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FACE TO FACE EDUCATION

SESSION NOTES

PURPOSE AND CONTENT

Using drugs is very personal. It touches deep beliefs about our health, and ultimately about life or death. To reconsider the way we use drugs, we need to talk with a person we trust. This person needs to know about and respect our ideas, and to have good communication and education skills. If we are to take action on new instructions on which drugs to use, and how to use them correctly, or when drugs are not needed at all, the person should be available to us in the community over time. We may have questions about the drugs, and we may have forgotten exactly how to use them after some time.

This module explains what face to face education is, why it is important, and what it can achieve. The module will help you to understand how a client or a customer feels, acts and changes. And it explains structural and management issues related to planning a face to face education project in public and private sector settings.

The choice of the most appropriate face to face method depends on context, and culture. The purpose of this module is to highlight which elements you have to consider, including understanding how people change on a micro-level by looking also at your own change process.

OBJECTIVES

Upon completion of this module participants will have an understanding of:

1. What face to face education is.2. The advantages and disadvantages of face to face education.3. Why face to face education is important, and what results can be

achieved.4. How and when to use face to face education.5. How to plan a face to face education project.

They will also have developed the skills needed to:

1. Understand someone’s problem and encourage the person to try a new practice or change a present one.

© World Health Organization 2002

Face to face education Session Notes

PREPARATION

1. Read the Session Notes.2. Reflection: Think about your own learning process, from primary

school until today. Which teachers and trainers do you remember well? What makes you remember them? Reflect on how the teacher(s) made you feel as a person, as well as on how you learnt (or did not learn) the topic. You can use negative as well as positive examples. Make some brief notes about the teachers, and the effect they had on you and your learning, and also note questions you have.

A. WHAT IS FACE TO FACE EDUCATION?

Face to face education is a method where an educator speaks directly with an individual or a small group of people. For rational drug use, the educator could be, for example, a trainer, a drug dispenser, a health worker (formal or informal), or a community leader. For good face to face education the attitude of the educator is as important as his or her knowledge. Two-way communication is the key to a good result.

The method can be used directly to discuss the use of drugs with a customer or a patient. It can also be used in other situations like supportive supervision, training courses, or convincing managers of the need for a programme or activity.

What characterises good face to face education?

Relevant to personal and cultural needs: The content must be established through formative research, or through participatory research.

Respect and bridge-building: For people to consider change, the educator must understand and respect their present practices, and be able to make a bridge from these to the new practices.

Skills and credibility: The educator must be skilled in participatory education and communication techniques, and must have credibility in the community.

Key information: The educator should focus on key information relating to behavioural change, using simple local language.

Discuss and negotiate: The educator should listen carefully to the person(s) receiving the information, watch their body language and discuss suggestions for new practices.

Check for understanding: The person should repeat key information, e.g. about dosage of drugs, to make sure he/she has understood what to do.

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B. HOW AND WHERE CAN FACE TO FACE EDUCATION BE USED?

Face to face can be used:

To change practices: face to face is an effective method to encourage people to change practices, e.g. such as how they use drugs. When used well, it can result in important changes.

With other methods: to increase awareness about the need for change, and to give opportunities to discuss the topics in various fora.

With educational materials: face to face should be supported by educational materials such as drug instructions, stamps, leaflets etc. to help the client or customer remember why and how to take the drugs.

In one-to-one and small groups: The most effective way of using face to face is probably in a one-to-one situation, but face to face can also be used in small groups. In a larger group, there is less time and opportunity for interaction, and thus less likelihood that all participants get their concerns addressed.

In many other venues: such as health clinics, pharmacies, local shops and community groups.

C. IMPACT AND OPPORTUNITIES

Face to face is a powerful educational method to improve people’s understanding of how to use drugs correctly. Lack of communication and understanding will often lead to problems of low adherence to treatment and other misuse of drugs.

Advantages and disadvantages of face to face education:

Advantages:

Improves adherence to treatment: Learning about correct drug use in a dialogue with an effective educator makes people use drugs better.

Empowers people: Learning why you need to use the drugs in a certain way gives people new knowledge, which they will use to make their own (informed) decisions.

Good communication: an effective dialogue between the health worker/provider and client/customer can motivate further learning about health.

Changes behaviour: When people see that the new ways of using drugs actually work, many will leave the traditional methods behind and continue to use drugs (biomedically) correctly.

Closer to home: Training face to face educators in the community (informal providers, community health workers) gives people access to quality service closer to home, from people they trust, and who respect them as fellow community members. This reduces the economic burden of having to travel to the clinic when it is not necessary.

Reduces morbidity and mortality: When community members use drugs correctly, it reduces the length and severity of illness.

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Disadvantages:

Expensive: Since the interaction is mostly one-to-one, the number of people each educator reaches is small.

Requires skills and motivation: Finding and training good face to face educators is time-consuming and expensive.

Studies show impact of face to faceA review of 37 studies on patients’ compliance with medical treatment in developing countries, all of which studied compliance from the biomedical perspective (see Homedes and Ugalde, 1993 in additional reading list) states that:

Several studies found that “teaching patients in the administration of therapies increased compliance” (using face to face education).

