HELPING HEALTH WORKERS LEARN - DAVID WERNER

Helping  Health  Workers  Learn  (2005)

Helping

Health  Workers

Learn

A book  of  methods,  aids,
and  ideas  for  instructors
at  the  village  level

David  Werner  and  Bill  Bower

drawings  by

David  Werner  Pablo  Chavez

Regina  Faul-Jansen  Marie  Ducruy

Helping  Health  Workers  Learn  (2005)

Library  of  Congress  Cataloging-in-Publication  Data

Catalog  Card  No.:  81-85010

Werner,  David  Bradford  and  Bower,  Bill  Lamed
Helping  Health  Workers  Learn

Palo  Alto,  CA:  Hesperian  Foundation

632  p.

8111  811015

ISBN:  0-942364-10-4

PUBLISHED  BY:

The  Hesperian  Foundation
1 91  9 Addison  Street,  Suite  304
Berkeley,  California  94704  U.S.A.

Copyright  © 1982  by  the  Hesperian  Foundation.  All  Rights  Reserved.
First  Edition,  January  1982

Thirteenth  Printing,  January  2005

The  Hesperian  Foundation  encourages  others  to  copy,  reproduce,  or  adapt  to  meet  local
needs  any  or  all  parts  of  this  book,  including  the  illustrations,  provided  that  the  parts
reproduced  are  distributed  free  or  at  cost  — not  for  profit.

Any  organization  or  person  who  wishes  to  copy,  reproduce,  or  adapt  any  or  all  parts  of  th
book  for  commercial  purposes  must  obtain  permission  from  the  Hesperian  Foundation.

Before  beginning  any  translation  or  adaptation  of  this  book  or  its  contents,  please  contact
the  Hesperian  Foundation  for  suggestions,  updates  on  the  information,  and  to  avoid
duplication  of  efforts.  Please  send  us  a copy  of  any  materials  in  which  text  or  illustrations
from  this  book  have  been  used.

Helping  Health  Workers  Learn  (2005)

This  book  is  dedicated  to  the  village
health  team  of  Ajoya,  Mexico,  from
whom  we  have  learned  a great
deal...

and  to  health  workers  everywhere
who  side  with  the  poor.

REQUEST  FOR  YOUR  COMMENTS,
CRITICISMS,  AND  IDEAS:

This  book  is  only  a beginning.  We  want  to
improve  it— with  your  help.

If  you  have  any  ideas,  teaching  methods,
visual  aids,  or  ways  of  exploring  or  learning
that  you  feel  might  be  put  into  this  book,  please
send  them  to  us.

Also  let  us  know  which  parts  of  the  book  you
find  most  useful,  and  which  parts,  pages,  or
paragraphs  you  find  confusing,  badly  written,
least  useful,  incorrect,  or  unfair.  We  think  the
book  is  too  long,  and  ask  your  help  in  deciding
what  to  leave  out.

WE  ARE  ESPECIALLY  INTERESTED  IN
GETTING  SUGGESTIONS  FROM  VILLAGE
AND  COMMUNITY  HEALTH  WORKERS
WHO  HAVE  BECOME  INSTRUCTORS.

Please  write  to:

The  Hesperian  Foundation
1919  Addison  Street,  Suite  304
Berkeley,  California  94704  U.S.A.

Thank  you.

Helping  Health  Workers  Learn  (2005)

THANKS

The  creation  of  this  book  has  been  a long,  cooperative  effort.  We  have  borrowed
ideas  from  many  sources.  Included  in  these  pages  are  methods  and  suggestions  from  health
and  development  programs  in  35  countries  on  5 continents.  Often  we  mention  the  programs
or  countries  from  which  particular  ideas  have  come  as  we  discuss  them  in  the  text.  Here,
however,  we  give  our  warm  thanks  to  all  programs,  groups,  and  persons  whose  ideas,
suggestions,  and  financial  assistance  have  contributed  to  this  book.

Our  heartfelt  appreciation  goes  to  the  village  health  team  in  Ajoya,  Mexico,
especially  to  Martin  Reyes,  Miguel  Angel  Manjarrez,  Roberto  Fajardo,  Miguel  Angel
Alvarez,  Pablo  Chavez,  Jesus  Vega  Castro,  Rosa  Salcido,  Guadalupe  Aragon,  Alejandro
Alvarez,  Teresa  Torres,  Anacleto  Arana,  and  Marcelo  Acevedo.  It  is  from  working  with  the
Ajoya  team  for  many  years  that  we  have  come  to  understand  the  meaning  of  community-
based  health  care.

We  would  also  like  to  renew  our  thanks  to  the  dedicated  persons  who  helped  put
the  first  edition  of  this  book  together  back  in  1982:  Myra  Polinger,  Lynn  Gordon,  Mary  Klein,
Michael  Blake,  Hal  Lockwood,  Christine  Taylor,  Richard  Friedman,  Susan  Klein,  Andy  Browne,
KenTull  of  World  Neighbors,  Meg  Gramto,  and  Emily  Goldfarb.  Trude  Bock  generously
provided  her  home  and  all-round  assistance  during  the  three  years  it  took  to  give  birth  to  this
book

Our  special  thanks  to  B.A.  Laris  for  undertaking  the  editing,  layout,  and  paste-up  for  the
tenth  printing.  Her  efforts  make  this  printing  easier  to  use  with  the  1992  revision  of  Where
There  Is  No  Doctor.  Davida  Coady  updated  the  antibiotic  learning  game  found  in  Chapter  19
and  Martin  Lamarque  provided  current  information  on  organizations  that  make  practical
teaching  materials  available.

For  their  outstanding  drawings,  we  thank  Regina  Faul-Jansen,  Marie  Ducruy,  and
Pablo  Chavez  of  the  village  health  team  in  Ajoya.  Pablo  also  invented  and  helped  develop
several  of  the  most  imaginative  teaching  aids  shown  in  this  book.  For  many  of  the  drawings
and  most  of  the  photographs,  credit  also  goes  to  David  Werner.

David  Morley,  Murray  and  Gerri  Dickson,  Fred  Abbatt,  Pia  Moriarity,  Sunil  Mehra,  Laura
Goldman,  and  Esther  de  Gaily  reviewed  early  drafts  of  this  book.  We  remain  grateful  for  their
valuable  suggestions  and  encouragement.

Early  drafts  of  Helping  Health  Workers  Learn  were  field  tested  in  Latin  America,  Africa,
and  the  Philippines.  From  these  various  field  trials  we  received  many  helpful  ideas  and
suggestions.  We  are  deeply  thankful  to  all  those  health  workers,  instructors,  volunteers,  and
health  officers  who  contributed.

For  many  years  our  books  have  been  packaged  and  mailed  by  a dedicated  group  of
volunteers  who  contribute  their  labor  to  support  the  Foundation's  efforts  to  make  health
information  available.  Without  their  commitment,  far  fewer  copies  of  our  publications  would
now  be  available  to  people  throughout  the  world.  Our  thanks  to  Barbara  and  Herb  Hultgren,
Tom  Beckett,  Paul  Chandler,  Bob  and  Kay  Schauer,  Marge  West,  and  Betsy  Wallace.

Over  the  years  we  have  received  financial  assistance  from  many  sources  for  the
development  and  distribution  of  this  book.  We  are  grateful  to  the  Ella  Lyman  Cabot  Trust,  the
Public  Welfare  Foundation,  Brot  fur  die  Welt,  OXFAM  England,  the  Sunflower  Foundation,
Misereor,  Helmut  and  Brigitte  Gollwitzer,  and  Reinhart  Freudenberg.  We  also  thank  the
Carnegie  Corporation  of  New  York  for  funding  gratis  distribution  of  this,  and  other  Hesperian
publications,  in  Africa.  We  wish  to  thank  the  many  generous  friends  of  the  Hesperian
Foundation  who  have  donated  their  time  and  resources  to  support  the  struggle  for  better
health  and  a better  world.

Helping  Health  Workers  Learn  (2005)

HOW  TO  USE  THIS  BOOK

This  book  is  mainly  for  instructors  of  village  health  workers— especially  those
instructors  who  are  village  health  workers  themselves.  But  it  may  be  of  use  to
anyone  involved  in  community  education.

The  book  can  be  used  in  several  ways:

One  way  is  to  start  at  the  beginning  and  read  through  it.  But  most  of  you  will
be  too  busy  to  do  this.

Another  way  is  to  skim  the  book,  going  through  it  quickly  for  the  main  ideas.
To  do  this,  look  at  and  read  what  stands  out  most,  namely:

• the  pictures

• what  is  written  in  dark  letters

• what  is  inside  the  boxes  like  this

As  you  skim,  you  can  stop  and  read  complete  pages  or  sections  about  ideas  that
especially  interest  you.

Still  another  way  is  to  use  this  as  a reference  book.  Review  those  pages  or
sections  that  apply  to  a particular  activity  you  are  planning— a class,  a role  play,
the  preparation  of  teaching  materials,  or  whatever.  (In  most  cases,  the  book  will
not  tell  you  ‘how  to  do  it',  but  will  give  ideas  or  examples  you  can  choose  from,
think  about,  or  adapt  to  your  own  needs.)

To  find  a topic  you  are  looking  for  in  the  book,  you  can  use  either  the  list  of
CONTENTS  or  the  INDEX.

The  CONTENTS,  at  the  front  of  the  book,  lists  the  chapters  in  the  order  that
they  appear.  On  first  getting  the  book,  we  suggest  that  you  review  this  list  of
CONTENTS.

The  INDEX,  at  the  back  of  the  book,  lists  all  of  the  important  topics  covered,
in  alphabetical  order.

This  book  is  organized  mostly  according  to  methods,  aids,  and  ideas  for
learning,  rather  than  according  to  specific  health  topics.

For  example,  information  about  'oral  rehydration'  appears  in  several  different
chapters:  "Looking  at  Learning  and  Teaching,”  "Appropriate  and  Inappropriate
Technology,"  and  "Children  as  Health  Workers."  If  you  are  planning  a class  or
activity  on  oral  rehydration,  you  may  want  to  look  up  all  3 of  these  references.
So  check  the  INDEX.

For  more  suggestions  on  how  to  use  this  book,  see  the  inside  of  the
back  cover.

Helping  Health  Workers  Learn  (2005)

HOW  TO  USE  THIS  BOOK

(continued)

This  book  is  arranged  into  5 major  parts,  each  with  a brief  introduction.  To
make  them  easier  to  find,  the  introductory  pages  of  each  part  are  marked  with  a
black  strip  at  different  heights  along  the  outer  margin.  The  margins  of  fhe  Contents
and  Index  pages  are  also  lined  with  black.

By  looking
at  the  edges
of  the  book,
you  can  see
where  each
part  begins.

Page  numbering:

Pages  are  numbered  according  to  the  sections  or  chapters  they  are  in.  In  each
chapter  or  section,  page  numbering  starts  again  from  page  1.  In  the  top  outer
corner  of  each  page,  you  will  see  numbers  like  these:

Front-3,  or  4-12,  or  Part  Two-7

The  first  word  or  number  in  dark  letters  is  the  section  or  the  chapter  number.
The  last  number  is  the  page  number  of  that  particular  section  or  chapter.  Thus,
4-12  means  Chapter  4,  page  12.  At  first  this  numbering  system  may  seem
confusing.  But  it  will  make  it  easier  for  us  to  add  more  pages  or  rearrange  chapters
in  future  editions.

Language:

We  have  tried  to  keep  language  simple.  Where  difficult  words  are  used,  we  try
to  explain  them,  or  to  use  them  in  such  a way  that  the  meaning  is  clear.

Sometimes  we  put  difficult  words  in  italics  (letters  like  these).  And  sometimes
the  word  is  explained  in  small  letters  at  the  bottom  of  the  page,  after  an  asterisk*.

Social  viewpoint:

In  this  book  we  take  a strong  social  position  in  favor  of  the  poor.  Recognizing
that  health  is  closely  linked  with  self-reliance  and  politics,  we  have  combined
discussion  of  social  factors  with  practical  aspects  of  health  education.

To  better  understand  our  social  viewpoint  and  the  practical  experiences  on
which  it  is  based,  we  suggest  that  you  start  by  reading  the  front  matter— the
introduction  (Front-1 ) and  "Why  This  Book  Is  So  Political"  (Front-7).  Chapter  1,
"Looking  at  Learning  and  Teaching,"  will  also  help  you  put  the  rest  of  the  book
in  perspective.

'Asterisk:  This  little  star  is  called  an  asterisk.  It  is  used  to  indicate  that  there  is  more  information  about  a
word  or  idea  at  the  bottom  of  the  page.

Helping  Health  Workers  Learn  (2005)

CONTENTS

page

INTRODUCTION Front  1

WARNING Front-5

WHY  THIS  BOOK  IS  SO  POLITICAL Front-7

PART  ONE:  APPROACHES  AND  PLANS

Chapter  1:  Looking  at  Learning  and  Teaching 1-1  to  1-30

Chapter  2:  Selecting  Health  Workers,  Instructors,  and  Advisers 2-1  to  2-18

Chapter  3:  Planning  a Training  Program 3-1  to  3-32

Chapter  4:  Getting  off  to  a Good  Start  4-1  to  4-14

Chapter  5:  Planning  a Class 5-1  to  5-18

Chapter  6:  Learning  and  Working  with  the  Community 6-1  to  6-20

Chapter  7:  Helping  People  Look  at  Their  Customs  and  Beliefs 7-1  to  7-13

Chapter  8:  Practice  in  Attending  the  Sick 8-1  to  8-16

Chapter  9:  Examinations  and  Evaluation  as  a Learning  Process 9-1  to  9-22

Chapter  10:  Follow-up,  Support,  and  Continued  Learning 10-1  to  10-18

PART  TWO:  LEARNING  THROUGH  SEEING,  DOING,  AND  THINKING

Chapter  1 1 : Making  and  Using  Teaching  Aids 11-1  to  11-32

Chapter  12:  Learning  to  Make,  Take,  and  Use  Pictures 12-1  to  12-22

Chapter  13:  Story  Telling 13-1  to  13-14

Chapter  14:  Role  Playing 14-1  to  14-14

Chapter  15:  Appropriate  and  Inappropriate  Technology 15-1  to  15-18

Chapter  16:  Homemade,  Low-Cost  Equipment  and  Written  Materials  . . . 16-1  to  16-20

Chapter  17:  Solving  Problems  Step  by  Step  (Scientific  Method) 17-1  to  17-14

Chapter  18:  Learning  to  Use  Medicines  Sensibly 18-1  to  18-14

Chapter  19:  Aids  for  Learning  to  Use  Medicines  and  Equipment 19-1  to  19-18

PART  THREE:  LEARNING  TO  USE  THE  BOOK,  WHERE  THERE  IS  NO  DOCTOR

Chapter  20:  Using  the  Contents,  Index,  Page  References,

and  Vocabulary 20-1  to  20-12

Chapter  21 : Practice  Using  Guides,  Charts,  and  Record  Sheets 21-1  to  21-1 8

PART  FOUR:  ACTIVITIES  WITH  MOTHERS  AND  CHILDREN

Chapter  22:  Pregnant  Women,  Mothers,  and  Young  Children 22-1  to  22-20

Chapter  23:  The  Politics  of  Family  Planning 23-1  to  23-10

Chapter  24:  Children  as  Health  Workers 24-1  to  24-30

PART  FIVE:  HEALTH  IN  RELATION  TO  FOOD,  LAND,  AND  SOCIAL  PROBLEMS

Chapter  25:  Food  First 25-1  to  25-44

Chapter  26:  Looking  at  How  Human  Relations  Affect  Health  26-1  to  26-38

Chapter  27 : Ways  to  Get  People  Thinking  and  Acting:

Village  Theater  and  Puppet  Shows 27-1  to  27-39

A CALL  FOR  COURAGE  AND  CAUTION Back-1

ADDRESSES  FOR  TEACHING  MATERIALS Back-3

INDEX Back-5

ABOUT  PROJECT  PIAXTLA  AND  THE  AUTHORS Back-13

OTHER  BOOKS  BYTHE  HESPERIAN  FOUNDATION Back  16

Helping  Health  Workers  Learn  (2005)

Front  1

INTRODUCTION

Health  for  all  by  the  year  2000  has  become  the  goal  of  the  World  Health
Organization  (WHO)  and  most  countries  around  the  earth.

Such  a world  wide  goal  is  very  worthy.  But  in  some  ways  it  is  dangerous.  For
there  is  a risk  of  trying  to  reach  that  goal  in  ways  that  become  so  standardized,  so
impersonal,  so  controlled  by  those  in  power,  that  many  of  the  human  qualities
essential  to  health— and  to  health  care—  are  lost.

There  is  already  evidence  of  this  happening.  In  the  last  10  or  15  years,  a great
many  attempts  have  been  made  to  bring  basic  health  care  to  poor  communities.
Billions  have  been  spent  on  large  national  or  regional  programs  planned  by  highly
trained  experts.  But  the  results  have  often  been  disappointing.  In  most  countries,
the  number  of  persons  suffering  from  preventable  or  easily  curable  illness
continues  to  grow.

On  the  other  hand,  certain  community  health  programs  have  been  more  or  less
successful  in  helping  the  poor  meet  their  health-related  needs.  Studies  by
independent  observers*  have  shown  that  programs  generally  recognized  as
successful,  whether  large  or  small,  often  have  the  following  things  in  common:

1.  Small,  local  beginnings  and  slow,  decentralized  growth.  Even  the  more
successful  large  programs  usually  have  begun  as  small  projects  that  gradually
developed  and  evolved  in  response  to  the  needs  of  particular  communities.

As  these  programs  have  grown,  they  have  remained  decentralized.  This  means
that  important  planning  and  decision  making  still  take  place  at  the  village  or
neighborhood  level.

2.  Involvement  of  local  people— especially  the  poor— in  each  phase  of  the
program.  Effective  programs  recognize  and  try  to  deal  with  the  conflicts  of
interest  that  often  exist  between  the  strong  and  the  weak,  even  in  a small
community.  Not  just  local  leaders,  but  the  most  disadvantaged  members  of
society,  play  a leading  role  in  selecting  their  own  health  workers  and
determining  program  priorities.  A conscious  aim  of  such  programs  is  to  help
strengthen  the  position  and  bargaining  power  of  the  poor.

3.  An  approach  that  views  planning  as  a 'learning  process'.  The  planning  of
program  content  and  health  worker  training  does  not  follow  a predetermined
'blueprint'.  Instead,  planning  goes  on  continually  as  a part  of  a learning
process.  Participants  at  every  level  (instructors,  student  health  workers,  and
members  of  the  community)  are  invited  to  help  shape,  change,  and  criticize
the  plans.  This  allows  the  program  to  constantly  evolve  and  adapt,  so  as  to
better  meet  people's  changing  needs.  Planning  is  both  local  and  flexible.

See,  for  example,  David  Korten's  analysis  of  successful  programs  in  Asia,  "Community  Organization  and
Rural  Development:  A Learning  Process  Approach,"  Public  Administration  Review,  Septernber/October,
1980.  p 480-510.

Front-2

Helping  Health  Workers  Learn  (2005)

4 Leaders  whose  first  responsibility  is  to  the  poor.  Programs  recognized  as
effective  usually  have  leaders  who  are  strongly  committed  to  a just  society.
Often  they  have  had  intense  personal  experience  working  with  the  poor  in
community  efforts  to  help  solve  critical  needs.  Even  as  their  programs  have
grown  and  expanded,  these  program  leaders  have  kept  up  their  close  relations
with  the  poor  working  people  in  individual  communities.

5 A recognition  that  good  health  can  only  be  attained  through  helping  the
poor  improve  the  entire  situation  in  which  they  live.  Successful  programs  link
health  activities  with  other  aspects  of  social  development.  Health  is  seen  as  a
state  of  wholeness  and  well-being  in  which  persons  are  able  to  work  together
to  meet  their  needs  in  a self-reliant,  responsible  way.  This  means  that  to  become
fully  healthy,  each  person  needs  a clear  understanding  of  himself  or  herself  in
relation  to  others  and  to  the  factors  that  influence  all  people's  well-being.

In  many  of  the  most  effective  health  programs,  activities  that  help  people  to
develop  a more  critical  awareness  have  become  a key  part  of  training  and
community  work.

In  view  of  these  features  common  to  success,  the  failure  of  many  national  and
regional  'community  heal  th ' programs  is  not  surprising.  Most  are  carried  out  in
quite  the  opposite  way.  Although  their  top  planners  speak  proudly  of  "decision
making  by  the  community,"  seldom  do  the  people  have  much  say  about  what
their  health  workers  are  taught  and  told  to  do.  'Community  participation'  too
often  has  come  to  mean  "getting  those  people  to  do  what  we  decide."  Rather
than  helping  the  poor  become  more  self-reliant,  many  national  health  and
development  programs  end  up  increasing  poor  people's  dependency  on  outside
services,  aid,  and  authority.

One  of  the  biggest  obstacles  to  'health  by  the  people'  has  been  the  unwillingness
ol  experts,  professionals,  and  health  authorities  to  let  go  of  their  control.  As  a
result,  community  health  workers  are  made  to  feel  that  their  first  responsibility
is  to  the  health  system  rather  than  to  the  poor.  Usually  they  are  taught  only  a
very  limited  range  of  skills.  They  become  the  servants  or  'auxiliaries'  to  visiting
doctors  and  nurses,  rather  than  spirited  leaders  for  change.  They  learn  to  follow
orders  and  fill  out  forms,  instead  of  to  take  initiative  or  to  help  people  solve
their  problems  on  their  own  terms.  Such  health  workers  win  little  respect  and
have  almost  no  influence  on  overall  community  health.  Many  of  them  get
discouraged,  grow  careless,  become  corrupt,  or  quit.  Results  have  been  so
disappointing  that  some  experts,  even  within  WHO,  have  begun  to  feel  that  the
goal  of  'health  for  all  through  community  involvement'  is  like  the  pot  of  gold  at
the  end  of  the  rainbow— a dream  that  has  been  tried,  but  failed.

Helping  Health  Workers  Learn  (2005)

Front-3

In  spite  of  the  failure  of  most  large,  centrally  controlled  programs  to  achieve
effective  community  participation,  in  many  countries  there  are  outstanding
examples  of  enthusiastic  community  involvement  in  health.  This  is  especially
true  in  small,  non-government  programs  that  take  what  we  call  a people-centered
or  community-strengthening  approach  to  health  care.

Within  these  community-based  programs,  there  is  a wealth  of  variety  in  terms
of  innovation  and  adaptation  to  local  conditions.  But  at  the  same  time,  there  is  a
striking  similarity  in  their  social  and  political  objectives  in  many  parts  of  the
world— Pakistan,  India,  Mozambique,  the  Philippines,  Mexico,  Nicaragua,
Honduras,  El  Salvador,  and  Guatemala.

In  these  community-based  programs,  a new  kind  of  health  worker  has  begun  to
play  a leading  role.  These  health  workers  speak  out  for  the  'voiceless'  poor.  Their
goal  is  health  for  all— but  health  that  is  founded  on  human  dignity,  loving  care,
and  fairer  distribution  of  land,  wealth,  and  power.

To  us,  one  of  the  most  exciting  aspects  of  this  new  world-wide  community-
based  movement,  decentralized  and  uncoordinated  as  it  may  be,  is  that  it  goes  far
beyond  any  rigid  religious  or  political  doctrine.  Most  of  the  leaders  in  these
programs  recognize  the  dangers  to  ordinary  people  in  any  large,  centrally
controlled  system,  be  it  capitalist  or  communist.  They  have  far  greater  faith  in
small,  self-directed  groups  of  working  people.  Rather  than  accept  any  established
dogma,  they  are  asking  searching  questions.  They  welcome  criticism,  and
encourage  others  to  observe  for  themselves  and  form  their  own  conclusions.  They
believe  in  helping  the  powerless  to  gain  strength  through  a greater  understanding
of  the  factors  that  shape  their  health  and  their  lives.

