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Helping Health Workers Learn (2005)
Helping
Health Workers
Learn
A book of methods, aids,
and ideas for instructors
at the village level
David Werner and Bill Bower
drawings by
David Werner Pablo Chavez
Regina Faul-Jansen Marie Ducruy
Helping Health Workers Learn (2005)
Library of Congress Cataloging-in-Publication Data
Catalog Card No.: 81-85010
Werner, David Bradford and Bower, Bill Lamed
Helping Health Workers Learn
Palo Alto, CA: Hesperian Foundation
632 p.
8111 811015
ISBN: 0-942364-10-4
PUBLISHED BY:
The Hesperian Foundation
1 91 9 Addison Street, Suite 304
Berkeley, California 94704 U.S.A.
Copyright © 1982 by the Hesperian Foundation. All Rights Reserved.
First Edition, January 1982
Thirteenth Printing, January 2005
The Hesperian Foundation encourages others to copy, reproduce, or adapt to meet local
needs any or all parts of this book, including the illustrations, provided that the parts
reproduced are distributed free or at cost — not for profit.
Any organization or person who wishes to copy, reproduce, or adapt any or all parts of th
book for commercial purposes must obtain permission from the Hesperian Foundation.
Before beginning any translation or adaptation of this book or its contents, please contact
the Hesperian Foundation for suggestions, updates on the information, and to avoid
duplication of efforts. Please send us a copy of any materials in which text or illustrations
from this book have been used.
Helping Health Workers Learn (2005)
This book is dedicated to the village
health team of Ajoya, Mexico, from
whom we have learned a great
deal...
and to health workers everywhere
who side with the poor.
REQUEST FOR YOUR COMMENTS,
CRITICISMS, AND IDEAS:
This book is only a beginning. We want to
improve it— with your help.
If you have any ideas, teaching methods,
visual aids, or ways of exploring or learning
that you feel might be put into this book, please
send them to us.
Also let us know which parts of the book you
find most useful, and which parts, pages, or
paragraphs you find confusing, badly written,
least useful, incorrect, or unfair. We think the
book is too long, and ask your help in deciding
what to leave out.
WE ARE ESPECIALLY INTERESTED IN
GETTING SUGGESTIONS FROM VILLAGE
AND COMMUNITY HEALTH WORKERS
WHO HAVE BECOME INSTRUCTORS.
Please write to:
The Hesperian Foundation
1919 Addison Street, Suite 304
Berkeley, California 94704 U.S.A.
Thank you.
Helping Health Workers Learn (2005)
THANKS
The creation of this book has been a long, cooperative effort. We have borrowed
ideas from many sources. Included in these pages are methods and suggestions from health
and development programs in 35 countries on 5 continents. Often we mention the programs
or countries from which particular ideas have come as we discuss them in the text. Here,
however, we give our warm thanks to all programs, groups, and persons whose ideas,
suggestions, and financial assistance have contributed to this book.
Our heartfelt appreciation goes to the village health team in Ajoya, Mexico,
especially to Martin Reyes, Miguel Angel Manjarrez, Roberto Fajardo, Miguel Angel
Alvarez, Pablo Chavez, Jesus Vega Castro, Rosa Salcido, Guadalupe Aragon, Alejandro
Alvarez, Teresa Torres, Anacleto Arana, and Marcelo Acevedo. It is from working with the
Ajoya team for many years that we have come to understand the meaning of community-
based health care.
We would also like to renew our thanks to the dedicated persons who helped put
the first edition of this book together back in 1982: Myra Polinger, Lynn Gordon, Mary Klein,
Michael Blake, Hal Lockwood, Christine Taylor, Richard Friedman, Susan Klein, Andy Browne,
KenTull of World Neighbors, Meg Gramto, and Emily Goldfarb. Trude Bock generously
provided her home and all-round assistance during the three years it took to give birth to this
book
Our special thanks to B.A. Laris for undertaking the editing, layout, and paste-up for the
tenth printing. Her efforts make this printing easier to use with the 1992 revision of Where
There Is No Doctor. Davida Coady updated the antibiotic learning game found in Chapter 19
and Martin Lamarque provided current information on organizations that make practical
teaching materials available.
For their outstanding drawings, we thank Regina Faul-Jansen, Marie Ducruy, and
Pablo Chavez of the village health team in Ajoya. Pablo also invented and helped develop
several of the most imaginative teaching aids shown in this book. For many of the drawings
and most of the photographs, credit also goes to David Werner.
David Morley, Murray and Gerri Dickson, Fred Abbatt, Pia Moriarity, Sunil Mehra, Laura
Goldman, and Esther de Gaily reviewed early drafts of this book. We remain grateful for their
valuable suggestions and encouragement.
Early drafts of Helping Health Workers Learn were field tested in Latin America, Africa,
and the Philippines. From these various field trials we received many helpful ideas and
suggestions. We are deeply thankful to all those health workers, instructors, volunteers, and
health officers who contributed.
For many years our books have been packaged and mailed by a dedicated group of
volunteers who contribute their labor to support the Foundation's efforts to make health
information available. Without their commitment, far fewer copies of our publications would
now be available to people throughout the world. Our thanks to Barbara and Herb Hultgren,
Tom Beckett, Paul Chandler, Bob and Kay Schauer, Marge West, and Betsy Wallace.
Over the years we have received financial assistance from many sources for the
development and distribution of this book. We are grateful to the Ella Lyman Cabot Trust, the
Public Welfare Foundation, Brot fur die Welt, OXFAM England, the Sunflower Foundation,
Misereor, Helmut and Brigitte Gollwitzer, and Reinhart Freudenberg. We also thank the
Carnegie Corporation of New York for funding gratis distribution of this, and other Hesperian
publications, in Africa. We wish to thank the many generous friends of the Hesperian
Foundation who have donated their time and resources to support the struggle for better
health and a better world.
Helping Health Workers Learn (2005)
HOW TO USE THIS BOOK
This book is mainly for instructors of village health workers— especially those
instructors who are village health workers themselves. But it may be of use to
anyone involved in community education.
The book can be used in several ways:
One way is to start at the beginning and read through it. But most of you will
be too busy to do this.
Another way is to skim the book, going through it quickly for the main ideas.
To do this, look at and read what stands out most, namely:
• the pictures
• what is written in dark letters
• what is inside the boxes like this
As you skim, you can stop and read complete pages or sections about ideas that
especially interest you.
Still another way is to use this as a reference book. Review those pages or
sections that apply to a particular activity you are planning— a class, a role play,
the preparation of teaching materials, or whatever. (In most cases, the book will
not tell you ‘how to do it', but will give ideas or examples you can choose from,
think about, or adapt to your own needs.)
To find a topic you are looking for in the book, you can use either the list of
CONTENTS or the INDEX.
The CONTENTS, at the front of the book, lists the chapters in the order that
they appear. On first getting the book, we suggest that you review this list of
CONTENTS.
The INDEX, at the back of the book, lists all of the important topics covered,
in alphabetical order.
This book is organized mostly according to methods, aids, and ideas for
learning, rather than according to specific health topics.
For example, information about 'oral rehydration' appears in several different
chapters: "Looking at Learning and Teaching,” "Appropriate and Inappropriate
Technology," and "Children as Health Workers." If you are planning a class or
activity on oral rehydration, you may want to look up all 3 of these references.
So check the INDEX.
For more suggestions on how to use this book, see the inside of the
back cover.
Helping Health Workers Learn (2005)
HOW TO USE THIS BOOK
(continued)
This book is arranged into 5 major parts, each with a brief introduction. To
make them easier to find, the introductory pages of each part are marked with a
black strip at different heights along the outer margin. The margins of fhe Contents
and Index pages are also lined with black.
By looking
at the edges
of the book,
you can see
where each
part begins.
Page numbering:
Pages are numbered according to the sections or chapters they are in. In each
chapter or section, page numbering starts again from page 1. In the top outer
corner of each page, you will see numbers like these:
Front-3, or 4-12, or Part Two-7
The first word or number in dark letters is the section or the chapter number.
The last number is the page number of that particular section or chapter. Thus,
4-12 means Chapter 4, page 12. At first this numbering system may seem
confusing. But it will make it easier for us to add more pages or rearrange chapters
in future editions.
Language:
We have tried to keep language simple. Where difficult words are used, we try
to explain them, or to use them in such a way that the meaning is clear.
Sometimes we put difficult words in italics (letters like these). And sometimes
the word is explained in small letters at the bottom of the page, after an asterisk*.
Social viewpoint:
In this book we take a strong social position in favor of the poor. Recognizing
that health is closely linked with self-reliance and politics, we have combined
discussion of social factors with practical aspects of health education.
To better understand our social viewpoint and the practical experiences on
which it is based, we suggest that you start by reading the front matter— the
introduction (Front-1 ) and "Why This Book Is So Political" (Front-7). Chapter 1,
"Looking at Learning and Teaching," will also help you put the rest of the book
in perspective.
'Asterisk: This little star is called an asterisk. It is used to indicate that there is more information about a
word or idea at the bottom of the page.
Helping Health Workers Learn (2005)
CONTENTS
page
INTRODUCTION Front 1
WARNING Front-5
WHY THIS BOOK IS SO POLITICAL Front-7
PART ONE: APPROACHES AND PLANS
Chapter 1: Looking at Learning and Teaching 1-1 to 1-30
Chapter 2: Selecting Health Workers, Instructors, and Advisers 2-1 to 2-18
Chapter 3: Planning a Training Program 3-1 to 3-32
Chapter 4: Getting off to a Good Start 4-1 to 4-14
Chapter 5: Planning a Class 5-1 to 5-18
Chapter 6: Learning and Working with the Community 6-1 to 6-20
Chapter 7: Helping People Look at Their Customs and Beliefs 7-1 to 7-13
Chapter 8: Practice in Attending the Sick 8-1 to 8-16
Chapter 9: Examinations and Evaluation as a Learning Process 9-1 to 9-22
Chapter 10: Follow-up, Support, and Continued Learning 10-1 to 10-18
PART TWO: LEARNING THROUGH SEEING, DOING, AND THINKING
Chapter 1 1 : Making and Using Teaching Aids 11-1 to 11-32
Chapter 12: Learning to Make, Take, and Use Pictures 12-1 to 12-22
Chapter 13: Story Telling 13-1 to 13-14
Chapter 14: Role Playing 14-1 to 14-14
Chapter 15: Appropriate and Inappropriate Technology 15-1 to 15-18
Chapter 16: Homemade, Low-Cost Equipment and Written Materials . . . 16-1 to 16-20
Chapter 17: Solving Problems Step by Step (Scientific Method) 17-1 to 17-14
Chapter 18: Learning to Use Medicines Sensibly 18-1 to 18-14
Chapter 19: Aids for Learning to Use Medicines and Equipment 19-1 to 19-18
PART THREE: LEARNING TO USE THE BOOK, WHERE THERE IS NO DOCTOR
Chapter 20: Using the Contents, Index, Page References,
and Vocabulary 20-1 to 20-12
Chapter 21 : Practice Using Guides, Charts, and Record Sheets 21-1 to 21-1 8
PART FOUR: ACTIVITIES WITH MOTHERS AND CHILDREN
Chapter 22: Pregnant Women, Mothers, and Young Children 22-1 to 22-20
Chapter 23: The Politics of Family Planning 23-1 to 23-10
Chapter 24: Children as Health Workers 24-1 to 24-30
PART FIVE: HEALTH IN RELATION TO FOOD, LAND, AND SOCIAL PROBLEMS
Chapter 25: Food First 25-1 to 25-44
Chapter 26: Looking at How Human Relations Affect Health 26-1 to 26-38
Chapter 27 : Ways to Get People Thinking and Acting:
Village Theater and Puppet Shows 27-1 to 27-39
A CALL FOR COURAGE AND CAUTION Back-1
ADDRESSES FOR TEACHING MATERIALS Back-3
INDEX Back-5
ABOUT PROJECT PIAXTLA AND THE AUTHORS Back-13
OTHER BOOKS BYTHE HESPERIAN FOUNDATION Back 16
Helping Health Workers Learn (2005)
Front 1
INTRODUCTION
Health for all by the year 2000 has become the goal of the World Health
Organization (WHO) and most countries around the earth.
Such a world wide goal is very worthy. But in some ways it is dangerous. For
there is a risk of trying to reach that goal in ways that become so standardized, so
impersonal, so controlled by those in power, that many of the human qualities
essential to health— and to health care— are lost.
There is already evidence of this happening. In the last 10 or 15 years, a great
many attempts have been made to bring basic health care to poor communities.
Billions have been spent on large national or regional programs planned by highly
trained experts. But the results have often been disappointing. In most countries,
the number of persons suffering from preventable or easily curable illness
continues to grow.
On the other hand, certain community health programs have been more or less
successful in helping the poor meet their health-related needs. Studies by
independent observers* have shown that programs generally recognized as
successful, whether large or small, often have the following things in common:
1. Small, local beginnings and slow, decentralized growth. Even the more
successful large programs usually have begun as small projects that gradually
developed and evolved in response to the needs of particular communities.
As these programs have grown, they have remained decentralized. This means
that important planning and decision making still take place at the village or
neighborhood level.
2. Involvement of local people— especially the poor— in each phase of the
program. Effective programs recognize and try to deal with the conflicts of
interest that often exist between the strong and the weak, even in a small
community. Not just local leaders, but the most disadvantaged members of
society, play a leading role in selecting their own health workers and
determining program priorities. A conscious aim of such programs is to help
strengthen the position and bargaining power of the poor.
3. An approach that views planning as a 'learning process'. The planning of
program content and health worker training does not follow a predetermined
'blueprint'. Instead, planning goes on continually as a part of a learning
process. Participants at every level (instructors, student health workers, and
members of the community) are invited to help shape, change, and criticize
the plans. This allows the program to constantly evolve and adapt, so as to
better meet people's changing needs. Planning is both local and flexible.
See, for example, David Korten's analysis of successful programs in Asia, "Community Organization and
Rural Development: A Learning Process Approach," Public Administration Review, Septernber/October,
1980. p 480-510.
Front-2
Helping Health Workers Learn (2005)
4 Leaders whose first responsibility is to the poor. Programs recognized as
effective usually have leaders who are strongly committed to a just society.
Often they have had intense personal experience working with the poor in
community efforts to help solve critical needs. Even as their programs have
grown and expanded, these program leaders have kept up their close relations
with the poor working people in individual communities.
5 A recognition that good health can only be attained through helping the
poor improve the entire situation in which they live. Successful programs link
health activities with other aspects of social development. Health is seen as a
state of wholeness and well-being in which persons are able to work together
to meet their needs in a self-reliant, responsible way. This means that to become
fully healthy, each person needs a clear understanding of himself or herself in
relation to others and to the factors that influence all people's well-being.
In many of the most effective health programs, activities that help people to
develop a more critical awareness have become a key part of training and
community work.
In view of these features common to success, the failure of many national and
regional 'community heal th ' programs is not surprising. Most are carried out in
quite the opposite way. Although their top planners speak proudly of "decision
making by the community," seldom do the people have much say about what
their health workers are taught and told to do. 'Community participation' too
often has come to mean "getting those people to do what we decide." Rather
than helping the poor become more self-reliant, many national health and
development programs end up increasing poor people's dependency on outside
services, aid, and authority.
One of the biggest obstacles to 'health by the people' has been the unwillingness
ol experts, professionals, and health authorities to let go of their control. As a
result, community health workers are made to feel that their first responsibility
is to the health system rather than to the poor. Usually they are taught only a
very limited range of skills. They become the servants or 'auxiliaries' to visiting
doctors and nurses, rather than spirited leaders for change. They learn to follow
orders and fill out forms, instead of to take initiative or to help people solve
their problems on their own terms. Such health workers win little respect and
have almost no influence on overall community health. Many of them get
discouraged, grow careless, become corrupt, or quit. Results have been so
disappointing that some experts, even within WHO, have begun to feel that the
goal of 'health for all through community involvement' is like the pot of gold at
the end of the rainbow— a dream that has been tried, but failed.
Helping Health Workers Learn (2005)
Front-3
In spite of the failure of most large, centrally controlled programs to achieve
effective community participation, in many countries there are outstanding
examples of enthusiastic community involvement in health. This is especially
true in small, non-government programs that take what we call a people-centered
or community-strengthening approach to health care.
Within these community-based programs, there is a wealth of variety in terms
of innovation and adaptation to local conditions. But at the same time, there is a
striking similarity in their social and political objectives in many parts of the
world— Pakistan, India, Mozambique, the Philippines, Mexico, Nicaragua,
Honduras, El Salvador, and Guatemala.
In these community-based programs, a new kind of health worker has begun to
play a leading role. These health workers speak out for the 'voiceless' poor. Their
goal is health for all— but health that is founded on human dignity, loving care,
and fairer distribution of land, wealth, and power.
To us, one of the most exciting aspects of this new world-wide community-
based movement, decentralized and uncoordinated as it may be, is that it goes far
beyond any rigid religious or political doctrine. Most of the leaders in these
programs recognize the dangers to ordinary people in any large, centrally
controlled system, be it capitalist or communist. They have far greater faith in
small, self-directed groups of working people. Rather than accept any established
dogma, they are asking searching questions. They welcome criticism, and
encourage others to observe for themselves and form their own conclusions. They
believe in helping the powerless to gain strength through a greater understanding
of the factors that shape their health and their lives.
Around this practical human vision has gradually grown a whole new approach
to the training, role, and responsibilities of community health workers. Ideas and
methods are being shared and further developed through a series of informal
networks around the world.
