HE & HP for EOHS-IV.pptx for different health proffessionals

Good job these all are handouts for different ...... health proffetionals in health care setting ........ to improve the quality of service ......... .............. .. is that helpful ? Please give valuable comments thanks ..........................................................................

1. University of Gondar, College of Medicine & Health Science, Department of Health Education and Behavioral Sciences Course: Health Education Course number: Comh402 Department : EOHS - IV Credit Hour: 04 ECTS Instructor: Asmamaw A .(BSc, MPH) [phone] [email protected] 1

2. Cont…. Course Description This course introduces students about Health Education as an important public health tool of disease prevention and control . It also describes the different theories and models . Course Objectives   After completion of this course, the student will be able to Explain the objective and basic principles of health education. 2

3. Cont…. Describe the role of human behavior in health. Explain the principles of communication. Differentiate different models and theories in health education Describe the skills and methods required in health teaching. Identify the difference between group and team Explain methods of counseling 3

4. Teaching and Learning Methods Illustrated lectures and discussion Group activity and discussion Teaching and Learning Materials PC & Smart board Print handout Course Logistics Location: UOG CMHS room # 57 Course duration – 2 Cr.hr. (32 hrs) & Semester based 4

5. Course contents Introduction to Health Education 1.1. Definition of Health &Health Education 2. Primary health care (PHC) concepts 1.3. Aim & principles of Health Education Health & Behavior 2.1 Define Behavior 2.2. Factors affecting behavior 2.3. Principles of learning 3. Theories and Models of Health Education 3.1. Health Belief Model (HBM) 3.2. Theory of Reasoned Action (TRA) 3.3. Social Learning Theory 3.4. PRECEDE-PROCEED framework   5

6. 4. Communication 4.1. Define Communication 4.2. Components of Communication 4.3. Types of Communication 4.4. Traditional means of communication 4.5. Barrier of communication 4.6. Theory on stages in adoption & diffusion of Innovation 5. Teaching Methods & Materials 5.1. Types of Teaching Methods 5.2. Types of teaching Materials 6

7. 6. Group Dynamics 6.1.Definition 6.2 Types Of Group 6.3 Group Behaviors 6.4 Group Training 6.5 Conflict 7. Patient Education and Communication 1. objectives of patient education 2. Guidance and Counselling 3. Patient – Clinician communication models 8. Research in Health Education Definition Types of Research Data collection in qualitative research 7

8. Evaluation: Fixed Grading Quiz I & II----------------10% @ any time Attendance---------------5% always Asgmt / Prstn ------------20% in-between Mid Exam---------------25% in between Written Final Exam--- 40% @ the End any comment ? 8

9. Assignment to be Presented/ppt. Group I- Primary health care (PHC) concepts Group II- Health policy of Ethiopia 1993-2035 Group III- Medical/health care Errors Group IV- Patient- Clinician Communication models Group V- Health literacy 9

10. NB: Future roles of health care professionals Care giver Teacher/Instructor Manager Researcher Advocator 10

11. Chapter One I ntroduction to Health Education and Health Promotion 11

12. Contents of chapter one: Concept of Health Aspects of Health Determinants of health Domains of Education Rationales of Health Education Aims of Health Education Levels of HE & illness continuum 12

13. Introduction Concept of Health The concept of health is often difficult to define and measure. It is a broad concept and experience. Its boundary extends beyond the "sick". I t is often difficult to put a clear-cut demarcation between the "sick" and the "not sick". It depends on: 1) The perception of individuals 2) The threshold - e.g. pain 3) The ability to recognize symptoms and signs 13

14. WHO has defined health as follows: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity . This definition may seem very attractive but still has lots of drawbacks. It will be seen that even after having this definition it will be difficult to conceptualize and standardize positive health with specific clear-cut attributes and criteria for measurement. 14

15. Cont… A person may be enjoying mental equanimity and enthusiasm for doing something. He may also be physically able to do any amount of work, but He may be having some minor dysfunction or deficiency or even a mild infection causing a very minor disturbance which however does not upset his normal activities. 15

16. Cont…. Therefore Health may be regarded as a balance of physical, mental and social aspects of life in a being. State of being well and using every power the individual possesses "Health is not a condition, it is an adjustment. It is not a state, but a process. The process adapts the individual not only to our physical, but also our social environments" (President’s Commission) 16

17. Cont….. Most individuals define health as the following( Lay man definitions): being free of symptoms of disease and pain as much as possible being able to be active and able to do what they want or must do being in good spirits most of the time. 17

18. Aspects of Health Physical health – refers to anatomical integrity and physiological functioning of the body. To say a person is physically healthy: All the body parts should be there. All of them are in their natural place and position. None of them has any pathology. All of them are doing their physiological functions properly. And they work with each other harmoniously. 18

19. Cont…. Mental health Mental health refers to a human individual's emotional and psychological well-being. Mental health - WHO defines mental health as: a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community 19

20. Social health – ability to make and maintain acceptable interactions with other people. E.g. To feel sad when somebody close to you passes away. 20

21. Cont….. Emotional Health health is part of our overall health concerned with the way we think and feel . It refers to our sense of well-being and our ability to cope with life events. Emotional health is about our ability to acknowledge and respect our own emotions as well as those of others. 21

22. Cont…. The ability of expressing emotions in the appropriate way, for example, to fear, to be happy, and to be angry. The response of the body should be congruent with that of the stimuli. 22

23. Cont…. Spiritual Health Spirituality is unique to each individual. It is the inner most part of our that allows us to gain strength and hope. The basis of spirituality is discovering the sense of meaningfulness in your life and coming to know that you have a purpose to fulfill. For some, spirituality may be equated with religions such as Christianity, Hinduism or Buddhism. For others, it may mean growing in your personal relationships with others, or through being at peace with nature. 23

24. Cont…. The absence of health is denoted by such terms as disease, illness and sickness , which usually mean the same thing though social scientists give them different meaning to each. 24

25. Cont…. Disease is the existence of some pathology or abnormality of the body, which is capable of detection using, accepted investigation methods. Illness is the subjective state of a person who feels aware of not being well. Sickness is a state of social dysfunction: a role that an individual assumes when ill. 25

26. Cont… The international classification of diseases( ICD ) distinguished between 3 terms of disease: A) Impairments Are abnormalities of the body structure at the organ or system level. B) Disabilities Is defined in functional terms as a limitation of performance of one or more activities essential to daily living such that the person is depend on others. It is disturbances at the level of the whole body owing to impairment. (is a temporal loss). 26

27. Cont… C) Handicap/dependency Is a permanent or long term disability to achieve his/her independence as is normal at the level of individual’s environment and social interaction. Disease without illness The person may have pathological problems, but may not feel illness E.g. AIDS doesn’t feel immediately Illness without disease Emanates from daily living conditions like anxiety, frustration, depression… E.g. a person may perceive as he is ill and goes to health institution but diagnosed as free, like headache, spirit possession 27

28. Determinants of health There are four general determinants of health. These are human biology, Environment, Lifestyle, and Healthcare Services . A major environmental factor is water quality, especially for the health of infants and children in developing countries 28

29. Cont…. The context of people’s lives determines their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health 29

30. Cont… These determinants—or things that make people healthy or not—include the above factors, and many others: 1.Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health. 2 . Education – low education levels are linked with poor health, more stress and lower self-confidence 30

31. Cont… 3 . Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions .   4. Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health. 31

32. Cont… 5. Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behavior and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health. 6. Health services - access and use of services that prevent and treat disease influences health 7. Gender - Men and women suffer from different types of diseases at different ages. 32

33. Education   Education is the process by which learning is facilitated. It is a process in which an individual or group of people are in the facilities or opportunities by an agent or educator to learn. 33

34. Objectives of education: Learning domains ; Cognitive domain , refers to knowledge or body of subject matter B. Affective Domains , refers to emotions, beliefs C. Psychomotor Domain , refers to practical applications 34

35. A. Cognitive Domain 35

36. Cognitive Domain It has its own six components Knowledge It involves the recall of specifics and universals, and of methods & processes, or the remember of a patterns, structure or setting. Comprehension It includes grasping communication accurately putting it into a different form of presentation, recognizing material in summary form without changing the central meaning of communication , and extrapolation. 36

37. Cont…. Application or use of general ideas, principles or methods to new situation. Analysis : - It c onsists the breakdown of material into its constituent parts, and detection of the relationships of the parts & of the way they are organized . Synthesis : - It is the ability to put parts or elements together to form a coherent whole. 37

38. Cont…. Evaluation : - making of judgments about the value, for some purpose, of ideas, works, solutions, methods, and material. Involves the use of criteria as well as standards for appraising the extent to which particulars are accurate or satisfying. 38

39. Highest level Lowest level Evaluation Synthesis Analysis Application Comprehension Knowledge

40. B. Affective Domain 40

41. Affective Domain There are five categories Receiving or Attending : - Sensitivity to the existence of a certain p henomenon or stimulus, and awareness. It also includes willingness to receive, or attention . Responding: - At this level the learner is sufficiently involved in a subject, or activity that he will seek it out & gain satisfaction from working with it or engaged in it. 41

42. Cont…. Valuing : - at this stage behavior is consistent & stable. It involves acceptance of a value & commitment (conviction) for a certain point of preference for a value. Organization : - at this level the learner constructs a value system which guides his behavior. Characterization by a value or value complex :- at this stage of internalization the values already have a place in the individual’s value hierarchy, are organized in to some kind of internally consistent system . 42

43. The affective domain deals with attitudinal, emotional and valuing goals for learners Highest level Lowest level

44. C. Psychomotor Domain 44

45. Psychomotor Domain There are 5 categories Imitation - Observing and patterning behavior after someone else. Performance may be of low quality . Example: Copying a work of art. Manipulation - Perform an action according to instruction and not only on the bases of observation Example: Creating work on one's own, after taking lessons, or reading about it. Precision - Refining, becoming more exact . Few errors are apparent. Example: Working and reworking something, so it will be “just right.” 45

46. Psychomotor Domain Articulation - Involves the co-ordination of a series of acts by the establishment of an appropriate sequence (internal consistence) Example: Producing a video that involves music, drama, color, sound, etc. Naturalization - Having high level performance become natural, without needing to think much about it. Examples: Lebron James: playing basketball, Tiger Woods: hitting a golf ball etc. 46

47. Objectives in this domain relate to learning physical skills. This taxonomy delineates five levels of psychomotor complexity. Highest level Lowest level

48. Health Education Definition In the simplest terms, health education is the process of educating people about health. However more formal definitions have been frequently cited in the literature as: 49

49. Cont….. Health Education is “a process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community well-being ( Hubley , 1993). This process, based on scientific principles , facilitates learning and behavioral change in both health personnel and consumers, including children and youth." 50

50. Cont… The above definition emphasizes the following points Health education engages/involve/ the intellectual, psychological and social processes of people. 2. Health education encourages learning new things and performing them. 3. Health education fosters people's abilities to make decisions about their own and others' health and act on these. 51

51. Cont… 4. Health education helps people develop and organize the personal and social resources they need to make decisions about what to do for health and to act on these decisions. 52

52. Other definitions Any combination of learning experiences designed to lead to a situation where people " know how to attain health; do what they can individually and collectively do to maintain health, and seek help when needed." This definition help people to acquire the power to make decisions that have to do with their own health. 53

53. Cont…. OR Health education is a combination of learning experiences designed to facilitate voluntary actions conducive to health. Combination emphasizes the importance of matching the multiple determinants of behavior with multiple learning experiences or educational interventions. Designed distinguishes health education from incidental learning experiences as a systematically planned activity. Facilitate means, predispose, enable, and reinforce 54