Around  this  practical  human  vision  has  gradually  grown  a whole  new  approach
to  the  training,  role,  and  responsibilities  of  community  health  workers.  Ideas  and
methods  are  being  shared  and  further  developed  through  a series  of  informal
networks  around  the  world.

Many  of  the  ideas  in  this  book  have  been  gathered  from  these  networks  of
community-based  health  programs,  and  especially  from  Project  Piaxtla,  a small,
villager-run  program  based  in  Ajoya,  Sinaloa,  Mexico.

Helping  Health  Workers  Learn  (2005)

Helping  Health  Workers  Learn  (2005)

Front  5

WARNING

This  is  not  a 'recipe  book'  of  how  to  plan  and  conduct  a training  course  for
health  workers.  Experience  has  taught  us  that  such  a book  could  easily  do  more
harm  than  good.  Instead,  this  is  a collection  of  examples  and  ideas,  of  group
experiences  and  outrageous  opinions,  of  'triggers  to  the  imagination'.  It  is  an
invitation  to  adventure  and  discovery.

Part  of  the  value  and  excitement  of  learning  is  in  finding  out  'how  to  do  it'  for
yourself  and  with  others.  It  lies  in  looking  at  the  ways  things  have  been  done
before,  then  improving  and  adapting  them  to  suit  your  own  circumstances.  This
sort  of  open-ended,  creative  learning  process  is  as  important  for  instructors  of
health  workers  as  for  the  health  workers  themselves.  After  all,  finding  ways  to  do
things  better  is  the  key  to  improving  health.  The  instructor  can  set  the  example.

To  be  fully  alive  and  meaningful,  a training  course  cannot  be  either  pre-
packaged or  'replicable'  (able  to  be  copied).  It  needs  to  be  redesigned  not  only
for  each  area  and  set  of  conditions  where  it  is  taught,  but  each  time  it  is  taught.

A training  program,  like  a person,  ceases  to  be  interesting  when  it  ceases  to
grow  or  be  unique!

So  rather  than  being  a 'blueprint'  on  how  to  build  a training  program,  this
book  is  a craftsman's  kit  of  nuts  and  bolts  and  tools.  Many  of  the  methods  and
suggestions  come  from  our  personal  experience,  which  has  been  mostly  in  Latin
America.  So  pick  and  choose  from  them  critically.  Use  and  adapt  what  you  can,
in  order  to  create— and  continually  re-create— your  own  very  special,  unique,  and
always-new  program.  Try  to  make  planning  a continuous  learning  process  for
everyone  concerned:  instructors,  students,  and  members  of  the  community.

Many  of  the  ideas  and  suggestions  in  this  book  are  controversial  and  will  not
apply  to  all  areas.  We  do  not  ask  anyone  simply  to  accept  and  use  them.
Instead,  we  ask  you  to  challenge  them,  adapt  them,  criticize  them— and  use
only  what  makes  sense  for  the  people  and  needs  in  your  own  area.

We  ask  you  to  consider— and  urge  you  to
doubt  and  question— everything  we  say.

Helping  Health  Workers  Learn  (2005)

from  Where
There  Is  No
Doctor,  p.  1 14

www. ncspenan.org

Helping  Health  Workers  Learn  (2005)

Front-7

WHY  THIS  BOOK  IS  SO  POLITICAL

When,  1 7 years  ago,  I (David  Werner)  first  began  working  for  improvements  in
health  with  villagers  in  western  Mexico,  I did  not  look  far  beyond  the  immediate
causes  of  ill  health.  As  I saw  it,  worms  and  diarrhea  were  caused  by  poor  hygiene
and  contaminated  water.  Malnutrition  was  mainly  caused  by  scarcity  of  food  in  a
remote,  mountainous  area  where  drought,  floods,  and  violent  winds  made  farming
difficult  and  harvests  uncertain.  The  high  death  rate  in  children  (34%)  resulted
from  the  combination  of  infection,  poor  nutrition,  and  the  long  distance  to  the
closest  health  centers.

In  short,  I saw  people's  needs  in  physical  terms,  as  determined  by  their
physical  surroundings.  This  short-sightedness  on  my  part  was  understandable,  for
my  training  had  been  in  life  sciences.  I had  little  social  or  political  awareness.

I might  have  remained  that  way,  as  do  many  health  workers,  except  that  I
came  so  close  to  the  mountain  people.  I knew  from  the  first  that  they  had
strengths,  skills,  and  endurance  that  I lacked.  And  so  I was  able  to  let  them  teach
me  about  the  human— and  inhuman— side  of  their  needs  and  their  lives.  They  did
not  sit  down  and  spell  things  out  for  me;  rather  they  shared  with  me  their  homes,
their  hardships,  and  their  dreams.  Many  times  I have  struggled  with  a family,
against  odds,  to  prevent  the  loss  of  a child,  a cornfield,  or  hope.  Sometimes  we
won;  sometimes  we  lost.

Little  by  little,  I became  aware  that  many  of  their  losses— of  children,  of  land,
or  of  hope— not  only  have  immediate  physical  causes,  but  also  underlying  social
causes.  That  is  to  say,  they  result  from  the  way  some  people  treat  or  affect  the
lives  of  others.  Time  and  again,  I have  experienced  occasions  where  death  and
suffering  of  children  and  other  persons  I have  to  come  to  love  have  been  the  direct
or  indirect  result  of  human  greed.

On  page  114  of  Where  There  Is  No  Doctor  there  is  a photograph  of  a very  thin
little  boy  in  the  arms  of  his  malnourished  mother  The  boy  eventually  died — of
hunger.  The  family  was — and  still  is — very  poor  Each  year  the  father  had  to  borrow
maize  from  one  of  the  big  landholders  in  the  area.  For  every  liter  of  maize
borrowed  at  planting  time,  he  had  to  pay  back  3 liters  at  harvest  time.  With  these
high  interest  rates,  the  family  went  further  and  further  into  debt.  No  matter  how
hard  the  father  worked,  each  year  more  of  his  harvest  went  to  pay  what  he  owed
to  the  landholder.  Each  year  he  had  to  borrow  more,  and  pay  back  3 times  as
much.  Eventually,  the  family  had  to  sell  their  few  chickens  and  pigs,  and  finally
even  the  beans  they  had  grown  on  the  steep  mountain  slopes,  to  buy  enough  corn
to  survive.

With  no  eggs  or  beans  to  eat,  the  mother  became  increasingly  malnourished.  Her
breasts  failed  to  produce  milk  for  her  baby.  So  she  fed  him  the  only  food  they
had— cornmeal  and  water.  In  time  the  child  died.

Fronts

Helping  Health  Workers  Learn  (2005)

Part  of  the  problem  may  also  have  been  that  the  father  occasionally  drinks  with
the  other  men.  When  he  gets  drunk,  he  loses  his  judgement  and  sometimes,  to  buy
rounds  of  drinks,  sells  a part  of  the  family's  precious  supply  of  corn.

This  is  sad.  But  look  at  the  father's  life.  The  hard  work  he  does  only  to  go
deeper  into  debt.  The  death  of  a child  he  loved  and  whom  he  feels  he  failed.  The
apparent  hopelessness  of  his  situation.  And  frequently  his  own  hunger— not  only
for  food,  but  for  a fair  chance  to  benefit  from  his  own  hard  work.  We  cannot
blame  him  if  he  occasionally  drinks  too  much!

Perhaps  no  one  is  really  to  blame.  Or  perhaps  we  all  are— all  of  us,  at  least,  who
live  with  more  than  we  need  while  others  hunger.  In  any  case,  it  is  not  right,  it  is
not  kind,  it  is  not  human,  to  remain  silent  in  a world  that  permits  some  persons
to  grow  fat  from  the  hard  work  of  others  who  go  hungry.

The  child  in  the  photograph  who  died  is  not  alone.  In  the  mountain  villages  I
know,  there  are  hundreds  of  similar  children— some  dead  and  some  waiting.  In  the
world  there  are  millions.  One  fourth  of  the  world's  children  are  undernourished,
most  for  reasons  similar  to  those  I have  just  described.  Their  problems  will  not  be
solved  by  medicines  or  latrines  or  nutrition  centers  or  birth  control  (although  all
of  these,  if  approached  decently,  may  help).  What  their  families  need  is  a fair
chance  to  live  from  their  own  labor,  a fair  share  of  what  the  earth  provides.

Do  I make  myself  clear?  Let  me  tell  you  about  Chelo  and  his  family,  whom  I
have  become  close  to  over  the  years.  Chelo  has  advanced  tuberculosis.  Before  the
villager-run  health  center  was  started  in  his  village,  he  received  no  treatment.  He
knew  he  had  tuberculosis.  He  wanted  treatment.  But  he  could  not  afford  the
medicines.  (Basic  tuberculosis  medicines  are  not  expensive  to  produce.  But  in
Mexican  pharmacies,  they  are  sold  at  up  to  ten  times  their  generic  price  in  the
United  States  and  other  developed  countries.)  Although  the  government's
tuberculosis  control  program  does  give  free  medication,  it  requires  that  patients
go  often  to  one  of  its  city  health  centers  for  tests  and  medication.  For  Chelo,
this  would  have  meant  250  kilometers  of  travel  every  two  weeks.  He  simply
could  not  afford  it.

For  years,  Chelo  had  worked  for  the  richest  landholder  in  the  village.  The
landholder  is  an  unhappy,  overweight  man  who,  apart  from  his  enormous
landholdings,  owns  thousands  of  cattle.  When  Chelo  began  to  grow  weak  from
his  illness  and  could  not  work  as  hard  as  before,  the  landholder  fired  him,  and
told  him  to  move  out  of  the  house  he  had  been  lending  him.

Chelo,  his  wife,  Soledad,  and  his  stepson,  Raul,*  built  a mud-brick  hut  and
moved  into  it.  By  that  time  Chelo  was  coughing  blood.

Around  the  same  time,  the  community-based  health  program  was  getting
started  in  the  area,  but  as  yet  no  health  worker  had  been  trained  in  Chelo's
village.  So  a visiting  health  worker  taught  Chelo's  1 1 -year-old  stepson,  Raul,  to
inject  him  with  streptomycin.  Raul  also  learned  to  keep  records  to  be  sure  Chelo
took  his  other  medicines  correctly.  The  boy  did  a good  job,  and  soon  was
injecting  and  doing  follow-up  on  several  persons  with  tuberculosis  in  the  village.
By  age  13,  Raul  had  become  one  of  the  central  team  of  health  workers  in  the
area.  At  the  same  time,  he  was  still  attending  school.

•These  are  real  persons,  but  I have  changed  their  names.

Helping  Health  Workers  Learn  (2005)

Front  9

Meanwhile,  Chelo's  family  had  cleaned  up  a small  weed  patch  and  garbage  area
at  the  lower  edge  of  town.  With  much  hard  work  they  had  constructed  a simple
irrigation  system  using  ditches  and  grooved  logs.  At  last  they  had  a successful
vegetable  plot,  which  brought  in  a small  income.  Chelo's  health  had  improved,
but  he  would  never  be  strong.  T reatment  had  begun  too  late.

Economically,  Chelo  had  one  setback  after  another.  Just  when  he  was
beginning  to  get  out  of  debt  to  the  storekeepers  and  landholders,  he  fell  ill  with
appendicitis.  He  needed  hospital  surgery,  so  health  workers  and  neighbors  carried
him  23  kilometers  on  a stretcher  to  the  road,  and  from  there  took  him  to  the
city  by  truck.  The  surgery  (in  spite  of  the  fact  that  the  doctor  lowered  his  fee)
cost  as  much  as  the  average  farmworker  earns  in  a year.  The  family  was  reduced
to  begging.

The  only  valuable  possession  the  family  had  was  a donkey.  When  Chelo
returned  from  the  hospital,  his  donkey  had  disappeared.  Two  months  later,  a
neighbor  spotted  it  in  the  grazing  area  of  one  of  the  wealthier  families.  A new
brand— still  fresh— had  been  put  right  on  top  of  Chelo's  old  one.

Chelo  went  to  the  village  authorities,  who  investigated.  They  decided  in  favor
of  the  wealthy  thief,  and  fined  Chelo.  To  me,  the  most  disturbing  thing  about
this  is  that  when  he  told  me  about  it,  Chelo  did  not  even  seem  angry— just  sad.

He  laughed  weakly  and  shrugged,  as  if  to  say,  "That's  life.  Nothing  can  be  done."

His  stepson,  Raul,  however,  took  all  these  abuses  very  hard.  He  had  been  a
gentle  and  caring  child,  but  stubborn,  with  an  enormous  need  for  love.  As  he  got
older,  he  seemed  to  grow  angrier.  His  anger  was  often  not  directed  at  anything
in  particular.

An  incident  with  the  school  was  the  last  straw.  Raul  had  worked  very  hard  to
complete  secondary  school  in  a neighboring  town.  Shortly  before  he  was  to
graduate,  the  headmaster  told  him  in  front  of  the  class  that  he  could  not  be  given
a certificate  since  he  was  an  illegitimate  child— unless  his  parents  got  married.

(This  happened  at  a time  when  the  national  government  had  decided  to  improve
its  statistics.  The  president's  wife  had  launched  a campaign  to  have  all  unwed
couples  with  children  get  married.  The  headmaster's  refusal  to  give  graduation
certificates  to  children  of  unwed  parents  was  one  of  the  pressures  used.)  Chelo
and  his  wife  did  get  married— which  cost  more  money— and  Raul  did  get  his
certificate.  But  the  damage  to  his  pride  remains.

Young  Raul  began  to  drink.  When  he  was  sober,  he  could  usually  control
himself.  But  he  had  a hard  time  working  with  the  local  health  team  because  he
took  even  the  friendliest  criticism  as  a personal  attack.  When  he  was  drunk,  his
anger  often  exploded.  He  managed  to  get  hold  of  a high-powered  pistol,  which  he
would  shoot  into  the  air  when  he  was  drinking.  One  night  he  got  so  drunk  that
he  fell  down  unconscious  on  the  street.  Some  of  the  young  toughs  in  town,  who
also  had  been  drinking,  took  his  pistol  and  his  pants,  cut  off  his  hair,  and  left
him  naked  in  the  street.  Chelo  heard  about  it  and  carried  Raul  home.

After  this,  Raul  hid  in  shame  for  two  weeks.  For  a while  he  did  not  even  visit
his  friends  at  the  health  post.  He  was  afraid  they  would  laugh.  They  did  not.  But
Raul  had  sworn  revenge— he  was  never  quite  sure  against  whom.  A few  months
later,  when  drunk,  he  shot  and  killed  a young  man  who  had  just  arrived  from
another  village.  The  two  had  never  seen  each  other  before.

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Helping  Health  Workers  Learn  (2005)

This,  to  me,  is  a tragedy  because  Raul  was  fighting  forces  bigger  than  himself.

As  a boy  of  1 2,  he  had  taken  on  the  responsibilities  of  a man.  He  had  shown  care
and  concern  for  other  people.  He  had  always  had  a quick  temper,  but  he  was  a
good  person.  And,  I happen  to  know,  he  still  is.

Who,  then,  is  to  blame?  Again,  perhaps  no  one.  Or  perhaps  all  of  us.  Something
needs  to  be  changed.

After  the  shooting,  Raul  fled.  That  night,  the  State  Police  came  looking  for
him.  They  burst  into  Chelo's  home  and  demanded  to  know  where  Raul  was.

Chelo  said  Raul  had  gone.  He  didn't  know  where.  The  police  dragged  Chelo  into
a field  outside  town  and  beat  him  with  their  pistols  and  rifles.  Later,  his  wife
found  him  still  lying  on  the  ground,  coughing  blood  and  struggling  to  breathe.

It  was  more  than  a year  before  Chelo  recovered  enough  to  work  much  in  his
garden.  His  tuberculosis  had  started  up  again  after  the  beating  by  the  police.

Raul  was  gone  and  could  not  help  with  the  work.  The  family  was  so  poor  that,
again,  they  had  to  go  begging.  Often  they  went  hungry.

After  a few  months,  Chelo's  wife,  Soledad,  also  developed  signs  of  tuberculosis
and  started  treatment  at  the  village  health  post.  The  local  health  workers  did  not
charge  for  her  treatment  or  Chelo's,  even  though  the  health  post  had  economic
difficulties  of  its  own.  However,  Chelo's  wife  helped  out  when  she  could  by
washing  the  health  post  linens  at  the  river.  (This  work  may  not  have  been  the  best
thing  for  her  TB,  but  it  did  wonders  for  her  dignity.  She  felt  good  about  giving
something  in  return.)

About  4 years  have  passed  since  these  last  incidents.  Chelo  and  his  wife  are
now  somewhat  healthier,  but  are  still  so  poor  that  life  is  a struggle.

Then,  about  a year  ago,  a new  problem  arose.  The  landholder  for  whom  Chelo
had  worked  before  he  became  ill  decided  to  take  away  the  small  plot  of  land
where  Chelo  grew  his  vegetables.  When  the  land  had  been  a useless  weed  patch
and  garbage  dump,  Chelo  had  been  granted  the  rights  to  it  by  the  village
authorities.  Now  that  the  parcel  had  been  developed  into  a fertile  and  irrigated
vegetable  plot,  the  landholder  wanted  it  for  himself.  He  applied  to  the  village
authorities,  who  wrote  a document  granting  the  rights  to  him.  Of  course,  this
was  unlawful  because  the  rights  had  already  been  given  to  Chelo.

Chelo  took  the  matter  over  the  heads  of  the  village  authorities  to  the  Municipal
Presidency,  located  in  a neighboring  town.  He  did  not  manage  to  see  the  President,
but  the  President's  spokesman  told  Chelo,  in  no  uncertain  terms,  that  he  should
stop  trying  to  cause  trouble.  Chelo  returned  to  his  village  in  despair.

Chelo  would  have  lost  his  land,  which  was  his  one  means  of  survival,  if  the
village  health  team  had  not  then  taken  action.  The  health  workers  had  struggled
too  many  times— often  at  the  cost  of  their  own  earnings— to  pull  Chelo  through
and  keep  him  alive.  They  knew  what  the  loss  of  his  land  would  mean  to  him.

At  an  all-village  meeting,  the  health  workers  explained  to  the  people  about  the
threat  to  Chelo's  land,  and  what  losing  it  would  mean  to  his  health.  They  produced
proof  that  the  town  authorities  had  given  the  land  rights  to  Chelo  first,  and  they
asked  for  justice.  Although  the  poor  farm  people  usually  remain  silent  in  village
meetings,  and  never  vote  against  the  wishes  of  the  village  authorities,  this  time
they  spoke  up  and  decided  in  Chelo's  favor.

Helping  Health  Workers  Learn  (2005)

Front- 1 1

The  village  authorities  were  furious,  and  so  was  the  landholder.

The  health  team  had  taken  what  could  be  called  political  action.  But  the  health
workers  did  not  think  of  themselves  as  'political'.  Nor  did  they  consider  themselves
capitalists,  communists,  or  even  socialists.  (Such  terms  have  little  meaning  for
them.)  They  simply  thought  of  themselves  as  village  health  workers— but  in  the
larger  sense.  They  saw  the  health,  and  indeed  the  life,  of  a helpless  person
threatened  by  the  unfairness  of  those  in  positions  of  power.  And  they  had  the
courage  to  speak  out,  to  take  action  in  his  defense.

Through  this  and  many  similar  experiences,  the  village  health  team  has  come
to  realize  that  the  health  of  the  poor  often  depends  on  questions  of  social  justice.
They  have  found  that  the  changes  that  are  most  needed  are  not  likely  to  come
from  those  who  hold  more  than  their  share  of  land,  wealth,  or  authority.  Instead,
they  will  come  through  cooperative  effort  by  those  who  earn  their  bread  by  the
sweat  of  their  brows.  From  themselves!

More  and  more,  the  village  team  in  Ajoya  has  looked  for  ways  to  get  their
fellow  villagers  thinking  and  talking  about  their  situation,  and  taking  group
action  to  deal  with  some  of  the  underlying  causes  of  poor  health.

Some  of  the  methods  they  have  developed  and  community  actions  they  have
led  are  described  in  several  parts  of  this  book.  For  example,  three  of  the  village
theater  skits  described  in  Chapter  27  show  ways  in  which  the  health  team  has
helped  the  poor  look  at  their  needs  and  organize  to  meet  them.

These  3 skits  are:

SMALL  FARMERS  JOIN  TOGETHER  TO  OVERCOME  EXPLOITATION
(page  27-27),

USELESS  MEDICINES  THAT  SOMETIMES  KILL  (page  27-14),  and

THE  WOMEN  JOIN  TOGETHER  TO  OVERCOME  DRUNKENNESS  (page
27  19).

These  popular  theater  skits  had,  and  are  still  having,  a marked  social  influence.
Villagers  participate  with  new  pride  in  the  cooperative  maize  bank  set  up  to
overcome  high  interest  on  loans.  Women  have  organized  to  prevent  the  opening
of  a public  bar.  And  storekeepers  no  longer  carry  some  of  the  expensive  and
dangerous  medicines  that  they  sold  before.  In  general,  people  seem  more  alert
about  things  they  had  simply  accepted.

On  the  other  hand,  new  difficulties  have  arisen.  Some  of  the  health  workers
have  been  thrown  out  of  their  rented  homes.  Others  have  been  arrested  on  false
charges.  Threats  have  been  made  to  close  down  the  villager-run  program.

But  in  spite  of  the  obstacles,  the  health  team  and  the  people  have  stood  their
ground.  The  village  team  knows  the  road  ahead  will  not  be  easy.  They  also  know
that  they  must  be  careful  and  alert.  Yet  they  have  chosen  to  stand  by  their
people,  by  the  poor  and  the  powerless.

They  have  had  the  courage  to  look  the  whole  problem  in  the  eye— and  to  look
for  a whole  answer.

Front  12

Helping  Health  Workers  Learn  (2005)

The  story  of  Cheio  and  his  family  is  true,  though  I have  not  told  the  half  of  it.
It  is  typical,  in  some  ways,  of  most  poor  families.  Persons  in  several  parts  of  the
world  who  are  poor  or  know  the  poor,  on  reading  Chelo's  story  have  commented,
"It  could  have  been  written  here!"

I have  told  you  Chelo's  story  so  that  you  might  understand  the  events  that
have  moved  us  to  include  in  this  book  ideas  and  methods  that  might  be  called
'political'.

What  I have  tried  to  say  here  has  been  said  even  better  by  a group  of
peasant  school  boys  from  Barbiana,  Italy.  These  boys  were  flunked  out  of
public  school  and  were  helped,  by  a remarkable  priest,  to  learn  how  to
teach  each  other.*

The  Italian  peasant  boys  write:

Whoever  is  fond  of  the  comfortable  and  the  fortunate  stays  out  of  politics.
He  does  not  want  anything  to  change.

But  these  school  boys  also  realize  that:

To  get  to  know  the  children  of  the  poor  and  to  love
politics  are  one  and  the  same  thing.  You  cannot  love
human  beings  who  were  marked  by  unjust  laws  and  not
work  for  other  laws.

* Letter  to  a Teacher,  by  the  school  boys  of  Barbiana.  For  more  ideas  of  these  school  boys,  see  p.  16  16.

Helping  Health  Workers  Learn  (2005)

Part  One  1

PART  ONE

APPROACHES  AND  PLANS

In  Part  One  of  this  book,  we  look  at  approaches  to  planning  and  carrying  out  a
training  program  for  community  health  workers.