Many of the ideas in this book have been gathered from these networks of
community-based health programs, and especially from Project Piaxtla, a small,
villager-run program based in Ajoya, Sinaloa, Mexico.
Helping Health Workers Learn (2005)
Helping Health Workers Learn (2005)
Front 5
WARNING
This is not a 'recipe book' of how to plan and conduct a training course for
health workers. Experience has taught us that such a book could easily do more
harm than good. Instead, this is a collection of examples and ideas, of group
experiences and outrageous opinions, of 'triggers to the imagination'. It is an
invitation to adventure and discovery.
Part of the value and excitement of learning is in finding out 'how to do it' for
yourself and with others. It lies in looking at the ways things have been done
before, then improving and adapting them to suit your own circumstances. This
sort of open-ended, creative learning process is as important for instructors of
health workers as for the health workers themselves. After all, finding ways to do
things better is the key to improving health. The instructor can set the example.
To be fully alive and meaningful, a training course cannot be either pre-
packaged or 'replicable' (able to be copied). It needs to be redesigned not only
for each area and set of conditions where it is taught, but each time it is taught.
A training program, like a person, ceases to be interesting when it ceases to
grow or be unique!
So rather than being a 'blueprint' on how to build a training program, this
book is a craftsman's kit of nuts and bolts and tools. Many of the methods and
suggestions come from our personal experience, which has been mostly in Latin
America. So pick and choose from them critically. Use and adapt what you can,
in order to create— and continually re-create— your own very special, unique, and
always-new program. Try to make planning a continuous learning process for
everyone concerned: instructors, students, and members of the community.
Many of the ideas and suggestions in this book are controversial and will not
apply to all areas. We do not ask anyone simply to accept and use them.
Instead, we ask you to challenge them, adapt them, criticize them— and use
only what makes sense for the people and needs in your own area.
We ask you to consider— and urge you to
doubt and question— everything we say.
Helping Health Workers Learn (2005)
from Where
There Is No
Doctor, p. 1 14
www. ncspenan.org
Helping Health Workers Learn (2005)
Front-7
WHY THIS BOOK IS SO POLITICAL
When, 1 7 years ago, I (David Werner) first began working for improvements in
health with villagers in western Mexico, I did not look far beyond the immediate
causes of ill health. As I saw it, worms and diarrhea were caused by poor hygiene
and contaminated water. Malnutrition was mainly caused by scarcity of food in a
remote, mountainous area where drought, floods, and violent winds made farming
difficult and harvests uncertain. The high death rate in children (34%) resulted
from the combination of infection, poor nutrition, and the long distance to the
closest health centers.
In short, I saw people's needs in physical terms, as determined by their
physical surroundings. This short-sightedness on my part was understandable, for
my training had been in life sciences. I had little social or political awareness.
I might have remained that way, as do many health workers, except that I
came so close to the mountain people. I knew from the first that they had
strengths, skills, and endurance that I lacked. And so I was able to let them teach
me about the human— and inhuman— side of their needs and their lives. They did
not sit down and spell things out for me; rather they shared with me their homes,
their hardships, and their dreams. Many times I have struggled with a family,
against odds, to prevent the loss of a child, a cornfield, or hope. Sometimes we
won; sometimes we lost.
Little by little, I became aware that many of their losses— of children, of land,
or of hope— not only have immediate physical causes, but also underlying social
causes. That is to say, they result from the way some people treat or affect the
lives of others. Time and again, I have experienced occasions where death and
suffering of children and other persons I have to come to love have been the direct
or indirect result of human greed.
On page 114 of Where There Is No Doctor there is a photograph of a very thin
little boy in the arms of his malnourished mother The boy eventually died — of
hunger. The family was — and still is — very poor Each year the father had to borrow
maize from one of the big landholders in the area. For every liter of maize
borrowed at planting time, he had to pay back 3 liters at harvest time. With these
high interest rates, the family went further and further into debt. No matter how
hard the father worked, each year more of his harvest went to pay what he owed
to the landholder. Each year he had to borrow more, and pay back 3 times as
much. Eventually, the family had to sell their few chickens and pigs, and finally
even the beans they had grown on the steep mountain slopes, to buy enough corn
to survive.
With no eggs or beans to eat, the mother became increasingly malnourished. Her
breasts failed to produce milk for her baby. So she fed him the only food they
had— cornmeal and water. In time the child died.
Fronts
Helping Health Workers Learn (2005)
Part of the problem may also have been that the father occasionally drinks with
the other men. When he gets drunk, he loses his judgement and sometimes, to buy
rounds of drinks, sells a part of the family's precious supply of corn.
This is sad. But look at the father's life. The hard work he does only to go
deeper into debt. The death of a child he loved and whom he feels he failed. The
apparent hopelessness of his situation. And frequently his own hunger— not only
for food, but for a fair chance to benefit from his own hard work. We cannot
blame him if he occasionally drinks too much!
Perhaps no one is really to blame. Or perhaps we all are— all of us, at least, who
live with more than we need while others hunger. In any case, it is not right, it is
not kind, it is not human, to remain silent in a world that permits some persons
to grow fat from the hard work of others who go hungry.
The child in the photograph who died is not alone. In the mountain villages I
know, there are hundreds of similar children— some dead and some waiting. In the
world there are millions. One fourth of the world's children are undernourished,
most for reasons similar to those I have just described. Their problems will not be
solved by medicines or latrines or nutrition centers or birth control (although all
of these, if approached decently, may help). What their families need is a fair
chance to live from their own labor, a fair share of what the earth provides.
Do I make myself clear? Let me tell you about Chelo and his family, whom I
have become close to over the years. Chelo has advanced tuberculosis. Before the
villager-run health center was started in his village, he received no treatment. He
knew he had tuberculosis. He wanted treatment. But he could not afford the
medicines. (Basic tuberculosis medicines are not expensive to produce. But in
Mexican pharmacies, they are sold at up to ten times their generic price in the
United States and other developed countries.) Although the government's
tuberculosis control program does give free medication, it requires that patients
go often to one of its city health centers for tests and medication. For Chelo,
this would have meant 250 kilometers of travel every two weeks. He simply
could not afford it.
For years, Chelo had worked for the richest landholder in the village. The
landholder is an unhappy, overweight man who, apart from his enormous
landholdings, owns thousands of cattle. When Chelo began to grow weak from
his illness and could not work as hard as before, the landholder fired him, and
told him to move out of the house he had been lending him.
Chelo, his wife, Soledad, and his stepson, Raul,* built a mud-brick hut and
moved into it. By that time Chelo was coughing blood.
Around the same time, the community-based health program was getting
started in the area, but as yet no health worker had been trained in Chelo's
village. So a visiting health worker taught Chelo's 1 1 -year-old stepson, Raul, to
inject him with streptomycin. Raul also learned to keep records to be sure Chelo
took his other medicines correctly. The boy did a good job, and soon was
injecting and doing follow-up on several persons with tuberculosis in the village.
By age 13, Raul had become one of the central team of health workers in the
area. At the same time, he was still attending school.
•These are real persons, but I have changed their names.
Helping Health Workers Learn (2005)
Front 9
Meanwhile, Chelo's family had cleaned up a small weed patch and garbage area
at the lower edge of town. With much hard work they had constructed a simple
irrigation system using ditches and grooved logs. At last they had a successful
vegetable plot, which brought in a small income. Chelo's health had improved,
but he would never be strong. T reatment had begun too late.
Economically, Chelo had one setback after another. Just when he was
beginning to get out of debt to the storekeepers and landholders, he fell ill with
appendicitis. He needed hospital surgery, so health workers and neighbors carried
him 23 kilometers on a stretcher to the road, and from there took him to the
city by truck. The surgery (in spite of the fact that the doctor lowered his fee)
cost as much as the average farmworker earns in a year. The family was reduced
to begging.
The only valuable possession the family had was a donkey. When Chelo
returned from the hospital, his donkey had disappeared. Two months later, a
neighbor spotted it in the grazing area of one of the wealthier families. A new
brand— still fresh— had been put right on top of Chelo's old one.
Chelo went to the village authorities, who investigated. They decided in favor
of the wealthy thief, and fined Chelo. To me, the most disturbing thing about
this is that when he told me about it, Chelo did not even seem angry— just sad.
He laughed weakly and shrugged, as if to say, "That's life. Nothing can be done."
His stepson, Raul, however, took all these abuses very hard. He had been a
gentle and caring child, but stubborn, with an enormous need for love. As he got
older, he seemed to grow angrier. His anger was often not directed at anything
in particular.
An incident with the school was the last straw. Raul had worked very hard to
complete secondary school in a neighboring town. Shortly before he was to
graduate, the headmaster told him in front of the class that he could not be given
a certificate since he was an illegitimate child— unless his parents got married.
(This happened at a time when the national government had decided to improve
its statistics. The president's wife had launched a campaign to have all unwed
couples with children get married. The headmaster's refusal to give graduation
certificates to children of unwed parents was one of the pressures used.) Chelo
and his wife did get married— which cost more money— and Raul did get his
certificate. But the damage to his pride remains.
Young Raul began to drink. When he was sober, he could usually control
himself. But he had a hard time working with the local health team because he
took even the friendliest criticism as a personal attack. When he was drunk, his
anger often exploded. He managed to get hold of a high-powered pistol, which he
would shoot into the air when he was drinking. One night he got so drunk that
he fell down unconscious on the street. Some of the young toughs in town, who
also had been drinking, took his pistol and his pants, cut off his hair, and left
him naked in the street. Chelo heard about it and carried Raul home.
After this, Raul hid in shame for two weeks. For a while he did not even visit
his friends at the health post. He was afraid they would laugh. They did not. But
Raul had sworn revenge— he was never quite sure against whom. A few months
later, when drunk, he shot and killed a young man who had just arrived from
another village. The two had never seen each other before.
Front 1 0
Helping Health Workers Learn (2005)
This, to me, is a tragedy because Raul was fighting forces bigger than himself.
As a boy of 1 2, he had taken on the responsibilities of a man. He had shown care
and concern for other people. He had always had a quick temper, but he was a
good person. And, I happen to know, he still is.
Who, then, is to blame? Again, perhaps no one. Or perhaps all of us. Something
needs to be changed.
After the shooting, Raul fled. That night, the State Police came looking for
him. They burst into Chelo's home and demanded to know where Raul was.
Chelo said Raul had gone. He didn't know where. The police dragged Chelo into
a field outside town and beat him with their pistols and rifles. Later, his wife
found him still lying on the ground, coughing blood and struggling to breathe.
It was more than a year before Chelo recovered enough to work much in his
garden. His tuberculosis had started up again after the beating by the police.
Raul was gone and could not help with the work. The family was so poor that,
again, they had to go begging. Often they went hungry.
After a few months, Chelo's wife, Soledad, also developed signs of tuberculosis
and started treatment at the village health post. The local health workers did not
charge for her treatment or Chelo's, even though the health post had economic
difficulties of its own. However, Chelo's wife helped out when she could by
washing the health post linens at the river. (This work may not have been the best
thing for her TB, but it did wonders for her dignity. She felt good about giving
something in return.)
About 4 years have passed since these last incidents. Chelo and his wife are
now somewhat healthier, but are still so poor that life is a struggle.
Then, about a year ago, a new problem arose. The landholder for whom Chelo
had worked before he became ill decided to take away the small plot of land
where Chelo grew his vegetables. When the land had been a useless weed patch
and garbage dump, Chelo had been granted the rights to it by the village
authorities. Now that the parcel had been developed into a fertile and irrigated
vegetable plot, the landholder wanted it for himself. He applied to the village
authorities, who wrote a document granting the rights to him. Of course, this
was unlawful because the rights had already been given to Chelo.
Chelo took the matter over the heads of the village authorities to the Municipal
Presidency, located in a neighboring town. He did not manage to see the President,
but the President's spokesman told Chelo, in no uncertain terms, that he should
stop trying to cause trouble. Chelo returned to his village in despair.
Chelo would have lost his land, which was his one means of survival, if the
village health team had not then taken action. The health workers had struggled
too many times— often at the cost of their own earnings— to pull Chelo through
and keep him alive. They knew what the loss of his land would mean to him.
At an all-village meeting, the health workers explained to the people about the
threat to Chelo's land, and what losing it would mean to his health. They produced
proof that the town authorities had given the land rights to Chelo first, and they
asked for justice. Although the poor farm people usually remain silent in village
meetings, and never vote against the wishes of the village authorities, this time
they spoke up and decided in Chelo's favor.
Helping Health Workers Learn (2005)
Front- 1 1
The village authorities were furious, and so was the landholder.
The health team had taken what could be called political action. But the health
workers did not think of themselves as 'political'. Nor did they consider themselves
capitalists, communists, or even socialists. (Such terms have little meaning for
them.) They simply thought of themselves as village health workers— but in the
larger sense. They saw the health, and indeed the life, of a helpless person
threatened by the unfairness of those in positions of power. And they had the
courage to speak out, to take action in his defense.
Through this and many similar experiences, the village health team has come
to realize that the health of the poor often depends on questions of social justice.
They have found that the changes that are most needed are not likely to come
from those who hold more than their share of land, wealth, or authority. Instead,
they will come through cooperative effort by those who earn their bread by the
sweat of their brows. From themselves!
More and more, the village team in Ajoya has looked for ways to get their
fellow villagers thinking and talking about their situation, and taking group
action to deal with some of the underlying causes of poor health.
Some of the methods they have developed and community actions they have
led are described in several parts of this book. For example, three of the village
theater skits described in Chapter 27 show ways in which the health team has
helped the poor look at their needs and organize to meet them.
These 3 skits are:
SMALL FARMERS JOIN TOGETHER TO OVERCOME EXPLOITATION
(page 27-27),
USELESS MEDICINES THAT SOMETIMES KILL (page 27-14), and
THE WOMEN JOIN TOGETHER TO OVERCOME DRUNKENNESS (page
27 19).
These popular theater skits had, and are still having, a marked social influence.
Villagers participate with new pride in the cooperative maize bank set up to
overcome high interest on loans. Women have organized to prevent the opening
of a public bar. And storekeepers no longer carry some of the expensive and
dangerous medicines that they sold before. In general, people seem more alert
about things they had simply accepted.
On the other hand, new difficulties have arisen. Some of the health workers
have been thrown out of their rented homes. Others have been arrested on false
charges. Threats have been made to close down the villager-run program.
But in spite of the obstacles, the health team and the people have stood their
ground. The village team knows the road ahead will not be easy. They also know
that they must be careful and alert. Yet they have chosen to stand by their
people, by the poor and the powerless.
They have had the courage to look the whole problem in the eye— and to look
for a whole answer.
Front 12
Helping Health Workers Learn (2005)
The story of Cheio and his family is true, though I have not told the half of it.
It is typical, in some ways, of most poor families. Persons in several parts of the
world who are poor or know the poor, on reading Chelo's story have commented,
"It could have been written here!"
I have told you Chelo's story so that you might understand the events that
have moved us to include in this book ideas and methods that might be called
'political'.
What I have tried to say here has been said even better by a group of
peasant school boys from Barbiana, Italy. These boys were flunked out of
public school and were helped, by a remarkable priest, to learn how to
teach each other.*
The Italian peasant boys write:
Whoever is fond of the comfortable and the fortunate stays out of politics.
He does not want anything to change.
But these school boys also realize that:
To get to know the children of the poor and to love
politics are one and the same thing. You cannot love
human beings who were marked by unjust laws and not
work for other laws.
* Letter to a Teacher, by the school boys of Barbiana. For more ideas of these school boys, see p. 16 16.
Helping Health Workers Learn (2005)
Part One 1
PART ONE
APPROACHES AND PLANS
In Part One of this book, we look at approaches to planning and carrying out a
training program for community health workers.
But before getting into different aspects of planning, in Chapter 1 we explore
alternative approaches to learning and teaching. We do this because the educational
methods instructors decide to use will in part determine how the training course is
designed and who takes part in the planning. In health education, the methods are
as important as the message.
Chapter 2 is about the selection of both health workers and instructors. We
consider the reasons why persons selected from and by their own communities
usually make the best leaders for change. We also discuss why experienced village
health workers often make the best instructors of new health workers.
In Chapter 3, we consider steps in planning a training course, and in Chapter 4,
how to get the course off to a good start.
Chapters 5, 6, 7, and 8 explore activities in the 3 main places of learning in a
training course: the classroom (Chapter 5), the community (Chapters 6 and 7),
and the clinic or health center (Chapter 8). We point out that in each of these
places, the classroom included, the most effective form of learning is through
actual practice in solving common problems.
Chapter 9 discusses ways of finding out how well people are teaching, learning,
and meeting local needs. Here we look for ways in which tests, exams, and
evaluation can be organized to strengthen the position of the weak and help
everyone reach a better understanding of the training program as a whole.
In Chapter 10, we consider what happens after the initial training course is
completed and health workers are back in their own communities. This includes
supportive follow-up and continued opportunities to learn.
Helping Health Workers Learn (2005)
Helping Health Workers Learn (2005)
1 1
T x . CHAPTER +
Looking at Learning 1
and Teaching
A health worker's most important job is to teach— to encourage sharing of
knowledge, skills, experiences, and ideas. The health worker's activities as an
'educator' can have a more far-reaching effect than all his or her preventive and
curative activities combined.
But depending on how it is approached, and by whom, health education can
have either a beneficial or harmful effect on people's well-being. It can help
increase people's ability and confidence to solve their own problems. Or, in
some ways, it can do just the opposite.