54. Cont… Voluntary means without coercion and with the full understanding and acceptance of the purposes of the action. Action means behavioral steps taken by an individual, group or community to achieve an intended health effect.   55

55. Health Promotion Definition: Any planned combination of educational, political, environmental, regulatory, or organizational mechanisms that support actions and conditions of living conducive to the health of individuals, groups, and communities . "Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. 56

56. Cont…. Health is, therefore, seen as a resource for everyday life, not the objective of living . Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion goes beyond healthy lifestyles to well-being." (WHO, 1986 ). 57

57. The basic strategies for health promotion: Improvement in health requires a secure foundation in these basic prerequisites. Advocate Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioural and biological factors can all favor health or be harmful to it. Health promotion action aims at making these conditions favorable through advocacy for health . 58

58. Enable-make possible/ allow,permite,facilitate Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. This must apply equally to women and men . 59

59. Mediate/intervene The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media. People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health 60

60. Cont…. Health education is defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of Health. The ultimate aim of health education is positive behavioural modification 61

61. Cont… . Health promotion, the process of enabling people to increase control over, and to improve their health, can be considered as an umbrella term that incorporates these activities. Health promotion is one of the important tool for disease prevention. 62

62. Cont… Prevention can be divided into three levels for comparison. Primary prevention is directed toward preventing the initial occurrence of a disorder; Secondary prevention seeks to arrest or retard existing disease and its effects; and Tertiary prevention seeks to reduce the occurrence of relapses. Relapse prevention includes specific clinical strategies. 63

63. Rationale for health education Continued existence and spread of communicable diseases such as malaria, TB, HIV/AIDS that need the involvement of the community members 2. Increasing threats to the young from new and harmful behaviors. E.g., tobacco use, teenage pregnancy ,substance abuse 3. Health education is the only practical option for some diseases in order to contain the spread of disease. e. g., HIV/AIDS 4.The cost of health care is rising. E.g. treatment and hospitalization costs are rising. 64

64. Rationale …. 5.The tendency of increasing magnitude of chronic conditions (diseases) that require cooperation of individuals to deal with the problem. E.g. hypertension. 6.Increased awareness of people on chronic health problems and the need to know preventive actions. E.g. prevention of cardiac complications 65

65. Aims of Health Education The aims or fundamental objectives of health education are to help each individual, each family to exercise their right to achieve the harmonious development of their physical, mental and social potential. Promote health, prevent illnesses and minimize avoidable deaths. 66

66. Goals of health education to provide appropriate knowledge: The goal is to give specific knowledge and information. 2. to help develop positive attitude : concerned with opinions of people, their feeling and beliefs. 3. to help exercise healthy practice ( behavior ): is concerned with carrying out a decision and actually doing something about a health matter. 67

67. Cont…. 4. Decision making : Involves both "knowing" and "feeling" objectives and is concerned with deciding what to do in the future about health or a particular aspect of health. 5. Social change : Goal of changing the physical and/or social environment so that people are encouraged to adopt healthier behaviour. 68

68. Levels of Health Education in Health-illness continuum Primary health education : Directed at healthy people and the primary aim is to prevent occurrence of ill-health. Many health promotion programs focus on primary HE. Health education programs on good nutrition, immunization, and breastfeeding are some of the examples. Children who are vaccinated against major killer diseases such as measles, poliomyelitis, etc will be protected from suffering and dying from these diseases 69

69. Cont…. 2. Secondary Health Education : Educating patients about their condition and what to do about it. The primary aim at this level is to stop the progress of diseases to the severest form of the problem. At this level complete recovery from the diseases or problem is possible, but if neglected complications may occur. e.g. Early treatment of Malaria, Tuberculosis treatment 70

70. Cont…. 3. Tertiary health education : Used in patients whose ill- health has not been or could not be, prevented and who can not be completely cured . It is concerned with educating the person or his or her relatives about how to make the most about the remaining potential for healthy living and had to avoid unnecessary hardships, restrictions and complications. 71

71. Chapter Two HEALTH AND BEHAVIOR 72

72. Contents of the Chapter Definition of Behavior Components of Behavior Human behaviors important for health Factors affecting human behavior Learning theories and Motivation 73

73. Behavior is an action that has a specific frequency, duration, and purpose, whether conscious or unconscious. Health behaviour is any activity undertaken by a person believing him/herself to be healthy for the purpose of preventing disease or detecting it at an early stage Any activity undertaken by an individual, regardless of actual or perceived health status, for the purpose of promoting, protecting or maintaining health, whether or not such behavior is objectively effective towards that end 8/3/2021 74

74. Components of Behavior Basically our behavior has 3 domains A) Cognitive domain Encodes, stores, retrieves, processes information; purpose is manipulation of information . Eg . knowledge, awareness B) Affective domain -cognition +feeling purpose is to create arousal Eg . Attitude ,Beliefs 75

75. Components of Behavior…… C ) Psychomotor domain Psycho-mind & Motor – action Practice/action/behavior- when our knowledge and attitude are expressed in terms of action 76

76. Healthy behaviors Health behavior- is an action that healthy people undertake to keep themselves or others healthy and prevent disease. Aimed to prevent disease “Any activity undertaken by a person believing himself to be healthy for the purpose of preventing disease or detecting it at an asymptomatic stage” 77

77. Human behaviors important for health promotion Promotive behaviors:- such as Physical exercise, use of latrine, Child-spacing, proper disposal of dirty water, Good nutrition, clean storage of food, Breast-feeding and reduction /cessation of unhealthy practices such as cigarette smoking, and excessive alcohol consumption. Preventive behaviors immunization using mosquito bed nets 78

78. Human behaviors… 3) Utilization behaviors Is concerned with utilization of health services such as: ANC services Immunization services Child-health services Screening programs FP service 79

79. Human behaviors… 4) Illness behaviors The action people take before consulting health care workers, including recognition of symptoms, taking home remedies (self-medication), consulting family and healers are called illness behaviors. It is recognition of early symptoms and prompt self-referral for treatment before the disease becomes serious ( -oral rehydration ) 80

80. Stages of illness behavior Becoming aware of symptoms Consulting others family/friends Self-medication Decision to go to treatment HW- patient consultation Following advice & taking prescribed drugs Returning for follow up 81

81. Human behaviors… 5) Compliance behaviors A behavior following a course of prescribed drugs/medication. 6) Rehabilitation behaviors A type of behavior that prevent further disabilities after a serious illness/ surgery to recover. 82

82. Human behaviors… 7) Community action Action undertaken by the individuals and groups to change or improve their surrounding to meet special needs. For example community participation in: Installation of improved water supply Building of latrines and upgrading the unimproved 83

83. Factors Determine Health Life style/Behavior Health Environment F.g.1. Relationships of Behaviors/life style & environment as a cause of health 84

84. Factors determine Health… Broadly, health is determined by two major categories of determinants or factors. These are Behaviors and environmental determinants. Behaviors :are those daily actions which are under the possibility of the control of the person/individual/ where as Environmental determinants or factors are those factors which are not easily under the control of the person 85

85. Factors affecting human behavior Predisposing factors Reinforcing factors Enabling factors Behavior Environment Health F.g.1.2 Relationships of Predisposing, Reinforcing, & Enabling factors as determinants of behaviors and environment for health 86

86. A. Predisposing Factors Are antecedents or prior to behavior that provide the rationale or creation of motivation for the behavior to occur. This type of factor include: Perception -Confidence/self-efficacy - Knowledge Belief – Attitude -Values 87

87. Predisposing… 1. Knowledge Knowledge is, “A clear and certain mental perception, understanding, the fact of being aware of something, experience of acquaintance of familiarity with information of, learning that which is known, facts learned or study of.” Therefore, one`s knowledge of something include some combination of ; Simple awareness of facts and understanding of how these facts relate to one another. 88

88. Predisposing… Knowledge is necessary but not sufficient in behavior change. It is necessary, because, without adequate knowledge , people may unaware of and concerned about health problem and unable to manage their behavior. Simple logic for the specific knowledge is that before act voluntarily people need to know, Why they should act? What actions are needed? When or under what circumstances? How to act and where? 89

89. Knowledge about/awareness Vs How-to/ essential knowledge Knowledge about/awareness: Knowledge about a topic may be important in developing interest in the topic and may even motivate the behavior How-to/ essential knowledge: Intentional behavior change depends on it It is practical/applicable Therefore, one of the main task in health education is helping the learner to become knowledgeable about some health topic. 90

90. Perception Perception: a process by which individuals organize and interpret their sensory information in order to give meaning it. Perception is a means of acquiring knowledge and it is highly subjective 91

91. Perception is subjective 92

92. Predisposing… 2. Skills/practice Skills is the capability of accomplishing something with precision and certainty. Skills require practical knowledge and ability On many occasions inappropriate or ineffective health behavio may result from the lack of mastery of specific skills. Knowledge and skills are interrelated in that skills are the practical application of essential knowledge 93

93. Predisposing… 3.Attitude Is “a tendency of mind of a relatively constant feeling towards a certain category of objects, people, or situation.” Mucchielli (1970) Attitudes are often a matter of good or bad; as soon as you know what something is, you start to know whether you like it or dislike it. Knowledge+ Feeling /sense of like or dislike =Attitude 94

94. Characteristics of attitude 1) Predisposition- exposure related to an attitudinal object. No exposure, no attitude 2) Has directions- polar, +ve or -ve, good or bad. Negative ……………… positive 3) Evaluation- can be evaluated by intensity or judgment e.g . Favorable or unfavorable 95

95. Characteristics… 96 4) Changeability- can be changed, not static. 5) Stability or consistency Stability=related to time Consistency= sameness of attitude e.g. “Mood” changed quite often.

96. Link between knowledge(K) and Attitude (A)… With the knowledge or information that we have on things, the mind is able to develop a sense of like or dislike, positiveness or negativeness /feeling. It is thus, the feeling component is added to the knowledge which keeps the individual react to a stimulus positively or negatively. 97

97. Link among knowledge(K) and Attitude (A) and Practice (P) The general trend or normal way of thinking and acting the proper sequence and linkage among KAP is that knowledge (K) is followed by attitude (A) and is followed by practice (P). 98

98. Link among KAP…. But this rule is not universally applicable to every behavior i.e. different possibilities and combinations can come across with regard to KAP. For example, Notice: When P or A precedes K, it is due either to an imitation (modeling) 99

99. Predisposing… 4.Belief Belief :- is a conviction that a phenomenon or object is true or real. Beliefs are what one perceive as a true; it may be correct or not. They are derived from parents, grand parents, and other people we respect to listen and are accepted as true. But we accept beliefs without trying to prove that they are true or false. 100

100. Difficulty index of changing beliefs It is usually difficult to change those beliefs that are held by the whole community Have been deep rooted in the culture Come from highly respected and trusted sources Are part of the a religion or traditional medical system 101

101. Predisposing… Types of beliefs Harmful belief: is a belief which damage health Helpful beliefs: is a belief which preserves health Neutral beliefs : is a belief which neither damages nor preserves health Concentrate on trying to change only the harmful and encourage the helpful ones 102

102. Predisposing… Relation ship between beliefs and attitudes It is certain that our beliefs about things affect the way we think about them. Our beliefs, in turn, are influenced by our attitudes. The judgment as good or bad and worth carrying out a behavior will depend on the beliefs about the consequences of performing the behavior. 103

103. Predisposing… Beliefs perceived to have good outcomes +ve attitude Beliefs perceived to have bad outcomes -ve attitude . 104

104. Predisposing… 105 For example, a mother may believe that breast feeding will improve the health of her baby (+ ve belief) may also believe that it will make her appear old fashioned (- ve belief). Overall, if she beliefs that performing the behavior lead to mainly to good outcomes, then her attitude will be favorable . And if the outcomes of performing the behavior are perceived as mainly bad , her attitude to the behavior will be unfavorable