Poor communication between practitioner and patients was the most frequent problem leading to non-compliance (Pakistan-Mull et al., 1989).

Most cases of non-compliance were due to patients not understanding the problem and miscommunication between family and health providers (Mexico, Martinez et al., 1982).

When non-compliers receive education, they comply (Martinez et al).

Rural shopkeepers gave correct advice: The Kilifi study

A study from Kilifi, Kenya, (Changing home treatment of childhood fevers by training shopkeepers in rural Kenya, Marsh et al.,1999) demonstrates the potential of face to face education: In a pilot study, shopkeepers from 23 shops were trained to treat all childhood fevers with a full course of chloroquine, and given reasons why they should do so. Participatory methods were used to teach knowledge as well as communication skills, so that shopkeepers could give good face to face education to the customers.

Results: While only 4% had given correct advice on chloroquine dosage before the training, 98% did so after the training (in their shops, under observation). Before training, 32% of the customers bought an adequate amount of chloroquine for the child; after training 83% did so. The biggest and most important change came in the amount of chloroquine that was actually given to the child with fever. Less than 4% of the mothers gave an adequate amount to the child over three days before, and 65% did so after the shopkeeper training. This means the mothers were willing to listen to the shopkeepers, and followed their advice - even when it meant spending more money on drugs.

In a follow-up main study in Kilifi (still underway at the end of 1999), local government health workers and community health workers are training the shopkeepers (rather than specialist trainers, as in the pilot study). Mid-term results show that 95% of the shopkeepers are giving correct advice about the use of chloroquine. Before the training of the shopkeepers, 5% of the mothers used an appropriate dose of chloroquine over three days for their children with fever. After training, 37% of the mothers gave their children a sufficient dose over three days. Because of the high rate of illiteracy in these communities, and for the sake of keeping down cost, customers are not given handouts with their drugs. However, the shopkeepers have stamps with the correct dosages for children of different ages, and stamp this information on the paper they wrap the drugs in. This method helps the mothers

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remember the dosages, after the shopkeeper has explained the dosages and asked the mother to repeat the advice.

In the qualitative assessment impact, several community leaders, health workers and traditional healers said there was less malaria among the children in their community since the programme started, and fewer children died from malaria. This finding is not confirmed statistically, but the comments from the leaders and from other community members were consistent on this point and positive overall.

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CommentThe pilot study showed that a very large percentage (83%) of the customers followed the advice of the shopkeepers. This result is to a large extent due to good training and frequent monitoring, which gave the project a relatively high profile and positively influenced both shopkeepers and customers.Since the project went to scale, training and monitoring of shopkeepers has been conducted by Public Health Technicians (PHTs) and Village Health Workers (VHWs). The PHTs conduct this training as one of their many duties, and the VHWs are volunteers with no formal background in health or training methods. Both groups receive very basic remuneration for the training they conduct. Considering these limitations, the mid term impact of 37% mothers giving their children a sufficient dose of chloroquine still appears high, particularly since this figure also includes mothers advised by shopkeepers who have not been trained (assistants in shops included in the study). When controlling for these the result is 49%. The training is being monitored to see how it could be improved.

A study in Kenya and Indonesia, (Ross-Degnan et al., 1996) The impact of face to face educational outreach on diarrhoea treatment in pharmacies, assessed the effect of one-to-one training of pharmacists and group training of pharmacy counter attendants. The results show a significant increase in knowledge, and a 30% increase in ORS sales in Kenya and 21% in Indonesia. There was also a trend towards increased communication in both countries, and in Kenya a significant increase in discussion about dehydration during pharmacy visits. The researchers did not measure the long-term effect of their intervention.

D. SUSTAINABLE OR PILOT PROJECT

Many projects end up as interesting pilot projects with no chance of being translated to “real life”, or being integrated into the existing structures. When planning face to face education in a project, the first question to ask is:

“Pilot" solution: Do I want to demonstrate that my method works in a small area/project, without the ambition to make it work on a larger scale? And if I choose this option how do I justify it?

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Sustainable solution: Do I want to find a way to solve problems which can be used in the larger health system (formal and/or informal), in other words do I aim for a sustainable solution?

The approach to planning will be very different, depending on which option you choose. In the “pilot” case, projects will often use an amount of resources and expertise which cannot be reproduced on a larger scale, and the project will be filed as an “interesting and promising experiment”. But sometimes, people start with a small pilot project to try out new methods, and then go to scale and implement them in the larger health system. It is important to keep in mind the limitations of the government health programmes, and not plan for anything that cannot be picked up by the health system.

Integrating face to face education in the existing health structure requires resources, and careful planning. Understanding the system well is important for planning a successful programme. Working with the people in the system to define the problem, and agree on a strategy to find solutions, will make it more likely that the methods and programme will be used widely by the system. Coming from the outside to criticise the system, or propose a different approach, is usually perceived as a threat, unless the people concerned are involved in the process. Working together can be seen as an opportunity for renewal and change.

Lessons from ORS education in Nepal

A 1982 survey in Nepal showed that 40% of people were aware of ORS, but less than 5% used it when their children had diarrhoea. Diarrhoea was then still one of the major child killers in Nepal.