Consider, for example, a village health worker who calls together a group of
mothers and gives them a 'health talk' like this:
What effect does this kind of teaching have on people?
You can discuss this question with your fellow instructors or with the health
workers you are training. Or health workers can discuss it with people in their
villages. You (or the learning group) may come up with answers
something like these:
"It's the same old message everybody's heard
a hundred times! But what good does it do?"
"It goes in one ear and out the other!"
"The mothers just sit and listen.
They don't take part."
1-2
Helping Health Workers Learn (2005)
The more deeply your group explores this example of 'health education', the
clearer the picture wi II become. Encourage the group to notice ways in which
this kind of teaching affects how people view themselves, their abilities, and their
needs. Persons may observe that:
"That kind of teaching makes the mothers
feel ashamed and useless— as if their own
carelessness and backwardness were to blame
for their children's ill health."
"The health worker acts like she is God
Almighty! She thinks she knows it all and
the mothers know nothing!"
"Her uniform separates her from the mothers
and makes her seem superior. It gives her
outside authority. This may strengthen
people's respect for her, but it weakens
their confidence in their ability to take
the lead themselves."
"I don't think her health advice is realistic. Not for
the poor in our area! It's easy to tell people to
boil drinking water. But what if a mother with
hungry children spends her food money to buy
firewood? Also, where we live, the land is already
being turned into a desert because so many trees
are being cut. For us, this 'health message' would
make no sense."*
"This is the way most of us were
taught in school. The teacher is
the boss. The students are
considered to 'know nothing'.
They are expected simply to
repeat what they're told.
But isn't this just another
way of keeping the poor
on the bottom?"
"I agree! This kind of 'health
education' might get mothers
to boil water, wash their
hands, and use latrines. But
in the long run it may do
more to prevent than to
promote the changes we
need for lasting
improvements in our
health."
The instructors, health workers, or villagers who discuss this question may
arrive at answers similar to or very different from those suggested above. Their
responses will depend, in part, on the local situation. But in part they will depend
on how carefully the group looks at, thinks about, and 'analyzes' the issues involved.
For more discussion about boiling drinking water, see p. 15-3.
Helping Health Workers Learn (2005)
1-3
Mow consider another example. Here, a health worker gets together with a
group of mothers and discusses their problems with them. She starts by asking
questions like these:
What effect does this kind of teaching have on people? In discussing this
question with your group, you may hear answers like these:
"Everybody takes part. It gets the group of mothers
thinking and talking about their own problems."
"The health worker doesn't just tell them the answers. I
Everyone looks for answers together."
"The health worker dresses like the other mothers and
puts herself on their level. She is their friend, not their
'master'. It makes everyone feel equal." m fir ' 'r
"This sort of teaching certainly * * “|
isn't like what we got in
school! It lets people feel their
ideas are worth something. It helps people figure out
their problems and work toward solving them
themselves."
"I'll bet the mothers will want to keep working and
learning together, because they are respected as
thoughtful, capable human beings. It makes learning
fun!"
Once again, when you discuss this teaching example with fellow instructors,
health workers, or villagers, their answers may be very different from the ones
shown here— or from your own. But if the group discusses the issues in depth,
relating them to their own concerns and experiences, they will make many
valuable observations. You will all learn from each other.
1-4
Helping Health Workers Learn (2005)
How something is taught is
just as important as what is
taught.
And the most important
part of how something is
taught is the caring, respect,
and shared concern that go
into it.
Aristotle, "Father of
Science," wisely said .
HOW CAN I TEACH
BUT TO A FRIEND?
DIRECTING HEALTH EDUCATION TOWARD THOSE
WHOSE NEEDS ARE GREATEST
People usually teach in the way they themselves were taught— unless something
either alarming or loving happens to change the way they view things and do
things. This is true for health workers. And it is true for those of us who are
instructors of health workers. Most of us teach as we were taught in school.
Unfortunately, the purposes and methods of public schools are not always in
the best interests of those whose needs are greatest. As we shall discuss, schools
tend to reward the stronger students and leave the weak behind.
But the aim of 'people-centered' learning is just the opposite. It is to help
those who are weakest become stronger and more self-reliant.
Community health education is appropriate to the
extent that it helps the poor and powerless gain
greater control over their health and their lives.
To become effective community educators, health workers need to develop
approaches very different from what most of us have experienced in school.
For this to happen, it is essential that student health workers critically examine
different ways of teaching during their training. They need to develop and practice
teaching methods that can help ordinary working people to gain the awareness
and courage needed to improve their situation.
In this chapter, we will look at the educational roles of both health workers
and their teachers. Then we will consider some ways of helping health workers
explore alternative approaches for teaching and learning with people.
Helping Health Workers Learn (2005)
1-5
THE TEACHING ROLE OF HEALTH WORKERS
V
Early during training, be sure to have health workers think about the range of
opportunities they will have for sharing and exchanging ideas in their communities.
After discussing the many possibilities, they might post them on a wall as a
reminder:
OPPORTUNITIES FOR SHARING AND EXCHANGING IDEAS WITH PEOPLE
IN OUR VILLAGES
/
We health workers can look for ways to . . .
Help families of sick
persons find ways to care
for them better and to
prevent similar sickness
in the future.
Help mothers find ways
to protect their own health
and that of their children.
Interest school children
(and those who do not go
to school) in learning to
meet the health needs of
their younger brothers and
sisters.
Help organize village
meetings to discuss local
problems. Encourage
others to become ‘health
leaders’.
Exchange ideas and
information with local
midwives, bone setters,
and traditional healers.
Talk with youth groups
and farmers about possible
ways to improve their
crops or to defend their
land and rights.
This list is only a beginning. Your group may think of many other possibilities.
Also, try to get the group thinking about the different ways people learn. In
their village, there may be many people who have never gone to school. They may
not be used to classes, lectures, or 'health talks'. Traditionally, people learn from
stories and play, by watching, copying, and helping others work, and through
practical experience. Ask your students what are the customary ways of learning
in their villages.
Encourage your students to think of ways that they might adapt health
education to people's local forms of learning. Here are some possibilities, which
we discuss in the chapters indicated.
• story telling, Ch. 13
• songs, p. 1-26 and 15-1 5
• play (learning games), Ch. 1 1 , 19, and 24
• make-believe (learning by imitating), Ch. 24
• role playing (acting out problems and
situations), Ch. 14
• popular theater and puppet shows, Ch. 27
• apprenticeship (learning by helping someone
more skilled) , Ch. 8
• practical experience, Ch. 6 and 8
• smal I group discussions, Ch. 4 and 26
• solving real problems, Ch. 8, 10, 14, 17, 25, 26,
and 27
• trial and error (finding things out for oneself),
Ch. 11, 17, and 24
• building on the knowledge, skills, customs, and
experience that people already have, Ch. 7
and 1 3
We health workers need to adapt our teaching to people's
traditional ways of learning— ways they are already used to and enjoy.
1-6
Helping Health Workers Learn (2005)
THE ROLE OF HEALTH WORKER INSTRUCTORS
It is not enough to explain to health workers about 'people-centered' education.
We teachers must set an example. This means we must carefully and frequently
examine our own teaching habits, in terms of both the methods we use and the
way we relate to our students.
• The methods we use. If we would like health workers to use stories when
teaching village mothers, then we, too, need to use stories for helping health
workers learn. If we would like them to help children learn through puppet
shows, games, and discovering things for themselves, we must let them
experience the excitement of learning in these ways. If health workers are to
help farm workers discuss problems and choose their own courses of action,
then we must give health workers similar opportunities during training. Health
workers will be more able to help others learn by doing if they, themselves,
learn by doing.
• How we relate. How we instructors teach health workers is just as important
as what we teach them. But how we teach depends greatly on how we feel
toward our students.
If we respect our students' ideas, and encourage them to question our
authority and to think for themselves, then they will gain attitudes and skills
useful for helping people meet their biggest needs.
But if we fail to respect our students, or make them memorize lessons
without encouraging them to question and think, we may do more harm than
good. Our experience has shown us that health workers trained in this way
make poor teachers and bossy leaders. Rather than helping people gain the
understanding and confidence to change their situation, they can even stand
in the way.
To set a good example for health workers, we instructors need to:
• T reat the health workers as our equals— and as friends.
• Respect their ideas and build on their experiences.
• Invite cooperation; encourage helping those who are behind.
• Make it clear that we do not have all the answers.
• Welcome criticism, questioning, initiative, and trust.
• Live and dress modestly; accept only modest pay.
• Defend the interests of those in greatest need.
• Live and work in the community. Learn together with the people, and
share their dreams.
These ideas are beautifully expressed in this old Chinese verse:
Q-o in search, of If our people- ■.
£ove Them -,
Team from Them. ;
flan with Them*-,
<Serve Them.-,
Beginwith what They have ;
Build on what They j^no-w.
But of { he hest leaders
when their task is
accomplished,
their work *5 doner ,
The people all remar k:
"V)e have done it Ourselves.’
Helping Health Workers Learn (2005)
The rest of this chapter concerns methods
for helping people look at the strengths and
weaknesses of different educational approaches,
especially as they affect the lives and well-
being of the poor. We try to do this by using
the same methods we recommend. We include
examples of stories, role plays, and discussions
that various groups have found
useful in health worker training.
1-7
We ask you to use these
materials not as they are, but
as sparks for ideas. Think about them.
Criticize them. Tear them to pieces. If you
find any parts useful, adapt them to fit the people and needs in your own area.
We encourage you to tear our ideas to
pieces. Save only what you can use or
adapt to your area.
BEGINNING WITH YOUR OWN TRUE STORY
Helping people begin to look at things in new ways is a teacher's chief job.
This is easier if we look at ideas, not in terms of general theories, but through
real-life examples. It is better still when the examples come from the lives and
experiences of the learning group.
As the instructor, why not start by setting the example? Tell a story from
your own experience, one that brings out certain points or problems that need to
be considered. The group can then discuss the story, adding to it from their own
ideas and experiences.
Stories can bring learning closer to I ife —
especially true stories told from personal experience.
It is important that, as group leader, you 'expose' yourself by telling personal
experiences that matter deeply, or that somehow changed the way you look at
things. This will help others to open up and speak of things that really matter
to them.
The following story is both true and personal. We have used it to start groups
of health workers and instructors thinking about some of the human factors
related to teaching and learning. But we do not provide any follow-up discussion
here. We leave that up to you and your group.
You can try using this story 'as is' with your students and your group. Or even
better, tell a story from your own experience. Let your students know you as
a person!
A suggestion for reading stories:
If a story like that which follows is
read in a group, take turns reading.
Let each person read a paragraph.
Helping Health Workers Learn (2005)
true story:
THE IMPORTANCE OF NOT KNOWING IT ALL
A teacher of village health workers who had a college degree was working as
a volunteer in the mountains of western Mexico. One day he arrived at a small
village on muleback. A father approached him and asked if he could heal his
son. The health worker followed the father to his hut.
The boy, whose name was Pepe, was sitting on the floor. His legs were
crippled by polio (infantile paralysis). The disease had struck him as a baby.
Now he was 13 years old. Pepe smiled and reached up a friendly hand.
The health worker examined the boy. "Have you ever tried to walk with
crutches?" he asked. Pepe shook his head.
"We live so far away from the city," his father explained apologetically.
"Then why don't we try to make some crutches?" asked the health worker.
The next morning the health worker got up
at dawn. He borrowed a machete (long curved
knife) and went into the forest. He hunted
until he found two forked branches.
He took the branches back to the home of
the crippled boy and began to make them into
crutches, like this.
The father came up and the health worker showed him the crutches he was
making. The father examined them for a moment and said, "They won't work!"
The health worker frowned. "Wait and see!" he said.
When both crutches were finished, they showed them to Pepe, who was
eager to try them out. His father lifted him into a standing position and the
health worker placed the crutches under the boy's arms.
But as soon as Pepe tried to put his weight on
the crutches, they doubled and broke.
"I tried to tell you they wouldn't work," said
the father. "It's the wrong kind of tree. Wood's
weak as water! But now I see what you have in
mind. I'll go cut some branches of jutamo. Wood's
tough as iron, but light! Don't want the crutches
to be too heavy."
He took the machete and trotted into the forest.
Fifteen minutes later he was back with two forked
sticks of jutamo. At once he set about making the
crutches, his strong hands working rapidly. The
health worker and Pepe assisted him.
When the new crutches were finished, Pepe's
father tested them by putting his full weight on them. They held him easily, yet
were lightweight. Next the boy tried them. He had trouble balancing at first, but
soon was able to hold himself upright. By afternoon, he was actually walking
with the crutches. But they rubbed him under the arms.
Helping Health Workers Learn (2005)
1-9
“I have an idea," said Pepe's father. He went
across the clearing to a pochote, or wild kapok /\
tree, and picked several of the large, ripe fruits
He gathered the downy cotton from the pods, and =s’*’s*aLT
put a soft cushion of kapok onto the top crosspiece \r>
of each crutch. Then he wrapped the kapok in ([
place with strips of cloth Pepe tried the crutches <pe>
again and found them comfortable. 1 1 (j | J |
"Gosh, Dad, you really fixed them great!" cried O y f/ ijf
the boy, smiling at his father with pride. "Look f a / if
how well I can walk nowl" He bounded about the I I j J
dusty patio on his new crutches.
"I'm proud of you, son!" said his father, smiling too.
As the health worker was saddling his mule to leave, the whole family came
to say good-bye
I can't thank you enough,” said
the father. "It's so wonderful to see
my son able to walk upright. I don't
know why I never thought of making
crutches before . . ."
"It's I who must thank you," said
the health worker. "You have taught
me a great deal.”
As the health worker rode down
the trail he smiled to himself "How
foolish of me," he thought, "not to
have asked the father's advice in the
first place. He knows the trees better
than I do. And he is a better
craftsman.
"But how fortunate it is that the
crutches that I made broke. The idea
for making the crutches was mine, and
the father felt bad for not having
thought of it himself. When my
crutches broke, he made much better
ones. That made us equal again!”
So the health worker learned many things from the father of the crippled
boy— things that he had never learned in college. He learned what kind of
wood is best for making crutches. But he also learned how important it is to
use the skills and knowledge of the local people— important because a better
job can be done, and because it helps maintain people's dignity. People feel
more equal when each learns from the other.
It was a lesson the health worker will always remember. I know. I was the
health worker.
1-10
Helping Health Workers Learn (2005)
IDEAS FOR A DISCUSSION ABOUT
SHARING AND SELF-RELIANCE
People's health depends on many things— on food, on water, on cleanliness, on
safety. But above all, it depends on sharing— on letting everyone have a fair share
of land, opportunity, resources— and knowledge.
Unfortunately, many doctors (and many traditional healers) tend to carefully
guard their knowledge rather than to share it openly. Too often they use their
special knowledge to gain power or privilege, or to charge more for their services
than is fair.
Health workers can easily fall into these same unhealthy habits. So their
training must help them guard against this. It should help them realize that to
share their knowledge and skills freely is important to people's health. Sharing of
knowledge helps people become more self-reliant.
Self-reliance as a measure of health: A person who
is very sick needs to be cared for completely. He
can do almost nothing for himself. But as his
health improves, so does his capacity for self-care.
Health is closely related to people's ability to care
for themselves and each other— as equals.
These may be important ideas. But at present they are just our ideas. How is it
possible to get a group of health workers thinking about and reacting to ideas
like these? And forming their own ideas? Lecturing will do little good. A better
way is to help people discover things through thoughtful discussion.
To start, you might find it helpful to ask questions like these:
Health Is The
Opposite of
How are persons who are sick different from persons who are healthy?
Which are better able to care for
themselves? Who needs to be taken
care of?
Who have more health problems,
the rich or the poor? Why?
What do health and well-being have
to do with self-reliance? Of a
person? Of a family? Of a village
or community? Of a nation?
Can you give examples from your
own experience?
After discussing these questions,
you might ask:
• What should be the main goal of
health education?
• What should be your responsibilities
as a health worker?
DO VOU THIN K THIS
IS TRUE ?
STARTING A DISCUSSION
Guide the students in discussing these things, but let them come up with their
own answers.
Helping Health Workers Learn (2005)
1-11
A PUZZLE TO GET PEOPLE THINKING IN NEW WAYS
All of us, teachers
and students alike, get
into 'ruts'. And like
horses with blinders, we
often tend to look at
things from a narrow
point of view. We keep
on trying to solve
problems in the same
old way.
New approaches to health care require new approaches to teaching and learning.
This means tearing off the conventional 'blinders' that limit our vision and
imagination. It means going beyond the walls of the standard classroom and
exploring afresh the world in which we live and learn.
A number of 'tricks' or puzzles can be used to help planners, instructors, or
students realize the importance of looking at things in new ways— of going beyond
the limits their own minds have set. Here is an example:
Draw 9 dots on a paper, on the blackboard, or in the
dust, like this:
Ask everyone to try to figure out a way to connect
all the dots with 4 straight lines joined together
(drawn without lifting the pencil from the paper).
You will find that most persons will try to draw lines
that do not go outside the imaginary square or 'box'
formed by the dots.
Some may even conclude that it is impossible to join all
the dots with only 4 lines. You can give them a clue by
saying that, to solve the puzzle, they must go beyond
the limits they set for themselves.
At last, someone will probably figure out how to do
it. The lines must extend beyond the 'box' formed by
the dots. (Be careful not to shame the students or make
them feel stupid if they cannot solve the puzzle. Explain
that many doctors and professors also have trouble
with it.)