105. Relationship between beliefs and attitudes 106

106. Predisposing… 5.Value Every individual places or gives a relative worth to every thing around. This worth or preference or judgment is known as value. It is defined as the regard that something is held to be important or worth; and prized by an individuals or community 107

107. Predisposing… Examples of characteristics that can be valued by the communities include: Being a good mother -having many children/cattle Being approved by friends - academically success Being attractive to opposite sex -being healthy success in foot ball events Being a man of God being ‘modern’ 108

108. These values that have advantages for the self and for the society are known as positive values. And these values that are harmful and disadvantageous are known as negative values . 109

109. Value conflict and value clarification People value life, health. However, in opposite engaged in unhealthy behavior, for instance, smoking. This reveals conflict of values=inconsistencies between two or more values. In health education one shouldn’t seek to change values rather should help people recognize inconsistencies between and among their values. But we can sometimes bring about changes by emphasizing values which don’t involve health. We, often trying to encourage people to think about their values. This process is called value-clarification 110

110. Relationship between attitude and value Values are more permanent and resistant to change than attitudes and beliefs and they determine attitude . 111

111. As a summary 112

112. B. Enabling factors Enabling factors are those antecedents to behavior that facilitate a motivation to be realized Enabling factors are those skills, resources, barriers that can help or hinder the desired behavioral changes as well as environmental changes. They help individuals to choose, decide and adopt behaviors and may be barriers and assets to needed changes. 113

113. Enabling… This category of factors include: The health-care environment -availability -accessibility -affordability New skills Resources. E.g.. Facilities, money, time, labor services, transportation, materials and the distribution and their location. 114

114. Enabling… Other environmental factors such as community and /or governmental laws, policy, rules, regulations, priority and commitment can be a barrier or a facilitator of the behavior change to be occurred. The absence of enabling conditions inhibits action. Sometimes a person may intend to perform but still not do so. This is because of the influence of enabling factors such as time, money, equipment, skills and health services. 115

115. Enabling… Mind now! Behaviors which involve spending much time, money, requiring new skills or conflict with existing practices will be more difficult to promote than those which are simple to carry out or fit with the existing practices. 116

116. C. Reinforcing factors Reinforcing factors are those factors subsequent to a behavior that provide the continuing reward or incentives for the behavior to be persistent and repeated. Are those consequences of actions that determine whether the actor receives positive or negative feedback and is supported socially or by significant others after it occur. Tangible rewards ( economic benefits or avoidance of cost) 117

117. Reinforcing factors Significant others Can also be called relevant others or influential others . These are people who are significant (determine or influence) the behavior of others to encourage or discourage to do something. We often listen to what he or she says and tries to do what he or she does. Eg . The woman does not adopt FP because her husband disapproves. The young man who starts smoking because his friends encourage him to do so. 118

118. Reinforcing factors… Mother/father Friends Husband/wife l employer political leaders Brothers/sisters chiefs Parent-in-low religious leaders Grand parents traditional healers Health workers Fig 2.1. The influence of social pressure (circle of influence) Source: Dr. John Hubley . Communicating health. 2nd ed. Copy right John Hubley 1993. VIKAS publishing agency 119

119. Changes in behavior can be natural or planned changes. Natural change - our behavior changes all the time. Some changes take place because of natural events or processes such as age-sex related behaviors. E.g. eating clay during pregnancy. b) Planned change - we make plans to improve our lives or to survive for that matter and we act accordingly. Example: plan to stop smoking or drinking, plan to become a health professional. Planned change in behavior can be faster or slower depending on the response of the acceptor and adapter of the behavior. 120

120. LEARNING Learning is relatively permanent change in behavior as a result of knowledge, experience or practice. Learning is acquiring new knowledge, behaviors, skills, values, preferences or understanding, and may involve synthesizing different types of information. The ability to learn is possessed by humans and animals. Progress over time tends to follow learning curves. 121

121. The study of how learning occurs is part of neuropsychology, educational psychology, learning theory, and pedagogy. Learning may occur as a result of habituation or classical conditioning, seen in many animal species, or as a result of more complex activities such as play seen only in relatively intelligent animals and humans. 122

122. Learning is understood as the modification of behavior through practice, training, or experience . This is supplemented with five important components of learning: Learning involves change : a change may be for good or bad . Change may not be evident until a situation arises in which the new behavior can occur. Learning is not always reflected in performance 123

123. 2. Not all changes reflect learning : to constitute learning, change should be relatively permanent . Temporary changes may be only reflective and fail to represent any learning . This requirement, therefore, rules out behavioral changes caused by fatigue or drugs 3. Learning is reflected in behavior : a change in an individual’s thought process or attitude, not accompanied by behavior, is not learning. It should be further clarified that learning needs to result in behavior change potentiality . . 124

124. 4. The change in behavior should occur as a result of experience, practice or training : 5. The practice or experience must be reinforced in order for learning to occur : if reinforcement does not accompany the practice or experience, the behavior will eventually disappear 125

125. THEORIES OF LEARNING There are four theories which explain how learning occurs. They are: Classical conditioning Operant conditioning Social learning theory Cognitive theory Read for details!!! 126

126. Classical conditioning : A neutral stimulus gradually acquires the ability to elicit a response through repeated association with other stimuli that elicits response. Associating behaviors and attitudes as "good" or "bad. e.g., it's good to tell the truth, it's bad to steal).

127. Operant conditioning: learning attitudes based on direct experiences or being rewarded or punished for behavior and attitudes. Observational learning : learning attitudes through peer behavior and the media . C ognitive appraisals : weighing logical arguments in determining your attitude.

128. Principles of learning There are three principles of learning: 1. Learning by association 2. Learning by reinforcement , punishment and, 3. Learning by motivation Learning by association - Connection between events in time, place, etc. It is the most important part of the learning process. It is first formed in the physical environment. See the following examples, If we see lightening we expect thunder When we see a needle/syringe, we think of injection When we see pregnancy we expect delivery 129

129. Reinforcement & punishment Reinforcement and punishment play a key role in learning process. Reinforcement is used to enhance desirable behavior; is the attempt to develop or strengthen desirable behavior punishment is employed to minimize undesirable behavior. 130

130. Positive reinforcement; add something desirable such as praise to increase the likelihood of a behavior Negative reinforcement; subtract something undesirable to increase the likelihood of a behavior 131

131. Reinforcement… Thus, both positive and negative reinforcement are procedures that strengthen or increase behavior. Positive reinforcement strengthens and increase behavior by the presentation of desirable consequences. Negative reinforcement strengthens and increases behavior by the threat of and the use of an undesirable consequence or the termination or withdrawal of an undesirable consequence . 132

132. Punishment is the attempt to eliminate or weaken undesirable behavior. It is used in two ways. One way to punish a person is to apply a negative consequence called punishers – following an undesirable behavior. Positive punishment; add something undesirable to decrease the likelihood of a behavior Negative punishment; subtract something desirable to decrease the likelihood of a behavior 133

133. Learning by reinforcement and punishment Reinforcement increases the likelihood of the occurrence of the situation. It increases the association between the response and stimulus. Reinforcing tools (reinforcers): Asking , Praising, Encouragement, Advice, Checking, and Listening. Punishment decreases the likelihood of a behavior 134

134. Motivation : Desire or willingness to perform something The concept of motivation is basic because, without motivation learning does not take place or, at least, is not discernible. An individual who is not motivated will gain or learn nothing i.e. it can affect the learning process 135

135. 3. Theories and Models of Health Behavior used in Health Education 136

136. Learning objectives After this session students will be able to Define theory Describe theories at different levels (intrapersonal, interpersonal) List the most commonly used behavioural models Describe Health Belief model Describe Transtheoretical model of change Apply models to practical exercises 137

137. Introduction #1 What is Theory? A theory is a set of interrelated concepts , definitions, and propositions that present a systematic view of events or situations by specifying relations among variables, in order to explain and predict the events or situations. ( Kerlinger , 1986) 138

138. Introduction #2 Is “A systematic explanation for the observations that relate to a particular aspect of life ( Babbie , 1989) E.g screening service use It can be applicable to a broad variety of situations. 139

139. Introduction #3 It is a symbolic depiction of aspects of reality that are discovered or invented to describe, explain, predict, or prescribe responses, events, situations, conditions, or relationships. Theories can be tested, challenged, modified, or replaced, or they can become obsolete. 140

140. Introduction #4 Concepts are the building blocks—the primary elements—of a theory (generalized notion related to aspect of phenomena) . E.g severe diseases threat people Constructs Is the term used for a concept developed for use in a particular theory. key concepts of a given theory are its constructs Variables : are the operational forms of constructs. they define the way a construct is to be measured in a specific situation. 141

141. Introduction # 5 MODELS are generalized, hypothetical descriptions, often based on an analogy, used to analyze or explain something. It provides a plan for investigating and/or addressing a phenomenon. It provides the vehicle for applying the theories. 142

142. Commonly used models and theories 1. Health Belief Model (HBM) 2. Transtheoretical Model of Behavior Change 3. The Theory of Reasoned Action (TRA) 4. Theory of Planned Behavior (TPB) 5. PRECEDE/PROCEED FRAMEWORK 6. Social Cognitive/Learning Theory( SCT/SLT) 143

143. 1.Health Belief Model (HBM) ( Hochbaum , Rosenstock &Becker,1950-1974) 144

144. 1.Health Belief Model (HBM) This model was developed to explain preventive health behaviour by examining the extent to which an individual perceives a problem as having serious consequences and a high probability of taking place. The HBM contains primary concepts that predict why people will take action to prevent , to screen for, or to control illness conditions Perceived susceptibility perceived severity perceived benefits perceived barriers Cues to action Self efficacy 145

145. HBM…. This implies that  health behaviour decisions are invariably/ regularlly   made through computational analysis of how susceptible to the disease one is, the severity of the disease condition when it occurs and cost/benefit of treatment. 146

146. HBM… It is important to note that perception is a critical variable in HBM construct. The key variables of the HBM are as follows Perceived Threat : Consists of two parts: perceived susceptibility and perceived severity of a health condition. Perceived Susceptibility : One's subjective perception of the risk of contracting a health condition, Perceived Severity : Feelings concerning the seriousness of contracting an illness or of leaving it untreated (including evaluations of both medical and clinical consequences and possible social consequences). 147

147. HBM.. Perceived Benefits : The believed effectiveness of strategies designed to reduce the threat of illness. Perceived Barriers : The potential negative consequences that may result from taking particular health actions , including physical, psychological, and financial demands. Cues to Action : Events, either bodily (e.g., physical symptoms of a health condition) or environmental (e.g., media publicity) that motivate people to take action. 148

148. HBM… Figure : The health belief model Source: Nutbeam and Harris (2002) 149

149. HBM… Exercise If this model was used to shape a public education programme for HIV prevention, what beliefs would it be necessary for people to adopt so as to minimize their risk of infection? 150

150. HBM… Solution for exercise Individuals would need to: believe that they are at risk of HIV infection believe that the consequences of infection are serious receive supportive cues for action which may trigger/activate/ a response (such as targeted media publicity) believe that risk minimization practices (such as safe sex or abstinence) will greatly reduce the risk of infection 151

151. HBM… Solution for exercise…. believe that the benefits of action to reduce risk will outweigh potential costs and barriers, such as reduced enjoyment and negative reactions of their partner believe in their ability to take effective action , such as following and maintaining safe sex behaviors 152

152. 153 2.The trans-theoretical model (TTM) (prochaska & Diclemente, 1979) …change is a process with stages not just an event … so first look the concern of stage theories

153. TTM The Trans theoretical Model of Change, a theoretical model of behavior change , which has been the basis for developing effective interventions to promote health behavior change. The model describes how people modify a problem behavior or acquire a positive behavior. The central organizing construct of the model is the Stages of Change . 154

154. Stage of change theories 155 View behavior as habitual pattern that requires gradual development rather than event happening without process ( e.g : TTM)…addictive behaviors OR As an event requiring deliberate steps under individual conscious awareness w hat is to be modeled here is necessary stages & processes for complete adaptation to a new behavior with desired intervention .