A Redd Barna (Norwegian Save the Children)/MOH project, asked the following questions: What will make the 40% change from awareness to action? Who will encourage them to make this change? Who are the 5% who are using ORS, and how can we engage them in sharing their knowledge

with the others? In what setting should such a process take place?

In the health clinics, there were Auxiliary Nurse Midwives (ANMs) who had a limited role. They were interested in the ORS problem. The project gave them a two-week course in face to face education methods, and communication skills - including how to run a community meeting. The MOH selected some villages for a trial project. Village leaders gave their permission for meetings with the women. Discussions took place with the traditional healers, who have a lot of power in the villages, and could obstruct - or encourage - the adoption of new practices. They agreed that diarrhoea is a big problem, and that their medicines did not always help. They were interested in ORS, and discussed the ideas thoroughly with the ANMs. They were invited to the meeting that had been called (by the community leaders) to discuss with the women.

In these meetings, the ANMs asked women to describe what experiences they had with diarrhoea in the community. Many women stood up and described how their children had died. Most of them had stopped giving the children liquids when they had diarrhoea, because then the diarrhoea also stops after a while. One or two women stood up and said they had given their children ORS when they had diarrhoea, and the children had survived (these were the “5%” we had been looking for). They were challenged by the others - how could they give more water? Did this not make the diarrhoea worse? Did the mothers-in-law not protest? All the counter-arguments were given, and the ANM directed the discussion by making sure everybody was listened to, and only one person spoke at a time. The ANM

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gave a short input - on why it is important for a child with diarrhoea to get more fluids, and how ORS works to “balance” the child’s stomach and help him fight the diarrhoea. There were questions, and more discussion.

The women who had used ORS had a powerful argument with them - a healthy child. The other women saw this, and - in an environment, (the group meeting, “blessed” by the community leaders) where it was OK to discuss these practices a lot of learning took place. One of the women who had used ORS was then invited up to demonstrate how to make ORS. The other women watched with interest. There was further discussion. The ANM demonstrated once more, and repeated the “recipe”. Simple handouts with a pictorial description of how to make ORS were given out. Two traditional healers were present in the first meeting; they stayed at the back and did not contribute.

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At least two meetings were held in each community. In the second meeting, several more women had tried the ORS, and reported that their children were OK. One said it was not worth the extra work with having to clean up the diarrhoea, but she was challenged by the others - how could she say that, when the medicine helped the child to survive? In some meetings, the traditional healers also contributed their experiences, and said they had used ORS with their own children - with good results. This was important for accepting the practice in the area. The ANMs also had special meetings with some of the healers to discuss what they could do to help spread the use of ORS in their communities.

In the three project areas, the use of ORS went up from 5% to 60-70% within six months.

(Unpublished report, Redd Barna, Nepal, 1983).

Lessons learnt from the Nepal case study:

Opinion leaders in the community need to be addressed first, to gain their support for the project or idea. The community leaders were contacted to get permission to meet with the women. The traditional healers were contacted to discuss the problem, invite their opinions, and request their participation. (In another health project in Nepal, the traditional healers had been invited and trained by an NGO to be family planning motivators; they were so successful that the medical decision makers in the MOH stopped the project - thus, in the ORS project the traditional healers had to be involved, but not the principal actors).

Opinion leaders can make a real difference to getting a new practice accepted and used. Frequent meetings to discuss project strategy and progress with the leaders is important.

Providing a forum for exchange of experiences - a village meeting of women is a good setting for spreading new knowledge.

The positive experience of neighbours using a new practice is a powerful inspiration to change, especially when confronted with the result of the experience - a healthy child.

Health worker as facilitator: the role of the health worker was changed, from the “lecturer who knows it all” to a facilitator who encourages women to share experiences and help build each other’s confidence. The ANMs were from the same area, spoke the local language, and were willing to travel to the different villages (on foot).

E. ESSENTIAL RESEARCH

Face to face education will only be effective long-term if developed through interaction with the community, using qualitative and/or participatory methods as discussed in earlier modules. Researchers must investigate and understand community attitudes, practices, the underlying reasons and their context. Research should look at people’s perception of a need for change, what this change should be, and how it is brought about. In other words finding the solution(s) together with people. The interaction must build on an understanding of and respect for present practices, and use this as a bridge to explaining new practices (understanding what is important to people, and why). Relevant research methods are discussed in earlier modules.

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Of course it is possible to use powerful face to face methods to promote changes that authorities believe are “good for people”, without going through the process of finding out what they believe, and do, or what they would like to do. Ample experience from failed educational projects of this kind has demonstrated that such an approach will fail in the long run (although short-term changes might be registered).

Your research will enable you, the planner, to understand the nature of the problem. It will also underline the educational approach you decide to adopt and which will form the basis of training for the face to face education. To be able to help a client or customer solve a problem or change a practice (which is usually the aim of face to face education), you need to be able to understand what is important to the person, and see the problem from his or her perspective: How does the person think and act, and what are the reasons behind beliefs and actions: To understand WHAT she does, and WHY she does it. A sensitive and skilled educator can link this understanding to the new practice a person is encouraged to use, and help her see connections she can recognise.