But  before  getting  into  different  aspects  of  planning,  in  Chapter  1 we  explore
alternative  approaches  to  learning  and  teaching.  We  do  this  because  the  educational
methods  instructors  decide  to  use  will  in  part  determine  how  the  training  course  is
designed  and  who  takes  part  in  the  planning.  In  health  education,  the  methods  are
as  important  as  the  message.

Chapter  2 is  about  the  selection  of  both  health  workers  and  instructors.  We
consider  the  reasons  why  persons  selected  from  and  by  their  own  communities
usually  make  the  best  leaders  for  change.  We  also  discuss  why  experienced  village
health  workers  often  make  the  best  instructors  of  new  health  workers.

In  Chapter  3,  we  consider  steps  in  planning  a training  course,  and  in  Chapter  4,
how  to  get  the  course  off  to  a good  start.

Chapters  5,  6,  7,  and  8 explore  activities  in  the  3 main  places  of  learning  in  a
training  course:  the  classroom  (Chapter  5),  the  community  (Chapters  6 and  7),
and  the  clinic  or  health  center  (Chapter  8).  We  point  out  that  in  each  of  these
places,  the  classroom  included,  the  most  effective  form  of  learning  is  through
actual  practice  in  solving  common  problems.

Chapter  9 discusses  ways  of  finding  out  how  well  people  are  teaching,  learning,
and  meeting  local  needs.  Here  we  look  for  ways  in  which  tests,  exams,  and
evaluation  can  be  organized  to  strengthen  the  position  of  the  weak  and  help
everyone  reach  a better  understanding  of  the  training  program  as  a whole.

In  Chapter  10,  we  consider  what  happens  after  the  initial  training  course  is
completed  and  health  workers  are  back  in  their  own  communities.  This  includes
supportive  follow-up  and  continued  opportunities  to  learn.

Helping  Health  Workers  Learn  (2005)

Helping  Health  Workers  Learn  (2005)

1 1

T x . CHAPTER  +

Looking  at  Learning  1

and  Teaching

A health  worker's  most  important  job  is  to  teach— to  encourage  sharing  of
knowledge,  skills,  experiences,  and  ideas.  The  health  worker's  activities  as  an
'educator'  can  have  a more  far-reaching  effect  than  all  his  or  her  preventive  and
curative  activities  combined.

But  depending  on  how  it  is  approached,  and  by  whom,  health  education  can
have  either  a beneficial  or  harmful  effect  on  people's  well-being.  It  can  help
increase  people's  ability  and  confidence  to  solve  their  own  problems.  Or,  in
some  ways,  it  can  do  just  the  opposite.

Consider,  for  example,  a village  health  worker  who  calls  together  a group  of
mothers  and  gives  them  a 'health  talk'  like  this:

What  effect  does  this  kind  of  teaching  have  on  people?

You  can  discuss  this  question  with  your  fellow  instructors  or  with  the  health
workers  you  are  training.  Or  health  workers  can  discuss  it  with  people  in  their
villages.  You  (or  the  learning  group)  may  come  up  with  answers
something  like  these:

"It's  the  same  old  message  everybody's  heard
a hundred  times!  But  what  good  does  it  do?"

"It  goes  in  one  ear  and  out  the  other!"

"The  mothers  just  sit  and  listen.

They  don't  take  part."

1-2

Helping  Health  Workers  Learn  (2005)

The  more  deeply  your  group  explores  this  example  of  'health  education',  the
clearer  the  picture  wi II  become.  Encourage  the  group  to  notice  ways  in  which
this  kind  of  teaching  affects  how  people  view  themselves,  their  abilities,  and  their
needs.  Persons  may  observe  that:

"That  kind  of  teaching  makes  the  mothers
feel  ashamed  and  useless— as  if  their  own
carelessness  and  backwardness  were  to  blame
for  their  children's  ill  health."

"The  health  worker  acts  like  she  is  God
Almighty!  She  thinks  she  knows  it  all  and
the  mothers  know  nothing!"

"Her  uniform  separates  her  from  the  mothers
and  makes  her  seem  superior.  It  gives  her
outside  authority.  This  may  strengthen
people's  respect  for  her,  but  it  weakens
their  confidence  in  their  ability  to  take
the  lead  themselves."

"I  don't  think  her  health  advice  is  realistic.  Not  for
the  poor  in  our  area!  It's  easy  to  tell  people  to
boil  drinking  water.  But  what  if  a mother  with
hungry  children  spends  her  food  money  to  buy
firewood?  Also,  where  we  live,  the  land  is  already
being  turned  into  a desert  because  so  many  trees
are  being  cut.  For  us,  this  'health  message'  would
make  no  sense."*

"This  is  the  way  most  of  us  were
taught  in  school.  The  teacher  is
the  boss.  The  students  are
considered  to  'know  nothing'.
They  are  expected  simply  to
repeat  what  they're  told.

But  isn't  this  just  another
way  of  keeping  the  poor
on  the  bottom?"

"I  agree!  This  kind  of  'health
education'  might  get  mothers
to  boil  water,  wash  their
hands,  and  use  latrines.  But
in  the  long  run  it  may  do
more  to  prevent  than  to
promote  the  changes  we
need  for  lasting
improvements  in  our
health."

The  instructors,  health  workers,  or  villagers  who  discuss  this  question  may
arrive  at  answers  similar  to  or  very  different  from  those  suggested  above.  Their
responses  will  depend,  in  part,  on  the  local  situation.  But  in  part  they  will  depend
on  how  carefully  the  group  looks  at,  thinks  about,  and  'analyzes'  the  issues  involved.

For  more  discussion  about  boiling  drinking  water,  see  p.  15-3.

Helping  Health  Workers  Learn  (2005)

1-3

Mow  consider  another  example.  Here,  a health  worker  gets  together  with  a
group  of  mothers  and  discusses  their  problems  with  them.  She  starts  by  asking
questions  like  these:

What  effect  does  this  kind  of  teaching  have  on  people?  In  discussing  this
question  with  your  group,  you  may  hear  answers  like  these:

"Everybody  takes  part.  It  gets  the  group  of  mothers
thinking  and  talking  about  their  own  problems."

"The  health  worker  doesn't  just  tell  them  the  answers.  I

Everyone  looks  for  answers  together."

"The  health  worker  dresses  like  the  other  mothers  and
puts  herself  on  their  level.  She  is  their  friend,  not  their
'master'.  It  makes  everyone  feel  equal."  m fir ' 'r

"This  sort  of  teaching  certainly  * * “|

isn't  like  what  we  got  in
school!  It  lets  people  feel  their
ideas  are  worth  something.  It  helps  people  figure  out
their  problems  and  work  toward  solving  them
themselves."

"I'll  bet  the  mothers  will  want  to  keep  working  and
learning  together,  because  they  are  respected  as
thoughtful,  capable  human  beings.  It  makes  learning
fun!"

Once  again,  when  you  discuss  this  teaching  example  with  fellow  instructors,
health  workers,  or  villagers,  their  answers  may  be  very  different  from  the  ones
shown  here— or  from  your  own.  But  if  the  group  discusses  the  issues  in  depth,
relating  them  to  their  own  concerns  and  experiences,  they  will  make  many
valuable  observations.  You  will  all  learn  from  each  other.

1-4

Helping  Health  Workers  Learn  (2005)

How  something  is  taught  is
just  as  important  as  what  is
taught.

And  the  most  important
part  of  how  something  is
taught  is  the  caring,  respect,
and  shared  concern  that  go
into  it.

Aristotle,  "Father  of
Science,"  wisely  said  .

HOW  CAN  I TEACH
BUT  TO  A FRIEND?

DIRECTING  HEALTH  EDUCATION  TOWARD  THOSE
WHOSE  NEEDS  ARE  GREATEST

People  usually  teach  in  the  way  they  themselves  were  taught— unless  something
either  alarming  or  loving  happens  to  change  the  way  they  view  things  and  do
things.  This  is  true  for  health  workers.  And  it  is  true  for  those  of  us  who  are
instructors  of  health  workers.  Most  of  us  teach  as  we  were  taught  in  school.

Unfortunately,  the  purposes  and  methods  of  public  schools  are  not  always  in
the  best  interests  of  those  whose  needs  are  greatest.  As  we  shall  discuss,  schools
tend  to  reward  the  stronger  students  and  leave  the  weak  behind.

But  the  aim  of  'people-centered'  learning  is  just  the  opposite.  It  is  to  help
those  who  are  weakest  become  stronger  and  more  self-reliant.

Community  health  education  is  appropriate  to  the
extent  that  it  helps  the  poor  and  powerless  gain
greater  control  over  their  health  and  their  lives.

To  become  effective  community  educators,  health  workers  need  to  develop
approaches  very  different  from  what  most  of  us  have  experienced  in  school.

For  this  to  happen,  it  is  essential  that  student  health  workers  critically  examine
different  ways  of  teaching  during  their  training.  They  need  to  develop  and  practice
teaching  methods  that  can  help  ordinary  working  people  to  gain  the  awareness
and  courage  needed  to  improve  their  situation.

In  this  chapter,  we  will  look  at  the  educational  roles  of  both  health  workers
and  their  teachers.  Then  we  will  consider  some  ways  of  helping  health  workers
explore  alternative  approaches  for  teaching  and  learning  with  people.

Helping  Health  Workers  Learn  (2005)

1-5

THE  TEACHING  ROLE  OF  HEALTH  WORKERS

V

Early  during  training,  be  sure  to  have  health  workers  think  about  the  range  of
opportunities  they  will  have  for  sharing  and  exchanging  ideas  in  their  communities.

After  discussing  the  many  possibilities,  they  might  post  them  on  a wall  as  a
reminder:

OPPORTUNITIES  FOR  SHARING  AND  EXCHANGING  IDEAS  WITH  PEOPLE

IN  OUR  VILLAGES

/

We  health  workers  can  look  for  ways  to  . . .

Help  families  of  sick
persons  find  ways  to  care
for  them  better  and  to
prevent  similar  sickness
in  the  future.

Help  mothers  find  ways
to  protect  their  own  health
and  that  of  their  children.

Interest  school  children
(and  those  who  do  not  go
to  school)  in  learning  to
meet  the  health  needs  of
their  younger  brothers  and
sisters.

Help  organize  village
meetings  to  discuss  local
problems.  Encourage
others  to  become  ‘health
leaders’.

Exchange  ideas  and
information  with  local
midwives,  bone  setters,
and  traditional  healers.

Talk  with  youth  groups
and  farmers  about  possible
ways  to  improve  their
crops  or  to  defend  their
land  and  rights.

This  list  is  only  a beginning.  Your  group  may  think  of  many  other  possibilities.

Also,  try  to  get  the  group  thinking  about  the  different  ways  people  learn.  In
their  village,  there  may  be  many  people  who  have  never  gone  to  school.  They  may
not  be  used  to  classes,  lectures,  or  'health  talks'.  Traditionally,  people  learn  from
stories  and  play,  by  watching,  copying,  and  helping  others  work,  and  through
practical  experience.  Ask  your  students  what  are  the  customary  ways  of  learning
in  their  villages.

Encourage  your  students  to  think  of  ways  that  they  might  adapt  health
education  to  people's  local  forms  of  learning.  Here  are  some  possibilities,  which
we  discuss  in  the  chapters  indicated.

• story  telling,  Ch.  13

• songs,  p.  1-26  and  15-1 5

• play  (learning  games),  Ch.  1 1 , 19,  and  24

• make-believe  (learning  by  imitating),  Ch.  24

• role  playing  (acting  out  problems  and
situations),  Ch.  14

• popular  theater  and  puppet  shows,  Ch.  27

• apprenticeship  (learning  by  helping  someone
more  skilled) , Ch.  8

• practical  experience,  Ch.  6 and  8

• smal  I group  discussions,  Ch.  4 and  26

• solving  real  problems,  Ch.  8,  10,  14,  17,  25,  26,
and  27

• trial  and  error  (finding  things  out  for  oneself),
Ch.  11,  17,  and  24

• building  on  the  knowledge,  skills,  customs,  and
experience  that  people  already  have,  Ch.  7
and  1 3

We  health  workers  need  to  adapt  our  teaching  to  people's
traditional  ways  of  learning— ways  they  are  already  used  to  and  enjoy.

1-6

Helping  Health  Workers  Learn  (2005)

THE  ROLE  OF  HEALTH  WORKER  INSTRUCTORS

It  is  not  enough  to  explain  to  health  workers  about  'people-centered'  education.
We  teachers  must  set  an  example.  This  means  we  must  carefully  and  frequently
examine  our  own  teaching  habits,  in  terms  of  both  the  methods  we  use  and  the

way  we  relate  to  our  students.

• The  methods  we  use.  If  we  would  like  health  workers  to  use  stories  when
teaching  village  mothers,  then  we,  too,  need  to  use  stories  for  helping  health
workers  learn.  If  we  would  like  them  to  help  children  learn  through  puppet
shows,  games,  and  discovering  things  for  themselves,  we  must  let  them
experience  the  excitement  of  learning  in  these  ways.  If  health  workers  are  to
help  farm  workers  discuss  problems  and  choose  their  own  courses  of  action,
then  we  must  give  health  workers  similar  opportunities  during  training.  Health
workers  will  be  more  able  to  help  others  learn  by  doing  if  they,  themselves,
learn  by  doing.

• How  we  relate.  How  we  instructors  teach  health  workers  is  just  as  important
as  what  we  teach  them.  But  how  we  teach  depends  greatly  on  how  we  feel
toward  our  students.

If  we  respect  our  students'  ideas,  and  encourage  them  to  question  our
authority  and  to  think  for  themselves,  then  they  will  gain  attitudes  and  skills
useful  for  helping  people  meet  their  biggest  needs.

But  if  we  fail  to  respect  our  students,  or  make  them  memorize  lessons
without  encouraging  them  to  question  and  think,  we  may  do  more  harm  than
good.  Our  experience  has  shown  us  that  health  workers  trained  in  this  way
make  poor  teachers  and  bossy  leaders.  Rather  than  helping  people  gain  the
understanding  and  confidence  to  change  their  situation,  they  can  even  stand
in  the  way.

To  set  a good  example  for  health  workers,  we  instructors  need  to:

• T reat  the  health  workers  as  our  equals— and  as  friends.

• Respect  their  ideas  and  build  on  their  experiences.

• Invite  cooperation;  encourage  helping  those  who  are  behind.

• Make  it  clear  that  we  do  not  have  all  the  answers.

• Welcome  criticism,  questioning,  initiative,  and  trust.

• Live  and  dress  modestly;  accept  only  modest  pay.

• Defend  the  interests  of  those  in  greatest  need.

• Live  and  work  in  the  community.  Learn  together  with  the  people,  and
share  their  dreams.

These  ideas  are  beautifully  expressed  in  this  old  Chinese  verse:

Q-o  in  search,  of  If  our  people-  ■.
£ove  Them  -,

Team  from  Them. ;
flan  with  Them*-,

<Serve  Them.-,

Beginwith  what  They  have ;
Build  on  what  They  j^no-w.

But  of  { he  hest  leaders
when  their  task  is
accomplished,
their  work  *5  doner ,

The  people  all  remar k:
"V)e  have  done  it  Ourselves.’

Helping  Health  Workers  Learn  (2005)

The  rest  of  this  chapter  concerns  methods
for  helping  people  look  at  the  strengths  and
weaknesses  of  different  educational  approaches,

especially  as  they  affect  the  lives  and  well-
being of  the  poor.  We  try  to  do  this  by  using
the  same  methods  we  recommend.  We  include
examples  of  stories,  role  plays,  and  discussions
that  various  groups  have  found
useful  in  health  worker  training.

1-7

We  ask  you  to  use  these
materials  not  as  they  are,  but
as  sparks  for  ideas.  Think  about  them.

Criticize  them.  Tear  them  to  pieces.  If  you
find  any  parts  useful,  adapt  them  to  fit  the  people  and  needs  in  your  own  area.

We  encourage  you  to  tear  our  ideas  to
pieces.  Save  only  what  you  can  use  or
adapt  to  your  area.

BEGINNING  WITH  YOUR  OWN  TRUE  STORY

Helping  people  begin  to  look  at  things  in  new  ways  is  a teacher's  chief  job.

This  is  easier  if  we  look  at  ideas,  not  in  terms  of  general  theories,  but  through
real-life  examples.  It  is  better  still  when  the  examples  come  from  the  lives  and
experiences  of  the  learning  group.

As  the  instructor,  why  not  start  by  setting  the  example?  Tell  a story  from
your  own  experience,  one  that  brings  out  certain  points  or  problems  that  need  to
be  considered.  The  group  can  then  discuss  the  story,  adding  to  it  from  their  own
ideas  and  experiences.

Stories  can  bring  learning  closer  to  I ife —
especially  true  stories  told  from  personal  experience.

It  is  important  that,  as  group  leader,  you  'expose'  yourself  by  telling  personal
experiences  that  matter  deeply,  or  that  somehow  changed  the  way  you  look  at
things.  This  will  help  others  to  open  up  and  speak  of  things  that  really  matter
to  them.

The  following  story  is  both  true  and  personal.  We  have  used  it  to  start  groups
of  health  workers  and  instructors  thinking  about  some  of  the  human  factors
related  to  teaching  and  learning.  But  we  do  not  provide  any  follow-up  discussion
here.  We  leave  that  up  to  you  and  your  group.

You  can  try  using  this  story  'as  is'  with  your  students  and  your  group.  Or  even
better,  tell  a story  from  your  own  experience.  Let  your  students  know  you  as
a person!

A suggestion  for  reading  stories:

If  a story  like  that  which  follows  is
read  in  a group,  take  turns  reading.
Let  each  person  read  a paragraph.

Helping  Health  Workers  Learn  (2005)

true  story:

THE  IMPORTANCE  OF  NOT  KNOWING  IT  ALL

A teacher  of  village  health  workers  who  had  a college  degree  was  working  as
a volunteer  in  the  mountains  of  western  Mexico.  One  day  he  arrived  at  a small
village  on  muleback.  A father  approached  him  and  asked  if  he  could  heal  his
son.  The  health  worker  followed  the  father  to  his  hut.

The  boy,  whose  name  was  Pepe,  was  sitting  on  the  floor.  His  legs  were
crippled  by  polio  (infantile  paralysis).  The  disease  had  struck  him  as  a baby.

Now  he  was  13  years  old.  Pepe  smiled  and  reached  up  a friendly  hand.

The  health  worker  examined  the  boy.  "Have  you  ever  tried  to  walk  with
crutches?"  he  asked.  Pepe  shook  his  head.

"We  live  so  far  away  from  the  city,"  his  father  explained  apologetically.

"Then  why  don't  we  try  to  make  some  crutches?"  asked  the  health  worker.

The  next  morning  the  health  worker  got  up
at  dawn.  He  borrowed  a machete  (long  curved
knife)  and  went  into  the  forest.  He  hunted
until  he  found  two  forked  branches.

He  took  the  branches  back  to  the  home  of
the  crippled  boy  and  began  to  make  them  into
crutches,  like  this.

The  father  came  up  and  the  health  worker  showed  him  the  crutches  he  was
making.  The  father  examined  them  for  a moment  and  said,  "They  won't  work!"

The  health  worker  frowned.  "Wait  and  see!"  he  said.

When  both  crutches  were  finished,  they  showed  them  to  Pepe,  who  was
eager  to  try  them  out.  His  father  lifted  him  into  a standing  position  and  the
health  worker  placed  the  crutches  under  the  boy's  arms.

But  as  soon  as  Pepe  tried  to  put  his  weight  on
the  crutches,  they  doubled  and  broke.

"I  tried  to  tell  you  they  wouldn't  work,"  said
the  father.  "It's  the  wrong  kind  of  tree.  Wood's
weak  as  water!  But  now  I see  what  you  have  in
mind.  I'll  go  cut  some  branches  of  jutamo.  Wood's
tough  as  iron,  but  light!  Don't  want  the  crutches
to  be  too  heavy."

He  took  the  machete  and  trotted  into  the  forest.

Fifteen  minutes  later  he  was  back  with  two  forked
sticks  of  jutamo.  At  once  he  set  about  making  the
crutches,  his  strong  hands  working  rapidly.  The
health  worker  and  Pepe  assisted  him.

When  the  new  crutches  were  finished,  Pepe's
father  tested  them  by  putting  his  full  weight  on  them.  They  held  him  easily,  yet
were  lightweight.  Next  the  boy  tried  them.  He  had  trouble  balancing  at  first,  but
soon  was  able  to  hold  himself  upright.  By  afternoon,  he  was  actually  walking
with  the  crutches.  But  they  rubbed  him  under  the  arms.

Helping  Health  Workers  Learn  (2005)

1-9

“I  have  an  idea,"  said  Pepe's  father.  He  went
across  the  clearing  to  a pochote,  or  wild  kapok  /\

tree,  and  picked  several  of  the  large,  ripe  fruits
He  gathered  the  downy  cotton  from  the  pods,  and  =s’*’s*aLT
put  a soft  cushion  of  kapok  onto  the  top  crosspiece  \r>

of  each  crutch.  Then  he  wrapped  the  kapok  in  ([

place  with  strips  of  cloth  Pepe  tried  the  crutches  <pe>

again  and  found  them  comfortable.  1 1 (j  | J |

"Gosh,  Dad,  you  really  fixed  them  great!"  cried  O y f/  ijf

the  boy,  smiling  at  his  father  with  pride.  "Look  f a / if

how  well  I can  walk  nowl"  He  bounded  about  the  I I j J

dusty  patio  on  his  new  crutches.

"I'm  proud  of  you,  son!"  said  his  father,  smiling  too.

As  the  health  worker  was  saddling  his  mule  to  leave,  the  whole  family  came
to  say  good-bye

I can't  thank  you  enough,”  said
the  father.  "It's  so  wonderful  to  see
my  son  able  to  walk  upright.  I don't
know  why  I never  thought  of  making
crutches  before  . . ."

"It's  I who  must  thank  you,"  said
the  health  worker.  "You  have  taught
me  a great  deal.”

As  the  health  worker  rode  down
the  trail  he  smiled  to  himself  "How
foolish  of  me,"  he  thought,  "not  to
have  asked  the  father's  advice  in  the
first  place.  He  knows  the  trees  better
than  I do.  And  he  is  a better
craftsman.

"But  how  fortunate  it  is  that  the
crutches  that  I made  broke.  The  idea
for  making  the  crutches  was  mine,  and
the  father  felt  bad  for  not  having
thought  of  it  himself.  When  my
crutches  broke,  he  made  much  better
ones.  That  made  us  equal  again!”

So  the  health  worker  learned  many  things  from  the  father  of  the  crippled
boy— things  that  he  had  never  learned  in  college.  He  learned  what  kind  of
wood  is  best  for  making  crutches.  But  he  also  learned  how  important  it  is  to
use  the  skills  and  knowledge  of  the  local  people— important  because  a better
job  can  be  done,  and  because  it  helps  maintain  people's  dignity.  People  feel
more  equal  when  each  learns  from  the  other.

It  was  a lesson  the  health  worker  will  always  remember.  I know.  I was  the
health  worker.

1-10

Helping  Health  Workers  Learn  (2005)

IDEAS  FOR  A DISCUSSION  ABOUT
SHARING  AND  SELF-RELIANCE

People's  health  depends  on  many  things— on  food,  on  water,  on  cleanliness,  on
safety.  But  above  all,  it  depends  on  sharing— on  letting  everyone  have  a fair  share
of  land,  opportunity,  resources— and  knowledge.