After the group has seen how to solve the puzzle, ask some questions that help
them consider its larger significance. You might begin with questions like these:
• In what way is a classroom like the box formed by the dots?
• • •
• How does the idea that 'education belongs in a classroom'
affect the way we look at learning? At health? At each * # »
other? • • •
And end with questions like these: * *
• What can we do to help each other climb out of the mental 'boxes' or 'ruts'
that confine our thinking, so we can explore new ways with open minds? Is
this important to people's health? How so?
1-12
Helping Health Workers Learn (2005)
'CRITICAL STUDY OF TEACHING METHODS'
AS PART OF HEALTH WORKER TRAINING
Some training programs schedule several hours a week for the study of 'learning
how to teach'. The learning group starts by exploring and critically analyzing
different educational approaches. Next they practice teaching— first with each
other, then with mothers and children. They also learn to develop their own
teaching materials.
To start by looking at and analyzing alternative teaching methods is especially
important. Sometimes health workers go through a people-centered course
without fully understanding the value of the new methods used. They may not
realize that the way they teach can either break down or build up people's
self-confidence and community strength. Without such understanding, they may
later slip back into the more conventional 'teacher as boss' style of teaching. We
have often seen this happen.
' U‘
t*> /
\7\ TV:* "VJH
A'm
>h
"\
• r-y 'J
; . ,r'
PRACTICE
Health workers need to
experience and to
practice appropriate
teaching methods during
their training.
But they also need to
fully understand why such
methods are so important.
UNDERSTANDING
To assist health workers in developing this understanding, be sure to allow time
for the critical study of alternative approaches to learning. Help the group to:
• Experience, analyze, and compare contrasting educational methods.
• Look critically at the existing school system in your area and how it affects
the lives, economy, social position, and health of the poor. Discuss how
conventional schooling influences the values and job performance of health
officers, civil servants, teachers, and others.
• Look for ways that they (the health workers) can begin to change unfair or
inappropriate social structures, especially the school system. This would
mean to . . .
• Explore possibilities of working with school children, non-school children,
and teachers in ways that relate learning to the lives and needs of the
children. (See Chapter 24.)
• Try using more appropriate, friendlier teaching methods. And help others
discover for themselves the value and excitement of people-centered learning.
The study of these issues will, of course, be more effective if you use the same
methods you want your students to learn (see p. 16). Students can conduct their
own investigation of different educational methods. Your role as instructor is to
help the learning group ask searching questions, look critically at alternatives, and
try out more people-centered teaching methods during training.
Helping Health Workers Learn (2005)
M3
IDEAS FOR DISCUSSION ABOUT
THE PURPOSE OF SCHOOLING
Many educators agree that the primary purpose of education should be to help
persons gain the knowledge, skills, and awareness necessary to meet life's needs.
But do the schools that most children— or health workers— attend really do
this?
To answer this question, you and your group of teachers or health workers may
first want to consider carefully: What are the biggest problems or needs of most
people in your village or community? To do this, you probably do not have to
conduct a survey or 'community diagnosis'— at least not at first. You may already
have a good idea of how most people in your area live, whether they have enough
to eat, what they suffer from most, and why.
What is necessary is to openly and honestly discuss the people's needs, why
they exist, and what might be the biggest obstacles to overcoming them.
If you live in a village or poor community— as do most of the people in the
world— your local situation may be something like this:
A TYPICAL VI LLAGE (How does it compare with your own?)
PROBLEMS OR NEEDS
Poor health, unnecessary
suffering
• many children are thin, small,
big bellied, often sick; many die
• mothers are often pale, weak,
and tired; many die, especially
during or after childbirth
• many fathers cannot find work,
are not paid enough, or do not
have enough land to meet the
family's needs for food, water,
housing, health care, and
education; many get drunk or
lose hope; violence is the main
cause of death in young men
(between ages 15 and 40)
CAUSES
Poverty, too much in the
hands of too few
• poor food, sweets and 'junk
food', poor sanitation,
inadequate health care;
poor nutrition lowers
resistance to infectious
disease
• large families because of
economic necessity (children
provide low-cost labor)
• most of the land, wealth,
and power are in the hands
of a few; the rich underpay
and exploit the poor
• government (local, national,
and international) favors the
rich
OBSTACLES TO IMPROVEMENT
Selfishness of some,
hopelessness of others
• greed and corruption of those
in control
• people's lack of self-
confidence; no hope that
things can be changed
(fatalism)
• lack of organization and
effective leadership among
the poor
• increasing dependency of
the poor on outside services,
giveaways, resources,
entertainment, and authority
• inadequate and inappropriate
education (for rich and poor
alike)
After discussing the needs in your village, ask questions about the local schools
and whose needs they are designed to serve.
1-14
Helping Health Workers Learn (2005)
Examples of questions to get people thinking
and talking about the purpose of schooling:
• How much of what children are taught in
school is relevant (related) to their daily
lives and needs?
• How long do most of the children stay in
school7 Which children drop out early?
Why? What becomes of them?
• Which children continue with their
schooling? Why? Do they usually return to
serve the community? Why or why not?
• In what ways does the teacher set a good
example or a bad example for the students?
How does he or she relate to them? As a
friend? As an equal? As their master?
• Who does the work that makes money available for schooling?
• Who decides what is taught in the schools and how7 Should the people in a
village or community have some say as to what their children are taught?
Should the opinions of the children be listened to?* (See footnote.)
• In what ways do schools shape children's values? How does this affect their
families? Their community? The poor?
• Are children taught to question those in positions of authority, or to obey
them? Why7 How does this affect those who are powerless?
• Whose needs does schooling serve the most, the weak or the strong? In what
ways?
• In what ways does schooling benefit or harm people in villages? In slums?
• What changes have been taking place in recent years in the content or approach
to schooling? Why? What changes would be needed for the schools to better
serve the interests of the poor?
In what ways do our
schools help this child
to meet his needs?
‘For those who believe that children are too unwise or loo inexperienced to make intelligent judgements about
their educational needs, we suggest you read Letter to a Teacher, by the school boys of Barbiana, Italy
(see p. 16-16).
These school boys from poor farming communities make remarkably sound and challenging suggestions
for changing the school system to better meet the needs of the poor majority. Recognizing that many
children of the poor leave school after only a few years, they insist that, "If schooling has to be so brief,
then it should be planned according to the most urgent needs." They question the usefulness of each major
subject. They ask, "How much math does one have to know for his immediate needs at home and at work?"
History as taught in schools, they insist, is "no history at all," but "one-sided tales passed down to the
peasants by the conqueror. There is talk only of kings, generals, and stupid wars among nations. The
sufferings and struggles of the workers are either ignored or stuck into a corner."
These boys also criticize the fact that most schools encourage competition among students. It would be
better, they say, if schools helped each child to feel that "Others' problems are like mine. To come out of
them together is good politics. To come out alone is stinginess."
Helping Health Workers Learn (2005)
1-15
Schooling as a form of social control
Government schools tend to serve
government purposes. Only to the extent
that government is truly by and for the
people, is schooling likely to prepare
students to work toward meeting the
needs of the majority of citizens in
effective and lasting ways.
READ AGAIN -WITH MORE'
FEELING -THE PASSAGE
ABOUT THE HEROES OF J
THE REVOLUTION.
Whose needs does your school system serve?
In the world today, most governments do not represent all their people equally.
Many governments are controlled by a powerful minority of politicians,
businessmen, wealthy landholders, military leaders, and professionals (especially
lawyers and doctors). These persons often care more about protecting their own
interests than about looking for ways to improve the well-being of the poor
majority. When they do consider doing something to help the poor, they are
usually careful to do so in ways that do not threaten their own interests and
authority.
Schooling, from the viewpoint of those in power, involves a risk. When the poor
learn to read and write, they can communicate and organize in new ways, in
greater numbers, over larger distances. They can read things that help them
discover their legal and human rights. They may ask themselves if it is really
'God's will' that a few persons have far more than they need, while others do not
have enough to eat. They may even begin to realize that they can do something to
change their situation.
This means that, for the few to keep their control, schools must teach poor
people to obey authority as well as to read and write. So most schools teach
students to fit into the existing social order rather than to question or try to
change it.
How is this done? By putting emphasis on following rules, being on time, and
'behaving'. Students are encouraged to compete more than cooperate, to memorize
rather than think. School books paint the present government as completely good
and just, with leaders who always have the interests of all the people at heart.
But perhaps the most powerful means the schools have for teaching children to
'listen and obey' are the teaching methods themselves. Students are led to believe
that the only way to learn is to be taught— by someone who knows more than
they do. The teacher is set up as the 'master', an authority whose statements must
not be questioned.
This kind of education is called authoritarian, because its purpose is to
strengthen the authority of those in control. It is education designed to keep
things as they ar e-education that resists change.
" The lecture method of
teaching is the best way to
transfer the teacher's notes
to the students' notebooks
without ever passing through
their minds. "
6
Helping Health Workers Learn (2005)
DOES YOUR TEACHING RESIST CHANGE,
OR ENCOURAGE IT?
One of the main purposes of conventional or
authoritarian education is to teach students to
fit obediently into the existing social order. The
teacher provides the approved knowledge, and
the students receive it. The emptier the student's
head to begin with, the better a student he is—
according to the teacher and the system.
Unfortunately, many training programs for
village or community health workers use this
same kind of authoritarian approach. Students
are taught to follow, not to explore; to
memorize, not to think. They are taught to
believe that their first responsibility is to the
health system rather than to the poor.
LEARN THIS AND DON’T ASH
WHY !~ BLA, BL A, BL A. . .
EDUCATION OF AUTHORITY:
putting ideas in
Usually instructors teach this way, not because they mean any harm, but
simply because they themselves grew up in an authoritarian school system. They
may not know any other way to teach.
EDUCATION THAT ENCOURAGES CHANGE:
But there are other ways— ways that build
the students' confidence in their capacity to
observe, criticize, analyze, and figure things
out for themselves. These ways let the students
discover that they are just as good as their
teachers and everyone else. They learn to
cooperate rather than compete in order to
gain approval. They are encouraged to
consider the whole social context of their people's needs, and to look for
imaginative and courageous ways of meeting them.
Teaching suggestion
Rather than tell the members of
your group these things, help them
to recall their own experiences and
to figure things out for themselves.
(SO WHAT DO you THINK 'j
OF THAT IDEA ? J
EDUCATION OF CHANGE:
drawing ideas out
This we will call education for change. Emphasis
is more on learning than on teaching. Students are
encouraged to voice their own ideas. They figure
things out for themselves, and explore ways to
help people free themselves from the causes of
poverty and poor health.
If a health worker is to be a 'leader for change',
helping people find ways to solve their biggest
problems, then it is important that his training
itself set an example.
Good teaching is the art,
not of PUTTING IDEAS INTO people's heads,
but of DRAWING IDEAS OUT.
Helping Health Workers Learn (2005)
1-17
ROLE PLAYS THAT HELP PEOPLE
EXPLORE TWO KINDS OF TEACHING
For health workers to appreciate the
importance of appropriate teaching, it
helps if they experience two kinds of
teaching and then compare them.
A good way to do this is through 'role
The bossy teacher playing' (see Chapter 14). Here we give
ideas for two role plays to compare the bossy teacher with the good group leader.
The friendly
group leader
These role plays are most effective if they take the students by surprise.
Although the whole class participates, at first students will not realize that the
instructor is 'acting'— and that they are actors, too!
In the role plays, the instructor (or two different instructors) will teach the
same health topic in two very different ways. Then the students compare their
reactions to the two lessons. They discuss how each of the classes affects the
learners personally, and how each prepares them to meet important needs in
their communities.
The two role plays we present here deal with dental care. They have been used
effectively in Latin America and Africa. But of course you can choose any health
topic you want.
The first role play: THE BOSSY TEACHER in a conventional classroom
Suggestions to the instructor:
• Before the students arrive, put chairs or benches in
neat rows, with a desk or podium at the front.
• When the students arrive, greet them stiffly and ask
them to sit down. Make sure they are quiet and
orderly.
• Begin the lecture exactly on time. Talk rapidly in a
dull voice. Walk back and forth behind the desk.
If some students come late, scold them! Use big words the students
cannot understand. Do not give them a chance to ask questions. (It helps
if you prepare in advance a few long, complicated sentences that use
difficult medical terminology. Look in a medical dictionary, or copy
phrases out of any professional textbook.)
• If any student does not pay attention, or whispers to a neighbor, or begins
to go to sleep, BANG on the table, call the student by his last name, and
scold him angrily. Then continue your lecture.
• From time to time, scribble something on the blackboard. Be sure it is
difficult to see and understand.
• Act as if you know it all, as if you think the students are stupid, lazy,
rude, and worthless. Take both yourself and your teaching very seriously.
Permit no laughter or interruptions. But be careful not to exaggerate too
much ! Try not to let the students know you are acting.
; Helping Health Workers Learn (2005)
The first role play: THE BOSSY TEACHER
the teacher talks over the heads of the bored and confused students, like this:
THE BUCCAL CAVITY, OR MOUTH, VS THE ANTERIOR - THAT
IS TO SAY PROXIMAL- PORTION OF THE ALIMENTARY CANAL,
SITUATED IN THE INFERIOR PORTION Of THE FACE ANO
CIROOMSCRABEO BY THE LIPS, CHEERS, PALATOGLOSSAL ARCH,
UVULA, ORAL PHARYNX, AND TONGUE — MR.. GOME^. I
MUST ASK. VOU hot TD-SPEAVL DURING CLASS.
.HAVE VOU HO
\MAHHBRS ? - the
-LJt \ TEETH ARP EACH ONE
OF A SET OF HARD,
WHITE STRUCTURES
PCCO-EOnNfc INTO THE
BUCCAL CAVITY FROM
THE ALVEOLAR. BONE
Of THE MAXILLA ANO
MANDIBLE AND
UTIH7ED FOR, THE
MASTICATION CF
FOOD...
THERE are TWO SETS OF DENTITION- DECIDUOUS AND PERMANENT
KS. HECLNANDEX, PLEASE WY ATTENTION. DO NOT
GLEAM YOUR- MAILS IW CLASS -these are composed cf
INFERIOR AND SUPERIOR INCISORS , CANINES, PREMOLARS, AND
MOLARS- MR.. VEGA. WAViE UP. THIS IS NO PLACe POR.
LAXY STUDENTS — carves vs the molecular decay cf
*tja*AEL DENTINE AND PULP, PRODUCING DISCOLORATION , CHRONIC
, INFLAMMATION CF THE
PERIOSTEUM AND
NECROSIS OF THE
MEDIAL NERVE LEADIN6
TD- MR.. VEGA.THIS
\S MOT SIESTA TIME-.
PLEASE STAND IN
THE CDPK1EC,- leading
TO A PYOGENIC ABSCESS
ON THE OSSEOUS tissue
CONTIGUOUS WITH THE
APEX Of THE ROOT AMD
PRECIPITATING A
SYSTEMIC,.,
The lecture goes on and on— all very serious. At the end of the class, the teacher
may simply walk out. Or he may ask a few questions like, "MR. REYES, WILL
YOU GIVE US THE DEFINITION OF CAR I ES?" And when he gets no answer,
scold him by shouting, "SO, YOU WERE SLEEPING, TOO! THIS GROUP HAS
THE ATTENTION SPAN OF 5-YEAR-OLDS!" And so on.
Helping Health Workers Learn (2005)
1-
The second role play: THE GOOD GROUP LEADER or 'facilitator'
This time, the instructor treats the students in a friendly, relaxed way— as
equals. (This role can be played by the same instructor or a different one. Or
perhaps a student could prepare for it in advance.)
Suggestions to the group leader:
• At the beginning of class, suggest that people sit in a circle so they can see
each others' faces. Join the circle yourself as one of the group.
• Asa group leader, you 'teach' the same subject as the instructor in the
first role play. But whenever possible, try to draw information out of the
students from their own experience.
• Be careful to use words the students understand. Check now and then to
be sure they do understand.
• Ask a lot of questions. Encourage students to think critically and figure
things out for themselves.
• Emphasize the most useful ideas and information (in this case, what the
students can do in their communities to prevent tooth decay).
• Use teaching aids that are available locally and are as close to real life as
possible. For example, you might invite a young child to the class so
students can see for themselves the difference between baby teeth and
permanent teeth.
• Do not waste a lot of time
discussing detailed anatomy,
Instead, include such information
when it is needed for understanding
specific problems.
• Have students look in each others'
mouths for cavities. Then pass
around some rotten teeth that were
pulled at the health center. Let
students smash the teeth open with
a hammer or rock, so they can see
the different layers (hard and soft)
and how decay spreads inside a
tooth. Ask someone to draw the
inside of a tooth on the blackboard.
• Encourage students to relate what
they have seen and learned to real
needs and problems in their own
communities. Discuss what action
they might take.
Students can break open teeth that
have been pulled to see for them-
selves what the inside of a tooth
looks like and what damage a cavity
can cause.
1-20
Helping Health Workers Learn (2005)
The second role play: THE GOOD GROUP LEADER
The teacher or leader tries to get a discussion started— then stays in the
background as much as possible, like this:
To follow this discussion,
start here and follow
the arrows.
WE'VE SEEM THE HARM
DONE ©V TOOTH DECAY.
BUT DO YOU KNOW
W HAT CAUSES IT ?
WHAT DO YOU THINK,
JOSE ?
THEY SAY THAT
EATVN& A LOT
OF SWEETS ROtS |
THE TEETH . BUT
I •'vie heard
THAT BAD TEETH
RESULT FROM
WOT EATING
ENOUGH SOOD
FOOD ...