If we as educators only attempt to get people to change one (bad, from our point of view) practice with another (good, from our point of view), without addressing the underlying reasons for the practice, then the change will be superficial, and won’t last. Very likely, there might be no change at all.

Planning face to face: internal and external factors

The factors the planner (and the educator) have to understand to be able to influence someone’s behaviour or practice can be grouped under “Internal factors” and “External factors”.

Internal factors (which are “inside a person’s head”) are for example: Knowledge related to the action, perceived risks, what consequences the action will lead to, attitudes and social norms related to performing the action, experiences with different forms of treatment, and intent or motivation to change. These factors can be explored during formative research, or participatory research.

External factors (outside the individual, those which can influence a practice positively or negatively) are for example: Availability of services, demographic factors, epidemiology, policies, cultural norms, and skills and their consequences.

F. SELECTING EDUCATORS

The people who we allow to influence us to change are usually important people to us - someone we trust, someone we have known for a long time. Or someone we respect, for a number of different reasons. The person needs to be someone we can identify with, someone who is close enough to us in status, function, culture, way of thinking etc. Ideally, it should be a person we can consult during the process of change (when trying out

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and evaluating the new practice, we will have questions - and we will have a strong pull from our “old habit” to go back and do what we did before). Sometimes family members will oppose a change, and then it is especially important to have someone you feel safe with to consult about how you are doing, and to keep giving you good arguments for staying with the new practice.

A good face to face educator needs a combination of the right personality and the right knowledge, skills and attitudes. Planners would be wise to keep this in mind when selecting people for this job. However, very often there is not much choice - your educators may be the formal and informal health workers, the informal providers/drug store vendors or pharmacists. Be aware of what makes a good face to face educator, and aim to move the trainees as far as possible in this direction.

The ideal face to face educator

Approachable Makes everybody feel welcome, and at ease Respectful of others’ knowledge and skills Curious, willing to learn from others Good communicator and good listener Inspires dialogue and views Able to identify problems and solve them constructively Knowledgeable about the subject Not afraid to admit to not knowing the answer. Will find out. Can accept and reflect on criticism, and does not become defensive Non judgemental

The credibility of the educator is essential to the success of the interaction with clients or customers. It is influenced by the educator’s ability to:

Understand the person’s background (perceptions, practices, reasons)

Respect this background, and also the reasons why it might feel impossible for the person to follow advice to change

Use this background/ideas as a starting point for the education (build a bridge from the informal knowledge to the biomedical knowledge)

Be sensitive to the person’s emotional state (someone whose child is very sick will feel very scared, and needs to be treated in a friendly and considerate way)

Be available for follow-up advice.

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G. TRAINING IN CORE COMMUNICATION SKILLS

The educator should have been trained in the necessary factual knowledge and skills about the common diseases, and how to treat them. The community members should know that the educator has these formal qualifications. However, knowledge without communication skills will not convince community members to change their practices.

G1. Understanding the problem

Understanding the problem of the client or customer requires three main communication skills: (1) Observation, (2) Asking open questions, and (3) Listening carefully. These are very important skills in face to face education - and in any other education activity. The skills need to be accompanied by a friendly and respectful attitude to the client or customer. An uninterested, unfriendly educator will not gain the confidence of the customer or client, and will therefore not be able to understand the problem, and influence him or her to change their practice.

The educator who understands a mother’s difficulties and her dilemma, and is respectful, sympathetic and understanding, has a chance to get through to her and encourage her to try a new practice. Blaming her for sticking with the old ideas will only make her angry or unsure, and will only make her more likely to stay with what feels safe - i.e. doing what she has done before.

G2. Communication, with feedback

Communication is a two-way process consisting of giving information to a person, and getting feedback. Two main skills are important throughout the face to face education process, as well as in most other training methods:

Communication, with feedback Asking open questions, and listening carefully

These skills should be mastered by anyone working with this method (including planners). See Annex 3 for Zimbabwe approach to key communication training messages.

It is only by getting feedback that you know if the person has understood what you meant to say. See box for an example:

Peter: So I understand you came to this training because your boss told you to go?Daniel: Yes, he did, but I also very much wanted to come, I want to learn how to

implement a community drug education programme in our village, there is so much

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misuse of drugs. My aunt died after getting the wrong dosage of antibiotics, and many other family members have been very sick. We have to do something!

Peter: Yes, drug misuse is a big problem, also in my area. What do you plan to do?Daniel: Well, I’ll tell you....... and then I want to hear about your plans!

Peter had the idea that Daniel was there because he got an order to go (i.e. he assumed). If he had not checked this out (i.e. asked Daniel, and received feedback that he also had a strong personal interest), Peter might have treated Daniel as a bureaucrat whose heart was in his career, not in community education (where Peter’s was). Now that they have exchanged ideas, and found out that they share a personal motivation to solve an important problem, their continued communication will be on a much deeper level.To communicate means to exchange, or share. Good communication should lead to a shared understanding - which does not always mean that people agree! By asking about and listening to what the other person thinks and feels (i.e. getting feedback), you can find out if you have a common goal.

If a message is given from one person to another with no feedback, it is called Information: This is a one-way “product”. When a health worker (or informal provider) gives a mother instructions about how to use the drugs, he gives her information. If he does not discuss the instructions with her, he cannot be sure she has understood - and accepted - what he has said. This is usually the problem with information.