Unfortunately,  many  doctors  (and  many  traditional  healers)  tend  to  carefully
guard  their  knowledge  rather  than  to  share  it  openly.  Too  often  they  use  their
special  knowledge  to  gain  power  or  privilege,  or  to  charge  more  for  their  services
than  is  fair.

Health  workers  can  easily  fall  into  these  same  unhealthy  habits.  So  their
training  must  help  them  guard  against  this.  It  should  help  them  realize  that  to
share  their  knowledge  and  skills  freely  is  important  to  people's  health.  Sharing  of
knowledge  helps  people  become  more  self-reliant.

Self-reliance  as  a measure  of  health:  A person  who
is  very  sick  needs  to  be  cared  for  completely.  He
can  do  almost  nothing  for  himself.  But  as  his
health  improves,  so  does  his  capacity  for  self-care.
Health  is  closely  related  to  people's  ability  to  care
for  themselves  and  each  other— as  equals.

These  may  be  important  ideas.  But  at  present  they  are  just  our  ideas.  How  is  it
possible  to  get  a group  of  health  workers  thinking  about  and  reacting  to  ideas
like  these?  And  forming  their  own  ideas?  Lecturing  will  do  little  good.  A better
way  is  to  help  people  discover  things  through  thoughtful  discussion.

To  start,  you  might  find  it  helpful  to  ask  questions  like  these:

Health  Is  The
Opposite  of

How  are  persons  who  are  sick  different  from  persons  who  are  healthy?
Which  are  better  able  to  care  for
themselves?  Who  needs  to  be  taken
care  of?

Who  have  more  health  problems,
the  rich  or  the  poor?  Why?

What  do  health  and  well-being  have
to  do  with  self-reliance?  Of  a
person?  Of  a family?  Of  a village
or  community?  Of  a nation?

Can  you  give  examples  from  your
own  experience?

After  discussing  these  questions,
you  might  ask:

• What  should  be  the  main  goal  of
health  education?

• What  should  be  your  responsibilities
as  a health  worker?

DO  VOU  THIN  K THIS
IS  TRUE  ?

STARTING  A DISCUSSION

Guide  the  students  in  discussing  these  things,  but  let  them  come  up  with  their
own  answers.

Helping  Health  Workers  Learn  (2005)

1-11

A PUZZLE  TO  GET  PEOPLE  THINKING  IN  NEW  WAYS

All  of  us,  teachers
and  students  alike,  get
into  'ruts'.  And  like
horses  with  blinders,  we
often  tend  to  look  at
things  from  a narrow
point  of  view.  We  keep
on  trying  to  solve
problems  in  the  same
old  way.

New  approaches  to  health  care  require  new  approaches  to  teaching  and  learning.

This  means  tearing  off  the  conventional  'blinders'  that  limit  our  vision  and
imagination.  It  means  going  beyond  the  walls  of  the  standard  classroom  and
exploring  afresh  the  world  in  which  we  live  and  learn.

A number  of  'tricks'  or  puzzles  can  be  used  to  help  planners,  instructors,  or
students  realize  the  importance  of  looking  at  things  in  new  ways— of  going  beyond
the  limits  their  own  minds  have  set.  Here  is  an  example:

Draw  9 dots  on  a paper,  on  the  blackboard,  or  in  the
dust,  like  this:

Ask  everyone  to  try  to  figure  out  a way  to  connect
all  the  dots  with  4 straight  lines  joined  together
(drawn  without  lifting  the  pencil  from  the  paper).

You  will  find  that  most  persons  will  try  to  draw  lines
that  do  not  go  outside  the  imaginary  square  or  'box'

formed  by  the  dots.

Some  may  even  conclude  that  it  is  impossible  to  join  all
the  dots  with  only  4 lines.  You  can  give  them  a clue  by
saying  that,  to  solve  the  puzzle,  they  must  go  beyond
the  limits  they  set  for  themselves.

At  last,  someone  will  probably  figure  out  how  to  do
it.  The  lines  must  extend  beyond  the  'box'  formed  by
the  dots.  (Be  careful  not  to  shame  the  students  or  make
them  feel  stupid  if  they  cannot  solve  the  puzzle.  Explain
that  many  doctors  and  professors  also  have  trouble
with  it.)

After  the  group  has  seen  how  to  solve  the  puzzle,  ask  some  questions  that  help
them  consider  its  larger  significance.  You  might  begin  with  questions  like  these:

• In  what  way  is  a classroom  like  the  box  formed  by  the  dots?

• • •

• How  does  the  idea  that  'education  belongs  in  a classroom'

affect  the  way  we  look  at  learning?  At  health?  At  each  * # »

other?  • • •

And  end  with  questions  like  these:  * *

• What  can  we  do  to  help  each  other  climb  out  of  the  mental  'boxes'  or  'ruts'
that  confine  our  thinking,  so  we  can  explore  new  ways  with  open  minds?  Is
this  important  to  people's  health?  How  so?

1-12

Helping  Health  Workers  Learn  (2005)

'CRITICAL  STUDY  OF  TEACHING  METHODS'
AS  PART  OF  HEALTH  WORKER  TRAINING

Some  training  programs  schedule  several  hours  a week  for  the  study  of  'learning
how  to  teach'.  The  learning  group  starts  by  exploring  and  critically  analyzing
different  educational  approaches.  Next  they  practice  teaching— first  with  each
other,  then  with  mothers  and  children.  They  also  learn  to  develop  their  own
teaching  materials.

To  start  by  looking  at  and  analyzing  alternative  teaching  methods  is  especially
important.  Sometimes  health  workers  go  through  a people-centered  course
without  fully  understanding  the  value  of  the  new  methods  used.  They  may  not
realize  that  the  way  they  teach  can  either  break  down  or  build  up  people's
self-confidence  and  community  strength.  Without  such  understanding,  they  may
later  slip  back  into  the  more  conventional  'teacher  as  boss'  style  of  teaching.  We
have  often  seen  this  happen.

' U‘

t*>  /

\7\  TV:*  "VJH

A'm

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• r-y  'J
; . ,r'

PRACTICE

Health  workers  need  to
experience  and  to
practice  appropriate
teaching  methods  during
their  training.

But  they  also  need  to
fully  understand  why  such
methods  are  so  important.

UNDERSTANDING

To  assist  health  workers  in  developing  this  understanding,  be  sure  to  allow  time
for  the  critical  study  of  alternative  approaches  to  learning.  Help  the  group  to:

• Experience,  analyze,  and  compare  contrasting  educational  methods.

• Look  critically  at  the  existing  school  system  in  your  area  and  how  it  affects
the  lives,  economy,  social  position,  and  health  of  the  poor.  Discuss  how
conventional  schooling  influences  the  values  and  job  performance  of  health
officers,  civil  servants,  teachers,  and  others.

• Look  for  ways  that  they  (the  health  workers)  can  begin  to  change  unfair  or
inappropriate  social  structures,  especially  the  school  system.  This  would
mean  to  . . .

• Explore  possibilities  of  working  with  school  children,  non-school  children,
and  teachers  in  ways  that  relate  learning  to  the  lives  and  needs  of  the
children.  (See  Chapter  24.)

• Try  using  more  appropriate,  friendlier  teaching  methods.  And  help  others
discover  for  themselves  the  value  and  excitement  of  people-centered  learning.

The  study  of  these  issues  will,  of  course,  be  more  effective  if  you  use  the  same
methods  you  want  your  students  to  learn  (see  p.  16).  Students  can  conduct  their
own  investigation  of  different  educational  methods.  Your  role  as  instructor  is  to
help  the  learning  group  ask  searching  questions,  look  critically  at  alternatives,  and
try  out  more  people-centered  teaching  methods  during  training.

Helping  Health  Workers  Learn  (2005)

M3

IDEAS  FOR  DISCUSSION  ABOUT
THE  PURPOSE  OF  SCHOOLING

Many  educators  agree  that  the  primary  purpose  of  education  should  be  to  help
persons  gain  the  knowledge,  skills,  and  awareness  necessary  to  meet  life's  needs.

But  do  the  schools  that  most  children— or  health  workers—  attend  really  do
this?

To  answer  this  question,  you  and  your  group  of  teachers  or  health  workers  may
first  want  to  consider  carefully:  What  are  the  biggest  problems  or  needs  of  most
people  in  your  village  or  community?  To  do  this,  you  probably  do  not  have  to
conduct  a survey  or  'community  diagnosis'— at  least  not  at  first.  You  may  already
have  a good  idea  of  how  most  people  in  your  area  live,  whether  they  have  enough
to  eat,  what  they  suffer  from  most,  and  why.

What  is  necessary  is  to  openly  and  honestly  discuss  the  people's  needs,  why
they  exist,  and  what  might  be  the  biggest  obstacles  to  overcoming  them.

If  you  live  in  a village  or  poor  community— as  do  most  of  the  people  in  the
world— your  local  situation  may  be  something  like  this:

A TYPICAL  VI LLAGE  (How  does  it  compare  with  your  own?)

PROBLEMS  OR  NEEDS

Poor  health,  unnecessary
suffering

• many  children  are  thin,  small,
big  bellied,  often  sick;  many  die

• mothers  are  often  pale,  weak,
and  tired;  many  die,  especially
during  or  after  childbirth

• many  fathers  cannot  find  work,
are  not  paid  enough,  or  do  not
have  enough  land  to  meet  the
family's  needs  for  food,  water,
housing,  health  care,  and
education;  many  get  drunk  or
lose  hope;  violence  is  the  main
cause  of  death  in  young  men
(between  ages  15  and  40)

CAUSES

Poverty,  too  much  in  the
hands  of  too  few

• poor  food,  sweets  and  'junk
food',  poor  sanitation,
inadequate  health  care;
poor  nutrition  lowers
resistance  to  infectious
disease

• large  families  because  of
economic  necessity  (children
provide  low-cost  labor)

• most  of  the  land,  wealth,
and  power  are  in  the  hands
of  a few;  the  rich  underpay
and  exploit  the  poor

• government  (local,  national,
and  international)  favors  the
rich

OBSTACLES  TO  IMPROVEMENT

Selfishness  of  some,
hopelessness  of  others

• greed  and  corruption  of  those
in  control

• people's  lack  of  self-
confidence;  no  hope  that
things  can  be  changed

(fatalism)

• lack  of  organization  and
effective  leadership  among
the  poor

• increasing  dependency  of
the  poor  on  outside  services,
giveaways,  resources,
entertainment,  and  authority

• inadequate  and  inappropriate
education  (for  rich  and  poor
alike)

After  discussing  the  needs  in  your  village,  ask  questions  about  the  local  schools
and  whose  needs  they  are  designed  to  serve.

1-14

Helping  Health  Workers  Learn  (2005)

Examples  of  questions  to  get  people  thinking

and  talking  about  the  purpose  of  schooling:

• How  much  of  what  children  are  taught  in
school  is  relevant  (related)  to  their  daily
lives  and  needs?

• How  long  do  most  of  the  children  stay  in
school7  Which  children  drop  out  early?

Why?  What  becomes  of  them?

• Which  children  continue  with  their
schooling?  Why?  Do  they  usually  return  to
serve  the  community?  Why  or  why  not?

• In  what  ways  does  the  teacher  set  a good
example  or  a bad  example  for  the  students?

How  does  he  or  she  relate  to  them?  As  a
friend?  As  an  equal?  As  their  master?

• Who  does  the  work  that  makes  money  available  for  schooling?

• Who  decides  what  is  taught  in  the  schools  and  how7  Should  the  people  in  a
village  or  community  have  some  say  as  to  what  their  children  are  taught?
Should  the  opinions  of  the  children  be  listened  to?*  (See  footnote.)

• In  what  ways  do  schools  shape  children's  values?  How  does  this  affect  their
families?  Their  community?  The  poor?

• Are  children  taught  to  question  those  in  positions  of  authority,  or  to  obey
them?  Why7  How  does  this  affect  those  who  are  powerless?

• Whose  needs  does  schooling  serve  the  most,  the  weak  or  the  strong?  In  what
ways?

• In  what  ways  does  schooling  benefit  or  harm  people  in  villages?  In  slums?

• What  changes  have  been  taking  place  in  recent  years  in  the  content  or  approach
to  schooling?  Why?  What  changes  would  be  needed  for  the  schools  to  better
serve  the  interests  of  the  poor?

In  what  ways  do  our
schools  help  this  child
to  meet  his  needs?

‘For  those  who  believe  that  children  are  too  unwise  or  loo  inexperienced  to  make  intelligent  judgements  about
their  educational  needs,  we  suggest  you  read  Letter  to  a Teacher,  by  the  school  boys  of  Barbiana,  Italy
(see  p.  16-16).

These  school  boys  from  poor  farming  communities  make  remarkably  sound  and  challenging  suggestions
for  changing  the  school  system  to  better  meet  the  needs  of  the  poor  majority.  Recognizing  that  many
children  of  the  poor  leave  school  after  only  a few  years,  they  insist  that,  "If  schooling  has  to  be  so  brief,
then  it  should  be  planned  according  to  the  most  urgent  needs."  They  question  the  usefulness  of  each  major
subject.  They  ask,  "How  much  math  does  one  have  to  know  for  his  immediate  needs  at  home  and  at  work?"
History  as  taught  in  schools,  they  insist,  is  "no  history  at  all,"  but  "one-sided  tales  passed  down  to  the
peasants  by  the  conqueror.  There  is  talk  only  of  kings,  generals,  and  stupid  wars  among  nations.  The
sufferings  and  struggles  of  the  workers  are  either  ignored  or  stuck  into  a corner."

These  boys  also  criticize  the  fact  that  most  schools  encourage  competition  among  students.  It  would  be
better,  they  say,  if  schools  helped  each  child  to  feel  that  "Others'  problems  are  like  mine.  To  come  out  of
them  together  is  good  politics.  To  come  out  alone  is  stinginess."

Helping  Health  Workers  Learn  (2005)

1-15

Schooling  as  a form  of  social  control

Government  schools  tend  to  serve
government  purposes.  Only  to  the  extent
that  government  is  truly  by  and  for  the
people,  is  schooling  likely  to  prepare
students  to  work  toward  meeting  the
needs  of  the  majority  of  citizens  in
effective  and  lasting  ways.

READ  AGAIN  -WITH  MORE'
FEELING -THE  PASSAGE
ABOUT  THE  HEROES  OF J
THE  REVOLUTION.

Whose  needs  does  your  school  system  serve?

In  the  world  today,  most  governments  do  not  represent  all  their  people  equally.
Many  governments  are  controlled  by  a powerful  minority  of  politicians,
businessmen,  wealthy  landholders,  military  leaders,  and  professionals  (especially
lawyers  and  doctors).  These  persons  often  care  more  about  protecting  their  own
interests  than  about  looking  for  ways  to  improve  the  well-being  of  the  poor
majority.  When  they  do  consider  doing  something  to  help  the  poor,  they  are
usually  careful  to  do  so  in  ways  that  do  not  threaten  their  own  interests  and
authority.

Schooling,  from  the  viewpoint  of  those  in  power,  involves  a risk.  When  the  poor
learn  to  read  and  write,  they  can  communicate  and  organize  in  new  ways,  in
greater  numbers,  over  larger  distances.  They  can  read  things  that  help  them
discover  their  legal  and  human  rights.  They  may  ask  themselves  if  it  is  really
'God's  will'  that  a few  persons  have  far  more  than  they  need,  while  others  do  not
have  enough  to  eat.  They  may  even  begin  to  realize  that  they  can  do  something  to
change  their  situation.

This  means  that,  for  the  few  to  keep  their  control,  schools  must  teach  poor
people  to  obey  authority  as  well  as  to  read  and  write.  So  most  schools  teach
students  to  fit  into  the  existing  social  order  rather  than  to  question  or  try  to
change  it.

How  is  this  done?  By  putting  emphasis  on  following  rules,  being  on  time,  and
'behaving'.  Students  are  encouraged  to  compete  more  than  cooperate,  to  memorize
rather  than  think.  School  books  paint  the  present  government  as  completely  good
and  just,  with  leaders  who  always  have  the  interests  of  all  the  people  at  heart.

But  perhaps  the  most  powerful  means  the  schools  have  for  teaching  children  to
'listen  and  obey'  are  the  teaching  methods  themselves.  Students  are  led  to  believe
that  the  only  way  to  learn  is  to  be  taught— by  someone  who  knows  more  than
they  do.  The  teacher  is  set  up  as  the  'master',  an  authority  whose  statements  must
not  be  questioned.

This  kind  of  education  is  called  authoritarian,  because  its  purpose  is  to
strengthen  the  authority  of  those  in  control.  It  is  education  designed  to  keep
things  as  they  ar e-education  that  resists  change.

" The  lecture  method  of
teaching  is  the  best  way  to
transfer  the  teacher's  notes
to  the  students'  notebooks
without  ever  passing  through
their  minds. "

6

Helping  Health  Workers  Learn  (2005)

DOES  YOUR  TEACHING  RESIST  CHANGE,
OR  ENCOURAGE  IT?

One  of  the  main  purposes  of  conventional  or
authoritarian  education  is  to  teach  students  to
fit  obediently  into  the  existing  social  order.  The
teacher  provides  the  approved  knowledge,  and
the  students  receive  it.  The  emptier  the  student's
head  to  begin  with,  the  better  a student  he  is—
according  to  the  teacher  and  the  system.

Unfortunately,  many  training  programs  for
village  or  community  health  workers  use  this
same  kind  of  authoritarian  approach.  Students
are  taught  to  follow,  not  to  explore;  to
memorize,  not  to  think.  They  are  taught  to
believe  that  their  first  responsibility  is  to  the
health  system  rather  than  to  the  poor.

LEARN  THIS  AND  DON’T  ASH
WHY  !~  BLA,  BL  A,  BL  A.  . .

EDUCATION  OF  AUTHORITY:
putting  ideas  in

Usually  instructors  teach  this  way,  not  because  they  mean  any  harm,  but
simply  because  they  themselves  grew  up  in  an  authoritarian  school  system.  They
may  not  know  any  other  way  to  teach.

EDUCATION  THAT  ENCOURAGES  CHANGE:

But  there  are  other  ways— ways  that  build
the  students'  confidence  in  their  capacity  to
observe,  criticize,  analyze,  and  figure  things
out  for  themselves.  These  ways  let  the  students
discover  that  they  are  just  as  good  as  their
teachers  and  everyone  else.  They  learn  to
cooperate  rather  than  compete  in  order  to
gain  approval.  They  are  encouraged  to
consider  the  whole  social  context  of  their  people's  needs,  and  to  look  for
imaginative  and  courageous  ways  of  meeting  them.

Teaching  suggestion

Rather  than  tell  the  members  of
your  group  these  things,  help  them
to  recall  their  own  experiences  and
to  figure  things  out  for  themselves.

(SO  WHAT  DO  you  THINK  'j
OF  THAT  IDEA  ? J

EDUCATION  OF  CHANGE:
drawing  ideas  out

This  we  will  call  education  for  change.  Emphasis
is  more  on  learning  than  on  teaching.  Students  are
encouraged  to  voice  their  own  ideas.  They  figure
things  out  for  themselves,  and  explore  ways  to
help  people  free  themselves  from  the  causes  of
poverty  and  poor  health.

If  a health  worker  is  to  be  a 'leader  for  change',
helping  people  find  ways  to  solve  their  biggest
problems,  then  it  is  important  that  his  training
itself  set  an  example.

Good  teaching  is  the  art,
not  of  PUTTING  IDEAS  INTO  people's  heads,
but  of  DRAWING  IDEAS  OUT.

Helping  Health  Workers  Learn  (2005)

1-17

ROLE  PLAYS  THAT  HELP  PEOPLE
EXPLORE  TWO  KINDS  OF  TEACHING

For  health  workers  to  appreciate  the
importance  of  appropriate  teaching,  it
helps  if  they  experience  two  kinds  of
teaching  and  then  compare  them.

A good  way  to  do  this  is  through  'role
The  bossy  teacher  playing'  (see  Chapter  14).  Here  we  give
ideas  for  two  role  plays  to  compare  the  bossy  teacher  with  the  good  group  leader.

The  friendly
group  leader

These  role  plays  are  most  effective  if  they  take  the  students  by  surprise.
Although  the  whole  class  participates,  at  first  students  will  not  realize  that  the
instructor  is  'acting'—  and  that  they  are  actors,  too!

In  the  role  plays,  the  instructor  (or  two  different  instructors)  will  teach  the
same  health  topic  in  two  very  different  ways.  Then  the  students  compare  their
reactions  to  the  two  lessons.  They  discuss  how  each  of  the  classes  affects  the
learners  personally,  and  how  each  prepares  them  to  meet  important  needs  in
their  communities.

The  two  role  plays  we  present  here  deal  with  dental  care.  They  have  been  used
effectively  in  Latin  America  and  Africa.  But  of  course  you  can  choose  any  health
topic  you  want.

The  first  role  play:  THE  BOSSY  TEACHER  in  a conventional  classroom

Suggestions  to  the  instructor:

• Before  the  students  arrive,  put  chairs  or  benches  in
neat  rows,  with  a desk  or  podium  at  the  front.

• When  the  students  arrive,  greet  them  stiffly  and  ask
them  to  sit  down.  Make  sure  they  are  quiet  and
orderly.

• Begin  the  lecture  exactly  on  time.  Talk  rapidly  in  a
dull  voice.  Walk  back  and  forth  behind  the  desk.

If  some  students  come  late,  scold  them!  Use  big  words  the  students
cannot  understand.  Do  not  give  them  a chance  to  ask  questions.  (It  helps
if  you  prepare  in  advance  a few  long,  complicated  sentences  that  use
difficult  medical  terminology.  Look  in  a medical  dictionary,  or  copy
phrases  out  of  any  professional  textbook.)

• If  any  student  does  not  pay  attention,  or  whispers  to  a neighbor,  or  begins
to  go  to  sleep,  BANG  on  the  table,  call  the  student  by  his  last  name,  and
scold  him  angrily.  Then  continue  your  lecture.

• From  time  to  time,  scribble  something  on  the  blackboard.  Be  sure  it  is
difficult  to  see  and  understand.

• Act  as  if  you  know  it  all,  as  if  you  think  the  students  are  stupid,  lazy,
rude,  and  worthless.  Take  both  yourself  and  your  teaching  very  seriously.
Permit  no  laughter  or  interruptions.  But  be  careful  not  to  exaggerate  too
much ! Try  not  to  let  the  students  know  you  are  acting.

; Helping  Health  Workers  Learn  (2005)

The  first  role  play:  THE  BOSSY  TEACHER

the  teacher  talks  over  the  heads  of  the  bored  and  confused  students,  like  this:

THE  BUCCAL  CAVITY,  OR  MOUTH,  VS  THE  ANTERIOR  - THAT
IS  TO  SAY  PROXIMAL-  PORTION  OF  THE  ALIMENTARY  CANAL,
SITUATED  IN  THE  INFERIOR  PORTION  Of  THE  FACE  ANO
CIROOMSCRABEO  BY  THE  LIPS,  CHEERS,  PALATOGLOSSAL  ARCH,
UVULA,  ORAL  PHARYNX,  AND  TONGUE  — MR..  GOME^.  I

MUST  ASK.  VOU  hot  TD-SPEAVL  DURING  CLASS.

.HAVE  VOU  HO

\MAHHBRS  ? - the

-LJt  \ TEETH  ARP  EACH  ONE
OF  A SET  OF  HARD,
WHITE  STRUCTURES
PCCO-EOnNfc  INTO  THE
BUCCAL  CAVITY  FROM
THE  ALVEOLAR.  BONE
Of  THE  MAXILLA  ANO
MANDIBLE  AND
UTIH7ED  FOR, THE
MASTICATION  CF
FOOD...