THEN HOW COME1
THE CHILDREN
OF THE RICH
HAVE WORSE
TEETH THAN A
LOT OF THE
POOREST KIDS
IN THE
village? I
1
GETTER STILL, MAYBE WF CAW HELP
THE SCHOOL CHILDREN CONDUCT
THEIR OWN STUDY. IF THEY FIND
OUT FOR THEMSELVES WHAT
CAUSES THEIR TEETH TO ROT.
THEY’LL <3E MORE LIKELY TO
TAKE 6ETTER CARE OF THEM.
, WHAT DO YOU TH I NK ?
AND HOW
OFTEN THEY
CLEAN THEIR
TEETH.
I’LL BET 1Tb
BECAUSE THEIR
PARENTS ARE
ALWAYS BUYING
THEM CANDY
AND SWEET
SOFT DRINKS.
AGREE WITH
SANDRA.
WHY DON’T WE MANE A
STUDY Of THE SCHOOL
CHILDREN . WE COULD LOOK
AT HOW GOOD OR BAD
THEIR TEETH ARE AND
THENGOTOTHEIR homes
AND FIND OUT FROM THEIR
MOTHERS HOW MUCH
. CANDY AND SWEET THINGS
\THEV EAT AND DRINK.
At the end of class, the leader asks the group what they have learned and what
they plan to do with what they have learned. He helps them realize that the ideas,
raised in class need not end in the classroom, but can be carried out into the real
world— into the communities where the health workers live and work.
Helping Health Workers Learn (2005)
1-21
Group discussion following the two role plays
You may want to discuss what the students think about the first role play as
soon as it is over. Or you may want to wait until both role plays have been
presented, so the students can compare them.
Good questions to start a
discussion might be:
• What did you think of the
two classes (on dental care)?
• From which class did you
learn more?
• Which did you like better?
Why?
• Who do you think was the
better teacher? Why?
' FROM WHICH I
CLASS DID V
. YOU LEARN /
WMORE? J
FROM THE FIRST/)
BECAUSE THE
TEACHER
TOLD US /
MOR T-jJ
BUT HOW MUCH
OF IT DID YOU
UNDERSTAND ?
y>f\ WAS LUCKY IF
I UNDERSTOOD
y ONE OUT OF
Five words, it
~s MADE ME FEEL
LIKE A FOOL/
/ MAYBE 1 AM.
You may be surprised at some of the answers you get! Here are a few answers
we have heard students give:
"I learned more from the first class, because the teacher told us more. I learned
a lot of new words. Of course, I didn't understand them all . .
"The first class was much better organized."
"I liked the second class better, but the first one was better taught."
"The second class was too disorderly. You could scarcely tell the teacher from
the students."
"The first teacher wasn't as nice, but he had better control of the class."
"The first teacher was by far the best. He told us something. The second one
didn't tell us anything we didn't already know!"
"I felt more comfortable in the first class— I don't know why. I guess I knew
that as long as I kept my mouth shut, I'd be all right. It was more like real
school !”
"The second class was more fun. I forgot it was a class!"
By asking still more questions, you may be able to get the students to look
more closely at what they learned— and have yet to learn— from the two classes.
Follow through with questions like these:
• In which class did you understand more of what was said? Does this matter?
• From which class can you remember more? Does this matter?
1-22
Helping Health Workers Learn (2005)
• Do you remember something better when you are told the answer, or when
you have to figure out the answer for yourself?
• In which class did students seem more
interested? More bored?
• In which class did you feel freer to speak
up and say what you think?
• Which class had more to do with your own
lives and experience?
• From which class did you get more ideas about ways to involve people in
their own health care?
• Which class seemed to bring the group closer together? Why? Does this matter?
• Which teacher treated the students more as his equals? Could this affect the
way the students will relate to sick persons and to those they teach?
• Which is the better teacher— one who has to
be 'tough' in order to keep the students'
attention? Or one who keeps their attention
by getting them interested and involved?
• Did you learn anything useful from these
classes, apart from dental care7 What?
• In what ways are the relations between each teacher and the students similar
to relations between different people in your village? For example, between
landholders and sharecroppers? Between friends?
With questions like these, you can help the students to look critically at their
own situation. As much as you can, let them find their own answers, even if they
are different from yours. The less you tell them, the better.
If the discussion goes well, most of the questions listed above will be asked —
and answered— by the students themselves. Each answer, if approached critically,
leads to the next question— or to even better ones!
If the students do not think
things over as carefully as you
would like, do not worry. And
whatever you do, do not push
them. Your answers have value
only for yourself. Each person
must come up with his or her
own. There will be many other
opportunities during the training
to help students discover how
education relates to life. In
the last analysis, your example
will say far more than your
words— for better or for worse.
If you want lasting results:
POINT but don’t PUSH.
People will move by themselves once they
see the need clearly and discover a way.
Helping Health Workers Learn (2005)
1-23
Analysis of the two role plays
After discussing the differences between the two approaches to teaching, it
helps to summarize them in writing. (Or you may want to do this during, rather
than after, the discussion.) One of the students can write the group's ideas on a
blackboard or large sheet of paper.
71
\aT CLASS
i. Teacher lr> control
a. Teacher was mean
4. Class v/erq&isciplined "
Words we dont understand
icher knows it all
icher makes us -feel stupid
jcher -talks but doesn't
^ listen
%. Class net nsictted to life.
9, Bari na ■ w a fell asleep.
(C. Ug atfempt -to rmke it
in9
WE CAN*T >
co anything
WITH WHAT
WE WE£E
TAUGHT lH
the first ,
v CLASS! /
3.^0 CLASS
u -Students self-con trolled
^ Teacher friend Ilj *equal
i3. Class not well srganised
M. We understood ewefq-thina
6. Teacher made us feel important
Listened to and respected
oor iaeas .
7. Class gave. us ideas row to
irwonoe, ch i Idren
8. We liked seeing nsal teeth
and doing -thi rgs ourselues
1. We can , . ,
' EOT THE SECOND
CLASS GAVE OS
IDEAS OF THINGS
to do/
As everyone is leaving the classroom, perhaps one of the students will put his
hand on your shoulder and say:
"You know, I don't really think those two classes were to teach us about
teeth. I think they were to help us learn about ourselves."
"They were to do both at once. That's the secret of education," you will
reply. But you will want to hug him.
If no one says anything, however, don't worry. It takes time. You and your
students will learn from each other.
1-24
Helping Health Workers Learn (2005)
THREE APPROACHES TO EDUCATION
This chart gives a summary of 3 approaches to teaching. It may help instructors to evaluate
their own teaching approach. But we do not recommend that this analysis be given to health
workers. Analyzing stories and role plays will work better. So pass by this chart if you want.
CONVENTIONAL
PROGRESSIVE
LIBERATING
Function
to CONFORM
to REFORM
to TRANSFORM
Aim
Resist change.
Keep social order stable.
Change people to
meet society's needs.
Change society to
meet people's needs.
Strategy
Teach people to accept
and 'fit in' to the social
situation without changing
its unjust aspects.
Work for certain
improvements without
changing the unjust
aspects of society.
Actively oppose social
injustice, inequality,
and corruption. Work
for basic change.
Intention
toward
people
CONTROL them-
especia I ly poor working
people— farm and city.
PACIFY or CALM them—
especially those whose
hardships drive them
to protest or revolt.
FREE them
from oppression,
exploitation,
and corruption.
General
approach
AUTHORITARIAN
(rigid top-down control)
PATERNALISTIC
(kindly top-down control)
HUMANITARIAN and
DEM OCR A TIC
(control by the people)
Effect
on people
and the
community
OPPRESSIVE— rigid central
authority allows little
or no participation by
students and community.
DECEPTIVE— pretends to
be supportive, but
resists real change.
SUPPORTIVE— helps
people find ways to gain
more control over their
health and their lives.
How
students
(and people
generally)
Basically passive.
Empty containers
to be filled with
standard knowledge.
Basically irresponsible.
Must be cared for. Need
to be watched closely.
Basically active.
Able to take charge
and become self-
reliant.
Can and must be tamed.
when spoon fed.
and as equals.
What the
students
feel about
the teacher
FEAR— Teacher is an
absolute, all-knowing boss
who stands apart from
and above the students.
GRATITUDE— Teacher isa
friendly, parent-like
authority who knows what
is best for the students.
TRUST— Teacher is a
'facilitator' who
helps everyone look
for answers together.
Who decides
what should
be learned
The Ministry of
Education (or Health)
in the capital.
The Ministry, but with
some local decisions.
The students and
instructors together
with the community.
Teaching
method
• Teacher lectures.
• Students ask few
questions.
• Often boring.
• Teacher educates and
entertains students.
• Dialogue and group
discussions, but the
teacher decides which
are the 'right' answers.
• Open-ended dialogue,
in which many answers
come from people's
experience.
• Everyone educates
each other.
Main
way of
learning
PASSIVE— students
receive knowledge.
Memorization of facts.
More or less active.
Memorization still
basic.
ACTIVE— everyone
contributes. Learning
through doing and
discussing.
Helping Health Workers Learn (2005)
Important
subjects or
concepts
covered
CONVENTIONAL
• the strengths and
rightness of the present
social order
• national history
(distorted to make 'our
side' all heroes)
• rules and regulations
• obedience
• anatomy and physiology
• much that is not
practical or relevant—
it is taught because
it always has been
• unnecessary learning
of big words and boring
information
PROGRESSIVE
• integrated approach to
development
• how to make good use
of government and
professional services
• filling out forms
• desirable behavior
• simple practical skills
(often of little use-
such as learning 20
bandages and their
Latin names).
monocular
DRESSING
LIBERATING
• critical analysis
• social awareness
• communication skills
• teaching ski! Is
• organization skills
• innovation
• self-reliance
• use of local resources
• local customs
• confidence building
• abilities of women
and children
• human dignity
• methods that help the
weak grow stronger
Flow of
school or
school or
students -^-group -^-school i
knowledge
health
■ ail
health
■
mostly
leader health
and ideas
system
1 one
system
♦
teacher
]
one
•s. system
teacher
/T\ way
/\
way
• - -•*- ,E3
\
• • •
\
• • •
#•
students
students
both ways
Area for
The classroom.
The classroom and other
Life— the classroom
studying
controlled situations.
is life itself.
How does the
•
#
class sit?
•
•
. • .
• •
• • • •
•
•
• •
• •
•
• . •
• •
• • • •
•
•
• •
Class Often LARGE. Emphasis Often fairly small, to Often SMALL, to
size on quantity, not encourage participation. encourage communication
quality, of education. and apprenticeship learning.
Attendance
Students have to
attend. cyj
Students often want to
attend because classes
are entertaining and
they will earn more if
they graduate.
'Incentives' are given.
Students want to
attend because the
learning relates to
their lives and needs,
and because they are
listened to and respected.
Group
interaction
Competitive (cooperation
between students on tests
is called cheating).
Organized and directed
by teacher. Many games
and techniques used to
bring people together.
Cooperative— students
help each other. Those
who are quicker assist
others.
Purpose of
exams
Primarily to 'weed out'
slower students; grades
Variable, but generally
tests are used to pass
Primarily to see If ideas are
clearly expressed and if
teaching methods work
well. No grades. Faster
students help slower ones.
students pass.
Others fail.
<5jrj7
| others.
L
Evaluation
Often superficial—
by education or health
system. Students and
community are the
objects of study.
Often over-elaborate—
by education or
health 'experts'.
Community and
students participate
in limited ways.
Simple and continual—
by community, students,
and staff. Students
and teachers evaluate
each, others' work and
attitudes.
At end of
• diplomas
• diplomas gg O
• uniforms
• encouragement to work
training,
• irregular.
hard and keep learning
students
police-like j
£ =J
• salaries Jr^ Ljf
• supportive assistance
are given . . .
supervision
• supportive supervision
when asked for
After training,
a health
worker is
accountable to . . .
his supervisor, the
health authorities,
the government
mainly to the health
authorities, less so
to local authorities
and the community
mainly to the
community— especially
the poor, whose
interests he defends
1-26
Helping Health Workers Learn (2005)
APPROPRIATE AND INAPPROPRIATE TEACHING:
TWO STORIES
In addition to role plays, you may want to use stories to help students and
other instructors see the value of the new teaching methods. Telling stories often
takes less preparation than role plays, and if the stories are imaginary or from
another area, no one will be blamed for the mistakes that are described. Here are
2 stories comparing different teaching approaches and their results.
STORY 1*
A health worker named Sophie completed her training and passed all the exams
at the end of the course. Then she went back to her village. It was a long journey
because the village was far away. When Sophie arrived everybody was pleased to
see her again. Her mother was especially pleased and proud that her daughter had
done so well.
After the first greetings, Sophie's mother said, "It's good that you're back,
because your baby cousin is ill with diarrhea and doesn't look well at all. Do you
think you could help?”
Sophie went to see the baby and realized that
he was badly dehydrated. She thought the baby
should go to a health center, but the journey
was too long. So she thought about what she
had been taught. She could remember the
anatomy of the gastro-intestinal tract, and ail
about electrolyte balance. And she remembered
that a mixture of salt and sugar in water would
help. But she could not remember how much
sugar and how much salt to put in the water.
Sophie was very worried that the amounts
would be wrong. She did not know whether to
send for help or to guess how much to use. She
thought that the baby was so sick she would
have to do something. In the end, she made up
the sugar and salt solution in the wrong
proportions, and the baby died.
Moral of the story: Some training courses
spend too much time on detailed
facts, many of which have little
importance. As a result, the most
important things are not learned
well The most important facts are
those needed for solving common
problems in the community.
’Adapted from Teaching for Better Learning,
by Fred Abbatt, WHO, Geneva, 1980.
Helping Health Workers Learn (2005)
1-27
STORY 2
In a short training program for village health workers, students decided that
one of the most serious problems in their villages was diarrhea in children. They
learned that the main danger with diarrhea is dehydration. They discussed Oral
Rehydration Solution, and agreed that teaching mothers and children how to
make and use it should be one of their first responsibilities.
"It won't be easy," said one of the students, herself a mother. "People don't
understand funny words like oral, rehydration, or solution.” So the group
decided it would be better to speak of Special Drink— eye n among themselves,
so they would not be tempted to use fancy words in their villages.
"What if the mothers put in too much salt?" asked a student whose uncle was
a doctor. "Wouldn't that be dangerous?"
"Yes," said the instructor. "We need to find ways of teaching that will help
parents and children remember the right amounts. How do people remember
things best in your villages?"
"We all remember songs," said one of the health workers. "People are always
singing and learning new ones. We remember every word!"
So the group decided to write a song about diarrhea and Special Drink. They
all worked on it together. But they got into an argument over what to call the
baby's stool. For most people, a stool was something to sit on.
Nobody understood words like feces and excrement. The word shit
some people considered dirty. "But it's the word everyone
understands— even children," argued one health worker. "Especially
children!" said the mother. Finally they agreed that shit was the
most appropriate word— at least in their area.
The song they wrote is shown below. (It can be sung to "Twinkle, Twinkle,
Little Star" or another simple tune. With children, have them SHOUT the words
printed in CAPITAL LETTERS.)
H
” The P and V Blues”
(Di arrhea and Vomiting')
Babies who have D and v
Shrivel up and fail to pee.
To regain their health we oughta
Fill them up with LOTS OF WATER.
Making Special Drink’s a cinch--
Sugar *. 1 Teaspoon. Salt : 1 Pinch
Water ; 1 Glass --or BIG FAT CUP
Toss them in and Stir it op !
But careful / You would be. at fault
If you put \r» too much Salt f
So mix it. T/\STE IT. GIVE 3 CHEERS
it's no Saiti Pi
Each time your baby dribbles Shit
Give one glassful -- bit by bit.
And if the darling's on the breast
Give breast milk too-* for BREAST IS BEST/
1-28
Helping Health Workers Learn (2005)
Several months later, after the course
was over and the students were back in
their villages, one of the health workers,
named Rosa, was met in the street by a
mother. The mother gave her 7 eggs
wrapped in a leaf.
"Thank you," said Rosa with surprise.
"But why . . .?"
"You saved my baby's life!" said the
mother, hugging the health worker so
hard she broke 3 eggs.
"But I didn't even see your baby!"
said Rosa.
"I know," said the mother. "You see, She hugged the health worker
my baby had diarrhea, but the river was so hard she broke 3 eggs!
flooded so I couldn't bring him to the
health post. He was all shriveled up and couldn't pee. He was dying and I didn't
know what to do! Then I remembered a song you had taught the children in
school. My daughter's always singing it. So I made up the Special Drink, tasted it,
and gave it to my baby, just like the song says. And he got well!"
Moral of the story: T raining gives better results if it keeps language simple,
focuses on what is most important, and uses learning methods people are
used to and enjoy.
What other ideas about teaching and working with people can your students
draw from these stories? Have them list different teaching methods on the black-
board and discuss which are most appropriate and why. Can the students tell
similar stories from their own experience— ways they have learned things both in
and outside of school? (For more ideas about story telling as a teaching method,
see Chapter 1 3.)
To be a good teacher of health workers, you don't
need to know a great deal about medicine, about latrine
building, or about weighing babies. These things you
can learn together with your students. What you do need
to know about is people, how they feel, how they relate
to each other, and how they learn.
Helping Health Workers Learn (2005)
1-29
ON CHANGING HABITS AND ATTITUDES
Many experts now tell us that the principal goal of health education should be
to change people's habits and attitudes.