Information can change to communication when the person it is given to, gets involved and gives feedback: The health worker or informal provider asks the mother to repeat the instructions on how to take the drugs, asks her opinion about the new way of using them, etc.

Information is ONE-WAYCommunication is TWO-WAYCommunication is the most essential skill in face to face education.

G3. Responding to the problem

When the problem (and how the customer or client may change his/her practice) has been understood by the health worker or shopkeeper, he/she should respond by using three main skills: giving accurate and clear advice, and explaining why; discussing the choice of drugs and the treatment with the customer/client; and checking that the customer/client has understood the instructions. Maintaining a friendly and respectful attitude is as important here as when the educator is trying to understand the problem.

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See Annex 2 for an overview, using malaria treatment as an example, of how to give accurate advice, and check that the customer has understood the instructions.

G4. Planning a training course

Training courses in face to face education are most effective when using participatory methods. The length of the training depends on the background of the participants, and on the objectives of the training:

A group of health workers who are already skilled in other educational methods, might need a week to learn using face to face education.

If they have not been trained in the use of participatory methods already, two weeks (or longer) would be more appropriate.

Training courses for trainers often run for 2-3 months. For shopkeepers in the private sector, shorter programmes

might be more manageable. The shopkeepers in Kilifi were trained for three days, with a follow-up course for two days after six months. In Uganda, some informal providers preferred half days in their training course (which would then be ten days); others preferred five full days.

The main concern when planning a training programme for face to face education is to make sure there is enough time for practising. Each participant should be able to practise the new skills several times, and receive feedback from trainers and co-participants. For this to function well, you need a trainer-to-participant-ratio of about 1:7, i.e. for 15 participants, you need two trainers. It is not advisable to run such courses with more than 15 participants at a time.

H. MONITORING AND SUPPORTIVE SUPERVISION

It is essential to include this factor in the training, to help participants integrate the new practices into their daily routines. The monitoring needs to be regular (e.g. once every 1-2 weeks, at least two or three times), and should start as soon as possible (within two weeks) of ending the training programme.

The way the supervision is done is very important: It needs to be SUPPORTIVE, with the trainer continuing to build up the skills and confidence of the participants. This is done by helping participants to identify and reflect on problems they have, and on how to deal with them - rather than the trainer criticising what they are doing, and taking over control.

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I. SUPPORT FACE TO FACE WITH OTHER METHODS

Face to face is an effective method to influence people’s behaviour - i.e. encourage them to change their (drug use) practices. However, it does not reach many people at a time, and is therefore an expensive method. The programme planner will be faced with the challenge of being “cost-effective”, and getting as many people as possible educated for the amount of money available.

In the module Linking research to intervention there is an overview of educational strategies for promoting rational use of drugs in the community.

Some additional ideas on how to supplement face to face education on rational drug use (e.g. if you have run training courses for the Government health workers, and for the informal providers):

Encourage community groups to discuss/continue learning on the selected topics. Simple educational materials would be a good support, as would having health workers or informal providers participate in the group meetings as resource people. A short training programme for the community group leaders on how to use the materials would improve the quality of the subsequent group learning sessions.

Encourage learning in schools, possibly by using the same (or similar) materials for discussion. Teachers could participate in the short training programme, and/or they could invite health workers or informal providers as resource people.

Other channels: The following channels could be used to spread information about the topics, and make people aware of the need to learn. It is important to note that most people would not change their practice after only being exposed to the information through these channels, but - having heard about the topic(s) through these channels - they would be more ready to change when exposed to a face to face education situation. Some such channels are:

Discussing the topics in the PTT meetings Discussing at a community meeting Making a community drama, with subsequent discussion Making a radio programme (or a series).

Research shows that for any face to face method, the support of printed educational materials will usually improve the impact of intervention.

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J. COMMUNICATION BARRIERS

There are a number of potential reasons why face to face education might not work well. We can divide these into three main areas:

J1. The environment:

The place where the education is taking place is too noisy, cold, warm, full of distractions, not private, or does not feel safe.

J2. The educator:

Has an unfriendly attitude Judges the client/customer negatively: considers they are ignorant, has

no respect for their perceptions and concerns Doesn't find the real reason(s) for the problem, or understand the

needs and concerns of the client/customers Uses complicated technical language to show superiority Doesn't listen well Interrupts, argues, and is impatient Jumps to conclusions before the client/customer has finished

explaining Lacks knowledge - does not know the answers Doesn't follow-up to see if the advice is put into practice.

J3. The client or customer:

Doesn't trust the health worker or drug provider, feels uncomfortable Is nervous and worried, and is not met with sympathy Doesn't have enough money Has several children waiting at home, without supervision: is in a

hurry Doesn't feel free to say she does not understand, because she feels the

health worker or drug provider is not really interested in her perspective

Doesn't feel free to ask questions Feels he/she is being judged negatively (for not coming for medicine

earlier, for having used traditional herbs, for having used medicine she had at home, etc).

Gets too much information at a time, and no printed information to help her remember

Doesn't understand the language used by the health worker (too complicated) when she explains the reason for the disease to be different from what she believes, and simply says she is wrong

It is easy to see how these barriers could - and very often do - stop the client or customer from learning how to use drugs in a rational way.