THERE  are  TWO  SETS  OF  DENTITION-  DECIDUOUS  AND  PERMANENT

KS.  HECLNANDEX,  PLEASE  WY  ATTENTION.  DO  NOT
GLEAM  YOUR-  MAILS  IW  CLASS -these  are  composed  cf

INFERIOR  AND  SUPERIOR  INCISORS  , CANINES,  PREMOLARS,  AND
MOLARS-  MR..  VEGA.  WAViE  UP.  THIS  IS  NO  PLACe  POR.
LAXY  STUDENTS  — carves  vs  the  molecular  decay  cf

*tja*AEL  DENTINE  AND  PULP,  PRODUCING  DISCOLORATION , CHRONIC
, INFLAMMATION  CF  THE

PERIOSTEUM  AND
NECROSIS  OF  THE
MEDIAL  NERVE  LEADIN6

TD-  MR..  VEGA.THIS
\S  MOT  SIESTA  TIME-.
PLEASE  STAND  IN
THE  CDPK1EC,-  leading

TO  A PYOGENIC  ABSCESS
ON  THE  OSSEOUS  tissue
CONTIGUOUS  WITH  THE
APEX  Of  THE  ROOT  AMD
PRECIPITATING  A
SYSTEMIC,.,

The  lecture  goes  on  and  on— all  very  serious.  At  the  end  of  the  class,  the  teacher
may  simply  walk  out.  Or  he  may  ask  a few  questions  like,  "MR.  REYES,  WILL
YOU  GIVE  US  THE  DEFINITION  OF  CAR  I ES?"  And  when  he  gets  no  answer,
scold  him  by  shouting,  "SO,  YOU  WERE  SLEEPING,  TOO!  THIS  GROUP  HAS
THE  ATTENTION  SPAN  OF  5-YEAR-OLDS!"  And  so  on.

Helping  Health  Workers  Learn  (2005)

1-

The  second  role  play:  THE  GOOD  GROUP  LEADER  or  'facilitator'

This  time,  the  instructor  treats  the  students  in  a friendly,  relaxed  way— as

equals.  (This  role  can  be  played  by  the  same  instructor  or  a different  one.  Or

perhaps  a student  could  prepare  for  it  in  advance.)

Suggestions  to  the  group  leader:

• At  the  beginning  of  class,  suggest  that  people  sit  in  a circle  so  they  can  see
each  others'  faces.  Join  the  circle  yourself  as  one  of  the  group.

• Asa  group  leader,  you  'teach'  the  same  subject  as  the  instructor  in  the
first  role  play.  But  whenever  possible,  try  to  draw  information  out  of  the

students  from  their  own  experience.

• Be  careful  to  use  words  the  students  understand.  Check  now  and  then  to
be  sure  they  do  understand.

• Ask  a lot  of  questions.  Encourage  students  to  think  critically  and  figure
things  out  for  themselves.

• Emphasize  the  most  useful  ideas  and  information  (in  this  case,  what  the
students  can  do  in  their  communities  to  prevent  tooth  decay).

• Use  teaching  aids  that  are  available  locally  and  are  as  close  to  real  life  as
possible.  For  example,  you  might  invite  a young  child  to  the  class  so
students  can  see  for  themselves  the  difference  between  baby  teeth  and
permanent  teeth.

• Do  not  waste  a lot  of  time
discussing  detailed  anatomy,

Instead,  include  such  information
when  it  is  needed  for  understanding
specific  problems.

• Have  students  look  in  each  others'
mouths  for  cavities.  Then  pass
around  some  rotten  teeth  that  were
pulled  at  the  health  center.  Let
students  smash  the  teeth  open  with
a hammer  or  rock,  so  they  can  see
the  different  layers  (hard  and  soft)
and  how  decay  spreads  inside  a
tooth.  Ask  someone  to  draw  the
inside  of  a tooth  on  the  blackboard.

• Encourage  students  to  relate  what
they  have  seen  and  learned  to  real
needs  and  problems  in  their  own
communities.  Discuss  what  action
they  might  take.

Students  can  break  open  teeth  that
have  been  pulled  to  see  for  them-
selves what  the  inside  of  a tooth
looks  like  and  what  damage  a cavity
can  cause.

1-20

Helping  Health  Workers  Learn  (2005)

The  second  role  play:  THE  GOOD  GROUP  LEADER

The  teacher  or  leader  tries  to  get  a discussion  started— then  stays  in  the
background  as  much  as  possible,  like  this:

To  follow  this  discussion,
start  here  and  follow
the  arrows.

WE'VE  SEEM  THE  HARM
DONE  ©V  TOOTH  DECAY.
BUT  DO  YOU  KNOW
W HAT  CAUSES  IT  ?
WHAT  DO  YOU  THINK,
JOSE  ?

THEY  SAY  THAT
EATVN&  A LOT
OF  SWEETS  ROtS  |
THE  TEETH . BUT

I •'vie  heard

THAT  BAD  TEETH
RESULT  FROM
WOT  EATING
ENOUGH  SOOD
FOOD  ...

THEN  HOW  COME1
THE  CHILDREN
OF  THE  RICH
HAVE  WORSE
TEETH  THAN  A
LOT  OF  THE
POOREST  KIDS
IN  THE
village? I

1

GETTER  STILL,  MAYBE  WF  CAW  HELP
THE  SCHOOL  CHILDREN  CONDUCT
THEIR  OWN  STUDY.  IF  THEY  FIND
OUT  FOR  THEMSELVES  WHAT
CAUSES  THEIR  TEETH  TO  ROT.
THEY’LL  <3E  MORE  LIKELY  TO
TAKE  6ETTER  CARE  OF  THEM.

, WHAT  DO  YOU  TH I NK  ?

AND  HOW
OFTEN  THEY
CLEAN  THEIR
TEETH.

I’LL  BET  1Tb
BECAUSE  THEIR
PARENTS  ARE
ALWAYS  BUYING
THEM  CANDY
AND  SWEET
SOFT  DRINKS.

AGREE  WITH
SANDRA.

WHY  DON’T  WE  MANE  A
STUDY  Of  THE  SCHOOL
CHILDREN . WE  COULD  LOOK
AT  HOW  GOOD  OR  BAD
THEIR  TEETH  ARE  AND
THENGOTOTHEIR  homes

AND  FIND  OUT  FROM  THEIR
MOTHERS  HOW  MUCH
. CANDY  AND  SWEET  THINGS
\THEV  EAT  AND  DRINK.

At  the  end  of  class,  the  leader  asks  the  group  what  they  have  learned  and  what
they  plan  to  do  with  what  they  have  learned.  He  helps  them  realize  that  the  ideas,
raised  in  class  need  not  end  in  the  classroom,  but  can  be  carried  out  into  the  real
world— into  the  communities  where  the  health  workers  live  and  work.

Helping  Health  Workers  Learn  (2005)

1-21

Group  discussion  following  the  two  role  plays

You  may  want  to  discuss  what  the  students  think  about  the  first  role  play  as
soon  as  it  is  over.  Or  you  may  want  to  wait  until  both  role  plays  have  been
presented,  so  the  students  can  compare  them.

Good  questions  to  start  a
discussion  might  be:

• What  did  you  think  of  the
two  classes  (on  dental  care)?

• From  which  class  did  you
learn  more?

• Which  did  you  like  better?
Why?

• Who  do  you  think  was  the
better  teacher?  Why?

' FROM  WHICH  I
CLASS  DID  V
. YOU  LEARN  /
WMORE?  J

FROM  THE  FIRST/)
BECAUSE  THE

TEACHER
TOLD  US  /
MOR T-jJ

BUT  HOW  MUCH
OF  IT  DID  YOU
UNDERSTAND  ?

y>f\  WAS  LUCKY  IF
I UNDERSTOOD
y ONE  OUT  OF

Five  words,  it

~s  MADE  ME  FEEL
LIKE  A FOOL/

/ MAYBE  1 AM.

You  may  be  surprised  at  some  of  the  answers  you  get!  Here  are  a few  answers
we  have  heard  students  give:

"I  learned  more  from  the  first  class,  because  the  teacher  told  us  more.  I learned
a lot  of  new  words.  Of  course,  I didn't  understand  them  all  . .

"The  first  class  was  much  better  organized."

"I  liked  the  second  class  better,  but  the  first  one  was  better  taught."

"The  second  class  was  too  disorderly.  You  could  scarcely  tell  the  teacher  from
the  students."

"The  first  teacher  wasn't  as  nice,  but  he  had  better  control  of  the  class."

"The  first  teacher  was  by  far  the  best.  He  told  us  something.  The  second  one
didn't  tell  us  anything  we  didn't  already  know!"

"I  felt  more  comfortable  in  the  first  class— I don't  know  why.  I guess  I knew
that  as  long  as  I kept  my  mouth  shut,  I'd  be  all  right.  It  was  more  like  real
school !”

"The  second  class  was  more  fun.  I forgot  it  was  a class!"

By  asking  still  more  questions,  you  may  be  able  to  get  the  students  to  look
more  closely  at  what  they  learned— and  have  yet  to  learn— from  the  two  classes.
Follow  through  with  questions  like  these:

• In  which  class  did  you  understand  more  of  what  was  said?  Does  this  matter?

• From  which  class  can  you  remember  more?  Does  this  matter?

1-22

Helping  Health  Workers  Learn  (2005)

• Do  you  remember  something  better  when  you  are  told  the  answer,  or  when
you  have  to  figure  out  the  answer  for  yourself?

• In  which  class  did  students  seem  more
interested?  More  bored?

• In  which  class  did  you  feel  freer  to  speak
up  and  say  what  you  think?

• Which  class  had  more  to  do  with  your  own
lives  and  experience?

• From  which  class  did  you  get  more  ideas  about  ways  to  involve  people  in
their  own  health  care?

• Which  class  seemed  to  bring  the  group  closer  together?  Why?  Does  this  matter?

• Which  teacher  treated  the  students  more  as  his  equals?  Could  this  affect  the
way  the  students  will  relate  to  sick  persons  and  to  those  they  teach?

• Which  is  the  better  teacher— one  who  has  to
be  'tough'  in  order  to  keep  the  students'
attention?  Or  one  who  keeps  their  attention
by  getting  them  interested  and  involved?

• Did  you  learn  anything  useful  from  these
classes,  apart  from  dental  care7  What?

• In  what  ways  are  the  relations  between  each  teacher  and  the  students  similar
to  relations  between  different  people  in  your  village?  For  example,  between
landholders  and  sharecroppers?  Between  friends?

With  questions  like  these,  you  can  help  the  students  to  look  critically  at  their
own  situation.  As  much  as  you  can,  let  them  find  their  own  answers,  even  if  they
are  different  from  yours.  The  less  you  tell  them,  the  better.

If  the  discussion  goes  well,  most  of  the  questions  listed  above  will  be  asked  —
and  answered— by  the  students  themselves.  Each  answer,  if  approached  critically,
leads  to  the  next  question— or  to  even  better  ones!

If  the  students  do  not  think
things  over  as  carefully  as  you
would  like,  do  not  worry.  And
whatever  you  do,  do  not  push
them.  Your  answers  have  value
only  for  yourself.  Each  person
must  come  up  with  his  or  her
own.  There  will  be  many  other
opportunities  during  the  training
to  help  students  discover  how
education  relates  to  life.  In
the  last  analysis,  your  example
will  say  far  more  than  your
words— for  better  or  for  worse.

If  you  want  lasting  results:
POINT but  don’t  PUSH.

People  will  move  by  themselves  once  they
see  the  need  clearly  and  discover  a way.

Helping  Health  Workers  Learn  (2005)

1-23

Analysis  of  the  two  role  plays

After  discussing  the  differences  between  the  two  approaches  to  teaching,  it
helps  to  summarize  them  in  writing.  (Or  you  may  want  to  do  this  during,  rather
than  after,  the  discussion.)  One  of  the  students  can  write  the  group's  ideas  on  a
blackboard  or  large  sheet  of  paper.

71

\aT  CLASS

i.  Teacher  lr>  control
a.  Teacher  was  mean
4.  Class  v/erq&isciplined  "
Words  we  dont  understand
icher  knows  it  all
icher  makes  us -feel  stupid
jcher  -talks  but  doesn't
^ listen
%. Class  net  nsictted  to  life.

9,  Bari  na  ■ w a fell  asleep.
(C.  Ug  atfempt  -to  rmke  it

in9

WE  CAN*T  >
co  anything

WITH  WHAT
WE  WE£E
TAUGHT  lH

the  first  ,

v CLASS!  /

3.^0  CLASS

u -Students  self-con  trolled
^ Teacher  friend  Ilj  *equal
i3.  Class  not  well  srganised
M.  We  understood  ewefq-thina

6.  Teacher  made  us  feel  important
Listened  to  and  respected

oor  iaeas  .

7.  Class  gave.  us  ideas  row  to

irwonoe,  ch  i Idren

8.  We  liked  seeing  nsal  teeth

and  doing  -thi  rgs  ourselues
1.  We  can , . ,

' EOT  THE  SECOND
CLASS  GAVE  OS
IDEAS  OF  THINGS

to  do/

As  everyone  is  leaving  the  classroom,  perhaps  one  of  the  students  will  put  his
hand  on  your  shoulder  and  say:

"You  know,  I don't  really  think  those  two  classes  were  to  teach  us  about
teeth.  I think  they  were  to  help  us  learn  about  ourselves."

"They  were  to  do  both  at  once.  That's  the  secret  of  education,"  you  will
reply.  But  you  will  want  to  hug  him.

If  no  one  says  anything,  however,  don't  worry.  It  takes  time.  You  and  your
students  will  learn  from  each  other.

1-24

Helping  Health  Workers  Learn  (2005)

THREE  APPROACHES  TO  EDUCATION

This  chart  gives  a summary  of  3 approaches  to  teaching.  It  may  help  instructors  to  evaluate
their  own  teaching  approach.  But  we  do  not  recommend  that  this  analysis  be  given  to  health
workers.  Analyzing  stories  and  role  plays  will  work  better.  So  pass  by  this  chart  if  you  want.

CONVENTIONAL

PROGRESSIVE

LIBERATING

Function

to  CONFORM

to  REFORM

to  TRANSFORM

Aim

Resist  change.

Keep  social  order  stable.

Change  people  to
meet  society's  needs.

Change  society  to
meet  people's  needs.

Strategy

Teach  people  to  accept
and  'fit  in'  to  the  social
situation  without  changing
its  unjust  aspects.

Work  for  certain
improvements  without
changing  the  unjust
aspects  of  society.

Actively  oppose  social
injustice,  inequality,
and  corruption.  Work
for  basic  change.

Intention

toward

people

CONTROL  them-
especia I ly  poor  working
people— farm  and  city.

PACIFY  or  CALM  them—
especially  those  whose
hardships  drive  them
to  protest  or  revolt.

FREE  them
from  oppression,
exploitation,
and  corruption.

General

approach

AUTHORITARIAN

(rigid  top-down  control)

PATERNALISTIC

(kindly  top-down  control)

HUMANITARIAN  and
DEM  OCR  A TIC

(control  by  the  people)

Effect
on  people
and  the
community

OPPRESSIVE—  rigid  central
authority  allows  little
or  no  participation  by
students  and  community.

DECEPTIVE—  pretends  to
be  supportive,  but
resists  real  change.

SUPPORTIVE— helps
people  find  ways  to  gain
more  control  over  their
health  and  their  lives.

How

students
(and  people
generally)

Basically  passive.
Empty  containers
to  be  filled  with
standard  knowledge.

Basically  irresponsible.
Must  be  cared  for.  Need
to  be  watched  closely.

Basically  active.
Able  to  take  charge
and  become  self-
reliant.

Can  and  must  be  tamed.

when  spoon  fed.

and  as  equals.

What  the
students
feel  about
the  teacher

FEAR— Teacher  is  an
absolute,  all-knowing  boss
who  stands  apart  from
and  above  the  students.

GRATITUDE—  Teacher  isa
friendly,  parent-like
authority  who  knows  what
is  best  for  the  students.

TRUST— Teacher  is  a
'facilitator'  who
helps  everyone  look
for  answers  together.

Who  decides
what  should
be  learned

The  Ministry  of
Education  (or  Health)
in  the  capital.

The  Ministry,  but  with
some  local  decisions.

The  students  and
instructors  together
with  the  community.

Teaching

method

• Teacher  lectures.

• Students  ask  few
questions.

• Often  boring.

• Teacher  educates  and
entertains  students.

• Dialogue  and  group
discussions,  but  the
teacher  decides  which
are  the  'right'  answers.

• Open-ended  dialogue,
in  which  many  answers
come  from  people's
experience.

• Everyone  educates
each  other.

Main
way  of
learning

PASSIVE— students
receive  knowledge.
Memorization  of  facts.

More  or  less  active.
Memorization  still
basic.

ACTIVE— everyone
contributes.  Learning
through  doing  and

discussing.

Helping  Health  Workers  Learn  (2005)

Important
subjects  or
concepts
covered

CONVENTIONAL

• the  strengths  and
rightness  of  the  present
social  order

• national  history
(distorted  to  make  'our
side'  all  heroes)

• rules  and  regulations

• obedience

• anatomy  and  physiology

• much  that  is  not
practical  or  relevant—
it  is  taught  because

it  always  has  been

• unnecessary  learning

of  big  words  and  boring
information

PROGRESSIVE

• integrated  approach  to
development

• how  to  make  good  use
of  government  and
professional  services

• filling  out  forms

• desirable  behavior

• simple  practical  skills
(often  of  little  use-
such  as  learning  20
bandages  and  their
Latin  names).

monocular

DRESSING

LIBERATING

• critical  analysis

• social  awareness

• communication  skills

• teaching  ski! Is

• organization  skills

• innovation

• self-reliance

• use  of  local  resources

• local  customs

• confidence  building

• abilities  of  women
and  children

• human  dignity

• methods  that  help  the
weak  grow  stronger

Flow  of

school  or

school  or

students -^-group -^-school  i

knowledge

health

■ ail

health

■

mostly

leader  health

and  ideas

system

1 one

system

♦

teacher

]

one

•s.  system

teacher

/T\  way

/\

way

• - -•*-  ,E3

\

• • •

\

• • •

#•

students

students

both  ways

Area  for

The  classroom.

The  classroom  and  other

Life— the  classroom

studying

controlled  situations.

is  life  itself.

How  does  the

•

#

class  sit?

•

•

. • .

• •

• • • •

•

•

• •

• •

•

• . •

• •

• • • •

•

•

• •

Class  Often  LARGE.  Emphasis  Often  fairly  small,  to  Often  SMALL,  to

size  on  quantity,  not  encourage  participation.  encourage  communication

quality,  of  education.  and  apprenticeship  learning.

Attendance

Students  have  to
attend.  cyj

Students  often  want  to
attend  because  classes
are  entertaining  and
they  will  earn  more  if
they  graduate.
'Incentives'  are  given.

Students  want  to
attend  because  the
learning  relates  to
their  lives  and  needs,
and  because  they  are
listened  to  and  respected.

Group

interaction

Competitive  (cooperation
between  students  on  tests
is  called  cheating).

Organized  and  directed
by  teacher.  Many  games
and  techniques  used  to
bring  people  together.

Cooperative— students
help  each  other.  Those
who  are  quicker  assist
others.

Purpose  of
exams

Primarily  to  'weed  out'
slower  students;  grades

Variable,  but  generally
tests  are  used  to  pass

Primarily  to  see  If  ideas  are
clearly  expressed  and  if
teaching  methods  work
well.  No  grades.  Faster
students  help  slower  ones.

students  pass.
Others  fail.

<5jrj7

| others.

L

Evaluation

Often  superficial—
by  education  or  health
system.  Students  and
community  are  the
objects  of  study.

Often  over-elaborate—
by  education  or
health  'experts'.
Community  and
students  participate
in  limited  ways.

Simple  and  continual—

by  community,  students,
and  staff.  Students
and  teachers  evaluate
each,  others'  work  and
attitudes.

At  end  of

• diplomas

• diplomas  gg  O

• uniforms

• encouragement  to  work

training,

• irregular.

hard  and  keep  learning

students

police-like  j

£ =J

• salaries  Jr^  Ljf

• supportive  assistance

are  given  . . .

supervision

• supportive  supervision

when  asked  for

After  training,
a health
worker  is
accountable  to  . . .

his  supervisor,  the
health  authorities,
the  government

mainly  to  the  health
authorities,  less  so
to  local  authorities
and  the  community

mainly  to  the
community— especially
the  poor,  whose
interests  he  defends

1-26

Helping  Health  Workers  Learn  (2005)

APPROPRIATE  AND  INAPPROPRIATE  TEACHING:

TWO  STORIES

In  addition  to  role  plays,  you  may  want  to  use  stories  to  help  students  and
other  instructors  see  the  value  of  the  new  teaching  methods.  Telling  stories  often
takes  less  preparation  than  role  plays,  and  if  the  stories  are  imaginary  or  from
another  area,  no  one  will  be  blamed  for  the  mistakes  that  are  described.  Here  are
2 stories  comparing  different  teaching  approaches  and  their  results.

STORY  1*

A health  worker  named  Sophie  completed  her  training  and  passed  all  the  exams
at  the  end  of  the  course.  Then  she  went  back  to  her  village.  It  was  a long  journey
because  the  village  was  far  away.  When  Sophie  arrived  everybody  was  pleased  to
see  her  again.  Her  mother  was  especially  pleased  and  proud  that  her  daughter  had
done  so  well.

After  the  first  greetings,  Sophie's  mother  said,  "It's  good  that  you're  back,
because  your  baby  cousin  is  ill  with  diarrhea  and  doesn't  look  well  at  all.  Do  you
think  you  could  help?”

Sophie  went  to  see  the  baby  and  realized  that
he  was  badly  dehydrated.  She  thought  the  baby
should  go  to  a health  center,  but  the  journey
was  too  long.  So  she  thought  about  what  she
had  been  taught.  She  could  remember  the
anatomy  of  the  gastro-intestinal  tract,  and  ail
about  electrolyte  balance.  And  she  remembered
that  a mixture  of  salt  and  sugar  in  water  would
help.  But  she  could  not  remember  how  much
sugar  and  how  much  salt  to  put  in  the  water.

Sophie  was  very  worried  that  the  amounts
would  be  wrong.  She  did  not  know  whether  to
send  for  help  or  to  guess  how  much  to  use.  She
thought  that  the  baby  was  so  sick  she  would
have  to  do  something.  In  the  end,  she  made  up
the  sugar  and  salt  solution  in  the  wrong
proportions,  and  the  baby  died.

Moral  of  the  story:  Some  training  courses
spend  too  much  time  on  detailed
facts,  many  of  which  have  little
importance.  As  a result,  the  most
important  things  are  not  learned
well  The  most  important  facts  are
those  needed  for  solving  common
problems  in  the  community.

’Adapted  from  Teaching  for  Better  Learning,
by  Fred  Abbatt,  WHO,  Geneva,  1980.

Helping  Health  Workers  Learn  (2005)

1-27

STORY  2

In  a short  training  program  for  village  health  workers,  students  decided  that
one  of  the  most  serious  problems  in  their  villages  was  diarrhea  in  children.  They
learned  that  the  main  danger  with  diarrhea  is  dehydration.  They  discussed  Oral
Rehydration  Solution,  and  agreed  that  teaching  mothers  and  children  how  to
make  and  use  it  should  be  one  of  their  first  responsibilities.

"It  won't  be  easy,"  said  one  of  the  students,  herself  a mother.  "People  don't
understand  funny  words  like  oral,  rehydration,  or  solution.”  So  the  group
decided  it  would  be  better  to  speak  of  Special  Drink— eye n among  themselves,
so  they  would  not  be  tempted  to  use  fancy  words  in  their  villages.