155. …TTM 156 It emerged from comparative analysis of 18 psychotherapy systems & review of 300 therapy outcomes (prochaska,1984). It evolved out of studies comparing the experiences of smokers who quit on their own with those of smokers receiving professional treatment .

156. …TTM 157 The model’s basic premise/argument/ is that behavior change is a process that unfolds over time, not an event. It is one among stage theories. It uses stages of change to integrate processes and principles of change from across major theories of intervention.

157. …TTM…principles of change 158 People change voluntarily only when they Become concerned about the need for change Become convinced that the change is in their best interests or will benefit them more than cost them Intend to take action in some context & time. Organize a plan of action that they are committed to implementing Take the actions that are necessary to make the change and sustain the change

158. Core Constructs of TTM: 159 Stages of Change : Processes of Change : Decisional Balance : Self-Efficacy: temptation & confidence

159. 1 st : Stages of change: integrative 160 1 . Stages of change construct : spiral than linear Pre-contemplation contemplation preparation action maintenance termination

160. Pre contemplation Awareness of need to change Contemplation Increasing the Pros for Change and decreasing the Cons Action Implementing and Revising the Plan Termination Stages of Change Model Relapse and Recycling Maintenance Integrating Change into Lifestyle Preparation Commitment & Planning 161

161. …stages of change model 162 Stage Definition Potential change strategies Precontemplation Has no intention of taking action within the next six months Increase awareness of need for change; personalize information about risks and benefits. Contemplation Intends to take action in the next six months Motivate; encourage making specific plans Préparation Intends to take action within the next 30 days and has taken some behavioral steps in this direction Assist with developing and implementing concrete action plans; help set gradual goals Action Has changed behavior for less than six months Assist with feedback, problem solving, social support, and reinforcement Maintenance Has changed behavior for more than six months Assist with coping reminders, finding alternatives, avoiding slips/relapses (as applicable)

162. 2 nd :Processes of change; the steps 163 Processes of change are the covert and overt activities people use to progress through stages. Processes of change provide important guides for intervention programs; Processes are like independent variables that people need to apply to move from stage to stage.

163. …Processes of Change 10 main processes of change are observed A. Experiential Processes=5 Concern the person’s thought processes Generally seen in the early Stages . Consciousness raising Dramatic relief Environmental reevaluation Social liberation Self reevaluation . 164

164. Processes of change B. Behavioral Processes=5 Action oriented Usually seen in the later Stages Stimuli control Helping relationship Counter conditioning reinforcement management Self liberation 165

165. A…Experiential Processes of Change Consciousness raising …. Finding and learning new facts, ideas, and tips that support the healthy behavior change Dramatic relief ….Experiencing the negative emotions (fear, anxiety, worry) that go along with unhealthy behavioral risks Self-reevaluation ….Realizing that the behavior change is an important part of one’s identity as a person 166

166. Environmental reevaluation … Realizing the negative impact of the unhealthy behavior or the positive impact of the healthy behavior on one’s proximal social and/or physical environment Self-liberation … Making a firm commitment to change Helping relationships … Seeking and using social support for the healthy behavior change Counter conditioning Substitution of healthier alternative behaviors and cognitions for the unhealthy behavior 167

167. Reinforcement management .. Increasing the rewards for the positive behavior change and decreasing the rewards of the unhealthy behavior Stimulus control.. Removing reminders or cues to engage in the unhealthy behavior and adding cues or reminders to engage in the healthy behavior. Social liberation.. Realizing that the social norms are changing in the direction of supporting the healthy behavior change. 168

168. 169

169. 3 rd . Decisional Balance/Pros and Cons of change 170 Ambivalence is a normal part of the process of change. Decisional balance is derived via a comparison of the strength of perceived pros of the target behavior with the perceived cons. Pros= benefits of changing Cons= costs of changing Using this “conflict” to promote positive change Increasing Discrepancy… towards pros of new b/r

170. Decisional Balance Sheet 171 What are some good things about your current behavior? (PRO) What are some not-so-good things about your current behavior? (CON) What are some not-so-good things about the new behavior? (CON) What are some good things about the new behavior? (PRO)

171. 4 th . Self-Efficacy 172 Confidence : situation-specific confidence people have that they can cope with high-risk situations (confidence to engage in the healthy behavior) Temptation : the intensity of urges to engage in a specific risky habit when in the midst of difficult situations, including: Negative affect or emotional distress Positive social occasions Cravings; excessive urge

172. Critical Assumptions of TTM 173 No single theory can account for all the complexities of behavioral change. Behavioral change is a process that unfolds over time through a sequence of stages. There are a common set of change processes that people apply across a broad range of behaviors. Without planned interventions, populations will remain stuck in the early stages. There is no inherent motivation to progress through the stages of change

173. …Critical Assumptions 174 The majority of at-risk populations are not prepared for action and will not be served by traditional action-oriented prevention programs. Specific processes and principles of change need to be applied at specific stages: intervention programs must be matched to each individual’s stage of change. Stage-matched interventions have been designed primarily to enhance self-control.

174. Exercise Try to assess different stages that would occur during intervening tobacco cessation 175

175. Stages ( in Tobacco cessation program ) Precontemplation stage Smoking is not a problem. I do not want to quit. Consider brief interventions Educate on the negative effects of Tobacco Recommend quitting smoking List cessation options ( e.g . Nicotine replacement) Discuss patient's reaction to recommendations Reinforce at follow-up visits Physician example Most people agree that Tobacco use is harmful What do you think about this? I am concerned about your health How can I help you quit? 176

176. Contemplation stage Smoking is a problem. I want to quit. Continue to discuss benefits of quitting smoking Avoid negative long-term effects of Tobacco use Improved health and positive self-image Financial cost savings Physician example (Your morning cough will improve off Tobacco ) 177

177. Preparation stage Set a definite quit date (I will quit smoking on January 1) Facilitation measures Encourage social support Tobacco cessation program Friends and relatives provide support Provide a no-fail environment Remove Tobacco, ashtrays and other related items Others should not smoke around patient Be aware of Tobacco use triggers (rituals) Consider habit substitutions in place of Tobacco Avoid provocative behaviors (e.g. alcohol use) Offer Tobacco cessation pharmacologic measures Nicotine replacement 178

178. Action stage I stopped smoking today. Provide behavior support Smoking Cessation program Follow-up contact (e.g. Troubleshoot triggers) Weekly during first month of cessation At time of stopping pharmacologic measures Maintenance stage I only smoked on one stressful day in the last month. Continue behavior support Offer additional interventions if relapse occurs 179

179. 3.Theory of Reasoned Action/ Planned Behavior (TRA/TPB) ( Fishbein & Ajzen , 1970’s ) …TPB is the extension of TRA… 180

180. 3.THE THEORY OF REASONED ACTION (TRA) The theory provides a construct that links individual beliefs, attitudes, intentions, and behavior . Behavior : A specific behavior defined by a combination of four components: action, target, context, and time (e.g., implementing a sexual HIV risk reduction strategy (action) by using condoms with commercial sex workers (target) in brothel (context) every time (time). 181

181. Intention : The intent to perform a behavior is the best predictor that a desired behavior will actually occur. In order to measure it accurately and effectively, intent should be defined using the same components used to define behavior: action, target, context, and time. Both attitude and norms , described below, influence one's intention to perform a behavior. Attitude : A person's positive or negative feelings toward performing the defined behavior. 182

182. Behavioral Beliefs : Behavioral beliefs are a combination of a person's beliefs regarding the outcomes of a defined behavior and the person's evaluation of potential outcomes. These beliefs will differ from population to population. For instance, married heterosexuals may consider introducing condoms into their relationship an admission of infidelity, while for homosexual males in high prevalence areas it may be viewed as a sign of trust and caring. Norms : A person's perception of other people's opinions regarding the defined behavior . 183

183. Normative Beliefs : are a combination of a person's beliefs regarding other people's views of a behavior and the person's willingness to conform to those views. /Beliefs that important others have/ As with behavioral beliefs, normative beliefs regarding other people's opinions and the evaluation of those opinions will vary from population to population . The TRA provides a framework for linking each of the above variables together. 184

184. Essentially, the behavioral and normative beliefs -referred to as cognitive structures -- influence individual attitudes and subjective norms , respectively. In turn, attitudes and norms shape a person's intention to perform a behavior. Finally, as the authors of the TRA argue, a person's intention remains the best indicator that the desired behavior will occur. Overall, the TRA model supports a linear process in which changes in an individual's behavioral and normative beliefs will ultimately affect the individual's actual behavior . 185

185. THE THEORY OF REASONED ACTION (TRA) 186

186. 4.Theory of Planned Behavior (TPB) In psychology, the theory of planned behavior is a theory about the link between attitudes and behavior. It has been applied to studies of the relations among beliefs, attitudes, behavioural intentions and behaviors in various fields such as advertising, public relations, campanies , health care, etc. 187

187. The theory was developed from the Theory of reasoned action. According to the Theory of Reasoned Action, if people evaluated the suggested behavior as positive (attitude ), and if they think their significant others wanted them to perform the behavior (subjective norm ), this results in a higher intention (motivation) and they are more likely to do so. A high correlation of attitudes and subjective norms to behavioral intention, and subsequently to behavior has been confirmed in many studies. 188

188. In addition to attitudes and subjective norms (which make the Theory of Reasoned Action ), the additional concept of the Theory of Planned Behavior is perceived behavioral control , which originates from Self Efficacy Theory (SET). Self-efficacy is the conviction that one can successfully execute/perform/ the behavior required to produce the outcomes. The outcome expectancy refers to a person’s estimation that a given behavior will lead to certain outcomes. Self-efficacy is the most important precondition for behavioral change, since it determines the initiation of coping behavior. 189

189. Key Variables Attitude Toward Behavior . Is the degree to which performance of the behavior is positively or negatively valued Subjective Norm . the perceived social pressure to perform or not to perform the behavior Perceived Behavioral Control . Perception of the ease or difficulty of the particular behavior Behavioral intention. subjective probability that he or she will engage in a given behavior 190

190. Attitude toward Behaviour BEHAVIOUR Subjective Norm Intention Beliefs Regarding Behaviour Evaluation of outcomes Beliefs that Important Others have Motivation to Comply with Important Others Perceived Behavioral Control Control Variables Power over Control Factors TRA TPB 191

191. 5. PRECEDE/PROCEED FRAMEWORK 192

192. PRECEDE is an acronym for P redisposing, R einforcing, E nabling, C auses in, E ducational D iagnosis and E valuation. PROCEED is an acronym for P olicy, R egulatory, O rganizational C onstructs in E ducational and E nvironmental D evelopment. 193

193. DESCRIPTION OF THE MODEL PRECEDE - the first 5 phases(diagnostic phase) Phase 1 - Social Diagnosis Phase 2 - Epidemiological Diagnosis Phase 3 - Behavioral & Environmental Diagnosis Phase 4 - Education & Organizational Diagnosis Phase 5 - Administrative & Policy Diagnosis PROCEED - the second 4 phases(Implementation & evaluation phase) Phase 6 - Implementation Phase 7 - Process Evaluation Phase 8 - Impact Evaluation Phase 9 - Outcome Evaluation 194