Unfortunately, such a goal points the finger at what people do wrong, rather
than building on what they do right. It is based on the paternalistic view that the
'ignorance' of poor people is the main cause of their ill health, and that it is
society's job to correct their bad habits and attitudes.
A people-centered approach to health education takes the opposite position. It
recognizes that the ill health of the poor is, in large part, the result of a social
order that favors the strong at the expense of the weak. Its main goal is not to
change the poor, but to help them gain the understanding and skills needed to
change the conditions that cause poverty and poor health.
THE AIMS OF HEALTH EDUCATION
BEHAVIOR CHANGE or
SOCIAL CHANGE
W£ ARE\
GOING TON
CHANGE 1
VOU.^
In education that focuses on behavior and
attitude change, people are acted upon by
the system and the world that surrounds
them.
In education that works for social change,
people act upon the system and the world
that surrounds them.
In making these points, we are not saying that there is no need for changes in
personal attitudes and behavior. But whose attitudes need changing the most?
Whose attitudes and habits cause more human suffering— those of the poor or
those of the 'well-educated' dominating classes?
The unhealthy behavior of both rich and poor results partly from the unfair
social situation in which we live. So rather than trying to reform people, health
education needs to focus on helping people learn how to change their situation.
As people become more sure of themselves and their capacity for effective
action, their attitudes and behavior may change. But lasting changes will come
from inside, from the people themselves.
1-30
Helping Health Workers Learn (2005)
When considering your effectiveness
as a health educator, ask yourself: "How
much does what I do help the poor gain
more control over their health and
their lives?"
Helping Health Workers Learn (2005)
2-1
Selecting Health Workers, CHAPTER 2
Instructors, and Advisers
WHO MAKE THE BEST HEA LTH WORKERS?
SHOULD HEALTH WORKERS BE FROM THE VILLAGE
OR COMMUNITY WHERE THEY WORK?
Many health programs, large and small, agree that it is important for health
workers to be selected from the communities where they will work. But their
reasons differ:
TWO EXPLANATIONS FOR WHY IT IS BETTER THAT HEALTH
WORKERS BE FROM THE COMMUNITIES WHERE THEY WORK
The ‘expert’ with
little community experience:
Persons living and
working in the community:
PEOPLE ARE n
Quicker to trust
And listen to
Someone from
their own
common i ty
who speaks
IN THEIR TERMS
AND KNOWS
THEIR CUSTOMS
And prorlems.
*
people are
slower to trust
THE NEW SKILLS
OF A LOCAL PER50N.
But while an
outsider brings
DEPENDENCY , THE
LOCAL HEALTH
WORKER SHOWS
people THEY CAN
DO MORE FOR
. THEMSELVES.
Theory has it that community health
work is easier for the local person than
for an outsider, because people know and
trust him. And he knows the community.
Experience shows that at first it is
often harder for the local person. But in
time, health workers from the community
can do more to help build people’s self-
confidence and self-reliance.
There is an old saying: No one is a prophet in his own land. A villager complains,
"What does Mary, the health worker, know? I remember her as a skinny little
girl!"
Such distrust in their own health worker reflects people's lack of confidence in
themselves: "How could one of us understand new ideas or master new skills?"
This lack of self-confidence is especially great when it comes to health care. Most
people believe that modern medicine requires mysterious knowledge that only
"strangers better than ourselves" can master.
2-2
Helping Health Workers Learn (2005)
Some American Indian health workers in Arizona found it so hard to win the
trust of people in their own villages that they traded jobs with health workers in
distant villages. They found that as 'outsiders' they could command more
immediate authority. People were quicker to follow their advice without question.
Similar 'swaps' have been made by health workers in several countries. And
some of the larger health programs make it a point not to send health workers to
work in their own communities.
We feel this is a mistake. A stranger to a community, no matter how well he
works, perpetuates dependency on outside help. Only when a health worker is
from the community can his example show "what we people in this village can do
for ourselves."
WHO SELECTS HEALTH WORKERS AND HOW?
Many programs feel that health workers should not only be from the
community where they work, but that they should also be selected by the
community. These are the reasons:
• If everyone takes part in the selection, chances are greater that the health
worker will be well accepted.
• Participation in the selection process is a step toward greater responsibility
and control by people over factors that affect their health.
• A health worker chosen by the community is more likely to feel that his or
her first responsibility is to the community.
Problems with selection by the community
My young nephew is '
the only one in the
VILLAGE WHO HAS BEEN
TO SECONDARy SCHOOL.
i am sure you will all
agree that he should
Be the health worker.
THAT Boy IS A I5RUI
AN V A CROOK .'
Problem: In many
villages, the local headman,
mayor, or a powerful
landowner insists that one
of his children or family
members be chosen as
health worker. Even if a
public vote is taken, the
poorer people may be afraid
to suggest or vote for
someone else. As a result,
the health workers selected
may represent the interests
of those with land and
power rather than those
with greatest need. This
is a problem reported from
many countries.
Helping Health Workers Learn (2005)
2-3
Another problem: Sometimes villagers select a person who is very young,
inexperienced, or irresponsible. This may be because people feel that "study is for
the young." Also, older persons frequently have too many other responsibilities.
Part of the reason for poor choice of health workers, however, is that often the
selection is made in a hurry, without enough critical discussion. Somebody
suggests a friend, or someone he likes. Someone else suggests another friend, and
a vote is taken. More often than not, the winner is the person for whom the first
show of hands is called.
Still another problem: Many programs find that health workers with more than
a primary school education are likely to leave their villages for better-paying jobs
in the cities.
To avoid these and other problems, some community-based programs in the
Philippines do not accept the following persons for health worker training:
• close relatives of village leaders or officials
• young people and those likely to marry soon
• those with more than a primary school education
• those with many other responsibilities or official positions
In a similar way, a health program in Iran decided to exclude from health
worker selection, family members of any village authority or large landholder.
After this decision was made, villagers chose health workers who were more
representative of the poor and more concerned with their needs.
Ways to help communities select wisely
Rather than deciding for the community what kinds of persons it should or
should not select, it is often better to help the community decide wisely for itself.
But this takes time and care.
For example, instructors from the villager-run health program in Ajoya,
Mexico ride on muleback to mountain villages, spending a few days in each.
Often they will make several visits,
getting to know the people better.
Then an all-village meeting is held.
Women and children are encourage
to attend (instead of only men, as
is customary). The instructors try
to get an active discussion going:
What are our health needs ? Do we
need our own health worker ?
What qualities should this person
have? As the people make
suggestions, these are written
on large sheets of paper or a
blackboard, and discussed further.
2-4
Helping Health Workers Learn (2005)
The people's list might include any combination of the following.
We want a health worker who:
• is kind
• is responsible
• is honest and shows good judgement
• has a mature personality
• is interested in health and community work
• is humble: feels equal to and not superior to others
• will probably stay in the village (not move away)
• is accepted and respected by all the people, or at least by the poor
• has the full agreement and cooperation of his or her family
• can read and write (preferably)
• does not have more than a primary school education
• is eager to learn; open to new ideas
• is a good leader and organizer
• has healthy habits (does not smoke, does not drink too much)
• can draw, or is a good storyteller
• works well with mothers, children, and working people
• has a good record of taking part in or leading community activities
• has some experience in health care or healing (preferably)
• understands and respects people's beliefs and traditional practices
• identifies with and defends the interests of those in greatest need
THIS LIST CONTAINS
SUGGESTIONS FROM
SEVERAL PROGRAMS
The team in Ajoya feels it is important for the villagers to develop the list of
qualities themselves, rather than to have a list handed to them. If, however, the
people forget certain important qualities, the instructors may ask questions that
help the people consider those points.
Only after the list of qualities has been developed and thoroughly discussed,
are the people asked to suggest names of persons who might make good health
workers If certain persons are known to dominate discussions or decisions, they
are asked, politely, to remain silent so that those who seldom speak can make
their suggestions first, When necessary, the vote is taken by secret ballot.
In this way, selection of a health worker is
the beginning of a process in which the poor
find a voice and fairer representation. But all
this takes time, in the Makapawa program in
the Philippines, a team works in the village
for at least 3 months, helping the poor
organize and consider their needs before a
health worker is selected.
A village health committee is often chosen
at the same time. (See page 10-3).
^PLEASE LET OTHERS DO1
THE TALKING
Other programs take different approaches to the selection of health workers.
Some have requirements for age, sex, schooling, physical health, etc. Some give
simple tests to check for such things as skill with one's hands. Generally, the
more distant the headquarters, the more requirements are set in advance.
Helping Health Workers Learn (2005)
Joint selection by the community and program leaders
Some programs feel the best selection of health workers results from combining
the community's knowledge of its people with the program leaders’ experience.
The village is asked to pick 3 or 4 'candidates' From these, the instructors choose
the one they think most suited— perhaps after testing their skills and attitudes.
HANDICAPPED PERSONS AS HEALTH WORKERS
Some programs require that
health workers be in “excellent
physical health." Clearly, health
workers should be free of
contagious diseases such as
untreated tuberculosis, and healthy
enough to handle their
responsibilities.
We have found, however, that
some of the best health workers are
persons with serious physical
handicaps; polio, for instance, or an
amputated arm or leg. Unable to do
hard physical labor, they may find
more time for health work and
greater satisfaction in doing it.
Because of their own problems,
they also have more understanding
for others who are ill or
handicapped. In some ways, their
weakness becomes their strength.
As health workers serving their
community, they set an example
for others who are handicapped.
Handicapped persons often make excellent
health workers. Here a young man, himself
crippled by juvenile arthritis, repairs braces for
a child with polio. (Mexico— Project Piaxtla)
WHO MAKE BETTER HEALTH
WORKERS-MEN OR WOMEN?
Some programs train only men as health
workers. Others only women. Others train both.
Reasons often given for selecting women as
health workers:
• Women and children make up % of the
population. Their health needs are
especially great. And women usually prefer
health workers who are women.
• Women have more experience in caring for
children, and may be more tender.
Helping Health Workers Learn (2005)
Women usually stay closer to
the village, and so are more
available when needed.
Women often are more
exploited and abused than
men. Therefore their
sympathies are more likely to
lie with those who have less
power and greater need. A
health program in India states
"Women and children are the
more vulnerable groups in the
rural area, therefore a woman
is best able to motivate and bring about change."*
"With women there is less fear of misuse or malpractice," states the same
program from India, In many areas, women tend to be more responsible, and
they drink less. They may also be more willing to work for the people, not
the money.
Women health workers in Bangladesh ride
bicycles, which only the men used to do.
This is helping women gain more equal rights
Reasons often given for selecting men as health workers: f A
• Men often can move about more safely and freely than
women. They can go alone or at night to a distant house or
village to attend an emergency. f y' \
• Much of the work to improve health involves farming, water (r-| . j^
systems, latrine building, and other activities for which the
help of men is needed. Men can perhaps be better led by a male leader
• Where part of the health worker's job is to work toward social change, men
are more likely to take action and to organize the people than, are women.
(This is not necessarily true. It is interesting to note, however, that in some
countries where human rights are often violated, government-run
health programs train mostly women health workers. In those
same countries, community-based programs working for land \ J
rights and social change often train mostly men health workers.) I !
Some programs happen to train mostly men, others mostly women. Usually this
is not because they feel one sex makes better health workers. In some places there
are difficulties in recruiting either men or women. Men (especially young men) may
be too 'proud' to consider training for 'nursing' work— especially if on a volunteer
basis. In some areas, unmarried women may not be permitted to leave home to
attend a training program. And married women may be unable to leave their
children and their work, or their husbands may not let them.
Experience shows that both women and men can make good health workers.
Often men are able to relate better to the health needs of men, and women to the
needs of women and children. Some health programs resolve this difference by
training both a man and a woman (sometimes a married couple) from each village.
From Moving Closer to the Rural Poor, by the Mobile Orientation and Training Team, Indian Social
Institute, New Delhi.
Helping Health Workers Learn (2005)
2-7
YOUNGER OR OLDER HEALTH WORKERS-
WHICH WORK OUT BEST?
Although most health programs train
health workers who are quite young, many
find that somewhat older or middle-aged
persons often work out better. Young
people sometimes have more open minds
(and may be easier to recruit), but they
have more difficulty in winning people's
confidence and cooperation. Also, younger
persons may be less likely to stay in the
village. Some programs find that unmarried
girls are likely to get married and move away. Other programs find that young
men often move to the cities or to migrant farm-working camps.
Older persons are usually more likely to remain in their communities, and to
work with great dedication and responsibility. Also, people are more likely to
respect and listen to them. But they may be more fixed, or even rigid, in their
ideas. This can be both a strength and a problem.
In the experience of many programs, the most reliable age group is from about
25 to 40. When health workers are younger or older than that, more difficulties
seem to arise. There are, of course, many exceptions. In Ajoya, Mexico, the
present leaders of the program began as 'junior health workers' when they were
13 to 16 years old.
EDUCATIONAL LEVEL
Capable health workers have been trained from every educational level, from
persons who cannot read to those with university or medical degrees. Each level
presents special strengths and special problems.
Persons who cannot read and write often have unusually well -developed
memories— sometimes far better than those of us who depend on writing things
down. But to train health workers who cannot read and write calls for somewhat
different educational methods. Few instructors have been taught these methods,
but they can learn them with the help of the students.
In most programs, the average education level of community health workers is
from 3 to 6 years of primary school. Yet some programs make 6 years of primary
school a minimum requirement. Others require completion of secondary school.
Education requirements sometimes give rise to problems. For example, in
Guatemala, a government training program for 'health technicians' in the highland
Indian communities started with two requirements: 1 ) Applicants must speak a
native Indian language as well as Spanish. 2) They must have completed secondary
school. However, it turned out that very few native language speakers had finished
secondary school. One of the two requirements had to be dropped.
2-8
Helping Health Workers Learn (2005)
Unfortunately, the language requirement was dropped and the education
requirement kept. This meant that almost all the health technicians trained were
of Spanish (Ladinoj origin. They neither spoke the local languages nor represented
the people where they were to work. As a result, the program has had many
difficulties.
As we have already mentioned, persons who have completed secondary school
often do not make as good health workers as those with less schooling. Their
education seems to separate them from the majority of their people. Many are
more interested in getting 'higher education' or 'better jobs' in the city. They are
more likely to abandon their people.
Also, as we discussed in Chapter 1, persons with much formal education may
have an extra burden of unhealthy values. They need to unlearn and relearn a
great deal in order to become effective community health workers.
By contrast, persons with less formal education tend to feel themselves more
in harmony with, and equal to, the poor majority. They may be more ready to
commit themselves to community health work.
Persons with only a few years of schooling often make
more reliable, more community-strengthening health
workers than those who have had more formal education.
Once again, of course, there are exceptions.
TRADITIONAL HEALERS AND
MIDWIVES AS HEALTH WORKERS
Many programs have trained traditional healers,
herbalists, bone setters, and traditional midwives as
village health workers— often with good results.
Advantages to training traditional healers as health
workers:
• They already have the confidence of the people in
their own special area of health care.
• They have a strong grounding in traditional and spiritual forms of care and
healing. To these they can add concepts of modern health care and medicine.
Often the combination of the old and the new, unique to the area, is better
than either way by itself.
• They are usually persons with great experience and strong beliefs. So they
may be more able to defend their people's culture and resist the use of
foreign ideas and technologies not suited to local needs.
• They are often persons firmly rooted in their communities and deeply
committed to serving people in need. (But be careful. Some traditional
healers use their special knowledge to exploit or gain power over others.)
Helping Health Workers Learn (2005)
2-9
Difficulties in training traditional healers as health workers:
Traditional healers
often are very set in
their ways. Like
modern medicine,
traditional medicine
includes many
practices that are
helpful, others that are
useless, and some that
are harmful. Traditional
healers, like many
modern doctors, may
be reluctant to examine
critically the practices
they have always
followed. They may be
unwilling to omit or
change harmful but
profitable practices.
(These may include the
misuse or overuse of
certain modern
medicines, sometimes
combined with herbal
medicines.)
This 'herb doctor' was chosen by his village to train as a
health worker. His art of healing adds much to the science
of health care. Today, he combines aspects of modern and
folk medicine. (Mexico)
A common difficulty with traditional healers relates to their approach to
problem solving. Most traditional healers rely, to a large extent, on the
psychological 'power of suggestion'. This is a very important part of the healing
process as they know it. The traditional healer convinces the sick person and his
family that he or she knows immediately just what the illness is, what caused it,
and how to treat it. This immediate and absolute certainty is a key to traditional
healing.
But the science of modern medicine calls for just the opposite approach. The
scientific healer begins with doubt, not certainty. He starts by asking questions,
collecting related information, and systematically considering and testing
possibilities (seeCh. 17).
It is often difficult for persons used to traditional healing to learn the more
scientific approach. As established healers, they may find it especially difficult to
ask for advice or suggestions, or to admit when they have trouble diagnosing an
illness.
An instructor who is unaware of all this, may treat these persons as if they were
ignorant or dishonest. This makes it more difficult for both to admit their doubts
or mistakes. In our own experience, however, we have found that when an
instructor understands and appreciates the local forms of healing, most
misunderstandings with traditional healers can be avoided. When this is so . . .
Traditional healers can become some of the most
capable and dedicated primary care workers.
2-10
Helping Health Workers Learn (2005)
PERSONAL QUALITIES, ATTITUDES,
AND CONCERNS
Of far more importance than age, sex, experience, education, and even place of
origin, are a health worker's personal qualities— his or her understanding of people
and their needs. It is essential that the health worker identify with the poor and
have a strong sense of fairness and social justice. To some extent, these attitudes
can grow and develop during training. But the seeds need to be there already.