"What  if  the  mothers  put  in  too  much  salt?"  asked  a student  whose  uncle  was
a doctor.  "Wouldn't  that  be  dangerous?"

"Yes,"  said  the  instructor.  "We  need  to  find  ways  of  teaching  that  will  help
parents  and  children  remember  the  right  amounts.  How  do  people  remember
things  best  in  your  villages?"

"We  all  remember  songs,"  said  one  of  the  health  workers.  "People  are  always
singing  and  learning  new  ones.  We  remember  every  word!"

So  the  group  decided  to  write  a song  about  diarrhea  and  Special  Drink.  They
all  worked  on  it  together.  But  they  got  into  an  argument  over  what  to  call  the
baby's  stool.  For  most  people,  a stool  was  something  to  sit  on.

Nobody  understood  words  like  feces  and  excrement.  The  word  shit
some  people  considered  dirty.  "But  it's  the  word  everyone
understands— even  children,"  argued  one  health  worker.  "Especially
children!"  said  the  mother.  Finally  they  agreed  that  shit  was  the
most  appropriate  word— at  least  in  their  area.

The  song  they  wrote  is  shown  below.  (It  can  be  sung  to  "Twinkle,  Twinkle,
Little  Star"  or  another  simple  tune.  With  children,  have  them  SHOUT  the  words
printed  in  CAPITAL  LETTERS.)

H

” The  P and  V Blues”

(Di  arrhea  and  Vomiting')

Babies  who  have  D and  v
Shrivel  up  and  fail  to  pee.

To  regain  their  health  we  oughta
Fill  them  up  with  LOTS  OF  WATER.

Making  Special  Drink’s  a cinch--
Sugar  *.  1 Teaspoon.  Salt  : 1 Pinch
Water  ; 1 Glass  --or  BIG  FAT  CUP
Toss  them  in  and  Stir  it  op  !

But  careful  / You  would  be.  at  fault
If  you  put  \r»  too  much  Salt  f
So  mix  it.  T/\STE  IT.  GIVE  3 CHEERS

it's  no  Saiti  Pi

Each  time  your  baby  dribbles  Shit
Give  one  glassful  --  bit  by  bit.

And  if  the  darling's  on  the  breast
Give  breast  milk  too-*  for  BREAST  IS  BEST/

1-28

Helping  Health  Workers  Learn  (2005)

Several  months  later,  after  the  course
was  over  and  the  students  were  back  in
their  villages,  one  of  the  health  workers,
named  Rosa,  was  met  in  the  street  by  a
mother.  The  mother  gave  her  7 eggs
wrapped  in  a leaf.

"Thank  you,"  said  Rosa  with  surprise.
"But  why  . . .?"

"You  saved  my  baby's  life!"  said  the
mother,  hugging  the  health  worker  so
hard  she  broke  3 eggs.

"But  I didn't  even  see  your  baby!"
said  Rosa.

"I  know,"  said  the  mother.  "You  see,  She  hugged  the  health  worker

my  baby  had  diarrhea,  but  the  river  was  so  hard  she  broke  3 eggs!

flooded  so  I couldn't  bring  him  to  the

health  post.  He  was  all  shriveled  up  and  couldn't  pee.  He  was  dying  and  I didn't
know  what  to  do!  Then  I remembered  a song  you  had  taught  the  children  in
school.  My  daughter's  always  singing  it.  So  I made  up  the  Special  Drink,  tasted  it,
and  gave  it  to  my  baby,  just  like  the  song  says.  And  he  got  well!"

Moral  of  the  story:  T raining  gives  better  results  if  it  keeps  language  simple,
focuses  on  what  is  most  important,  and  uses  learning  methods  people  are
used  to  and  enjoy.

What  other  ideas  about  teaching  and  working  with  people  can  your  students
draw  from  these  stories?  Have  them  list  different  teaching  methods  on  the  black-
board and  discuss  which  are  most  appropriate  and  why.  Can  the  students  tell
similar  stories  from  their  own  experience— ways  they  have  learned  things  both  in
and  outside  of  school?  (For  more  ideas  about  story  telling  as  a teaching  method,
see  Chapter  1 3.)

To  be  a good  teacher  of  health  workers,  you  don't
need  to  know  a great  deal  about  medicine,  about  latrine
building,  or  about  weighing  babies.  These  things  you
can  learn  together  with  your  students.  What  you  do  need
to  know  about  is  people,  how  they  feel,  how  they  relate
to  each  other,  and  how  they  learn.

Helping  Health  Workers  Learn  (2005)

1-29

ON  CHANGING  HABITS  AND  ATTITUDES

Many  experts  now  tell  us  that  the  principal  goal  of  health  education  should  be
to  change  people's  habits  and  attitudes.

Unfortunately,  such  a goal  points  the  finger  at  what  people  do  wrong,  rather
than  building  on  what  they  do  right.  It  is  based  on  the  paternalistic  view  that  the
'ignorance'  of  poor  people  is  the  main  cause  of  their  ill  health,  and  that  it  is
society's  job  to  correct  their  bad  habits  and  attitudes.

A people-centered  approach  to  health  education  takes  the  opposite  position.  It
recognizes  that  the  ill  health  of  the  poor  is,  in  large  part,  the  result  of  a social
order  that  favors  the  strong  at  the  expense  of  the  weak.  Its  main  goal  is  not  to
change  the  poor,  but  to  help  them  gain  the  understanding  and  skills  needed  to
change  the  conditions  that  cause  poverty  and  poor  health.

THE  AIMS  OF  HEALTH  EDUCATION

BEHAVIOR  CHANGE  or

SOCIAL  CHANGE

W£  ARE\
GOING  TON
CHANGE  1
VOU.^

In  education  that  focuses  on  behavior  and
attitude  change,  people  are  acted  upon  by
the  system  and  the  world  that  surrounds
them.

In  education  that  works  for  social  change,
people  act  upon  the  system  and  the  world
that  surrounds  them.

In  making  these  points,  we  are  not  saying  that  there  is  no  need  for  changes  in
personal  attitudes  and  behavior.  But  whose  attitudes  need  changing  the  most?
Whose  attitudes  and  habits  cause  more  human  suffering— those  of  the  poor  or
those  of  the  'well-educated'  dominating  classes?

The  unhealthy  behavior  of  both  rich  and  poor  results  partly  from  the  unfair
social  situation  in  which  we  live.  So  rather  than  trying  to  reform  people,  health
education  needs  to  focus  on  helping  people  learn  how  to  change  their  situation.

As  people  become  more  sure  of  themselves  and  their  capacity  for  effective
action,  their  attitudes  and  behavior  may  change.  But  lasting  changes  will  come
from  inside,  from  the  people  themselves.

1-30

Helping  Health  Workers  Learn  (2005)

When  considering  your  effectiveness
as  a health  educator,  ask  yourself:  "How
much  does  what  I do  help  the  poor  gain
more  control  over  their  health  and
their  lives?"

Helping  Health  Workers  Learn  (2005)

2-1

Selecting  Health  Workers,  CHAPTER  2
Instructors,  and  Advisers

WHO  MAKE  THE  BEST  HEA LTH  WORKERS?

SHOULD  HEALTH  WORKERS  BE  FROM  THE  VILLAGE
OR  COMMUNITY  WHERE  THEY  WORK?

Many  health  programs,  large  and  small,  agree  that  it  is  important  for  health
workers  to  be  selected  from  the  communities  where  they  will  work.  But  their
reasons  differ:

TWO  EXPLANATIONS  FOR  WHY  IT  IS  BETTER  THAT  HEALTH
WORKERS  BE  FROM  THE  COMMUNITIES  WHERE  THEY  WORK

The  ‘expert’  with
little  community  experience:

Persons  living  and
working  in  the  community:

PEOPLE  ARE  n

Quicker  to  trust
And  listen  to
Someone  from
their  own
common  i ty
who  speaks

IN  THEIR  TERMS
AND  KNOWS
THEIR  CUSTOMS

And  prorlems.

*

people  are
slower  to  trust

THE  NEW  SKILLS
OF  A LOCAL  PER50N.

But  while  an
outsider  brings

DEPENDENCY  , THE
LOCAL  HEALTH
WORKER  SHOWS
people  THEY  CAN
DO  MORE  FOR
. THEMSELVES.

Theory  has  it  that  community  health
work  is  easier  for  the  local  person  than
for  an  outsider,  because  people  know  and
trust  him.  And  he  knows  the  community.

Experience  shows  that  at  first  it  is
often  harder  for  the  local  person.  But  in
time,  health  workers  from  the  community
can  do  more  to  help  build  people’s  self-
confidence  and  self-reliance.

There  is  an  old  saying:  No  one  is  a prophet  in  his  own  land.  A villager  complains,
"What  does  Mary,  the  health  worker,  know?  I remember  her  as  a skinny  little
girl!"

Such  distrust  in  their  own  health  worker  reflects  people's  lack  of  confidence  in
themselves:  "How  could  one  of  us  understand  new  ideas  or  master  new  skills?"
This  lack  of  self-confidence  is  especially  great  when  it  comes  to  health  care.  Most
people  believe  that  modern  medicine  requires  mysterious  knowledge  that  only
"strangers  better  than  ourselves"  can  master.

2-2

Helping  Health  Workers  Learn  (2005)

Some  American  Indian  health  workers  in  Arizona  found  it  so  hard  to  win  the
trust  of  people  in  their  own  villages  that  they  traded  jobs  with  health  workers  in
distant  villages.  They  found  that  as  'outsiders'  they  could  command  more
immediate  authority.  People  were  quicker  to  follow  their  advice  without  question.

Similar  'swaps'  have  been  made  by  health  workers  in  several  countries.  And
some  of  the  larger  health  programs  make  it  a point  not  to  send  health  workers  to
work  in  their  own  communities.

We  feel  this  is  a mistake.  A stranger  to  a community,  no  matter  how  well  he
works,  perpetuates  dependency  on  outside  help.  Only  when  a health  worker  is
from  the  community  can  his  example  show  "what  we  people  in  this  village  can  do
for  ourselves."

WHO  SELECTS  HEALTH  WORKERS  AND  HOW?

Many  programs  feel  that  health  workers  should  not  only  be  from  the
community  where  they  work,  but  that  they  should  also  be  selected  by  the
community.  These  are  the  reasons:

• If  everyone  takes  part  in  the  selection,  chances  are  greater  that  the  health
worker  will  be  well  accepted.

• Participation  in  the  selection  process  is  a step  toward  greater  responsibility
and  control  by  people  over  factors  that  affect  their  health.

• A health  worker  chosen  by  the  community  is  more  likely  to  feel  that  his  or
her  first  responsibility  is  to  the  community.

Problems  with  selection  by  the  community

My  young  nephew  is  '
the  only  one  in  the

VILLAGE  WHO  HAS  BEEN
TO  SECONDARy  SCHOOL.

i am  sure  you  will  all
agree  that  he  should
Be  the  health  worker.

THAT  Boy  IS  A I5RUI
AN  V A CROOK  .'

Problem:  In  many
villages,  the  local  headman,
mayor,  or  a powerful
landowner  insists  that  one
of  his  children  or  family
members  be  chosen  as
health  worker.  Even  if  a
public  vote  is  taken,  the
poorer  people  may  be  afraid
to  suggest  or  vote  for
someone  else.  As  a result,
the  health  workers  selected
may  represent  the  interests
of  those  with  land  and
power  rather  than  those
with  greatest  need.  This
is  a problem  reported  from
many  countries.

Helping  Health  Workers  Learn  (2005)

2-3

Another  problem:  Sometimes  villagers  select  a person  who  is  very  young,
inexperienced,  or  irresponsible.  This  may  be  because  people  feel  that  "study  is  for
the  young."  Also,  older  persons  frequently  have  too  many  other  responsibilities.

Part  of  the  reason  for  poor  choice  of  health  workers,  however,  is  that  often  the
selection  is  made  in  a hurry,  without  enough  critical  discussion.  Somebody
suggests  a friend,  or  someone  he  likes.  Someone  else  suggests  another  friend,  and
a vote  is  taken.  More  often  than  not,  the  winner  is  the  person  for  whom  the  first
show  of  hands  is  called.

Still  another  problem:  Many  programs  find  that  health  workers  with  more  than
a primary  school  education  are  likely  to  leave  their  villages  for  better-paying  jobs
in  the  cities.

To  avoid  these  and  other  problems,  some  community-based  programs  in  the
Philippines  do  not  accept  the  following  persons  for  health  worker  training:

• close  relatives  of  village  leaders  or  officials

• young  people  and  those  likely  to  marry  soon

• those  with  more  than  a primary  school  education

• those  with  many  other  responsibilities  or  official  positions

In  a similar  way,  a health  program  in  Iran  decided  to  exclude  from  health
worker  selection,  family  members  of  any  village  authority  or  large  landholder.
After  this  decision  was  made,  villagers  chose  health  workers  who  were  more
representative  of  the  poor  and  more  concerned  with  their  needs.

Ways  to  help  communities  select  wisely

Rather  than  deciding  for  the  community  what  kinds  of  persons  it  should  or
should  not  select,  it  is  often  better  to  help  the  community  decide  wisely  for  itself.
But  this  takes  time  and  care.

For  example,  instructors  from  the  villager-run  health  program  in  Ajoya,

Mexico  ride  on  muleback  to  mountain  villages,  spending  a few  days  in  each.

Often  they  will  make  several  visits,
getting  to  know  the  people  better.

Then  an  all-village  meeting  is  held.

Women  and  children  are  encourage
to  attend  (instead  of  only  men,  as
is  customary).  The  instructors  try
to  get  an  active  discussion  going:

What  are  our  health  needs ? Do  we
need  our  own  health  worker ?

What  qualities  should  this  person
have?  As  the  people  make
suggestions,  these  are  written
on  large  sheets  of  paper  or  a
blackboard,  and  discussed  further.

2-4

Helping  Health  Workers  Learn  (2005)

The  people's  list  might  include  any  combination  of  the  following.

We  want  a health  worker  who:

• is  kind

• is  responsible

• is  honest  and  shows  good  judgement

• has  a mature  personality

• is  interested  in  health  and  community  work

• is  humble:  feels  equal  to  and  not  superior  to  others

• will  probably  stay  in  the  village  (not  move  away)

• is  accepted  and  respected  by  all  the  people,  or  at  least  by  the  poor

• has  the  full  agreement  and  cooperation  of  his  or  her  family

• can  read  and  write  (preferably)

• does  not  have  more  than  a primary  school  education

• is  eager  to  learn;  open  to  new  ideas

• is  a good  leader  and  organizer

• has  healthy  habits  (does  not  smoke,  does  not  drink  too  much)

• can  draw,  or  is  a good  storyteller

• works  well  with  mothers,  children,  and  working  people

• has  a good  record  of  taking  part  in  or  leading  community  activities

• has  some  experience  in  health  care  or  healing  (preferably)

• understands  and  respects  people's  beliefs  and  traditional  practices

• identifies  with  and  defends  the  interests  of  those  in  greatest  need

THIS  LIST  CONTAINS
SUGGESTIONS  FROM
SEVERAL  PROGRAMS

The  team  in  Ajoya  feels  it  is  important  for  the  villagers  to  develop  the  list  of
qualities  themselves,  rather  than  to  have  a list  handed  to  them.  If,  however,  the
people  forget  certain  important  qualities,  the  instructors  may  ask  questions  that
help  the  people  consider  those  points.

Only  after  the  list  of  qualities  has  been  developed  and  thoroughly  discussed,
are  the  people  asked  to  suggest  names  of  persons  who  might  make  good  health
workers  If  certain  persons  are  known  to  dominate  discussions  or  decisions,  they
are  asked,  politely,  to  remain  silent  so  that  those  who  seldom  speak  can  make
their  suggestions  first,  When  necessary,  the  vote  is  taken  by  secret  ballot.

In  this  way,  selection  of  a health  worker  is
the  beginning  of  a process  in  which  the  poor
find  a voice  and  fairer  representation.  But  all
this  takes  time,  in  the  Makapawa  program  in
the  Philippines,  a team  works  in  the  village
for  at  least  3 months,  helping  the  poor
organize  and  consider  their  needs  before  a
health  worker  is  selected.

A village  health  committee  is  often  chosen
at  the  same  time.  (See  page  10-3).

^PLEASE  LET  OTHERS  DO1
THE  TALKING

Other  programs  take  different  approaches  to  the  selection  of  health  workers.
Some  have  requirements  for  age,  sex,  schooling,  physical  health,  etc.  Some  give
simple  tests  to  check  for  such  things  as  skill  with  one's  hands.  Generally,  the
more  distant  the  headquarters,  the  more  requirements  are  set  in  advance.

Helping  Health  Workers  Learn  (2005)

Joint  selection  by  the  community  and  program  leaders

Some  programs  feel  the  best  selection  of  health  workers  results  from  combining
the  community's  knowledge  of  its  people  with  the  program  leaders’  experience.

The  village  is  asked  to  pick  3 or  4 'candidates'  From  these,  the  instructors  choose
the  one  they  think  most  suited— perhaps  after  testing  their  skills  and  attitudes.

HANDICAPPED  PERSONS  AS  HEALTH  WORKERS

Some  programs  require  that
health  workers  be  in  “excellent
physical  health."  Clearly,  health
workers  should  be  free  of
contagious  diseases  such  as
untreated  tuberculosis,  and  healthy
enough  to  handle  their
responsibilities.

We  have  found,  however,  that
some  of  the  best  health  workers  are
persons  with  serious  physical
handicaps;  polio,  for  instance,  or  an
amputated  arm  or  leg.  Unable  to  do
hard  physical  labor,  they  may  find
more  time  for  health  work  and
greater  satisfaction  in  doing  it.
Because  of  their  own  problems,
they  also  have  more  understanding
for  others  who  are  ill  or
handicapped.  In  some  ways,  their
weakness  becomes  their  strength.

As  health  workers  serving  their
community,  they  set  an  example
for  others  who  are  handicapped.

Handicapped  persons  often  make  excellent
health  workers.  Here  a young  man,  himself
crippled  by  juvenile  arthritis,  repairs  braces  for
a child  with  polio.  (Mexico— Project  Piaxtla)

WHO  MAKE  BETTER  HEALTH
WORKERS-MEN  OR  WOMEN?

Some  programs  train  only  men  as  health
workers.  Others  only  women.  Others  train  both.

Reasons  often  given  for  selecting  women  as

health  workers:

• Women  and  children  make  up  % of  the
population.  Their  health  needs  are
especially  great.  And  women  usually  prefer
health  workers  who  are  women.

• Women  have  more  experience  in  caring  for
children,  and  may  be  more  tender.

Helping  Health  Workers  Learn  (2005)

Women  usually  stay  closer  to
the  village,  and  so  are  more
available  when  needed.

Women  often  are  more
exploited  and  abused  than
men.  Therefore  their
sympathies  are  more  likely  to
lie  with  those  who  have  less
power  and  greater  need.  A
health  program  in  India  states
"Women  and  children  are  the
more  vulnerable  groups  in  the
rural  area,  therefore  a woman
is  best  able  to  motivate  and  bring  about  change."*

"With  women  there  is  less  fear  of  misuse  or  malpractice,"  states  the  same
program  from  India,  In  many  areas,  women  tend  to  be  more  responsible,  and
they  drink  less.  They  may  also  be  more  willing  to  work  for  the  people,  not
the  money.

Women  health  workers  in  Bangladesh  ride
bicycles,  which  only  the  men  used  to  do.

This  is  helping  women  gain  more  equal  rights

Reasons  often  given  for  selecting  men  as  health  workers:  f A

• Men  often  can  move  about  more  safely  and  freely  than
women.  They  can  go  alone  or  at  night  to  a distant  house  or

village  to  attend  an  emergency.  f y'  \

• Much  of  the  work  to  improve  health  involves  farming,  water  (r-|  . j^

systems,  latrine  building,  and  other  activities  for  which  the

help  of  men  is  needed.  Men  can  perhaps  be  better  led  by  a male  leader

• Where  part  of  the  health  worker's  job  is  to  work  toward  social  change,  men
are  more  likely  to  take  action  and  to  organize  the  people  than, are  women.
(This  is  not  necessarily  true.  It  is  interesting  to  note,  however,  that  in  some
countries  where  human  rights  are  often  violated,  government-run

health  programs  train  mostly  women  health  workers.  In  those

same  countries,  community-based  programs  working  for  land  \ J

rights  and  social  change  often  train  mostly  men  health  workers.)  I !

Some  programs  happen  to  train  mostly  men,  others  mostly  women.  Usually  this
is  not  because  they  feel  one  sex  makes  better  health  workers.  In  some  places  there
are  difficulties  in  recruiting  either  men  or  women.  Men  (especially  young  men)  may
be  too  'proud'  to  consider  training  for  'nursing'  work— especially  if  on  a volunteer
basis.  In  some  areas,  unmarried  women  may  not  be  permitted  to  leave  home  to
attend  a training  program.  And  married  women  may  be  unable  to  leave  their
children  and  their  work,  or  their  husbands  may  not  let  them.

Experience  shows  that  both  women  and  men  can  make  good  health  workers.

Often  men  are  able  to  relate  better  to  the  health  needs  of  men,  and  women  to  the
needs  of  women  and  children.  Some  health  programs  resolve  this  difference  by
training  both  a man  and  a woman  (sometimes  a married  couple)  from  each  village.

From  Moving  Closer  to  the  Rural  Poor,  by  the  Mobile  Orientation  and  Training  Team,  Indian  Social
Institute,  New  Delhi.

Helping  Health  Workers  Learn  (2005)

2-7

YOUNGER  OR  OLDER  HEALTH  WORKERS-
WHICH  WORK  OUT  BEST?

Although  most  health  programs  train
health  workers  who  are  quite  young,  many
find  that  somewhat  older  or  middle-aged
persons  often  work  out  better.  Young
people  sometimes  have  more  open  minds
(and  may  be  easier  to  recruit),  but  they
have  more  difficulty  in  winning  people's
confidence  and  cooperation.  Also,  younger
persons  may  be  less  likely  to  stay  in  the
village.  Some  programs  find  that  unmarried
girls  are  likely  to  get  married  and  move  away.  Other  programs  find  that  young
men  often  move  to  the  cities  or  to  migrant  farm-working  camps.

Older  persons  are  usually  more  likely  to  remain  in  their  communities,  and  to
work  with  great  dedication  and  responsibility.  Also,  people  are  more  likely  to
respect  and  listen  to  them.  But  they  may  be  more  fixed,  or  even  rigid,  in  their
ideas.  This  can  be  both  a strength  and  a problem.

In  the  experience  of  many  programs,  the  most  reliable  age  group  is  from  about
25  to  40.  When  health  workers  are  younger  or  older  than  that,  more  difficulties
seem  to  arise.  There  are,  of  course,  many  exceptions.  In  Ajoya,  Mexico,  the
present  leaders  of  the  program  began  as  'junior  health  workers'  when  they  were
13  to  16  years  old.

EDUCATIONAL  LEVEL

Capable  health  workers  have  been  trained  from  every  educational  level,  from
persons  who  cannot  read  to  those  with  university  or  medical  degrees.  Each  level
presents  special  strengths  and  special  problems.

Persons  who  cannot  read  and  write  often  have  unusually  well -developed
memories— sometimes  far  better  than  those  of  us  who  depend  on  writing  things
down.  But  to  train  health  workers  who  cannot  read  and  write  calls  for  somewhat
different  educational  methods.  Few  instructors  have  been  taught  these  methods,
but  they  can  learn  them  with  the  help  of  the  students.