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When planning a training programme, make sure that these aspects are considered and fully included, and due attention is paid to them, to teach the educator to be aware and make sure he/she clears away as many barriers as possible before starting the education.

The work of the educator is strengthened by others in the community, such as influential neighbours, women’s groups and community leaders, reinforcing their suggestions for new practices. For example, an educator might be well advised to consult with the community leaders and other health workers (e.g. TBAs, Cs) before starting work with the community. If these influential people support the new practices, chances are high that these will be adopted much more effectively.

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ADDITIONAL READING

Aubel J, Rabei H, Mukhtar M (1991) Health Workers’ Attitudes Can Create Communication Barriers. World Health Forum 12(4):466-471.

Homedes N, Ugalde A (1993) Patient’s Compliance with Medical Treatments in the Third World. What Do We Know? Health Policy and Planning 8(4):291-314.

Hubley J (1993) Communicating Health, Chapter 5: Face to Face pp. 93-110. London: Macmillan.

Marsh V et al. (1999) Changing Home Treatment of Childhood Fevers by Training Shopkeepers in Rural Kenya. Tropical Medicine and International Health 4(5):383-389.

Piller A, Seidel R (1999) Lessons in Creating a Communication Training Video for Health Workers. In: Notes from the Field in Communication for Child Survival, chapter 17 pp. 157-66. Washington DC, Academy for Educational Development and U.S. Agency for International Development.

Pretty J, Gujit I, Thompson J, Scoones I (1995). Participatory Learning and Action. A Trainer's Guide. Chapter 1 pp.1-12. London, IIED, Participatory Methodology Series.

Ross-Degnan D et al. (1996) The Impact of Face to Face Educational Outreach on Diarrhoea Treatment In Pharmacies. Health Policy and Planning, 11(3): 308-318.

ZEDAP (1997). Next is not Enough. A Training Manual To Strengthen the Interpersonal Skills of Health Workers. Harare, Ministry of Health, WHO/UNICEF.

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ACTIVITY 1

Practise using face to face education skills (role-play)

Participants should split into groups of three: a "health worker" (or "shopkeeper"), a "client" (or "customer"), and an observer.

Instructions to the "client" or "customer":Read the instructions in your case study (A or B), and add your own thoughts and ideas without changing the basic content. Respond as “naturally” as possible to the way the health worker or shopkeeper deals with you (from the perspective of your role).

Instructions to the "health worker" or "shopkeeper/informal provider":Practise effective communication skills.

Instructions to observer:Observe and note how the health worker or shopkeeper practises the communication skill. Does she:

Understand the problem by: Observing the mood of the client/customer, and responding appropriately

(friendly, reassuring) Asking open questions Listening carefully, with the intention to understand.

Respond to the problem/needs by: Giving accurate and clear advice, and explaining why Discussing to reach an agreement Checking for understanding.

Give constructive feedback on each point. What should the health worker/shopkeeper do differently?

Case study AYou are a mother/father with a 5-year-old child who has had fever with slight cough for four days. Today, she started having diarrhoea, and has passed two loose stools. She has no other danger symptoms, except feeling slight pain in her body. You have given her an aspirin, but this did not help much. You do not have much money, and are planning to buy a single antibiotic capsule (or get medicine from the health worker). When you have used such a capsule earlier, your child got well for several days.

IF there is time, change roles in the group and tackle the second case study.

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Case study BYou are a young mother/father, and your 2-year-old child has had fever for two days. He does not react to the herbal drink you have given him, and you take him to the clinic/shop to get a chloroquine injection. You get irritated with the health worker/shopkeeper who says you should give the boy tablets instead. Your mother-in-law is a strong believer in injections, and says this will cure the boy. You are afraid for your son, because your sister lost a child to fever last week, after the child had an injection. You will not tell the health worker/shopkeeper this unless he/she is friendly and concerned, and you feel you can trust the advice he/she gives you. If the health worker/shopkeeper is very convincing, you will agree to get the tablets instead of the injection. Your son does not vomit, and he is able to eat and drink. He has no other danger signs.

In plenary:

One group will be asked to play out a role-play in front of the full group, with the other participants observing and later commenting.

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ACTIVITY 2

Convincing government managers of the need for a face to face community education programme.

Participants should work in 'table' groups. The facilitator will allocate the role of either programme planner or government manager to each group.

1: Programme plannersYou are programme planners/implementers who are preparing for a meeting with government officials (managers) from the Ministry of Health, to discuss the need for a face to face education programme in the community (choose the subject for the programme). The goal of your organisation is to cooperate with the MOH to run a programme (decide in the group whether it should be on a small or large scale). You don’t have much money, and need the MOH to bear at least half the cost.

Develop a list of arguments why the MOH should support such a programme. Think about the arguments the government officials might use against the idea, and how you will answer these. What resource materials (studies, economic data, etc.) will you bring with you to strengthen your case? Discuss the strategy you will use to meet your goal, and select the person(s) (one or two) from your group who would represent you at the meeting. Prepare for meeting the officials in their office.