People's attitudes are far more easily strengthened than changed.
Perhaps the most important quality to look for
when selecting a community health worker is
the person's concern for social justice.
Does he treat other people as his equals?
Is his first concern for those in greatest need?
I WAS HERB FI
DON'T /DU REAL
\WHO T AM t
/l'M SORRy MA'AM. MY RES PON S l Bl LIT7
IS TO SERVE FIRST THOSE WHOSE ^
.NEED IS GREATEST.
This is a scene from a ‘Farmworkers’ Theater1 production in Ajoya, Mexico. It was
presented to help villagers recognize the differences between a good health worker and
the typical doctor.
Helping Health Workers Learn (2005)
2-1 1
WHO MAKE THE BEST TEACHERS
OF VILLAGE HEALTH WORKERS?
Selection of appropriate instructors is just as important as selection of the
health workers themselves. Instructors provide the example or 'role model' for
teaching and learning that health workers follow when they return to their
communities.
If the instructor bosses and 'talks down' to students, the students, in turn, will
be more likely to 'talk down' and act superior to others when they become village
health workers. But if the instructor relates to the students as his equals, building
on strengths and knowledge that they already have, then the health workers will
be more likely to work with their people in a similar way.
THE EDUCATION GAP
A common problem: Instructors often have a very
different social and educational background from
that of the health workers they teach. They may be
doctors, nurses, social workers, or health officers who
have grown up in cities and have had far more formal
education. They can easily lose touch— if they ever
were in touch— with the wisdom, hardships, strengths,
and weaknesses of people who still live close to the
land, the seasons, and physical work.
The knowledge of highly educated persons is not
necessarily better than that of most of us, but it is
different. It is as difficult for the doctor to speak in the basic, clear, colorful
language of the villager, as it is for the villager to understand the long Latin words
of the doctor.
This wide separation between instructor and students is called an 'education
gap'. When the 'gap' is too wide, it is often difficult to bridge. So teacher and
students never really come to know, appreciate, or learn very much from each
other.
2 12
Helping Health Workers Learn (2005)
Many kinds of professionals have served as trainers of health workers:
• doctors
• senior medical students
• nurses
• paramedics
• intermediate-level health workers
• public health graduates (often
foreigners)
• social workers
• school teachers
• teaching teams made up of
doctors, nurses, anthropologists,
social workers, agricultural
extension officers, and
foreign experts
Little study has been done to compare the strengths and weaknesses of these
different professionals as health worker trainers. But here are some common
Doctors. As a general rule, doctors make poor instructors of
health workers. Their curative, hospital-based training does
not prepare them to look at the needs of a whole community.
Attitudes are also a problem. Doctors have a tendency to
take charge, to regard themselves as decision-makers even in
areas they know little about. Feeling that even simple
diagnosis and treatment are 'risky' without years of medical
school, they often limit teaching of curative medicine to a
few minor chores. This severely weakens the role of health
workers in the community. Yet the courses doctors teach usually include a deadly
overdose of anatomy, with countless Latin names. This gives the health worker a
magic vocabulary with which to confuse and impress the people in his community.
Nurses. Some nurses make excellent instructors of health
workers. But such nurses are exceptional. The nurses' job has
traditionally been to take orders without question, and to
clean up after the doctors. They are given little decision-
making responsibility. So it is not surprising that, when
nurses instruct village health workers, they place strong
emphasis on unquestioning obedience, filling out forms, and
functioning as errand boys or girls. As they have been
dominated and undervalued, they tend to do the same with
health workers. For a nurse to effectively prepare health workers as leaders of
social change, she must be a true rebel. Fortunately, many such nurses exist!
Unfortunately, they are rarely chosen as instructors.
School teachers. In Honduras, some young school teachers
have proved to be surprisingly good instructors of village
health workers. These teachers are given 2 or 3 months of
special training in community development and primary care
activities. Then they are sent to teach and work with village
health workers. The young teachers are far more willing to go
to remote villages than are nurses or doctors. They also are
able to relate well to the health workers and local people.
Having a limited background in health, they do not set
themselves up as 'authorities'. Rather, they explore and learn with others about
approaches to solving different health problems. This puts them on a more equal
footing with students and villagers. It seems that, in some circumstances at least,
teaching skills may be more important than an extensive background in medicine
and health care.
impressions:
Helping Health Workers Learn (2005)
2-13
Bridging the education gap
If, as an instructor, you find you are separated
from your students by a wide social and educational
gap, there are things you may be able to do to help
bridge it:
1 . Admit openly to your students that the gap
exists— and that the shortcoming is yours as
much as theirs. Invite your students to discuss
and look for ways of bridging the gap together.
2. Do whatever you can to understand in a personal way the life, language,
customs, and needs of your students and their communities. Live, if you can,
with one of the poorer families in the community (paying your way). Eat
their food. Drink their water. Help each day with some of the physical or
farm work. Accept no more income than an average member of the
community earns. (This is only a suggestion— but a good one.)
3. If you are from out of the area, or are specialized in a narrow field of health
care (like medicine), try not to be the main teacher, but rather a teaching
assistant or auxiliary. (The main teacher will need a wide range of skills and
knowledge, including, above all, teaching skills and inside knowledge of the
local people. He or she needs personal understanding of what it is like to
approach learning new things without much formal education.)
4. When teaching, make every effort to always begin with the knowledge and
skills the health workers already have, and help them build on these. You are
the stranger, so try to adapt your language to theirs; don't make them adapt
to yours. If they are used to learning from stories or from actually doing
things, rather than from lectures and books, try to adapt to their way of
learning— even if this means exploring forms of teaching and learning that are
new to you.
5. Most important! Make yourself as unnecessary as possible, as soon as
possible. Look for local persons who are socially more qualified (less
schooled, more in harmony with the people) to take over the training. Work
toward having more experienced village health workers become the teachers
of new village health workers as soon as possible. Every chance you get, move
one step further into the background. Become the teacher of teachers. Then,
just an adviser or 'person with ideas'. Then leave.
2-14
Helping Health Workers Learn (2005)
BRIDGING THE
EDUCATION GAP
If the student is
at this level
Primary
Education
Secondary
Education
(or more)
■ and you try to teach him
from this level,
you will be talking over his
head. You will bore him
and, in time, lose him. You
will make him feel stupid
and he may hate you for
it— because he is not
stupid. There are probably
many things he can do
much better than you can,
and many important things
he knows that you do not.
If you try to learn from
him, and to make good
use of the language,
knowledge, and skills
he already has, often
you can help him
bridge the gap
to learning
new skills.
4 A /
f'A M
There are many shortcuts
to increasing the student's
skill and understanding:
teaching aids, problem
solving, role playing,
learning by doing, etc. But
it is important to begin
with the skills and
understanding the person
already has.
Go more than halfway to
meet him.
Start with the knowledge and skills a person
already has— and help him build on these.
CLOSING THE GAP
If the educational gap is
wide, better than trying to
bridge it is to close it.
Work toward training
community persons n
who are closer to the CyC,
educational level f i
of the students,
so they can take \ T)
over most or ; / L
all of the |
teaching.
The sooner a local health
worker can be trained to
take over the teaching of
new health workers, the
better. Then training is
more likely to be
appropriate and helpful.
If you are an outsider, work toward making yourself as unnecessary as
possible, as soon as possible.
Helping Health Workers Learn (2005)
2-15
Closing the education gap:
community persons as instructors
When there is a wide 'education gap' between
instructor and students, try, instead of bridging it, to
close it or avoid it. This means trying to find or
prepare instructors who:
• are from the same immediate area as the health
workers-in-training
• speak the local language
• have the same cultural and social background
(a farmer, worker, father, mother, etc.)
• have had more or less the same amount of
formal education as those they teach (although they may have had far more
experience or training in health care at the community level)
• dress, act, speak, and feel as equals to the students and villagers
It is important that instructors be culturally close to the students. But they also
need enough basic knowledge and skills (in health care, in problem solving, and in
teaching) to help students learn effectively. At first it may be difficult to find
local persons with this combination of culture and skills. During the first few
years, 'outside' instructors may be needed. But their first responsibility should be
to prepare local people to take over most or all of the instruction. The more
outstanding and experienced health workers are often the best ones for the job.
CAN LOCAL PERSONS BECOME EFFECTIVE
INSTRUCTORS OF HEALTH WORKERS?
Health professionals may be skeptical (doubtful) about whether villagers can
make effective instructors. But community-based programs in many countries
have found that:
Experienced village health workers—
with appropriate preparation, back-up,
and friendly criticism from the learning
group— can make excellent instructors.
Just as with doctors and nurses, villagers who make good instructors are
exceptional. The challenge is to find persons with the right combination of
attitudes, interests, and talents, and then to create the situation that permits and
helps them to grow.
2-16
Helping Health Workers Learn (2005)
STRENGTHS AND WEAKNESSES OF VILLAGE-LEVEL INSTRUCTORS
A story:
When a training program is taught and run by village-level instructors, certain
problems and obstacles are avoided. But others commonly arise. Once, when we
were observing a training course taught by villagers, a visiting nurse was present.
Herself a trainer of health auxiliaries in a neighboring program, she was highly
critical of the way the village-level instructors conducted the course:
TOO INFORMAL.
CLASSES DO NOT BEGIN ON TIME.
INSTRUCTORS SLOPPILY DRESSED.
THEY USE VULGAR EXPRESSIONS.
MISSPELLED WORDS.
INCOMPLETE COVERAGE OF MATERIAL.
FREQUENT STRAYING FROM THE
TOPIC BEING TAUGHT.
TOO MUCH NOISE AND LAUGHTER.
INACCURATE INFORMATION.
After listening to her many complaints, the village instructors
invited the nurse to give a class to show them how to do it better.
They suggested a class on "The Human Body and How It Works."
So the visiting nurse presented a class on "Anatomy and Physiology." It was
carefully timed: 40 minutes of lecture with 10 minutes for questions at the end.
She briefly and expertly covered each of the body systems, naming the major
organs and stating their functions. When she finished, she asked one of the health
workers if he had understood. He slowly shook his head. "I didn't understand
beans!" She called on student after student to see what they had learned. But
with the exception of two who had studied in secondary school, her lecture had
gone completely over their heads. One of the village instructors had made a list of
over 60 words she had used, which no one understood. He asked her to explain
some of the words. But each time she tried, she used 2 or 3 more words that
nobody understood.
The students then asked if the nurse would be willing to give the class over
again, but more simply. The nurse admitted she didn't think she could. She asked
one of the village instructors to do it for her.
The next day, one of the local instructors led a discussion about "The Body
and How it Works" (not "Anatomy and Physiology"). Rather than lecturing, he
started by holding up a box. He challenged the students to ask as many questions
as they could in order to find out whether the box contained something living or
not. They asked questions like:
DOES IT GROW? OOES IT MOVE BY ITSELF ? DOES IT PEE AND SHIT ?
DOES IT BREATHE ? DOES IT NEED WATER AND FOOD ? CAN IT MAKE BABIES OR SEEDS?
The instructor wrote the questions on the
blackboard and then opened the box. Out jumped
a frog!
Next, the instructor asked how we, as people, also do each of the things listed
on the blackboard. He started with what the class knew about the body, and
built on that, asking questions like:
WHAT BECOMES OF THE FOOD WE EAT?
WHAT HAPPENS TO US WHEN WE DON'T GET ENOUGH FOOD ?
Helping Health Workers Learn (2005)
2-17
At one point, he asked two of the students to run fast around the building, and
had the group observe them and take their pulse. Then he asked.
WHY DO WE SWEAT, BREATHE HAR DJ AND HAVE A FAST PULSE
WHEN WE RUN OR DO HARD WORK ?
WHAT IS THE PURPOSE OF THE HEART AND LUNGS?
After the group had given their ideas (which were
mostly correct), he asked:
WHY DO PEOPLE WHO ARE VERY PALE GET TIRED MORE QUICKLY?
WHAT IS THE PURPOSE OF BLOOD 1
He spoke in the people's language, using the village names for different parts of
the body: 'guts' for intestines and 'belly' for abdomen.
In this way, the students themselves were able to piece together many of the
different systems of the body and their functions. It was like solving a mystery or
putting together a puzzle. The students loved it. And everyone understood. The
class was noisy and went overtime, but no one objected— this time not even the
nurse!
Of course, some of the body systems were forgotten, and others were barely
mentioned.
"There is a lot more to the body than we have talked about today," explained
the group leader at the close of the class. "But we will talk about other parts
of the body and how they work when we need to, to understand about particular
health problems as they come up." (See p. 5-1 1 . )
By the time the visiting nurse left, she had changed her mind— and said so. She
had seen that, in spite of certain inaccuracies and shortcomings of the teaching,
the students had learned more and taken a more active part in the classes taught
by their fellow villagers!
Not all the credit is due, of course, to the fact that the instructors were
villagers themselves. Much of the difference was in the teaching methods they
used. But the technique of building on the students' own knowledge and
experience is often easier for a local person who shares a common background.
In Project Piaxtla in Mexico, we (the authors) and other outsiders used to do
most of the teaching for the health worker training courses. Then, several years
ago, the local health team (made up entirely of experienced village health
workers) took charge of the training. The first year that the course was taught by
the village team only, 3 students were present who had taken previous courses
taught by outsiders. When asked which course they thought better and more
appropriate, all 3 agreed, "This one, taught by the village health workers." Their
reasons:
UNDERSTAND.
THE INSTRUCTORS SEEM TO KNOW JUST HOW SLOW
OR FAST TO CO TO BE SURE WE UNDERSTAND BUT
DON'T GET BORED.
WE FEEL MORE COMFORTABLE WITH THE TEACHERS WHO
ARE OUR OWN PEOPLE. IT MAKES LEARNING EASIER . IF
THEY CAN UNDERSTAND SOMETHING , WE KNOW WE CAN, TOO?
2-18
Helping Health Workers Learn (2005)
'TRAINING ORGANIZERS' OR 'BACK-UP PERSONS'
Supportive back-up (supervision) can be as important for instructors as for
health workers. This is true for instructors who are doctors and nurses, as well as
for village-level instructors. We all can benefit when someone with more
experience, or a different perspective, observes our teaching and makes helpful
suggestions.
The person who provides this sort of support and suggestions can be called a
'back-up person', 'advisor', or 'training organizer'. Since her main goal is to help
people meet their needs, the training adviser should not only be an experienced
health worker, but should also sympathize and identify with the poor.
The role of the training organizer in a health worker training program in
Bangladesh has been described as follows:*
"The 'Training Organizer' will sit in the class, quietly and discreetly at the
back, and then review the class with the teacher afterwards, with emphasis on
points like:
• Did the message get across
clearly?
• Did the trainees have an
active or passive role in
the class?
• Were visual aids used
effectively?
• How many of the trainees
fell asleep before the end
of the class?
"The 'Training Organizer'
will review some of the above
points with the trainees as well
as the teacher."
vou covered All
the IMPORTANT POINTS,,
But two st uoent s
PELL ASLEEP.
Village health workers can make excellent instructors. But at first they often
lack basic teaching skills and experience in course planning. It is here that the
training organizer can help. But it is essential that he or she be willing to stay in
the background and let the community-based instructors assume full
responsibility. Once again:
Advise, don't boss!
To emphasize the secondary role of this advisor, 'training assistant' might be a
better term than 'training organizer'. To move into this back-up role is a natural step
for the outside professional or foreigner who has been active as an instructor early
in the program. It allows the outside person to begin phasing herself out, to pass
teaching and organizing responsibilities to local workers. In time, outstanding local
instructors (who started off as community health workers) may likewise be able to
take over the role of 'training assistant'. In this way, the outsider moves one more
step into the background. The sooner she is not needed, the more successful she
has been.
* From a personal communication with Martin Schweiger, Medical Adviser/ Administrator, Rangput
Dinajpur Rehabilitation Service Program, Lalmanirhat-Rangpur, Bangladesh.
Helping Health Workers Learn (2005)
Planning a Training
Program
3-1
CHAPTER
The primary aim of this book is to look at ways of learning, not to discuss the
details of a training program. But the way a training course is planned, and by
whom, can greatly affect how teaching and learning take place.
Many approaches are possible. But two things are of key importance:
1 ) Each training program should be designed according to the special needs and
circumstances of the area it serves. 2) Each course should be adapted to the
experiences and needs of each new group of students.
We have reasons for placing this chapter on planning after those on approaches
to learning and selection of health workers, instructors, and advisers. The
educational approach and the persons involved can affect how course content is
decided. For if a 'community-strengthening' approach is taken, some of the
course planning is best done by the participants.
THE TRAINING COURSE AS PART OF A LARGER
LEARNING PROCESS
In this chapter we focus on training courses for health workers. But keep in
mind that 'training' takes place in many ways and on many levels.
The training course is— or should be— closely linked with a vital network of
continuous learning and teaching that takes place in the community. The
diagram below shows some of the possibilities.
THE NETWORK OF LEARNING FOR COMMUNITY HEALTH
E veryone
helps the
instructors
learn
COMMUNITY
Health workers
help parents
learn
Instructors
help
health
workers
learn
A
f.
if A
'TRAINING^
COURSE j
-Health workers —
help instructors
learn
Health workers
help children
learn
Children
help
parents
learn
Health workers
help workers\
earn
Parents help Parents
health workers help
learn children
learn
Children
help children
learn
Everyone
helps student
health workers
learn
Health workers
help
Workers help
health workers
learn
Midwives help
health workers
learn
3-2
Helping Health Workers Learn (2005)
THE IMPORTANCE OF HAVING STUDENTS TAKE PART
IN THE PLANNING
The ability to plan effectively— to analyze and organize what needs to be done—
is basic to the self-reliance of every individual, family, and community. Planning
skills are especially important for health workers who are to become leaders,
teachers, and organizers in their communities.