194. Currently Revised PRECEDE-PROCEED Model 195

195. Phase 1 - Social Diagnosis The focus of this phase is to identify and evaluate the social problems which impact the quality of life of a target population . This requires program planners to gain an understanding of the social problems which affects the quality of life of the patient, consumer, student, or community, as those populations see those problems. 196

196. This followed by the establishment of a link between these problems and specific health problems which may become the focus of health education. The link is essential in life and, in turn, how the quality of life affects social problems. 197

197. Methods used for social diagnosis may be one or more of the following: Community Forums Focus Groups Surveys Interviews 198

198. Phase 2 - Epidemiological Diagnosis This phase helps determine health issues associated with the quality of life. It helps identify behavioral and environmental factors related to the quality of life issues. The focus of this phase is to identify specific health problem and non health factors which are associated with a poor quality of life. Describing these health problems can: help establish relationships between health problems, other health conditions, and the quality of life; 2) lead to the setting of priorities which will guide the focus of program development and resources utilization; and 199

199. 3) make possible the delineation of responsibilities between involved professionals and organizations and agencies. These priorities are defined as program objectives which define the target population (WHO), the desired outcome (WHAT), and HOW MUCH benefit the target population should benefit, and by WHEN that benefit should occur. 200

200. Examples of Epidemiological data: vital statistics years of potential life loss(YPLL) disability prevalence morbidity incidences mortality From phase 1 and 2 program objectives are created - that is the goal or goals you hope to achieve as a result of implementing this program 201

201. Phase 3 - Behavioural and Environmental Diagnosis This phase focuses on the systematic identification of health practices and other factors which seem to be linked to health problems defined in Phase 2. This includes non-behavioral causes (personal and environmental factors) that can contribute to health problems, but are not controlled by behavior . These could include genetic predisposition , age, gender, existing disease, climate, and workplace, the adequacy of health care facilities, etc . 202

202. After assessing the behaviors which cause health problems in the target population. Another important component of this phase is the determination of the importance and relative changeability of each behavioral cause. 203

203. Behavioral Diagnosis is the analysis of behavioral links to the goals or problems that are identified in the epidemiological or social diagnosis. Environmental Diagnosis is a parallel analysis of factors in the social and physical environment other than specific actions that could be linked to behaviors. The Behavioral Matrix helps to identify targets where the most effective intervention measures can be applied. 204

204. Phase 4 - Educational Diagnosis This phase assesses the causes of health behaviors which were identified in Phase 3. Three kinds of causes are identified. predisposing factors, enabling factors, and reinforcing factors. The critical element of this phase is the selection of the factors which if modified, will be most likely to result in behavior change. 205

205. This selection process includes identifying and sorting (positive and negative) these factors in appropriate category, prioritizing factors among categories, and prioritizing with categories. Prioritization of factors is based on relative importance and changeability. Learning objectives are then developed which focus on these selected factors. 206

206. Predisposing Factors - any characteristics of a person or population that motivates behavior prior to the occurrence of that behavior knowledge Beliefs values attitudes Enablers - characteristic of the environment that facilitate action and any skill or resource required to attain specific behavior accessibility availability skills laws (local, state, federal) 207

207. Reinforces - rewards or punishments following or anticipated as a consequence of a behavior. They serve to strengthen the motivation for behavior. family peers teacher. 208

208. Phase 5 - Administrative and Policy Diagnosis This phase focuses on the administrative and organizational concerns which must be addressed prior to program implementation . This includes the assessment of resources, budget development and allocation, development of an implementation time table, organization or personnel within programs, and coordination of the program with all other departments, and institutional organizations and the community. 209

209. Administrative Diagnosis - the analysis of policies, resources and circumstances prevailing organizational situations that could hinder or facilitate the development of the health program. Policy Diagnosis - to assess the compatibility of your program goals and objectives with those of the organization and its administration; does it fit into the mission statements, rules and regulations. 210

210. Phase 6 - Implementation of the Program Phase 7 - Process Evaluation is used to evaluate the process by which the program is being implemented. Phase 8 - Impact Evaluation measures the program effectiveness in terms of intermediate objectives and changes in predisposing, enabling, and reinforcing factors. Phase 9 –Outcome Evaluation measures change in terms of overall objectives and changes in health and social benefits or the quality of life. It takes a very long time to get results and it may take years before an actual change in the quality of life is seen. 211

211. 4.Communication 212

212. Learning objectives Students are expected to: Define Communication Describe The Communication Process Explain Components Of Communication Process Explain Communication Model Elaborate Forms (Levels) Of Communication Apply Principles Of Communication Discus Diffusion Of Innovation 213

213. Definition The word communication is a derivative of the Latin word "communes ," which translates to sharing and understanding. To communicate is to show common interest. Communication helps to establish a common ground where two or more people meet and discus their views. It allows feelings, ideas and views to flow freely, to be understood and bring about clients.   214

214. Cont… To communicate means "to impart, pass on or transmit a message, information, etc.; to exchange ideas or information with, be in touch with, to have access, to be connected with,“ and communication means "the act of communication, the things communicated, the means of communicating."(Oxford dictionary definition) Essentially communication deals with transmission of information or ideas and sharing and exchanging of information 215

215. COMMUNICATION PROCESS The most important thing is what happens when the message reaches the people it is aims at. If they hear and understand it, and are inclined to believe it, good communication has taken place. 216

216. Components of communication process 1. Source (Encoder) : This is the originator of message, which can be an individual or groups; or it can also be institution or organization. The communicator has to arrange his thoughts and ideas in such a manner that he organizes his message for the benefit of the receiver. This process of arranging the ideas and preparing the message is called encoding . Encoding is the transmission of ideas into a receiver by the source. 217

217. Cont… 2 . Message: This is the idea that is communicated, something that is considered important for the people in the community to know or do. Many messages are expressed in the form of language symbols. Since this message is likely to evoke a response in the communicatee, it can be considered as a stimulus . The stimulation can be effected through any of the special sensory of the body. In a typical two-person conversation the verbal band carries one-third of the meaning; the non-verbal carries two-third of the meaning 218

218. Cont…. Effectiveness of the message depends on: 1. Psychological factors: intelligence, level of education, prior information, and selective perception. 2. Linguistic factors: vocabulary, grammar, etc. 3. Receiver factors: culture, class, etc. 219

219. Cont… 3. Channel : Physical means by which a message travels from source to receiver. Spoken words-by far the most common method,verbal Written words-any printed material Pictures-pictorial presentations Music/Sounds-artistic presentation of messages Non-verbal communication or body language. Any combination of the above 220

220. Cont… 4 . Receiver(Decoder): This is the person for whom the communication is intended. The receiver of the message exercises not only the sensory organs but also his brain and mind. The response to the message begins with the receipt of the stimulus and the perception. The brain analyses the message and makes sense out of it. In social psychology this is referred to the same process as perception. It consists of decoding the stimulus and interpreting it. Decoding is the mental process by which the stimuli that have been received through the sensory organs are given proper meaning according to the individual's own way of thinking. 221

221. Behavioral objectives of receiver Became aware of a certain idea. Gain adequate knowledge about an idea. Increase motivation to carryout a task. Learn new skills to manage an institute changed behavior. 222

222. Cont… 5. Effect: change in receiver's attitude, knowledge and practice. Feedback: Feedback is the mechanism of assessing what has happened on the receiver after communication has occurred. This can be either positive when desired change in KAP occurs or negative when desired change in KAP don't occurs. Feedback need not necessarily be a written message or written language, etc. Just like the onward process of communication feedback can also be by gesture, symbols or signs. 223

223. Communication model There are two types of models: 1. Linear (one-way) model - there is only unidirectional flow of information from the source to the receiver. 2. Systems (two-way) model - dynamic, bi-directional +-------+ Channel +---------+ ¦ Source¦------------------------->Receiver ¦ +-------+ Message +---------+ ¦ Effect +---------------------------------+ Feedback 224

224. Forms (levels) of communication Intrapersonal Interpersonal Mass media Intrapersonal communication: This type of communication occurs with in an individuals and limited at that level. This part shows how people process and understand a message within. Example: a person can look at an object and develop a certain understanding 225

225. Cont… 2.Interpersonal communication: means interaction between two or more people who are together at the same time and place. Example: between doctor and patient. Advantages 1. Dynamic or bi-directional. 2. Questions can be asked and answered. 3. Multi-channel effect of personal communication. 4. Useful in all stages of adoption of innovations. 5.Useful when topic is a taboo or sensitive . 226

226. Cont… Disadvantages 1.It calls for language ability of the source (often needs multilingual) 2.Requires personal status; 3.Needs professional knowledge and preparation 227

227. Cont… For Effective Interpersonal Communication: Exchange of ideas with clients; Realize the importance of first impression when we meet a person; Learn to observe the person and derive useful information for our work; Keep in mind that the same words mean different things to different persons; Pay attention to the body language of our partners and to our own: non-verbal behavior tells often more about people's feelings than the words spoken. 228

228. Cont…. 3. Mass Media or Mass Communication The aim of mass communication in health education is To create awareness of a problem, To transmit knowledge, To set and change norms, and if possible To offer alternatives of behavior. 229

229. Cont… Mass media have the greatest impact at: - Creating awareness for a large number of people. -Communicating new ideas to early adopters (opinion leaders) -Increasing self-awareness and knowledge Advantages of a mass media: 1. They can reach many people quickly. 2. They are believable. 3. They can provide continuing reminders and reinforcement. 230

230. Cont… Disadvantages of mass media a. Mass communication is one-sided. b. Mass communication may create anxiety (as in the case of HIV/AIDS ) or insecurity when contradictory messages are transmitted. C. Does not differentiate the target group. e. No feedback 231

231. Principles of communication The perception of the sender and receiver should be as close as possible to each other. There should be involvement of more than one sense organ The more the communication takes place face to face the more its effectiveness feedback should be there 232

232. Prerequisites for effective communication Communicator should be: knowledgeable Credible, sincere, honest, skillful Positive in his attitude to the receiver and subject able to ensure feedback 233

233. Message should be: clear and brief need-based, timely, relevant supported by factual material passed through appropriate channel treated in a way it is understandable and suited to the channel 234

234. Channel should be : familiar for both appropriate to message available and accessible Receiver should have: positive attitude intact sensory organs 235

235. Cont… Traditional means of communication Traditional means of communication exploits and develops the local means, materials and methods of communication. The forms are useful for the following reasons: 1. They are realistic and based on the daily lives of average citizens. 2. They can communicate attitudes, values and feelings in powerful ways. 3. They can motivate people to change behavior. 4. They can communicate problems of community life 5. They can show ways to solve problems. 236

236. Cont… 6. They may not require modern education or literacy in the majority of instances. 7. They can improve participation and self-esteem development. 8. Usually they are very interesting . 9. They are easily understood and captured . 10. They usually cost very little or no money 237

237. The following examples are some of the traditional means of communication in Ethiopia. 1.Proverbs( Ababaloch ) Can support or illustrate a point about health you get across. E.g “ Tamo Kememakek Askedimo Metenkek ” 2. Fables( teret teret ) Are make-believe stories that have been told to children for generations. The characters in fable are often animals. 3. Stories( Afe Tarik ) 238

238. Barriers to communication a) Physical Can the learner see and hear properly? Are the speech and visual presentations clear? Is the physical facility reasonably appropriate? b) Intellectual: affects the perception Can the learner understand what he sees and hears? Ability of the facilitator/educator/instructor c) Emotional Is the learner ready, willing and eager to receive the message? Emotional status of the educator d.) Language difference, vocabulary and use e.) Inconsistencies in verbal and non-verbal communication 239

