work.

2-Overcrowdness of work items and lack of time.

3-Deficient training as regards health education and difficulty in

incorporating such item in the training curriculum.

4-Some health profession consider that health education has to be in

the formal way and do not take opportunities to use informal way.

5-Students consider their trained professionals as a model but these

professionals may not have the necessary skills for health education.

Therefore, the role of health professionals may be improved if more emphasis

was given to health education during basic training. More flexible multi-

disciplinary approach, with more emphasis on prevention and quality of service.

This would create a climate conductive to effective health education practice.

2)The client capabilities so that we can build on.

Previously, we have identified the characteristics of the consumers and specially the

capabilities of their level of education, language, culture, level of knowledge,

expectations etc. All these will define the type of message, methods, aids, language

etc that we should use in order to develop a successful health education program.

3)People that can influence the client.

All people surrounding us can influence our attitude and behavior. Relatives, peers,

colleagues, etc can either help the health education program if their concept is similar



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and not contradictory or can affected it negatively if they have a different point of

view.

4)Existing policies and or plans.

The existing policies that are implemented by different organization, specially those

related to health agencies and educational agencies. These especially can have a great

impact because they can affect a sector of the population that are in need of the health

education and are more liable to accept and influence others at the same time.

5)Facilities and materials that can be used.

The materials and facilities in the health education program are the methods and aids

that can be used and are the suitable ones for the given situation.

Certain guidelines for the selection of methods and aids that can be used:

1-Will it add to the interest or understanding?

2-How will it be acceptable to the learner?

3-Will it provide the opportunity for the transfer of learning?

4-Will it involve the learner?

5-Is it appropriate to the learners age, ability and experience?

6-Is it feasible?

7-Is it readily available?

8-Is it worse the cost (Efficient) ?

9-Can the teacher use it with ease?

10-What contribution will it make to achieving the objectives?

Teaching Techniques:

What the

teacher hopes

to accomplish

Technique that

he can use

Learner

s ability

Status

Advantages Disadvantages

1-PresentInformation

2-Develop

Skills

-Lecture-Reading

-Audio-visual

-Demonstration

-Simulation

Passive

Active

-Save times-Large number

-Large amount of

information

-Learner feels

secure

-Learner

involvement and

interaction

-Facilitate

evaluation by theteacher

-No interaction-Teachers cannot

check what is

going on

-Learner

attentiveness low

-High cost in time

and resources

-Socialization

decrease

concentration-Difficult to



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3-Encourage

understanding

4-Encourage

examination of

attitudes and

values

-Problem

solving

-Groupdiscussion

-Counseling

-Group

discussion

Active

Active

-Same as previous

one

-Develop problemsolving skills

-Same as previous

one

-Learning situation

highly available

standardize for all

learners.

-Same as previous

one

-Same as previous

one

B-Planning of the program:

1-Plan Contents and Methods:At this stage, we have to decide what exactly we are going to do, using the available

resources.

We have to consider:

1-Which method and aids are the best for the objectives.

2-Which method and aids will be acceptable to the consumers.

3-Which methods and aids will be suitable for the contents.

2-Plan Evaluation Methods:

In any program, we evaluate the structure, the process and the outcome. The

evaluation will determine the success that we were able to accomplish. At each level

of the program we have plan to carry out:

1-Self-Evaluation:

-What we did was well?

-Are we satisfied or dissatisfied?

-How can we improve?

2-Peer Evaluation:

-Ask a colleague to evaluate?

3-Client Evaluation:

-Whats the Feedback?

-What is the type of attitude? -tense -puzzled -do they enjoy it -do they benefit.

II-Implementation

Take Action, Carry out:



50/70

In order to implement a successful health education program, several aspects have to

be considered:

1-The relationship between educator and clients.

2-The communication styles

3-Barriers.

1-The relationship between educator and clients.

In order to explore such relationship, we have to consider the following:

A-Accepting or judging:

These two aspects that can help or hinder the relationship between the

educator and the clients. It is evident that losing the clients can occur

easily if he or she feels that we are judging him and not respecting his

or her behavior.

The items that reflect the attitudes of the educator are:

-Accepting:

1-Recognize clients knowledge and beliefs as part of

life experience.

2-Understand that the educators knowledge, values and

standards are part of your profession.

3-Recognize clients points of view.

4-Recognize that differences between clients and health

educators does not mean that the health professionals

are better.

-Judging:

1-Valuing the persons by his attitudes: he drinks so he

is stupid.

2-Ranking by knowledge and behavior: I am the expert

so I know more than you.

B-Dependency or Autonomy:

The aspects of dependency and autonomy reflect the way the educator

will adopt to carry out the changes that he wants the clients to do.

-Autonomy:

According to this way the educator will try to:

-Encourage the client to take owns decisions.

-Encourage him to think for himself.



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-Respect his ideas,

-Dependency:

Opposite to the previous behavior the educator will:

-Impose solutions.

-Tell him what to do because he took too long time.

-Tell him that his ideas are not good.

C-One way or Two ways:

The way the education process that the educator will use, can have a

great impact on the acceptance of the clients about what it is taught.

-One Way:

This is usually carried out as a lecture and has the following

drawbacks:

-Clients are not encouraged to ask any questions.

-Lecturer is not expecting to hear or learn anything from

the client.

-Two Ways:

It is usually in the form of group discussions or face to face and it has

the following advantages:

-A trust and open atmosphere prevails.

-Clients are asked about their views.

-Educators are expected to learn from clients.

D-Health profession: source of all knowledge:

Sometimes, the educator starts to take the role of the experts and

consider that he has all the necessary information and thus clients had

to follow him. However this can lead to some drawbacks:

-First, the educator will deny the value of the clients

which can lead to a negative feeling from the client.

-Second, the educator had all the answers and gave

advices to the clients; again this will result in rejection

from the clients.

-Finally, the educator denies any possibility that the

clients are able to teach one another, which can lead to



52/70

loss of an important opportunity that can have a great

impact on the acceptability of the clients.

E-Clients Feeling: Positive or Negative:

The clients, during the sessions of health education, will develop a

feeling which will depend to a great extent on the ways the educator is

handling the situation. These feelings can lead at the end to either

accepting or refusing of the delivered message.

Situation in which the clients adopt a negative feelings:

-Educator ignores the strength and capabilities of the

client.

-Clients efforts and achievement are ignored.

-The educator attempts to raise the sense of guilt and

anxiety.

Situation in which the clients adopt a positive feelings:

-The educator praises any effort the clients did.

-The educator does not imply that the client behavior is

morally bad.

-The educator adopts a behavior that explores how to

overcome difficulties and thus minimizing the feeling of

helpless.

2-The communication styles:

The communication that the educator uses to convey the desired

message to the clients can have some positive and some negative

aspects. Therefore, it is very important to choose the appropriate way

according to the type of clients and the type of message to be

delivered.

1-Authoritarian Style:

This style has a positive aspect that it implies a clear guidance and thus

can easily resolves the problem, while it has a negative implication that

the clients are not given any responsibility and thus adopt a passive

attitude. In short it implies strict obedience from the clients.

2-Paternalistic Style:

The paternalistic style is mainly protective and thus is most suitable for

vulnerable groups such as children and handicapped. It

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