2: Government managersYou are government managers running your country’s health programme, which has lately been criticised for being very top-down. You have been contacted by a group of people who would like to cooperate with you to develop and implement a face to face education programme. Your department has not tried this method before, and you are sceptical, but not uninterested. You know you need to do something to improve the MOH image in the population. Your budget is limited, but you do have a senior director who has said she is willing to support some new projects, if she is convinced they will work.

Discuss your strategy for the meeting: What do you need to know from the group/representative? What are your concerns? What will you tell him/them about the situation in your department? How will you run the meeting? Select one or two representatives from your group for the meeting.

Plenary:One team from each of the two groups (i.e. one Programme Planner and one Government Manager group) will be selected to conduct a role-play based on their preparatory work.

The trainers will note on the flipchart the arguments that are used on each side. Groups that did not participate in the role-play will be invited to contribute additional arguments.

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As the role-play takes place think about and note which arguments were the most successful (content), and how did the way they were presented (form/interpersonal communication) influence how they were received?

Also note and discuss what the planners did, that had a negative effect on the government manager(s).

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ANNEX 1. ADVANTAGES AND DISADVANTAGES OF FACE TO FACE EDUCATION METHODS

Method Advantages Disadvantages CommentsOne-to-one discussion

Common method to patient, and drug provider to customer. Gives chance for explanation, questions and discussion. Visual aids can be used. Client/customer can be given handout to remember how to take the drugs. Can come back for further explanation, or treatment.

Takes time - often in a hurry, blaming the client. Informal providers often not trained in correct dispensing, and in communication. Clients/customers not used to asking questions. Clients/customers have different perception of disease causality and treatment (from the bio-medical ones).

Most effective when client/customer trusts the health worker/provider, and the health worker/ provider has good communication skills.

Groupdiscussion

Builds group consensus. Participants can exchange opinions and increase knowledge, understanding and tolerance. Can give impetus to try new practices, and information on whom to discuss with further.

Requires trained leaders. Some members may dominate. Can be difficult to control, or to keep focus on the main issue. Needs conscious selection of participants.

Can be used with interested audience to discuss specific problem. Procedure: flexible and informal. Summary to be presented at the end.Group members to decide on group’s stand on the issue.Requires selection of good chairperson.

Drama Groups can be active: “learning by doing”. Can attract community attention and stimulate thinking and discussion - if situations are effectively dramatised.

Actors need training in preparing script. Field worker might not have right background. Difficult to organise, requires good skills and careful guidance.

Mainly to be used in training courses. Should be restricted to one issue. Can be used for public meeting as entertainment - if well prepared.

Presentation of case study

Can illustrate a situation where audience can provide suggestions. Can elicit local initiatives if the case corresponds to local problems.

Difficult to organise. Rewording of events and personalities might reduce effectiveness. Some audiences may not identify with the case.

Can be used in training course. Should be carefully prepared. Discussion should lead to recommendations for action. Audience should be encouraged to prepare case studies relevant to its experience

Home visit Can establish good personal relationships between fieldworkers and families. Can provide information about families that is otherwise difficult to

Fieldworker cannot visit every home in the community. Requires good interpersonal skills in the fieldworker.

Records should be kept of families visited. Schedule of home visits should be developed together with families, to find the best time.Handouts can be given

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Method Advantages Disadvantages Commentscollect. Encourages families to participate in public functions, demonstrations and group work.Careful selection of families can help information be spread effectively.

to families.

Demon-stration

Participants can be active and learn by doing. Convinces the audience that things can easily be done. Establishes confidence in field worker’s ability. Gives chance for community members to show their skills. Provides opportunity for combining fun with learning.

Requires preparation and careful selection of demonstration topic and place. Outside factors can affect demonstration results and might affect confidence in demonstrator/field worker.

Demonstration should be rehearsed in advance. Audience should participate in the actual process. Educational materials can be distributed at the end to help people remember. Place and time should be suitable for attendance.

Role-play Especially useful for dealing with sensitive issues, e.g. emotions, taboos, myths, power imbalance.Good for controversial issues: can present facts and opinions from different viewpoints. Can encourage people to re-evaluate their stand. Invites audience participation. Deepens group insight into personal relations.

Some role-players may feel upset by playing a role they do not agree with. Requires careful selection of topic, and preparation of actors. Requires good educator to lead discussion, and to focus on essential points.

Primarily to be used in training courses. Follow-up discussion should focus on the issue rather than on actor’s performance. Actors should comment first on how they felt, being in the role.Source materials can be provided to actors to prepare arguments, or time allocated for the preparation, and information on purpose and main contents given by trainer.

Table partly adapted from “Using communication support in projects: The World Bank’s Experience”, by Heli Perrett (198) and Summary table in module on Linking research to intervention.

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ANNEX 2. GIVING ADVICE AND CHECKING UNDERSTANDING, MALARIA EXAMPLE

Give accurate and clear advice, and explain why

A shopkeeper has decided a customer’s child has malaria, and suggests that the mother buy anti-malarial drugs for him (chloroquine), plus paracetamol to reduce the fever. He explains why he has come to this conclusion - that most of the children who have fever in this area have malaria. It is safer to treat them with anti-malarial drugs right away.