239. HEALTH COMMUNICATIONS Definitions Health Communication is any type of communication whose content is concerned with health." "Health communication is the art and technique of Informing, Influencing,and motivating individual, institutional, and public audiences about important health issues. 240

240. Health communications strategies can be designed to inform Influence or regulate motivate audiences in setting policy or making other decisions that have a positive impact on public health. 241

241. Health Communications can: Remind audiences of knowledge, attitudes , or behavior that have an impact on health Create attitudes to support change for a particular policy or action Increase awareness of a health problem, concern, or solution Demonstrate skills or technology Increase demand for health services and for health-affirming policies 242

242. Good health communications Define the communication goal Define the intended audience Create effective and targeted health messages Pretest and revise the materials and messages Implement the campaign carefully 243

243. Methods of health communication Social Marketing Media Advocacy Support for policy change Educational Entertainment/edutainment/ Websites with online discussions 244

244. The Health Communications Process Effective health communications strategies must be based on a clear understanding of the needs and perceptions(attitudes) of the target audience(s). 245

245. HEALTH COMMUNICATION PROCESS 246

246. DIFFUSION OF AN INNOVATIONS Diffusion is a special type of communication concerned with the spread of new behaviors and ideas to the community Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system. 247

247. DIFFUSION OF INNOVATIONS There are four main elements in the diffusion of new ideas: 1. The innovation 2. Communication channels 3. The social system 4. Time 248

248. CONT,D 1.Innovation : An idea, practice, or object that is perceived as new by an individual or other unit of adoption. Innovation could be ideas and practices -based innovations; ideas based innovation-most difficult to implement Practice-based innovation-best chance of success 249

249. CONT,D 2.Communication Channels : Means by which messages are spread, including mass media, interpersonal channels, and electronic communications. e.g. HDA in HEP 250

250. CONT,D 3. Social System : Set of interrelated units that are engaged in joint problem solving to accomplish a common goal. Social systems have structure, including norms and leadership. The social system constitutes a boundary within which an innovation diffuses. 4. Time : time dimension is involved in diffusion 251

251. COMMUNICATION OF INNOVATIONS Both health promotion and health education are concerned to promote change. One of the best researched and most useful of such theories is communication of innovations theory 252

252. COMMUNICATION OF INNOVATIONS Factors that influence adoption of innovation include: 1. The characteristics of potential adopters; 2. The rate of adoption; 3. The characteristics of the innovation; 4.Change Agents: An individual who influences clients innovation decision 253

253. 1.CHARACTERISTICS OF ADOPTERS&RATE OF ADOPTION 1. Innovator = 2.5% of population: eager but a ‘deviant’; probably mistrusted by the safe majority. 2. Early adopter = 13.5% of population: respectable but amenable to change; good candidate for opinion leader or community aide. 3 . Early majority = 34% of population according to Rogers and Shoemaker their motto might be ‘Be not the last to lay the old aside, nor the first by which the new is tried’? 4. Late majority = 34% of population: reluctant to change until benefits of innovation have been clearly proven 5. Laggards =16% of population: the diehard conservatives! Will doubtless incorporate a subgroup who will never change and appear to be against everything most of the time E.g. Grandparents 254

254. 2.Stages in the adoption of innovation 1.Stage of awareness (knowledge): the individual learns of the existence of an idea or Adoption of innovation: decisions to adopt an innovation are made only after multiple contacts with a variety of communication channels over a long period. 2.Stage of interest (approval, acceptance): the individual develops interest in the idea. He seeks more information about it and considers its general merits. 3.Evaluation (intention, interest ): the individual makes mental application of the idea and weighs its merit for his own situation. 4.Trial (practice): actual application of idea, usually on a small scale. 5.Adoption (maintenance): acceptance leading to continual use. 255

255. Communication of an innovations 3. characteristics of the innovation An innovation is an idea, practice, or object perceived as new by an individual. The characteristics of an innovation as perceived by the members of a social system determine its rate of adoption . Why do certain innovations spread more quickly than others? The characteristics which determine an innovation's rate of adoption are: 1. relative advantage, 2. compatibility, 3. Easy to perform 4. trialability, and, 5. observability. 256

256. 5 . TEACHING METHODS AND MATERIALS 257

257. Teaching materials include all materials that are used as teaching aids to support the communication process and bring desired effects on the audience. Teaching methods range from what is heard to what is seen and done and thus are ways to convey messages 258

258. Cont,d The methods and materials could be classified broadly as follows: audio, written word, visuals, audio-visuals, direct experience and multi-sensory modalities. 259

259. Teaching Methods I. Audios : Audio means something heard E.g. Music, dramas, sound, spoken word (talks) etc. Talks are most commonly used audio teaching methods. Effective when based on known experience. Could be distorted or misunderstood when translated. They can create misunderstanding and are easily forgotten 260

260. Health Talks When talks are on a health agenda , we call it a health talk. The most natural way of communicating with people is to talk with them. In health education, we have many opportunities to talk with people. We may do this with one person or with a family, with a small group or with many people together. Health talks have been, and remain, the most common way to share health knowledge and facts. 261

261. II. Visual : means something seen (apart from written words) E.g. poster. Visuals are one of the stronges t methods of communicating messages. The following are among the outstanding characteristics of visuals . Visuals arouse interest Provide a clear mental picture Speed up understanding Can stimulate active thinking Help memory and provide a shared experience 262

262. III. Written word It includes anything written such as books, journals, magazines, leaflets etc . Written words have the advantage to be distributed to the audience so that they read and understand them at their convenient times. 263

263. IV. Direct experience It includes learning through doing - e.g. Doing a Gram stain, giving an injection. This teaching method is useful when the objective of the training is to make the trainee perform the tasks. There will be deeper understanding of the subject and the issues involved. In this case, talks and teaching materials will only supplement (but can not substitute) the process. 264

264. Visuals are more effective than words alone but wherever possible, they need to be related to experience and action. If I hear, I forget ------------->Symbols (spoken words) If I see, I remember ---------> Visuals If I do, I know ------------> Experience Note that You remember 10% of what you hear You remember 50% of what you hear, and see You remember 90% of what you hear, see and do and near to 100% with repetition. 265

265. V. Audiovisuals or teaching aids Communications are supported with different teaching aids or tools depending on the purpose . If the purpose is to transfer skills and knowledge , combinations of these methods are used. The availability of the technology and materials limits the usage. Audiovisuals are multi-sensory materials. E.g. TV 266

266. When teaching aids are effectively used, people can receive experiences through all five senses. E.g. examining a patient A message is more likely to be understood if it can appeal to more than one sense. Note also that different media appeal to different people . Presence of teaching aids improves communication. However, it also depends on how we are utilizing the available teaching aids. 267

267. Types of visuals 1. Posters/charts 2. Demonstrations 3. Role playing - Drama 4. Chalkboard 5. Tours and visits 6. Objects and specimens 7. Models 8. Projected still pictures/ projection screens-slides (filmstrip) 9. Overhead projectors 10. Projected moving pictures-Movie films 268

268. POSTERS and CHARTS   Posters A poster is a large sheet of paper often about 60 cm wide by 90 cm high with words and pictures or symbols that put across a message. Widely used by commercial films for advertising products. And also in Health affairs. There are two types of posters: 1. Single-glance posters : these types of posters can be read and understood quickly without any spoken word. 2. Stop - and - study posters : With these types of posters one needs time to look at the variety. They also do not need verbal explanation.  269

269. Purpose of posters To give information and advice To give directions and instructions (prevention strategies) To announce important events and programs e.g. World AIDS Group Size Can be small or large groups Can be to individuals such as counseling HIV/AIDS patient . 270

270. Content 1. All words should be in local language 2. Words should be few and simple 3. Symbols that illiterate people will also understand should be used (understandable words) 4. Color should be used to attract attention 5. Put one idea on a poster. Avoid too many ideas. For many ideas use flipcharts. 6. The poster should encourage action/ practice/ 271

271. Posters announcing events should contain the following information The name of the event The date and time The place The organization sponsoring the event  Gondar zuria woreda health office in collaboration with UNICEF would under take polio campaign from june20-24/2015 in all kebele health post starting at 12:00 in the morning up to 12:00 evening in all four days. Placing posters Post them where many people can see them when passing by - market areas, meeting halls, etc. Get permission before posting on a house or building. Never put posters on sacred places or worshipping areas. Do not leave a poster for more than one month . If so, people will become bored and begin to ignore it.  272

272. Charts : are used to present facts in a visual form. A) Wall charts are sometimes similar to stop-and- study posters. They may include more information with symbols and diagrams, e.g. Child Growth Monitoring Chart B) Teaching charts are accompanied by teacher's verbal explanation to help in formal education e.g. Diarrhea Treatment Chart C) Flipcharts are series of pictures, diagrams, or titles on a related subject. They are good to transmit many ideas. 273

273. DRAMA Through drama, ideas are communicated to participants and to spectators. characters are studied and rehearsed Drama is very valuable in subjects where personal and social relationships are often more important than details of appearance. Basic ideas like health can be communicated through drama to people of different ages, education, and experience. 274

274. Drama.. Drama is a very suitable teaching method for people who cannot read because they often experience things dramatically. It can be used during the training of CHWs, teaching of school children, for a people in a village, festivals, etc. 275

275. Role-play A type of drama but character not studied A role-play is the unrehearsed acting of real-life situations An individual takes the part of some other character; and also can explore his own emotions and reactions in specific situations It is like the real life. One can learn about him/herself and about how it feels to be some one else e.g. A farmer and an urban boy conversation A doctor and a patient It is good for exploring and clarifying problems and for testing alternate solutions . 276

276. Purpose By acting out a real-life situation people can better understand the causes of the problems and the results of their own behavior 2)Help an individual explore ways of improving his or her relationship with other people and of gaining the support of other people to live more healthily 3)Give people experience in communication, planning and decision-making 4)Helps people to reconsider attitudes and values. We can discover/ learn about our own behavior. 277

277. For a good role-play Have a relaxed atmosphere Involve everyone Make sure everyone understands the purpose of the role-play Give clear instructions what they have to do Remind them that they are playing only roles Make sure that the main issues are drawn out and made clear to all Allow plenty of time for discussion and evaluation 278

278. Group size for presenting role-plays Usually done with small groups , two to three people Time- A role-play should last about 20 minutes Allow the play to continue if the audience is interested Stop the play if:- a. The players have solved the problem b. The players are confused and cannot solve the problem C. The audience looks bored Allow another 20 - 30 minutes for discussion   279

279. DEMONSTRATIONS A pleasant way of sharing knowledge and skills. Although basically focuses on practice it also involves both theoretical and practical teaching. Showing how is better than telling how. Purpose;- Help people learn new skills E.g. Preparation of ORS, Measuring hematocrit, Taking contraceptive pills Size of group - individuals - small training groups 280

280. CHALKBOARD Any dark colored, flat, smooth surface on which you can write and draw with a chalk - Oldest and simples t of visual aids - Often called a blackboard but nowadays often painted green Advantage - Writing surface and chalk are cheap to get and maintain - Can be readily available any where - Transportable - The teacher can turn to the board at any time - With a little practice it is simple to use - Easy to draw on a chalkboard and people can imagine and understand 281

281. Disadvantage - You can not adjust the angle or position but this type is of the cheapest to make Two dimension Radio Of all the communication media, radio may now be the most effective for reaching very wide audiences with important messages. Purpose - Entertainment -Informational -Instruction and education Use in health education -to announce News, items about health events -Special health programs on health topics -Songs, stories, dramas, and plays if related to health educate while entertaining 282

282. Television   No other medium creates such lively/energetic/ interest as television. It can have a great impact on people. It can extend Knowledge, influence public opinion, and introduce new ways of life/new behavior/ . There is a new aspect of television that has much potential for health education. This is use of video films . 283

283. Cont,d Video films can bring a variety of experiences into your classroom. It can be used to show movement over time , speed up or slow down motion, view processes that can not be seen by the unaided human eye , present historical footage or recreation of events, show an artistic performance, and transport students to new places and surroundings. 284

284. However, the availability and utilization of these teaching aids at a health centers limited. The equipments are costly , maintenance and operations are not easy, they are breakable, difficult to transport and need electric power supply. In addition, message preparation is often difficult. 285

285. Transparencies and overhead projector Used in educations, conferences, seminars and trainings of a higher level Advantages One can write on transparency with out turning one's back to the audience Transparencies can be reused One can turn on and off the projector during the presentation to focus the students' attention on the lecture or on the visual materials   286

286. Disadvantages *Noise from the projector *The need to remain next to the projector *The cost *Need for electricity Selection of teaching methods and materials ;- The selection of methods and materials depends on:- the type of the message, the purpose/instructional/ the people addressed, the circumstance, the availability of resources and the availability of skills. 287

287. 6 . Group Dynamics 288

288. Learning Objectives Definition Types Of Group Group Behaviors Group Training Conflict 289

289. 290 Group: a gathering of two or more people who have a common interest. Types of groups Formal group :- well organized Characterized By 1. Has a purpose or goal that every one in the group knows, accepts and tries to achieve 2. There is a set membership either specifically stated or understood . So people know who belongs and who does not. 3. There are recognized leaders. The leaders are elected by the members or other authorities depending on the type of the formal group. .