In  most  programs,  the  average  education  level  of  community  health  workers  is
from  3 to  6 years  of  primary  school.  Yet  some  programs  make  6 years  of  primary
school  a minimum  requirement.  Others  require  completion  of  secondary  school.

Education  requirements  sometimes  give  rise  to  problems.  For  example,  in
Guatemala,  a government  training  program  for  'health  technicians'  in  the  highland
Indian  communities  started  with  two  requirements:  1 ) Applicants  must  speak  a
native  Indian  language  as  well  as  Spanish.  2)  They  must  have  completed  secondary
school.  However,  it  turned  out  that  very  few  native  language  speakers  had  finished
secondary  school.  One  of  the  two  requirements  had  to  be  dropped.

2-8

Helping  Health  Workers  Learn  (2005)

Unfortunately,  the  language  requirement  was  dropped  and  the  education
requirement  kept.  This  meant  that  almost  all  the  health  technicians  trained  were
of  Spanish  (Ladinoj  origin.  They  neither  spoke  the  local  languages  nor  represented
the  people  where  they  were  to  work.  As  a result,  the  program  has  had  many
difficulties.

As  we  have  already  mentioned,  persons  who  have  completed  secondary  school
often  do  not  make  as  good  health  workers  as  those  with  less  schooling.  Their
education  seems  to  separate  them  from  the  majority  of  their  people.  Many  are
more  interested  in  getting  'higher  education'  or  'better  jobs'  in  the  city.  They  are
more  likely  to  abandon  their  people.

Also,  as  we  discussed  in  Chapter  1,  persons  with  much  formal  education  may
have  an  extra  burden  of  unhealthy  values.  They  need  to  unlearn  and  relearn  a
great  deal  in  order  to  become  effective  community  health  workers.

By  contrast,  persons  with  less  formal  education  tend  to  feel  themselves  more
in  harmony  with,  and  equal  to,  the  poor  majority.  They  may  be  more  ready  to
commit  themselves  to  community  health  work.

Persons  with  only  a few  years  of  schooling  often  make
more  reliable,  more  community-strengthening  health
workers  than  those  who  have  had  more  formal  education.

Once  again,  of  course,  there  are  exceptions.

TRADITIONAL  HEALERS  AND
MIDWIVES  AS  HEALTH  WORKERS

Many  programs  have  trained  traditional  healers,
herbalists,  bone  setters,  and  traditional  midwives  as
village  health  workers— often  with  good  results.

Advantages  to  training  traditional  healers  as  health
workers:

• They  already  have  the  confidence  of  the  people  in
their  own  special  area  of  health  care.

• They  have  a strong  grounding  in  traditional  and  spiritual  forms  of  care  and
healing.  To  these  they  can  add  concepts  of  modern  health  care  and  medicine.
Often  the  combination  of  the  old  and  the  new,  unique  to  the  area,  is  better
than  either  way  by  itself.

• They  are  usually  persons  with  great  experience  and  strong  beliefs.  So  they
may  be  more  able  to  defend  their  people's  culture  and  resist  the  use  of
foreign  ideas  and  technologies  not  suited  to  local  needs.

• They  are  often  persons  firmly  rooted  in  their  communities  and  deeply
committed  to  serving  people  in  need.  (But  be  careful.  Some  traditional
healers  use  their  special  knowledge  to  exploit  or  gain  power  over  others.)

Helping  Health  Workers  Learn  (2005)

2-9

Difficulties  in  training  traditional  healers  as  health  workers:

Traditional  healers
often  are  very  set  in
their  ways.  Like
modern  medicine,
traditional  medicine
includes  many
practices  that  are
helpful,  others  that  are
useless,  and  some  that
are  harmful.  Traditional
healers,  like  many
modern  doctors,  may
be  reluctant  to  examine
critically  the  practices
they  have  always
followed.  They  may  be
unwilling  to  omit  or
change  harmful  but
profitable  practices.
(These  may  include  the
misuse  or  overuse  of
certain  modern
medicines,  sometimes
combined  with  herbal
medicines.)

This  'herb  doctor'  was  chosen  by  his  village  to  train  as  a
health  worker.  His  art  of  healing  adds  much  to  the  science
of  health  care.  Today,  he  combines  aspects  of  modern  and
folk  medicine.  (Mexico)

A common  difficulty  with  traditional  healers  relates  to  their  approach  to
problem  solving.  Most  traditional  healers  rely,  to  a large  extent,  on  the
psychological  'power  of  suggestion'.  This  is  a very  important  part  of  the  healing
process  as  they  know  it.  The  traditional  healer  convinces  the  sick  person  and  his
family  that  he  or  she  knows  immediately  just  what  the  illness  is,  what  caused  it,
and  how  to  treat  it.  This  immediate  and  absolute  certainty  is  a key  to  traditional
healing.

But  the  science  of  modern  medicine  calls  for  just  the  opposite  approach.  The

scientific  healer  begins  with  doubt,  not  certainty.  He  starts  by  asking  questions,
collecting  related  information,  and  systematically  considering  and  testing
possibilities  (seeCh.  17).

It  is  often  difficult  for  persons  used  to  traditional  healing  to  learn  the  more
scientific  approach.  As  established  healers,  they  may  find  it  especially  difficult  to
ask  for  advice  or  suggestions,  or  to  admit  when  they  have  trouble  diagnosing  an
illness.

An  instructor  who  is  unaware  of  all  this,  may  treat  these  persons  as  if  they  were
ignorant  or  dishonest.  This  makes  it  more  difficult  for  both  to  admit  their  doubts
or  mistakes.  In  our  own  experience,  however,  we  have  found  that  when  an
instructor  understands  and  appreciates  the  local  forms  of  healing,  most
misunderstandings  with  traditional  healers  can  be  avoided.  When  this  is  so  . . .

Traditional  healers  can  become  some  of  the  most
capable  and  dedicated  primary  care  workers.

2-10

Helping  Health  Workers  Learn  (2005)

PERSONAL  QUALITIES,  ATTITUDES,

AND  CONCERNS

Of  far  more  importance  than  age,  sex,  experience,  education,  and  even  place  of
origin,  are  a health  worker's  personal  qualities— his  or  her  understanding  of  people
and  their  needs.  It  is  essential  that  the  health  worker  identify  with  the  poor  and
have  a strong  sense  of  fairness  and  social  justice.  To  some  extent,  these  attitudes
can  grow  and  develop  during  training.  But  the  seeds  need  to  be  there  already.
People's  attitudes  are  far  more  easily  strengthened  than  changed.

Perhaps  the  most  important  quality  to  look  for
when  selecting  a community  health  worker  is
the  person's  concern  for  social  justice.

Does  he  treat  other  people  as  his  equals?

Is  his  first  concern  for  those  in  greatest  need?

I WAS  HERB  FI
DON'T  /DU  REAL
\WHO  T AM  t

/l'M  SORRy  MA'AM.  MY  RES  PON  S l Bl  LIT7
IS  TO  SERVE  FIRST  THOSE  WHOSE  ^
.NEED  IS  GREATEST.

This  is  a scene  from  a ‘Farmworkers’  Theater1  production  in  Ajoya,  Mexico.  It  was
presented  to  help  villagers  recognize  the  differences  between  a good  health  worker  and
the  typical  doctor.

Helping  Health  Workers  Learn  (2005)

2-1  1

WHO  MAKE  THE  BEST  TEACHERS
OF  VILLAGE  HEALTH  WORKERS?

Selection  of  appropriate  instructors  is  just  as  important  as  selection  of  the
health  workers  themselves.  Instructors  provide  the  example  or  'role  model'  for
teaching  and  learning  that  health  workers  follow  when  they  return  to  their
communities.

If  the  instructor  bosses  and  'talks  down'  to  students,  the  students,  in  turn,  will
be  more  likely  to  'talk  down'  and  act  superior  to  others  when  they  become  village
health  workers.  But  if  the  instructor  relates  to  the  students  as  his  equals,  building
on  strengths  and  knowledge  that  they  already  have,  then  the  health  workers  will
be  more  likely  to  work  with  their  people  in  a similar  way.

THE  EDUCATION  GAP

A common  problem:  Instructors  often  have  a very
different  social  and  educational  background  from
that  of  the  health  workers  they  teach.  They  may  be
doctors,  nurses,  social  workers,  or  health  officers  who
have  grown  up  in  cities  and  have  had  far  more  formal
education.  They  can  easily  lose  touch— if  they  ever
were  in  touch— with  the  wisdom,  hardships,  strengths,
and  weaknesses  of  people  who  still  live  close  to  the
land,  the  seasons,  and  physical  work.

The  knowledge  of  highly  educated  persons  is  not
necessarily  better  than  that  of  most  of  us,  but  it  is
different.  It  is  as  difficult  for  the  doctor  to  speak  in  the  basic,  clear,  colorful
language  of  the  villager,  as  it  is  for  the  villager  to  understand  the  long  Latin  words
of  the  doctor.

This  wide  separation  between  instructor  and  students  is  called  an  'education
gap'.  When  the  'gap'  is  too  wide,  it  is  often  difficult  to  bridge.  So  teacher  and
students  never  really  come  to  know,  appreciate,  or  learn  very  much  from  each
other.

2 12

Helping  Health  Workers  Learn  (2005)

Many  kinds  of  professionals  have  served  as  trainers  of  health  workers:

• doctors

• senior  medical  students

• nurses

• paramedics

• intermediate-level  health  workers

• public  health  graduates  (often

foreigners)

• social  workers

• school  teachers

• teaching  teams  made  up  of

doctors,  nurses,  anthropologists,
social  workers,  agricultural
extension  officers,  and
foreign  experts

Little  study  has  been  done  to  compare  the  strengths  and  weaknesses  of  these
different  professionals  as  health  worker  trainers.  But  here  are  some  common

Doctors.  As  a general  rule,  doctors  make  poor  instructors  of
health  workers.  Their  curative,  hospital-based  training  does
not  prepare  them  to  look  at  the  needs  of  a whole  community.
Attitudes  are  also  a problem.  Doctors  have  a tendency  to
take  charge,  to  regard  themselves  as  decision-makers  even  in
areas  they  know  little  about.  Feeling  that  even  simple
diagnosis  and  treatment  are  'risky'  without  years  of  medical
school,  they  often  limit  teaching  of  curative  medicine  to  a
few  minor  chores.  This  severely  weakens  the  role  of  health
workers  in  the  community.  Yet  the  courses  doctors  teach  usually  include  a deadly
overdose  of  anatomy,  with  countless  Latin  names.  This  gives  the  health  worker  a
magic  vocabulary  with  which  to  confuse  and  impress  the  people  in  his  community.

Nurses.  Some  nurses  make  excellent  instructors  of  health
workers.  But  such  nurses  are  exceptional.  The  nurses'  job  has
traditionally  been  to  take  orders  without  question,  and  to
clean  up  after  the  doctors.  They  are  given  little  decision-
making responsibility.  So  it  is  not  surprising  that,  when
nurses  instruct  village  health  workers,  they  place  strong
emphasis  on  unquestioning  obedience,  filling  out  forms,  and
functioning  as  errand  boys  or  girls.  As  they  have  been
dominated  and  undervalued,  they  tend  to  do  the  same  with
health  workers.  For  a nurse  to  effectively  prepare  health  workers  as  leaders  of
social  change,  she  must  be  a true  rebel.  Fortunately,  many  such  nurses  exist!
Unfortunately,  they  are  rarely  chosen  as  instructors.

School  teachers.  In  Honduras,  some  young  school  teachers
have  proved  to  be  surprisingly  good  instructors  of  village
health  workers.  These  teachers  are  given  2 or  3 months  of
special  training  in  community  development  and  primary  care
activities.  Then  they  are  sent  to  teach  and  work  with  village
health  workers.  The  young  teachers  are  far  more  willing  to  go
to  remote  villages  than  are  nurses  or  doctors.  They  also  are
able  to  relate  well  to  the  health  workers  and  local  people.
Having  a limited  background  in  health,  they  do  not  set
themselves  up  as  'authorities'.  Rather,  they  explore  and  learn  with  others  about
approaches  to  solving  different  health  problems.  This  puts  them  on  a more  equal
footing  with  students  and  villagers.  It  seems  that,  in  some  circumstances  at  least,
teaching  skills  may  be  more  important  than  an  extensive  background  in  medicine
and  health  care.

impressions:

Helping  Health  Workers  Learn  (2005)

2-13

Bridging  the  education  gap

If,  as  an  instructor,  you  find  you  are  separated
from  your  students  by  a wide  social  and  educational
gap,  there  are  things  you  may  be  able  to  do  to  help
bridge  it:

1 . Admit  openly  to  your  students  that  the  gap

exists— and  that  the  shortcoming  is  yours  as
much  as  theirs.  Invite  your  students  to  discuss
and  look  for  ways  of  bridging  the  gap  together.

2.  Do  whatever  you  can  to  understand  in  a personal  way  the  life,  language,
customs,  and  needs  of  your  students  and  their  communities.  Live,  if  you  can,
with  one  of  the  poorer  families  in  the  community  (paying  your  way).  Eat
their  food.  Drink  their  water.  Help  each  day  with  some  of  the  physical  or
farm  work.  Accept  no  more  income  than  an  average  member  of  the
community  earns.  (This  is  only  a suggestion— but  a good  one.)

3.  If  you  are  from  out  of  the  area,  or  are  specialized  in  a narrow  field  of  health
care  (like  medicine),  try  not  to  be  the  main  teacher,  but  rather  a teaching
assistant  or  auxiliary.  (The  main  teacher  will  need  a wide  range  of  skills  and
knowledge,  including,  above  all,  teaching  skills  and  inside  knowledge  of  the
local  people.  He  or  she  needs  personal  understanding  of  what  it  is  like  to
approach  learning  new  things  without  much  formal  education.)

4.  When  teaching,  make  every  effort  to  always  begin  with  the  knowledge  and
skills  the  health  workers  already  have,  and  help  them  build  on  these.  You  are

the  stranger,  so  try  to  adapt  your  language  to  theirs;  don't  make  them  adapt
to  yours.  If  they  are  used  to  learning  from  stories  or  from  actually  doing
things,  rather  than  from  lectures  and  books,  try  to  adapt  to  their  way  of
learning— even  if  this  means  exploring  forms  of  teaching  and  learning  that  are
new  to  you.

5.  Most  important!  Make  yourself  as  unnecessary  as  possible,  as  soon  as
possible.  Look  for  local  persons  who  are  socially  more  qualified  (less
schooled,  more  in  harmony  with  the  people)  to  take  over  the  training.  Work
toward  having  more  experienced  village  health  workers  become  the  teachers
of  new  village  health  workers  as  soon  as  possible.  Every  chance  you  get,  move
one  step  further  into  the  background.  Become  the  teacher  of  teachers.  Then,
just  an  adviser  or  'person  with  ideas'.  Then  leave.

2-14

Helping  Health  Workers  Learn  (2005)

BRIDGING  THE
EDUCATION  GAP

If  the  student  is
at  this  level

Primary

Education

Secondary
Education
(or  more)

■ and  you  try  to  teach  him
from  this  level,

you  will  be  talking  over  his
head.  You  will  bore  him
and,  in  time,  lose  him.  You
will  make  him  feel  stupid
and  he  may  hate  you  for
it— because  he  is  not
stupid.  There  are  probably
many  things  he  can  do
much  better  than  you  can,
and  many  important  things
he  knows  that  you  do  not.

If  you  try  to  learn  from
him,  and  to  make  good
use  of  the  language,
knowledge,  and  skills
he  already  has,  often
you  can  help  him
bridge  the  gap
to  learning
new  skills.

4 A /
f'A  M

There  are  many  shortcuts
to  increasing  the  student's
skill  and  understanding:
teaching  aids,  problem
solving,  role  playing,
learning  by  doing,  etc.  But
it  is  important  to  begin
with  the  skills  and
understanding  the  person
already  has.

Go  more  than  halfway  to
meet  him.

Start  with  the  knowledge  and  skills  a person
already  has— and  help  him  build  on  these.

CLOSING  THE  GAP

If  the  educational  gap  is
wide,  better  than  trying  to
bridge  it  is  to  close  it.

Work  toward  training
community  persons  n

who  are  closer  to  the  CyC,
educational  level  f i

of  the  students,
so  they  can  take  \ T)

over  most  or  ; / L

all  of  the  |

teaching.

The  sooner  a local  health
worker  can  be  trained  to
take  over  the  teaching  of
new  health  workers,  the
better.  Then  training  is
more  likely  to  be
appropriate  and  helpful.

If  you  are  an  outsider,  work  toward  making  yourself  as  unnecessary  as
possible,  as  soon  as  possible.

Helping  Health  Workers  Learn  (2005)

2-15

Closing  the  education  gap:
community  persons  as  instructors

When  there  is  a wide  'education  gap'  between
instructor  and  students,  try,  instead  of  bridging  it,  to
close  it  or  avoid  it.  This  means  trying  to  find  or
prepare  instructors  who:

• are  from  the  same  immediate  area  as  the  health
workers-in-training

• speak  the  local  language

• have  the  same  cultural  and  social  background
(a  farmer,  worker,  father,  mother,  etc.)

• have  had  more  or  less  the  same  amount  of
formal  education  as  those  they  teach  (although  they  may  have  had  far  more
experience  or  training  in  health  care  at  the  community  level)

• dress,  act,  speak,  and  feel  as  equals  to  the  students  and  villagers

It  is  important  that  instructors  be  culturally  close  to  the  students.  But  they  also
need  enough  basic  knowledge  and  skills  (in  health  care,  in  problem  solving,  and  in
teaching)  to  help  students  learn  effectively.  At  first  it  may  be  difficult  to  find
local  persons  with  this  combination  of  culture  and  skills.  During  the  first  few
years,  'outside'  instructors  may  be  needed.  But  their  first  responsibility  should  be
to  prepare  local  people  to  take  over  most  or  all  of  the  instruction.  The  more
outstanding  and  experienced  health  workers  are  often  the  best  ones  for  the  job.

CAN  LOCAL  PERSONS  BECOME  EFFECTIVE
INSTRUCTORS  OF  HEALTH  WORKERS?

Health  professionals  may  be  skeptical  (doubtful)  about  whether  villagers  can
make  effective  instructors.  But  community-based  programs  in  many  countries
have  found  that:

Experienced  village  health  workers—
with  appropriate  preparation,  back-up,
and  friendly  criticism  from  the  learning
group— can  make  excellent  instructors.

Just  as  with  doctors  and  nurses,  villagers  who  make  good  instructors  are
exceptional.  The  challenge  is  to  find  persons  with  the  right  combination  of
attitudes,  interests,  and  talents,  and  then  to  create  the  situation  that  permits  and
helps  them  to  grow.

2-16

Helping  Health  Workers  Learn  (2005)

STRENGTHS  AND  WEAKNESSES  OF  VILLAGE-LEVEL  INSTRUCTORS

A story:

When  a training  program  is  taught  and  run  by  village-level  instructors,  certain
problems  and  obstacles  are  avoided.  But  others  commonly  arise.  Once,  when  we
were  observing  a training  course  taught  by  villagers,  a visiting  nurse  was  present.
Herself  a trainer  of  health  auxiliaries  in  a neighboring  program,  she  was  highly
critical  of  the  way  the  village-level  instructors  conducted  the  course:

TOO  INFORMAL.

CLASSES  DO  NOT  BEGIN  ON  TIME.
INSTRUCTORS  SLOPPILY  DRESSED.
THEY  USE  VULGAR  EXPRESSIONS.
MISSPELLED  WORDS.

INCOMPLETE  COVERAGE  OF  MATERIAL.

FREQUENT  STRAYING  FROM  THE
TOPIC  BEING  TAUGHT.

TOO  MUCH  NOISE  AND  LAUGHTER.
INACCURATE  INFORMATION.

After  listening  to  her  many  complaints,  the  village  instructors
invited  the  nurse  to  give  a class  to  show  them  how  to  do  it  better.
They  suggested  a class  on  "The  Human  Body  and  How  It  Works."

So  the  visiting  nurse  presented  a class  on  "Anatomy  and  Physiology."  It  was
carefully  timed:  40  minutes  of  lecture  with  10  minutes  for  questions  at  the  end.
She  briefly  and  expertly  covered  each  of  the  body  systems,  naming  the  major
organs  and  stating  their  functions.  When  she  finished,  she  asked  one  of  the  health
workers  if  he  had  understood.  He  slowly  shook  his  head.  "I  didn't  understand
beans!"  She  called  on  student  after  student  to  see  what  they  had  learned.  But
with  the  exception  of  two  who  had  studied  in  secondary  school,  her  lecture  had
gone  completely  over  their  heads.  One  of  the  village  instructors  had  made  a list  of
over  60  words  she  had  used,  which  no  one  understood.  He  asked  her  to  explain
some  of  the  words.  But  each  time  she  tried,  she  used  2 or  3 more  words  that
nobody  understood.

The  students  then  asked  if  the  nurse  would  be  willing  to  give  the  class  over
again,  but  more  simply.  The  nurse  admitted  she  didn't  think  she  could.  She  asked
one  of  the  village  instructors  to  do  it  for  her.

The  next  day,  one  of  the  local  instructors  led  a discussion  about  "The  Body
and  How  it  Works"  (not  "Anatomy  and  Physiology").  Rather  than  lecturing,  he
started  by  holding  up  a box.  He  challenged  the  students  to  ask  as  many  questions
as  they  could  in  order  to  find  out  whether  the  box  contained  something  living  or
not.  They  asked  questions  like:

DOES  IT  GROW?  OOES  IT  MOVE  BY  ITSELF ? DOES  IT  PEE  AND  SHIT ?

DOES  IT  BREATHE  ? DOES  IT  NEED  WATER  AND  FOOD ? CAN  IT  MAKE  BABIES  OR  SEEDS?

The  instructor  wrote  the  questions  on  the
blackboard  and  then  opened  the  box.  Out  jumped
a frog!

Next,  the  instructor  asked  how  we,  as  people,  also  do  each  of  the  things  listed
on  the  blackboard.  He  started  with  what  the  class  knew  about  the  body,  and
built  on  that,  asking  questions  like:

WHAT  BECOMES  OF  THE  FOOD  WE  EAT?

WHAT  HAPPENS  TO  US  WHEN  WE  DON'T  GET  ENOUGH  FOOD ?

Helping  Health  Workers  Learn  (2005)

2-17

At  one  point,  he  asked  two  of  the  students  to  run  fast  around  the  building,  and
had  the  group  observe  them  and  take  their  pulse.  Then  he  asked.

WHY  DO  WE  SWEAT,  BREATHE  HAR DJ  AND  HAVE  A FAST  PULSE

WHEN  WE  RUN  OR  DO  HARD  WORK ?

WHAT  IS  THE  PURPOSE  OF  THE  HEART  AND  LUNGS?

After  the  group  had  given  their  ideas  (which  were
mostly  correct),  he  asked:

WHY  DO  PEOPLE  WHO  ARE  VERY  PALE  GET  TIRED  MORE  QUICKLY?

WHAT  IS  THE  PURPOSE  OF  BLOOD 1

He  spoke  in  the  people's  language,  using  the  village  names  for  different  parts  of
the  body:  'guts'  for  intestines  and  'belly'  for  abdomen.

In  this  way,  the  students  themselves  were  able  to  piece  together  many  of  the
different  systems  of  the  body  and  their  functions.  It  was  like  solving  a mystery  or
putting  together  a puzzle.  The  students  loved  it.  And  everyone  understood.  The
class  was  noisy  and  went  overtime,  but  no  one  objected— this  time  not  even  the
nurse!

Of  course,  some  of  the  body  systems  were  forgotten,  and  others  were  barely
mentioned.