The chloroquine has to be taken for three days, and the shopkeeper explains carefully why this is so: each dose of the drug kills some of the malaria germs. When there are fewer germs, the fever is not so high, and the mother might think there are no more germs, and stop giving the medicine. However, some germs are still there, so she has to give all three doses. Otherwise, the germs will multiply and get strong again, and give her son a new attack of fever after some time.

The advice should be:Clear and simple: how the drug works, how often to take it, for how long. Avoid using technical words.

You should:Explain WHY this treatment should be given.Emphasise the importance of finishing the treatment, and what can happen if this is not done.Be confident, friendly and non-judgemental.Demonstrate: when possible show how to measure and give the first dose, and give it to the patient.

Discuss to reach an agreementThe mother is not sure about buying the full course of the drug, in her experience the fever goes down after one or two days, and that is how long she wants to give the drug. The shopkeeper explains again why it is important to give the full course, and what can happen if she doesn’t. He asks for previous experience when she has given the drug for one or two days, and the mother says the child got fever again after one or two weeks. The shopkeeper explains why this happened, and says it will not happen if she gives the drug for three days. This time the mother understands, and accepts the reasons for the new practice. The shopkeeper encourages her to ask questions. She has a few more concerns, and they discuss until she feels she knows what to do.

However, she does not have enough money. They negotiate, and the shopkeeper says she can take the drugs, and come back to pay him later. Then she can also tell him if the child is well after taking the drugs. The mother decides that if the shopkeeper is even willing to give her credit, then he must really believe in the need to take a full course. So, she agrees. Check for understandingThe shopkeeper has explained to the mother when to give the drugs. He wants to be sure she remembers, and asks her to tell him what she has understood about giving the drugs. She explains, and he corrects if necessary. It is NOT

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sufficient to ask: “Have you understood what I told you?” If she says “yes”, you still don’t know if she has remembered the advice in the right way.These skills are important in a drug transaction, and are core skills for a face to face educator.

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ANNEX 3. SOME KEY TRAINING MESSAGES FROM ZIMBABWE'S TRAINING MANUAL ON COMMUNICATION IN A HEALTH CARE CENTRE

Establish a warm and caring relationship

GreetingsFirst impressions are important. A smile and respectful greeting sets a positive mood for the rest of the consultation.

ReassuranceVisiting a health facility is always stressful - not being sure of what is wrong, or what treatment is going to be offered. You should try to reassure your patient that s/he made the right decision to visit the clinic, and that s/he will get better. Try to end the consultation with a few words of encouragement such as "I'm sure you will feel a lot better soon".

Body languageMost of the communication in a face to face encounter takes place through non-verbal mechanisms. Through your body language, you say much more than the spoken word, and may even contradict what you have said. Your facial expression, the way you sit and the gestures you make all give clues about what you are thinking and your attitude. You can also learn a great deal about your patient by being aware of his non-verbal signals.

Tone of voiceThe way you speak is also as important as the words. It is possible to say something nice in a harsh or condemning manner, just as serious words can be made softer by our tone of voice.

Respect your patient

Don't pass judgementYour job is to give advice on how to live a healthy life, not to criticise the behaviour and values of others. Respect your patient's right to think and act as s/he wishes, even if your own values are different.

Privacy and confidentialityEveryone has a right to privacy, including your patient. If s/he is assured privacy and confidentiality, s/he will feel more comfortable and feel safe enough to offer more information about her condition and her/his beliefs. S/he will feel free to ask questions about her/his concerns. Privacy extends from closed doors and screens, to knowing that you will not disclose information about her/him to anyone else.

History taking and examinationNo consultation is complete without taking a full history and carrying out an examination. You may well experience difficulties and taboos, especially when dealing with reproductive health complaints - even more so if the health worker and patient are of different sex. You can deal with this more easily if you adopt a professional approach. Try to convince your patient by your attitude that your history taking is not just a form-filling exercise.

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Communicate effectively

DiscussionHealth education is not a process of the health worker telling the patient facts. For it to be meaningful, and for the information to be accepted and used, a two-way discussion is required. Through discussion you can explore the concerns or misconceptions that your patient might have. You must create the atmosphere to empower her/him to say what s/he thinks, to feel safe enough to speak.

QuestionsAsking an open-ended question is an effective method of exploring concerns, and establishing if a discussion has been understood. An open-ended question generally includes words such as "why", "when", "what", "how". The answer to such questions cannot be merely "yes" or "no".

ListeningHaving asked a question, it is equally important to listen to the answer. Listening involves a lot more than just hearing the words. It includes behaviour such as showing interest in what your patient is saying, not writing while an answer is given, and looking at the speaker for non-verbal signals.

LanguageA meaningful discussion requires that both people understand each other. The language you use must be suited to your patient. There is no need to try to impress her/him with long clinical words, but remember that patients are not stupid. They are able to learn medical words and principles. Use correct medical terms but explain them in everyday language if necessary. Speak slowly and clearly, pausing between each new message to give the listener time to take in what has been said, and to ask any questions.

Source: ZEDAP (1997) Next is not enough: a training manual to strengthen the interpersonal skills of health workers. MOH Zimbabwe/WHO/UNICEF pp. 5-7.

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