290. Cont 291 5. There are rules that the member agree to follow. 6. Sense of belongingness every one in the group need to belong, to be liked, to be accepted, to be respected by other members. 7. We-feeling: attention is paid to the welfare of the members . 4. Organized activities such as regular meetings

291. Cont 292 Informal groups : are not organized . Characteristics of informal groups. 1. No special purpose or goal. That is, no special activities are planned together but have some common features. 2. No special membership and feeling of belongingness (no membership requirement) 3. No special rule apply: people come and go at their will. 4. No special leader within the group. 5. I-feeling there is usually more concern for the self, and less for the welfare of the other people.

292. 293 Value of group education It provides support and encouragement - to maintain healthy behavior. It permits sharing of experience and skills - people learn from each other . It makes possible to pool the resource of all members-it may be impossible for a family to build a protected well.

293. 294 Education with formal groups It is possible to plan educational programs, since they: - Have definite purpose and interests - Have group leaders - Have commitment to meet regularly and take action, and - Members know each other

294. 295 Education with informal groups Find out common interests and needs of each individuals in the group-(come out,discover ) Develop relationships and encourage participation. Try to make people in the group feel welcome -Hospitality Point out their common interests , needs and their backgrounds(literate/illiterate-( peak,end,tip )

295. Group behavior 296 A ) Helpful behavior Making suggestion Encouraging each other to talk Responding politely to the suggestion of others Helping make points clear Giving information Showing concern for each other Volunteering to help with work Attending meetings regularly and on time Thanking each other for suggestions given

296. 297 B) Non helpful, non-functional behaviors 1 .Blocking - Interfering with group process , Rejecting ideas - Preventing a decision 2 .Aggression - Criticizing/blaming others - Showing hostility 3.Seeking recognition Call attention himself/herself by excessive talking, boasting 4 . Withdrawing - Become indifferent or passive - Whispering to others 5.Dominating - Excessive manipulation or authority - Interrupting or undermining the contribution of others

297. 298 Group roles/functions Group building role Group maintenance role Task maintenance role Group dynamics the functioning of groups I t tells us what is happening among the group members or in the group itself.

298. 299 1.Group building functions Selection of individual members Collection of individual members . Arranging the physical environment and providing necessary equipments. Introduction and understanding of members Explaining the purpose and goal of the meeting Electing a leader, recorder, observer and procedural technicians. Arranging for resource person Standard setting

299. 300 2.Group maintenance functions 1.Encouraging - being friendly, Praising others and their ideas agreeing with and accepting the contributions of others. 2.Mediating - Helping people to work together - Making compromises 3.Gate Keeping Stimulating people to participate or facilitating 4.Relieving tension - Draining off negative feelings by making a joke or - Diverting attention from unpleasant to pleasant matters

300. 301 5 . Elaborating - Building on a previous comment - Enlarging on it, giving examples. 6 . Coordinating - Directing the discussion in terms of the group goals - Raising questions to redirect 7 . Testing - Checking the readiness of the group to take decision or action 8.Summarizing - Reviewing the content of past discussion

301. 302 3.Task maintenance or getting the job done functions 1.Initiating - Suggesting new ideas or Proposing new activities - A different way of looking at the group problem or goal E.g. Health education about HIV/AIDS Strategies: video shows rather than lecture 2.Information seeking Asking for relevant facts/or authoritative information 3.Information giving - Providing relevant facts or - Personal experience pertinent to the group task. 4.Clarifying - Probing for meaning and understanding relating something the group is considering

302. 303 Conflict Disagreement that result of differences in opinions and views of issues If we fail - No solution to our problems ----> Task failure If we succeed - There will be a solution to our problem -----> Task achievement . How to Handle

303. 304 GROUP TRAINING Training is the process of education in which both the mind and the body are brought under exercise and discipline. It is the act of acquiring necessary qualification . In training bring in resource people who have special skills to share with the others.

304. 305 Important points during the planning process of training : 1. The goals or purpose of the training 2. Duration of the training 3. Who will be the trainees: Students, Mothers, etc. - Their social, educational and work background - What knowledge/skill do they have in relation to the training - Their motivation 4.What are the specific training objectives of the course? each session? 5.Who will be the trainers, instructors, facilitators are they good role models

305. 306 6.Where will the learning take place? - Classroom - Practice areas - Training sites - Communities The arrangements - permission 7.What are the important domains (areas) of learning going to be changed, thinking, believing, feeling, doing or KAP 8.What teaching/learning methods will be used? - Lecture - Demonstration - Practice

306. 9.What will be the psychological climate of the learning environment: emotions, feelings, attitudes of teachers & learners 10. What about transport and housing 11.Are educational materials prepared? Are they accessible? Posters, projectors, photographs, handouts, blackboard, books, equipment 12.Is the time suitable for the trainees? 13.Does the program need money: Administrative arrangement 14.How will the learners and program be evaluated? . Pretest/post-test . Follow up 307

307. 308 Running the training session 1.Pay attention to relationships and interactions - Trainees Versus Trainers - Among trainees * Know each other 2. Review the objectives and activities of the program with the trainees of the program at the beginning of the session. -Make sure that the plan is acceptable. -Ask for suggestions for changes 3.Encourage participation of trainees

308. 309 4. A training program should be flexible The trainers should be willing to make changes at any time to make sure that the program will be successful

309. 310 Evaluating the training The following questions help to evaluate the program 1. Is the learning of skills and the availability of resources going as planned? During the training sessions. 2. Can all the trainees practice the skills they have been taught? At the end of the program and then after 3. Are the trainees able to put their new skills to use in the community? 4.Are these changes in the health behavior of the people in the community?

310. 311 Meetings To discuss and solve problems There are different kinds of meeting: Some involve participation in discussion/decisions e.g. - committee meetings - board " - Public "

311. 7. Patient Clinician Communication 312

312. Learning Objectives Guidance and Counselling Compliance Medical/Health Care Errors Patient Clinician Communication Models 313

313. INTRODUCTION Guidance & counseling are twin concepts & have emerged as essential elements of every educational activity. Guidance & counseling are not synonymous term. Counseling is a part of guidance. Guidance, in educational context, means to indicate, point out, show the way, lead out & direct. Counseling is a specialized service of guidance. It is the process of helping individuals learn more about themselves & their present & possible future situations to make a substantial contribution to the society.

314. GUIDANCE Guidance is an assistance made available by a competent counselor to an individual of any age to help him direct his own life, develop his own point of view, make his own decision & carry his own burden. - Hamrin & Erikson Guidance is a process of helping every individual, through his own effort to discover & develop his potentialities for his personal happiness & social usefulness. - Ruth Strang

315. COUNSELING Counseling is essentially a process in which the counselor assists the counselee to make interpretations of facts relating to a choice, plan or adjustment which he needs to make. - Glenn F. Smith Counseling is a series of direct contacts with the individual which aims to offer him assistance in changing his attitude & behaviors. - Carl Rogers

316. Difference Between Guidance And Counseling GUIDANCE Guidance is broader & comprehensive Guidance is more external, helps a person understand alternative solutions available to him & makes him understand his personality & choose the right solution. Guidance is mainly preventive & developmental COUNSELING Counseling is in-depth & narrow Counseling helps people understand themselves & is an inward analysis. Alternative solutions are proposed to help understand the problem at hand. Counseling is remedial as well as preventive & developmental

317. Difference Between Guidance And Counseling GUIDANCE Intellectual attitudes are the raw material of guidance Decision making is operable at an intellectual level in guidance Guidance is generally education & career related & may also be for personal problems COUNSELING Emotional rather than pure intellectual attitude are raw material of the counseling process. Counseling operates at an emotional level Counseling is mostly offered for personal & social issues.

318. COMMON STUDENT ISSUES Background issues: Poor upbringing Poor families Abuse: sexual, physical, emotional, etc Relationships Drugs Finances, etc

319. PURPOSES OF GUIDANCE AND COUNSELING Providing the needed information & assistance Helping in individual to make wise choices Improve the understanding of self Facilitate the adjustment Helps in adapting to the changes or new environment Making self-sufficient & independent

320. PURPOSES OF GUIDANCE AND COUNSELING Efficient use of capabilities & talent Promote the optimal personal & professional development Balanced physical, psychological, emotional, social & spiritual growth Helps in overall development & to live productive life

321. Other functions of guidance and counseling… To provide optimum development & well-being for individual. To help individuals adjust to themselves & the society. To help people understand themselves in relation to the world. To aid individuals in efficient decision making. To help individuals plan for a productive life in their social context by focusing on their assets, skills, strengths & possibilities for further development. To bring about changes in the attitude & behavior of individuals.

322. NEED OF GUIDANCE AND COUNSELLING I. Needs for personal & social domain Personal & social development of individual To adapt in different stages of development Offering art of better living Proper use of leisure time Holistic personality development Best use of available opportunities Motivates for effective utilization & development of self

323. NEED OF GUIDANCE AND COUNSELLING II. Needs for educational/professional domain Helps in academic growth & development Helps in vocational & professional maturity Facilitates an individual in the right education & profession Offer help to handle educational & professional situations Helps in the proper utilization of human resources Helps in adapting to the changing concept of education Prepares to adapt in changing professional situations & emerging challenges Helps in making proper career choice Helps to minimize indiscipline

324. Need of Guidance and Counseling in University Education… To help students adjusting with the new environment of the University Education. To help in developing qualities required for a successful Professional practice. To help students in getting adjusted with the University environment. To help students keeping in touch with the latest trends in their profession To help students in developing positive learning habits, especially skill learning To help in the development of appropriate coping strategies in order to deal with stress in a productive manner

325. Need of Guidance and Counseling in University Education… To help University students in establishing proper identity. To help them to develop a positive attitude towards life. To help to overcome periods of turmoil & confusion. To help students in developing their leadership qualities. To motivate them for taking membership in professional organizations after competing their studies. Helps them to make advantages of technological advancement. Helps them to readiness for changes & face challenges To carryout responsibilities as a team member Helps them to proper selection of career Motivate them for higher studies.