This does not mean that a training program must include special classes on
'planning and management'. Instead, it points to the value of including the
student group in the planning process.
LESS APPROPRIATE
MORE APPROPRIATE
Some of the most important skills are best learned through practice
in applying them to real situations, rather than by studying them as separate topics.
There are several good reasons for including the student health workers in
planning the content and organization of their own training:
• Through guided practice the students learn firsthand about analyzing,
planning, and organizing relevant activities.
• Students become more deeply involved in the teaching-learning process.
• They become— and feel— more equal to their instructors. This will help them
when they begin to plan and teach in their communities. They will be more
able to relate to their own people as equals, and to share responsibilities
with others.
• Students can help adapt the content of the training program to the problems,
needs, and resources within their particular communities. This helps make
each training session a new, special, exciting, and more relevant experience—
for the instructors as well as the students.
• The flexibility and shared responsibility of this approach are basic to
achieving community health and fairer distribution of control.
Helping Health Workers Learn (2005)
33
A COMMON PROBLEM: PLANNING THINGS BACKWARDS
• Why are so many health worker training
courses taught by persons who have no
community experience?
• Why do so many instructors give more
class time to the study of anatomy and
filling out forms than to child diarrhea,
nutrition, and teaching methods?
• Why do so many courses fail to prepare
health workers to solve many of the
basic problems they will face?
The answers to these questions lie in the fact that training programs too often
are planned backwards. The time and place are fixed, instructors chosen, and
course content decided before planners consider the special difficulties, resources,
customs, and strengths of the people involved. As a result, what is taught does
not match either the community's needs or the students' abilities.
Many training programs today teach too much of what matters little— and too
little of what matters most. To make things worse, the way they teach is often as
unrelated to people's needs as is the subject matter.
If training is to be appropriate (adapted to people's needs, resources, customs,
and abilities), things need to be done the other way around:
1st: Invite the people from the communities that the program will affect to
determine and make known their needs.
2nd: Let the people's needs, resources, and abilities determine what should be
taught, and to whom.
3rd: Let what should be taught, how, and to whom, determine who should
teach, where, for how long, and in what way.
This people-centered or 'decentralized' approach to planning can be relatively
easy for small programs that are community based. But it may be extremely
difficult for a large, regional program. An appropriate approach may still be
possible, however, if those in positions of central authority are willing to:
• Permit planning and basic decisions to take
place at the community level.
• Act not as a controlling body, but as a center
for communications, advice, support, and supply.
the decentralized
or
►
people-centered
approach
3-4
Helping Health Workers Learn (2005)
THE DECENTRALIZED APPROACH TO PLANNING
(the solid arrows show the main direction of flow)
The central ministry or program The communities provide most
provides most of the supplies, of the advice, planning, and
support, and coordination. control.
When groups are very large, central planning-and-control very easily becomes
rigid, bureaucratic, change resistant, and corrupt. Planning-and-control has more
chance of being appropriate, flexible, and responsive to human needs when it
takes place in groups that are small enough for everyone to know each other.
DECIDING HOW MUCH TO PLAN IN ADVANCE
AND HOW MUCH TO PLAN DURING THE COURSE
As we have noted, it is advisable to leave some of the planning of a training
course until after it begins. This allows the course content to be planned or
modified according to the students' interests, experiences, needs, and capabilities.
Clearly, however, some planning must be done in advance. Someone has to
make decisions about why, when, where, with whom, and for whom the training
will take place. Resources and needs must also be considered. And certain
preparations need to be made.
On the next four pages (3-5 to 3-8) we present an outline of IMPORTANT
CONSIDERATIONS FOR OVERALL COURSE PLANNING. It includes:
Section A: Planning to be done before the training course begins
Section B: Continued planning after the training course begins
Section C: Planning and programming after the course is completed
Helping Health Workers Learn (2005)
3-5
IMPORTANT CONSIDERATIONS FOR OVE RALL COURSE PLANNING
A. Planning to be done before the training
course begins:
1. FIRST CONSIDERATIONS—
PURPOSES AND QUESTIONS
• Whose needs will the training program be primarily
designed to meet?
• Will it only extend the existing health system, or
will it help to change it?
• How much will it prepare the health worker to
understand and deal with the social (economic,
cultural, political) causes of ill health?
• Will it make the poor more dependent, or help
them to be more self-reliant? Will it promote or
resist social change?
• What are the general goals and objectives of the
program? (To express goals in terms of numbers
and dates is probably unwise at this stage. Why?)
• Who is (or should be) involved in all these
decisions?
2. OBSERVATION OF NEEDS AND RESOURCES
(Talking with a few observant persons from the area
can often provide more useful information than a
census or elaborate 'community diagnosis', at far
lower cost, more quickly, and with less abuse.)
Information worth considering:
• Common health problems: how frequent and how
serious?
• Causes of main problems: physical and social,
coming from inside and outside the community.
• People's attitudes, traditions, and concerns.
• Resources: human, physical, economic, from
inside and outside the area.
• Characteristics of possible health workers: age,
experience, education, interest, etc.
• Possible choices of instructors and training
organizers.
• Possible sources of funding and assistance. (Which
are more appropriate?)
• Reports and experiences of other programs.
• Obstacles: certain, likely, and possible.
3. EARLY DECISIONS—
Who? Where? How many? When?
• Selection of health workers: by the community,
by the health program, or by both? (How can
selection of a health worker be a learning
experience for the community?)
• Selection of instructors and advisers:
♦ How much understanding and respect do they
have for village people? Do they treat them as
equals?
♦ How committed are they to working toward
social change?
♦ Do they have the necessary knowledge and skills
(public health, education, group dynamics,
community organization, medicine, etc.) or are
they willing to learn?
• Location:
♦ Where will the training take place? Near or far?
Village or city? Why?
♦ Where will everyone eat and sleep? I n hotels?
In special facilities? With village families?
(How can these decisions influence what they will
learn?)
• Numbers: How many students will take part in the
training course? (Beyond 1 2 or 15, quality of
training usually decreases. This must be weighed
against the need to train more health workers.)
• Timing:
♦ How long will the training course last?
♦ What time of year is best?
(Consider how these decisions may affect who
can take part in the course.)
♦ Will the training be done in one continuous
stretch, or be divided Into short blocks so that
students can return home (and practice what
they have learned) between sessions?
(Whose needs and opinions should be considered
in answering these questions?)
• Funding:
♦ From where? How much money should come
from outside the local area?
♦ What are the interests of possible funding
groups?
♦ What are the advantages and disadvantages of
asking communities to pay part of the cost of
training their health worker?
♦ How can costs be kept low? How much is
needed?
• Follow-up and support:
♦ What opportunities may there be for continued
learning or training after the course is over?
♦ What kind of support or supervision will the
health workers receive?
(Why is it important to consider follow-up before
the training program begins?)
3-6
Helping Health Workers Learn (2005)
4. ANALYSIS OF PRIORITIES
(deciding what is most important)
Problems can be compared by considering the
following:
• How common are they?
• How serious are they?
• How contagious are they?
• How much concern do people feel about them?
• How much do they affect other problems?
• How much could a community health worker do
about them in terms of . . .
♦ diagnosis and treatment?
♦ referral, when needed?
♦ prevention?
♦ education of local people?
♦ community action?
• How easy or difficult will it be to teach a health
worker to take safe, responsible action with
respect to the problem?
Then group the problems according to their relative
importance, or priority, and decide which ones to
include in the course. (Be sure to include common
social problems that affect health— such as drinking,
overuse and misuse of medicines, local forms of
exploitation of the poor, and misuse of resources—
as well as physical diseases.)
5. RE-EXAMINING OBJECTIVES
• In view of the information you have gathered and
analyzed, how can the training program be best
designed . . .
♦ so that it prepares health workers to help the
people in their villages solve their problems and
needs?
♦ so that it is adapted to fit the particular
strengths and weaknesses of the students?
6. ORGANIZING STUDY MATERIAL FOR
APPROPRIATE LEARNING
• What general subject areas and specific topics
might be taught in order to prepare students to
act upon the important problems and needs in
their communities?
• How many hours of organized study time will
there be during the course?
• How much time is needed to adequately cover
each topic?
• How can the time available be best divided
among the different topics, according to their
priority?
• Which topics are best approached through
classroom learning, through practice (in clinic,
community, or field), or a combination?
(At this point, some program planners make a list
for each subject area, stating exactly what the
health workers should know and be able to do.
What are the strengths and weaknesses of this
approach? See Chapter 5.)
7. PLANNING FOR BALANCE
• How can the subject matter be approached so as
to maintain an appropriate balance between . . .
♦ classwork and practical experience?
♦ learning in the training center and learning in
the community?
♦ preventive and curative health care?
♦ physical and social causes of ill health?
♦ the needs of the poor and the requirements of
those in positions of control?
♦ caution and innovation?
♦ health skills, teaching skills, and leadership
skills?
♦ work and play?
8. PREPARING A ROUGH TIMETABLE OR
CLASS SCHEDULE
(without details, to be changed later)
• How can different subjects and topics be arranged,
according to hours, days, and weeks, so that . . .
♦ there is enough variety to keep the students
interested (for example, classwork alternating
with farm work, community action, and
learning of practical skills)?
♦ related subjects are scheduled close together or
in a logical order?
♦ more difficult subjects come early in the day,
and more fun subjects later (when people are
tired)?
♦ all key subject matter is included?
♦ high-priority subjects are given more emphasis
in the training course?
♦ skills and knowledge needed for immediate use
and practice are learned early (for example,
learning about medical history, physical exams,
preventive advice, Road to Health charts)?
• How can study time and free time be best arranged
to meet students' and instructors' needs?
• How can the schedule be kept open and flexible
enough to allow for unplanned learning
opportunities and special needs as they arise?
(It helps to leave the last week of the course
unscheduled, to allow for review and for making
up 'displaced classes'.)
• How can the schedule be presented in a clear,
simple form that can be easily seen and
understood by students and instructors?
WEEKLY PLAN
—
Helping Health Workers Learn (2005)
3-7
9. PLANNING APPROPRIATE TEACHING
METHODS AND AIDS
• What teaching approach is best suited to persons
who are more used to learning from experience
than from lectures and books?
• What approaches to learning will help the health
worker be an effective teacher in his community?
• What attitudes on the part of the teacher will
encourage the health worker to share knowledge
gladly and treat others as equals?
• What teaching methods might aid the health
worker in helping community people to become
more confident and self-reliant?
• What teaching aids can be used that will lead the
health worker to make and invent teaching aids
after returning to his village?
• What approach to learning will best prepare the
health worker to help his people understand and
work together to solve their biggest problems?
• What approach to health problems will enable the
health worker to learn how to approach the
solving of other community problems?
• What can be done to ensure that all learning is
related to important needs?
• How can classwork be made more friendly and
fun?
• How can tests and exams be presented so that
students use them to help each other rather than
to compete? How can tests and exams be used
to judge the instructor as well as the students?
10. GETTING READY AND
OBTAINING SUPPLIES
• What preparations are needed before the course
begins? (transportation, eating and sleeping
arrangements, study area, wash area, etc.)
• What furnishings and teaching materials are
needed to begin? (benches, blackboard, etc.)
• What can be done if some of these are not ready
on time?
11. DETAILED PLANNING OF ACTIVITIES AND
CLASSES FOR THE BEGINNING OF THE
COURSE
• How many days of classes and activities should
be planned in detail before the course begins?
• Why is it important that the details of all the
classes and activities not be planned in advance?
B. Continued planning after the training
course begins:
12. INVOLVING STUDENTS IN PLANNING THE
COURSE CONTENT (based on their experience
and the needs in their communities)
• Why is it important that the students take part
in planning the course?
• How can the students' participation in planning
help them to learn about . . .
• examining and analyzing the needs in their
communities?
• recognizing both the strengths and the
weaknesses of their people's customs?
• ways to plan and organize a learning group?
• the value of learning by doing, and of respecting
and building on their own experiences?
• shared decision making?
13. REVISING THE PLAN OF STUDIES
(COURSE CONTENT) ACCORDING TO
STUDENT SUGGESTIONS
• To what extent do the priorities determined by
the students, according to problems and needs in
their own villages, correspond to those already
considered by the instructors and planners? (How
do you explain the similarities and differences?)
• How important is it to revise the course plans in
order to better meet the concerns and expressed
needs of the student group?
14. PREPARING INDIVIDUAL CLASSES AND
ACTIVITIES
• How detailed should class plans be?
• How far in advance should a class or activity be
planned? Why?
• Is it helpful to use a particular outline or formula
for preparing a class? If so, what should it include?
• Can each class or activity be planned to include . . .
♦ all of the basic points to be learned or
considered?
♦ active student participation and interaction?
♦ use of appropriate learning aids?
• opportunities for the students to explore
questions and discover answers for themselves?
• practice in solving problems similar to those
health workers will meet in their work?
• a chance for students to summarize what they
have learned and to ask questions?
• To what extent can students take part in the
preparation of classes and of teaching aids? (Is
this important? Why?)
3-8
Helping Health Workers Learn (2005)
15. CONTINUED REVISION OF THE
SCHEDULE— to make room for new ideas,
learning opportunities, needs, and problems
as they arise
• What are the advantages and disadvantages to
keeping the program open and flexible? (How
might this influence a health worker's ability
to work toward, or tolerate, change in his or
her community?)
18. STARTING OVER
The whole process is repeated:
1
PURPOSE
I
OBSERVATION
16. EVALUATION DURING THE TRAINING
PROGRAM —to consider how it might be
improved (see Chapter 9)
• I n what ways can this be done?
• Who should be involved?
• What is the value of . . .
♦ round-table discussions in which all students
and staff have a chance to express their feelings
about the program and each other?
♦ similar discussions with members of the
community where the training program takes
place?
♦ tests and exams?
♦ setting specific goals and seeing if they are met?
• If evaluation studies (informal or formal, ongoing
or final) are made, what can be done to help
assure that results are useful and will be used?
CE
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ANALYSIS OF NEEDS
EARLY DECISIONS AND OBJECTIVES
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-FOLLOW-UP AND FEEDBACK
C. Planning and programming after the
course is completed:
17. FOLLOW-UP AND FEEDBACK' (see
Chapter 1 0)
• How can a supportive learning situation be
continued between instructors and students,
and among the students themselves, once the
training course is completed?
• How can the following be involved in supporting
the health worker:
♦ members of the community (a health
committee)?
♦ other health workers?
♦ program instructors, leaders, and advisers?
♦ other support groups and referral centers?
• How can the experiences, successes, and
difficulties of the health workers in their
communities be recorded and used to make the
next training course better than the last? (Can
this be done so that health workers know they
are contributing, rather than being judged?)
* FEEDBACK : helpful ideas and suggestions
sent back to planners or instructors by health
workers.
Helping Health Workers Learn (2005)
3-9
EARLY DECISIONS
Location of training
It is best if training takes place in a situation close to that where health workers
will work. Closeness in distance is convenient. But closeness in terms of community
setting is essential. Village health workers are best trained in a village. That way,
they can practice solving problems and carrying out activities under conditions
much like those in their own communities.
If possible, training should take place in a village with a health center where
students can gain clinical experience. It helps if the health center is run by
experienced local health workers, and has strong community participation. A
small community-based health center is usually far more appropriate for training
villagers than a large clinic or hospital (see page 8 4). The closer the situation of
learning to the situation in which health workers will later work, the better.
For the same reasons, it is important that the building in which training takes
place— and even the furniture, if any— be similar to those in the villages of the
health workers.
In this book and in
Where There Is No
Doctor, we often show
drawings of health
workers-in-traimng
sitting on chairs or
benches. That is
because people
customarily make and
use such furniture in
the villages of Latin
America where we
work. But in areas
where people
traditionally sit on
the ground during
meetings and
discussions, it makes
sense that the same
traditions be observed
in the training course.
In places where villagers traditionally sit on the floor, it is
appropriate that the training course follow the same custom.
This drawing is from Ang Maayong Lawas Maagum, a
Philippine equivalent of Where There Is No Doctor.
In the same way, there are advantages to having health workers live with
families in the community rather than staying in a separate 'dormitory'. This is
discussed further in Chapter 6.
3-10
Helping Health Workers Learn (2005)
Numbers
LESS APPROPRIATE
Many programs have found
that from 1 2 to 1 5 is a good
number of students for a
course. A group this size is
large enough for discussions
to be exciting, but small
enough so that everyone can take part.
MORE APPROPRIATE
Timing
1. Continuous
2 to 3 months
Some training courses are taught in one continuous block of time. Two to
three months is the average length of such a course. This is usually long enough
for health workers to learn the basic skills needed for primary care. Yet it is
short enough so that villagers with families and responsibilities at home can
(sometimes) afford the time away.
2. Short blocks of training
alternating with practice
2 weeks
2 weeks
2 weeks
Other training courses are taught in a series of shorter blocks of time. Health
workers may train for blocks of 2 weeks, separated by periods of 1 or 2 months
in which they return to their villages to practice. This way health workers are not
apart from their families for so long at one time, and they have a chance to
put into practice what they have learned. The experience they gain and the
problems they meet in their village work add meaning and direction to their
continued training. However, if health workers must come a long distance by
foot or on muleback, training in short b
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