326. FUNCTIONS OF GUIDANCE AND COUNSELLLING Adjustmental Orientation Developmental

327. Guidance And Counseling Skills Communication skills Active listening Clarification Reflection Effective questioning skills Rapport Empathy

328. Qualities of a Good Counselor… G – Good technical knowledge O – Obtaining appropriate information from the patient O – Objectively answering questions D – Demonstrating professionalism C – Confidentiality maintenance O – Observant U – Unbiased N – Nonjudgmental S – Sensitive to the needs of the patient E – Empathetic L – Listens carefully O – Open minded R – Respects the rights of the patients

329. FACTORS/THINGS TO WATCH OUT FOR Transference Counter transference Being biased Attachment Sympathy

330. Characteristics or qualities of counselor… Personal characteristics : Should be imbibed with basic human qualities. Should be a person with cultural values & awareness. Should have a deep interest in helping people. Should patiently listen to others Should be sensitive to other’s attitude & reactions Should have a capability for being trusted by others. Should have respect for the personal autonomy of the students. Should be tolerate of & accept the student point of view.

331. Characteristics or qualities of counselor… Interpersonal relationships: Friendly nature Sympathetic understanding Sincerity Tactfulness Patience Ability to maintain confidentiality Attentive listener Show concern

332. Characteristics or qualities of counselor… Personal adjustment: Maintain emotional stability Emotionally sound & healthy Able to accept criticism Knowledge of self Patience

333. Characteristics or qualities of counselor… Scholastic potentialities: Relevant knowledge Motivated & committed Aware of policies, beliefs, misconception & rumors in community Possess common sense Good judgment

334. Characteristics or qualities of counselor… Health & personal appearance: Pleasing voice & appearance Vitality & endurance Free from any mannerism

335. Characteristics or qualities of counselor… Leadership skills: Ability to stimulate Reinforce important information Direct the counselee to ways to solve the problem

336. Characteristics or qualities of counselor… Philosophy of life: Good character Integrated personality Faith in human values

337. Characteristics or qualities of counselor… Professional dedication: Show enthusiasm Maintain helping relationship Have a nice sense of morality

338. COUNSELLING PROCESS Phase I: Establishing relationship Phase II: Assessment Phase III: Setting goals Phase IV: intervention Phase V: Termination & follow-up

339. Tools And Techniques For The Counselling Process There are two types of tools & techniques for the counseling process: Standardized tools and techniques Non-standardized tools

340. Standardized tools and techniques… Intelligence tests Achievement test Aptitude tests Interest tests Personality tests

341. Non-standardized tests… Autobiography Anecdotal records Questionnaire Cumulative record Observation Interview Socio-metric techniques Rating scale Case study

342. Managing Disciplinary Problems Common disciplinary problems seen in University students are Absenteeism, Non-submission or late submission of assignments, Cheating, plagiarism, Disturbing classroom atmosphere, Threatening strike, Damaging or spoiling institutional property, Picking quarrels over small matters, Using mobiles phones in the classroom & so on.

343. Strategies for management of disciplinary problems… Appropriate training of faculty & teachers Adequate practice of co-curricular & extracurricular activities Appropriate selection & use of disciplinary standards Use reward & punishment Promoting better teacher-student relationship Cultivation of ethical, moral & spiritual values A close teacher-parent-student contact Effective use of guidance & counseling programs

344. Management Of Crisis And Referral A sudden, generally unanticipated event can profoundly & negatively affect a significant segment of the institution population & often involves serious injury or death. Crisis events like an incidence of suicide, bus crashes, natural disasters or multiple injuries, deaths can quickly escalate all over the educational institution. Crisis must be managed promptly & skillfully to minimize chaos, rumors & impact of the crisis on the victims & other students.

345. In modern era there are reasons why doctor-patient interaction should be given due considerations. The contribution of health related problems and the environmental factors is great Chronic diseases are increasing The role of patient in the self care is required The need for involvement in disease prevention/control Home-based care is advocated against institution based care Patient education and participation in doctor-patient interaction not well recognized/less practiced especially in developing countries 346

346. Counseling is frequently defined in terms of advice, guidance and education But counseling is different. A. Counselling is not giving advice Advice is mainly:- a one-way exchange, giving an opinion, making a judgement, making a recommendation and there may be a persuasive/ influencial quality to the exchange. 347

347. B. Counselling is not guidance - Guidance is also mainly:- A One-way exchange Showing the way, Educating, Influencing, Instructing with an encouraging quality to the exchange. In the counselling process:- The counsellor avoids taking on the client's problem Or telling the client how to solve the problem Or what decision or action to take. 348

348. C . Counselling is also different from education. -Health education is mainly:- A one-way exchange. Health education is not usually personalised or confidential. It is designed in accordance with public health needs and provides basic information. - Although education can be an important part of counselling, the information provided must be appropriate and tailored to the individual client's needs . D.Counselling is also different from ongoing therapy. The counselling intervention is focused on an immediate presenting problem. 349

349. E. Counselling is not a conversation It is not just people exchanging information and opinions.   f. Counselling is not an interrogation. The client is not being questioned in order to find out the truth. The counsellor does not use counselling as a forum in which to speak or promote his own opinions G. Counselling is not a search for a diagnosis. The client is not questioned so that the counsellor can find a label or diagnosis for their problem. I. Counselling is not “ information giving ” . The client does not come to the counsellor solely for information although information may sometimes be given. J. Counselling is not praying.   350

350. Objectives of counseling Understand the causes of the problem Look for possible solutions Reach at decision Take action Principles of counseling Leave the right to decide for the client Ensure confidentiality Tell the truth Know what you are talking about Realize the limits in the counseling   351

351. Techniques of counseling Use the GATHER approach G-Greeting the client A- Ask the problem T- Tell about different possible solutions H- Help the client for the informed decisions E- Explain the chosen solution (method) R-Return visit (arrange appointment to come back) 352

352. Rules for counseling Show concern and caring attitude Try to understand the problem as the person sees it and listen carefully Develop empathy Participate Security Provide information 353

353. Pitfalls for counseling Directing and leading the ideas of the client Moralizing, preach and patronizing Judging and evaluating the patient through statements Labeling and diagnosing Unwanted reassurance Not accepting the client’s feeling Interrogating Encouraging dependence Advising before the client has enough information to arrive at a personal solution 354

354. There are three types of therapeutic relationship 1) Activity/passivity: Doctor centered! The doctor dominates in the management process. e.g. Medical emergency (unconscious patient) 2) Guidance (co-operation): Problematic symptoms predispose a co-operative response. This is the closest to the ideal expectations of the sick role. 3) Mutual participation: Patient centered! Marked by equality between doctor and patient. This type of relationship is found where patients suffer from chronic conditions which involve a great deal of self care. 355

355. Compliance Compliance:- is a medical term that is used to indicate a patient's correct following of medical advice.e.g patient taking medication (drug compliance), but may also apply to use of surgical appliances such as chronic wound care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy. 356

356. Cont,d Patients may not accurately report back to healthcare workers because fear of possible embarrassment, being chastised, or seeming to be ungrateful for a doctor's care. 357

357. Causes for poor compliance include: Forgetfulness Prescription not collected or not dispensed Purpose of treatment not clear Perceived lack of effect Real or perceived side-effects Instructions for administration not clear Physical difficulty in complying (e.g. opening medicine containers, handling small tablets, swallowing difficulties, travel to place of treatment) Unattractive formulation, such as unpleasant taste Complicated regimen Cost of drugs 358

358. HEALTH CARE ERROR Medical error may be defined as an unintended act of either omission or commission. While errors of commission, such as operating on the wrong knee, may be more visible and anxiety provoking, Errors of omission undoubtedly have an enormous cumulative impact on patient outcomes. 359

359. It depends on the disease , the treatment that is given or not given , and other contextual considerations. For example, an error of commission involving the provision of a relatively non-toxic treatment in the setting of a mild disease poses only modest risks for patient safety and outcome. An error of omission involving the failure to provide an effective treatment in the setting of a severe disease poses very substantial risks for patient safety and outcome. 360

360. Errors of omission 1.Those who are not currently seeking or receiving medical care for their illness or condition (the undiagnosed ) or for a symptom or risk factor that could warrant examination and health counseling (the unscreened) 2.Those who received a medical diagnosis, but did not receive, fill, or use a prescription or recommendation for a procedure or medicine that could benefit them (nonusers) 361

361. Errors of commission 1.Those made by physicians, pharmacists , or other who recommend or prescribe medications or self-care procedures (professional errors) 2. Those made by patients (patient errors) Nonpatient errors E.g. pregnant women and persons who medicate themselves 362

362. Error of commission occurs when: - a patient uses drug of others - a physician prescribes or a pharmacist dispenses incorrectly Error of omission occurs when: - a patient fails to receive or to apply a clinically important medication or procedure as needed Both types of error can be attributed to: - failures of health care professionals or - failures of patients or - both ( professionals + patients)    363

363. 8. Research in Health Education and Health promotion 364

364. Learning Objectives Definition Types of Research Identify main components of any research Data Collection methods in Research 365

365. Define research Research:- A systematic collection, analysis and interpretation of data to solve a problem. Is a systematic search for information and new knowledge. It covers topics in every field of science 8/3/2021 366 Temesgen Y.

366. Type of research Can be categorized in different ways; Based on the Goal = Basic/Applied Based on Approaches = Qualitative /quantitative Based on design=Crossectional/cohort Basic research- to generate new knowledge and technologies Applied research- solution to problems -to identify priority problems Qualitative- answers to questions why? How? Quantitative- questions about how much? How many? How often? 8/3/2021 367 Temesgen Y.

367. Basic Difference: Qualitative Vs Quantitative 8/3/2021 Temesgen Y. 368

368. Identify main components of any research work Introduction to research Definitions and characteristics of research Types of research Main components of any research work Topic Selection Problem identification Criteria for prioritizing problems for research How to write a research topic? 369

369. 7 Criteria for prioritizing problems for research Relevance (widespread, who is affected, severity) Avoidance of duplication Feasibility (available resources) Political acceptability Applicability Urgency Ethical applicability Prioritization: 1= LOW ; 2= MEDIUM; 3= HIGH 370

370. Identify main components… Statement of the problem and Justification Analyzing the problem Formulating the problem statement Justification Literature review and Referencing Uses of literature review Source of information Organization of information Conceptual framework Referencing Objectives Definitions Formulation of the research objectives 371

371. Identify main components… Research methods Types of study designs Study area and period Source and Study population Inclusion and Exclusion Criteria Sample size and sampling procedures Variables Operational definitions data collection and data quality control data processing and analysis Ethical considerations Dissemination of Results 372

372. Identify main components… Work Plan Budget Work Plan Budget Results and Discussion Result Discussion Conclusion and Recommendation Conclusion Recommendation 373

373. Data Collection methods in Research It is based on Availability of data Type of data Money Time Quality needed Characteristics of study participants 374

374. 375

375. References Health Education lecture note for health science students, Getnet Mitikei, 2002. Research Methodology lecture note, 2005. Guideline for HIV Counselling and Testing in Ethiopia. Making Health Communication programs work, a planners guide, 2002. national cancer institute. Health promotion planning. An educational and ecological approach. 3 rd Edition. Health Behavior and Health Education theory, research, and practice 4 th Edition. Degu G, Yigzaw T. Research Methodology Lecture Notes for Health Science Students. University of Gondar : 2006. Degu G, Tessema F. Biostatistics for Health Science Students: lecture note series. The Carter Center 9EPHTI), Addis Ababa; January 2005. Corlien M. Varkevisser , Indra Pathmanathan , and Ann Brownlee. Designing and conducting health systems research projects: Volume 1 Proposal development and fieldwork. KIT/IDRC. 2003 Zegeye A, Worku A, Tefera D, Getu M, Sileshi Y. Introduction to Research Methods: Graduate Studies and Research Office , Addis Ababa University. 2009 376