"There  is  a lot  more  to  the  body  than  we  have  talked  about  today,"  explained
the  group  leader  at  the  close  of  the  class.  "But  we  will  talk  about  other  parts
of  the  body  and  how  they  work  when  we  need  to,  to  understand  about  particular
health  problems  as  they  come  up."  (See  p.  5-1  1 . )

By  the  time  the  visiting  nurse  left,  she  had  changed  her  mind— and  said  so.  She
had  seen  that,  in  spite  of  certain  inaccuracies  and  shortcomings  of  the  teaching,
the  students  had  learned  more  and  taken  a more  active  part  in  the  classes  taught
by  their  fellow  villagers!

Not  all  the  credit  is  due,  of  course,  to  the  fact  that  the  instructors  were
villagers  themselves.  Much  of  the  difference  was  in  the  teaching  methods  they

used.  But  the  technique  of  building  on  the  students'  own  knowledge  and
experience  is  often  easier  for  a local  person  who  shares  a common  background.

In  Project  Piaxtla  in  Mexico,  we  (the  authors)  and  other  outsiders  used  to  do
most  of  the  teaching  for  the  health  worker  training  courses.  Then,  several  years
ago,  the  local  health  team  (made  up  entirely  of  experienced  village  health
workers)  took  charge  of  the  training.  The  first  year  that  the  course  was  taught  by
the  village  team  only,  3 students  were  present  who  had  taken  previous  courses
taught  by  outsiders.  When  asked  which  course  they  thought  better  and  more
appropriate,  all  3 agreed,  "This  one,  taught  by  the  village  health  workers."  Their
reasons:

UNDERSTAND.

THE  INSTRUCTORS  SEEM  TO  KNOW  JUST  HOW  SLOW
OR  FAST  TO  CO  TO  BE  SURE  WE  UNDERSTAND  BUT
DON'T  GET  BORED.

WE  FEEL  MORE  COMFORTABLE  WITH  THE  TEACHERS  WHO
ARE  OUR  OWN  PEOPLE.  IT  MAKES  LEARNING  EASIER . IF
THEY  CAN  UNDERSTAND  SOMETHING , WE  KNOW  WE  CAN, TOO?

2-18

Helping  Health  Workers  Learn  (2005)

'TRAINING  ORGANIZERS'  OR  'BACK-UP  PERSONS'

Supportive  back-up  (supervision)  can  be  as  important  for  instructors  as  for
health  workers.  This  is  true  for  instructors  who  are  doctors  and  nurses,  as  well  as
for  village-level  instructors.  We  all  can  benefit  when  someone  with  more
experience,  or  a different  perspective,  observes  our  teaching  and  makes  helpful
suggestions.

The  person  who  provides  this  sort  of  support  and  suggestions  can  be  called  a
'back-up  person',  'advisor',  or  'training  organizer'.  Since  her  main  goal  is  to  help
people  meet  their  needs,  the  training  adviser  should  not  only  be  an  experienced
health  worker,  but  should  also  sympathize  and  identify  with  the  poor.

The  role  of  the  training  organizer  in  a health  worker  training  program  in
Bangladesh  has  been  described  as  follows:*

"The  'Training  Organizer'  will  sit  in  the  class,  quietly  and  discreetly  at  the
back,  and  then  review  the  class  with  the  teacher  afterwards,  with  emphasis  on
points  like:

• Did  the  message  get  across

clearly?

• Did  the  trainees  have  an

active  or  passive  role  in
the  class?

• Were  visual  aids  used

effectively?

• How  many  of  the  trainees

fell  asleep  before  the  end
of  the  class?

"The  'Training  Organizer'
will  review  some  of  the  above
points  with  the  trainees  as  well
as  the  teacher."

vou  covered  All

the  IMPORTANT  POINTS,,

But  two  st uoent s
PELL  ASLEEP.

Village  health  workers  can  make  excellent  instructors.  But  at  first  they  often
lack  basic  teaching  skills  and  experience  in  course  planning.  It  is  here  that  the
training  organizer  can  help.  But  it  is  essential  that  he  or  she  be  willing  to  stay  in
the  background  and  let  the  community-based  instructors  assume  full
responsibility.  Once  again:

Advise,  don't  boss!

To  emphasize  the  secondary  role  of  this  advisor,  'training  assistant'  might  be  a
better  term  than  'training  organizer'.  To  move  into  this  back-up  role  is  a natural  step
for  the  outside  professional  or  foreigner  who  has  been  active  as  an  instructor  early
in  the  program.  It  allows  the  outside  person  to  begin  phasing  herself  out,  to  pass
teaching  and  organizing  responsibilities  to  local  workers.  In  time,  outstanding  local
instructors  (who  started  off  as  community  health  workers)  may  likewise  be  able  to
take  over  the  role  of  'training  assistant'.  In  this  way,  the  outsider  moves  one  more
step  into  the  background.  The  sooner  she  is  not  needed,  the  more  successful  she
has  been.

* From  a personal  communication  with  Martin  Schweiger,  Medical  Adviser/ Administrator,  Rangput
Dinajpur  Rehabilitation  Service  Program,  Lalmanirhat-Rangpur,  Bangladesh.

Helping  Health  Workers  Learn  (2005)

Planning  a Training
Program

3-1

CHAPTER

The  primary  aim  of  this  book  is  to  look  at  ways  of  learning,  not  to  discuss  the
details  of  a training  program.  But  the  way  a training  course  is  planned,  and  by
whom,  can  greatly  affect  how  teaching  and  learning  take  place.

Many  approaches  are  possible.  But  two  things  are  of  key  importance:

1 ) Each  training  program  should  be  designed  according  to  the  special  needs  and
circumstances  of  the  area  it  serves.  2)  Each  course  should  be  adapted  to  the
experiences  and  needs  of  each  new  group  of  students.

We  have  reasons  for  placing  this  chapter  on  planning  after  those  on  approaches
to  learning  and  selection  of  health  workers,  instructors,  and  advisers.  The
educational  approach  and  the  persons  involved  can  affect  how  course  content  is
decided.  For  if  a 'community-strengthening'  approach  is  taken,  some  of  the
course  planning  is  best  done  by  the  participants.

THE  TRAINING  COURSE  AS  PART  OF  A LARGER
LEARNING  PROCESS

In  this  chapter  we  focus  on  training  courses  for  health  workers.  But  keep  in
mind  that  'training'  takes  place  in  many  ways  and  on  many  levels.

The  training  course  is— or  should  be— closely  linked  with  a vital  network  of
continuous  learning  and  teaching  that  takes  place  in  the  community.  The
diagram  below  shows  some  of  the  possibilities.

THE  NETWORK  OF  LEARNING  FOR  COMMUNITY  HEALTH

E veryone
helps  the
instructors
learn

COMMUNITY

Health  workers
help  parents
learn

Instructors
help
health
workers
learn

A

f.

if  A
'TRAINING^
COURSE  j

-Health  workers  —
help  instructors

learn

Health  workers
help  children
learn

Children

help

parents

learn

Health  workers
help  workers\
earn

Parents  help  Parents
health  workers  help
learn  children

learn

Children
help  children
learn

Everyone
helps  student
health  workers
learn

Health  workers
help

Workers  help
health  workers
learn

Midwives  help
health  workers
learn

3-2

Helping  Health  Workers  Learn  (2005)

THE  IMPORTANCE  OF  HAVING  STUDENTS  TAKE  PART
IN  THE  PLANNING

The  ability  to  plan  effectively— to  analyze  and  organize  what  needs  to  be  done—
is  basic  to  the  self-reliance  of  every  individual,  family,  and  community.  Planning
skills  are  especially  important  for  health  workers  who  are  to  become  leaders,
teachers,  and  organizers  in  their  communities.

This  does  not  mean  that  a training  program  must  include  special  classes  on
'planning  and  management'.  Instead,  it  points  to  the  value  of  including  the
student  group  in  the  planning  process.

LESS  APPROPRIATE

MORE  APPROPRIATE

Some  of  the  most  important  skills  are  best  learned  through  practice
in  applying  them  to  real  situations,  rather  than  by  studying  them  as  separate  topics.

There  are  several  good  reasons  for  including  the  student  health  workers  in
planning  the  content  and  organization  of  their  own  training:

• Through  guided  practice  the  students  learn  firsthand  about  analyzing,
planning,  and  organizing  relevant  activities.

• Students  become  more  deeply  involved  in  the  teaching-learning  process.

• They  become— and  feel— more  equal  to  their  instructors.  This  will  help  them
when  they  begin  to  plan  and  teach  in  their  communities.  They  will  be  more
able  to  relate  to  their  own  people  as  equals,  and  to  share  responsibilities
with  others.

• Students  can  help  adapt  the  content  of  the  training  program  to  the  problems,
needs,  and  resources  within  their  particular  communities.  This  helps  make
each  training  session  a new,  special,  exciting,  and  more  relevant  experience—
for  the  instructors  as  well  as  the  students.

• The  flexibility  and  shared  responsibility  of  this  approach  are  basic  to
achieving  community  health  and  fairer  distribution  of  control.

Helping  Health  Workers  Learn  (2005)

33

A COMMON  PROBLEM:  PLANNING  THINGS  BACKWARDS

• Why  are  so  many  health  worker  training
courses  taught  by  persons  who  have  no
community  experience?

• Why  do  so  many  instructors  give  more
class  time  to  the  study  of  anatomy  and
filling  out  forms  than  to  child  diarrhea,
nutrition,  and  teaching  methods?

• Why  do  so  many  courses  fail  to  prepare
health  workers  to  solve  many  of  the
basic  problems  they  will  face?

The  answers  to  these  questions  lie  in  the  fact  that  training  programs  too  often
are  planned  backwards.  The  time  and  place  are  fixed,  instructors  chosen,  and
course  content  decided  before  planners  consider  the  special  difficulties,  resources,
customs,  and  strengths  of  the  people  involved.  As  a result,  what  is  taught  does
not  match  either  the  community's  needs  or  the  students'  abilities.

Many  training  programs  today  teach  too  much  of  what  matters  little— and  too
little  of  what  matters  most.  To  make  things  worse,  the  way  they  teach  is  often  as
unrelated  to  people's  needs  as  is  the  subject  matter.

If  training  is  to  be  appropriate  (adapted  to  people's  needs,  resources,  customs,
and  abilities),  things  need  to  be  done  the  other  way  around:

1st:  Invite  the  people  from  the  communities  that  the  program  will  affect  to

determine  and  make  known  their  needs.

2nd:  Let  the  people's  needs,  resources,  and  abilities  determine  what  should  be
taught,  and  to  whom.

3rd:  Let  what  should  be  taught,  how,  and  to  whom,  determine  who  should

teach,  where,  for  how  long,  and  in  what  way.

This  people-centered  or  'decentralized'  approach  to  planning  can  be  relatively
easy  for  small  programs  that  are  community  based.  But  it  may  be  extremely
difficult  for  a large,  regional  program.  An  appropriate  approach  may  still  be
possible,  however,  if  those  in  positions  of  central  authority  are  willing  to:

• Permit  planning  and  basic  decisions  to  take
place  at  the  community  level.

• Act  not  as  a controlling  body,  but  as  a center

for  communications,  advice,  support,  and  supply.

the  decentralized
or

►

people-centered

approach

3-4

Helping  Health  Workers  Learn  (2005)

THE  DECENTRALIZED  APPROACH  TO  PLANNING

(the  solid  arrows  show  the  main  direction  of  flow)

The  central  ministry  or  program  The  communities  provide  most

provides  most  of  the  supplies,  of  the  advice,  planning,  and

support,  and  coordination.  control.

When  groups  are  very  large,  central  planning-and-control  very  easily  becomes
rigid,  bureaucratic,  change  resistant,  and  corrupt.  Planning-and-control  has  more
chance  of  being  appropriate,  flexible,  and  responsive  to  human  needs  when  it
takes  place  in  groups  that  are  small  enough  for  everyone  to  know  each  other.

DECIDING  HOW  MUCH  TO  PLAN  IN  ADVANCE
AND  HOW  MUCH  TO  PLAN  DURING  THE  COURSE

As  we  have  noted,  it  is  advisable  to  leave  some  of  the  planning  of  a training
course  until  after  it  begins.  This  allows  the  course  content  to  be  planned  or
modified  according  to  the  students'  interests,  experiences,  needs,  and  capabilities.

Clearly,  however,  some  planning  must  be  done  in  advance.  Someone  has  to
make  decisions  about  why,  when,  where,  with  whom,  and  for  whom  the  training
will  take  place.  Resources  and  needs  must  also  be  considered.  And  certain
preparations  need  to  be  made.

On  the  next  four  pages  (3-5  to  3-8)  we  present  an  outline  of  IMPORTANT
CONSIDERATIONS  FOR  OVERALL  COURSE  PLANNING.  It  includes:

Section  A:  Planning  to  be  done  before  the  training  course  begins
Section  B:  Continued  planning  after  the  training  course  begins
Section  C:  Planning  and  programming  after  the  course  is  completed

Helping  Health  Workers  Learn  (2005)

3-5

IMPORTANT  CONSIDERATIONS  FOR  OVE RALL  COURSE  PLANNING

A.  Planning  to  be  done  before  the  training
course  begins:

1.  FIRST  CONSIDERATIONS—

PURPOSES  AND  QUESTIONS

• Whose  needs  will  the  training  program  be  primarily
designed  to  meet?

• Will  it  only  extend  the  existing  health  system,  or
will  it  help  to  change  it?

• How  much  will  it  prepare  the  health  worker  to
understand  and  deal  with  the  social  (economic,
cultural,  political)  causes  of  ill  health?

• Will  it  make  the  poor  more  dependent,  or  help
them  to  be  more  self-reliant?  Will  it  promote  or
resist  social  change?

• What  are  the  general  goals  and  objectives  of  the
program?  (To  express  goals  in  terms  of  numbers
and  dates  is  probably  unwise  at  this  stage.  Why?)

• Who  is  (or  should  be)  involved  in  all  these
decisions?

2.  OBSERVATION  OF  NEEDS  AND  RESOURCES

(Talking  with  a few  observant  persons  from  the  area

can  often  provide  more  useful  information  than  a

census  or  elaborate  'community  diagnosis',  at  far

lower  cost,  more  quickly,  and  with  less  abuse.)

Information  worth  considering:

• Common  health  problems:  how  frequent  and  how
serious?

• Causes  of  main  problems:  physical  and  social,
coming  from  inside  and  outside  the  community.

• People's  attitudes,  traditions,  and  concerns.

• Resources:  human,  physical,  economic,  from
inside  and  outside  the  area.

• Characteristics  of  possible  health  workers:  age,
experience,  education,  interest,  etc.

• Possible  choices  of  instructors  and  training
organizers.

• Possible  sources  of  funding  and  assistance.  (Which
are  more  appropriate?)

• Reports  and  experiences  of  other  programs.

• Obstacles:  certain,  likely,  and  possible.

3.  EARLY  DECISIONS—

Who?  Where?  How  many?  When?

• Selection  of  health  workers:  by  the  community,
by  the  health  program,  or  by  both?  (How  can
selection  of  a health  worker  be  a learning
experience  for  the  community?)

• Selection  of  instructors  and  advisers:

♦ How  much  understanding  and  respect  do  they
have  for  village  people?  Do  they  treat  them  as
equals?

♦ How  committed  are  they  to  working  toward
social  change?

♦ Do  they  have  the  necessary  knowledge  and  skills
(public  health,  education,  group  dynamics,
community  organization,  medicine,  etc.)  or  are
they  willing  to  learn?

• Location:

♦ Where  will  the  training  take  place?  Near  or  far?
Village  or  city?  Why?

♦ Where  will  everyone  eat  and  sleep?  I n hotels?

In  special  facilities?  With  village  families?

(How  can  these  decisions  influence  what  they  will
learn?)

• Numbers:  How  many  students  will  take  part  in  the
training  course?  (Beyond  1 2 or  15,  quality  of
training  usually  decreases.  This  must  be  weighed
against  the  need  to  train  more  health  workers.)

• Timing:

♦ How  long  will  the  training  course  last?

♦ What  time  of  year  is  best?

(Consider  how  these  decisions  may  affect  who
can  take  part  in  the  course.)

♦ Will  the  training  be  done  in  one  continuous
stretch,  or  be  divided  Into  short  blocks  so  that
students  can  return  home  (and  practice  what
they  have  learned)  between  sessions?

(Whose  needs  and  opinions  should  be  considered
in  answering  these  questions?)

• Funding:

♦ From  where?  How  much  money  should  come
from  outside  the  local  area?

♦ What  are  the  interests  of  possible  funding
groups?

♦ What  are  the  advantages  and  disadvantages  of
asking  communities  to  pay  part  of  the  cost  of
training  their  health  worker?

♦ How  can  costs  be  kept  low?  How  much  is
needed?

• Follow-up  and  support:

♦ What  opportunities  may  there  be  for  continued
learning  or  training  after  the  course  is  over?

♦ What  kind  of  support  or  supervision  will  the
health  workers  receive?

(Why  is  it  important  to  consider  follow-up  before
the  training  program  begins?)

3-6

Helping  Health  Workers  Learn  (2005)

4.  ANALYSIS  OF  PRIORITIES

(deciding  what  is  most  important)

Problems  can  be  compared  by  considering  the
following:

• How  common  are  they?

• How  serious  are  they?

• How  contagious  are  they?

• How  much  concern  do  people  feel  about  them?

• How  much  do  they  affect  other  problems?

• How  much  could  a community  health  worker  do
about  them  in  terms  of  . . .

♦ diagnosis  and  treatment?

♦ referral,  when  needed?

♦ prevention?

♦ education  of  local  people?

♦ community  action?

• How  easy  or  difficult  will  it  be  to  teach  a health
worker  to  take  safe,  responsible  action  with
respect  to  the  problem?

Then  group  the  problems  according  to  their  relative
importance,  or  priority,  and  decide  which  ones  to
include  in  the  course.  (Be  sure  to  include  common
social  problems  that  affect  health— such  as  drinking,
overuse  and  misuse  of  medicines,  local  forms  of
exploitation  of  the  poor,  and  misuse  of  resources—
as  well  as  physical  diseases.)

5.  RE-EXAMINING  OBJECTIVES

• In  view  of  the  information  you  have  gathered  and
analyzed,  how  can  the  training  program  be  best
designed  . . .

♦ so  that  it  prepares  health  workers  to  help  the
people  in  their  villages  solve  their  problems  and
needs?

♦ so  that  it  is  adapted  to  fit  the  particular
strengths  and  weaknesses  of  the  students?

6.  ORGANIZING  STUDY  MATERIAL  FOR
APPROPRIATE  LEARNING

• What  general  subject  areas  and  specific  topics
might  be  taught  in  order  to  prepare  students  to
act  upon  the  important  problems  and  needs  in
their  communities?

• How  many  hours  of  organized  study  time  will
there  be  during  the  course?

• How  much  time  is  needed  to  adequately  cover
each  topic?

• How  can  the  time  available  be  best  divided
among  the  different  topics,  according  to  their
priority?

• Which  topics  are  best  approached  through
classroom  learning,  through  practice  (in  clinic,
community,  or  field),  or  a combination?

(At  this  point,  some  program  planners  make  a list
for  each  subject  area,  stating  exactly  what  the
health  workers  should  know  and  be  able  to  do.
What  are  the  strengths  and  weaknesses  of  this
approach?  See  Chapter  5.)

7.  PLANNING  FOR  BALANCE

• How  can  the  subject  matter  be  approached  so  as

to  maintain  an  appropriate  balance  between  . . .

♦ classwork  and  practical  experience?

♦ learning  in  the  training  center  and  learning  in
the  community?

♦ preventive  and  curative  health  care?

♦ physical  and  social  causes  of  ill  health?

♦ the  needs  of  the  poor  and  the  requirements  of
those  in  positions  of  control?

♦ caution  and  innovation?

♦ health  skills,  teaching  skills,  and  leadership
skills?

♦ work  and  play?

8.  PREPARING  A ROUGH  TIMETABLE  OR
CLASS  SCHEDULE

(without  details,  to  be  changed  later)

• How  can  different  subjects  and  topics  be  arranged,
according  to  hours,  days,  and  weeks,  so  that  . . .

♦ there  is  enough  variety  to  keep  the  students
interested  (for  example,  classwork  alternating
with  farm  work,  community  action,  and
learning  of  practical  skills)?

♦ related  subjects  are  scheduled  close  together  or
in  a logical  order?

♦ more  difficult  subjects  come  early  in  the  day,
and  more  fun  subjects  later  (when  people  are
tired)?

♦ all  key  subject  matter  is  included?

♦ high-priority  subjects  are  given  more  emphasis
in  the  training  course?

♦ skills  and  knowledge  needed  for  immediate  use
and  practice  are  learned  early  (for  example,
learning  about  medical  history,  physical  exams,
preventive  advice,  Road  to  Health  charts)?

• How  can  study  time  and  free  time  be  best  arranged
to  meet  students'  and  instructors'  needs?

• How  can  the  schedule  be  kept  open  and  flexible
enough  to  allow  for  unplanned  learning
opportunities  and  special  needs  as  they  arise?

(It  helps  to  leave  the  last  week  of  the  course
unscheduled,  to  allow  for  review  and  for  making
up  'displaced  classes'.)

• How  can  the  schedule  be  presented  in  a clear,
simple  form  that  can  be  easily  seen  and
understood  by  students  and  instructors?

WEEKLY  PLAN

—

Helping  Health  Workers  Learn  (2005)

3-7

9.  PLANNING  APPROPRIATE  TEACHING
METHODS  AND  AIDS

• What  teaching  approach  is  best  suited  to  persons
who  are  more  used  to  learning  from  experience
than  from  lectures  and  books?

• What  approaches  to  learning  will  help  the  health
worker  be  an  effective  teacher  in  his  community?

• What  attitudes  on  the  part  of  the  teacher  will
encourage  the  health  worker  to  share  knowledge
gladly  and  treat  others  as  equals?

• What  teaching  methods  might  aid  the  health
worker  in  helping  community  people  to  become
more  confident  and  self-reliant?

• What  teaching  aids  can  be  used  that  will  lead  the
health  worker  to  make  and  invent  teaching  aids
after  returning  to  his  village?

• What  approach  to  learning  will  best  prepare  the
health  worker  to  help  his  people  understand  and
work  together  to  solve  their  biggest  problems?

• What  approach  to  health  problems  will  enable  the
health  worker  to  learn  how  to  approach  the
solving  of  other  community  problems?

• What  can  be  done  to  ensure  that  all  learning  is
related  to  important  needs?

• How  can  classwork  be  made  more  friendly  and
fun?

• How  can  tests  and  exams  be  presented  so  that
students  use  them  to  help  each  other  rather  than
to  compete?  How  can  tests  and  exams  be  used
to  judge  the  instructor  as  well  as  the  students?

10.  GETTING  READY  AND
OBTAINING  SUPPLIES

• What  preparations  are  needed  before  the  course
begins?  (transportation,  eating  and  sleeping
arrangements,  study  area,  wash  area,  etc.)

• What  furnishings  and  teaching  materials  are
needed  to  begin?  (benches,  blackboard,  etc.)

• What  can  be  done  if  some  of  these  are  not  ready
on  time?

11.  DETAILED  PLANNING  OF  ACTIVITIES  AND
CLASSES  FOR  THE  BEGINNING  OF  THE
COURSE

• How  many  days  of  classes  and  activities  should
be  planned  in  detail  before  the  course  begins?

• Why  is  it  important  that  the  details  of  all  the
classes  and  activities  not  be  planned  in  advance?

B.  Continued  planning  after  the  training
course  begins:

12.  INVOLVING  STUDENTS  IN  PLANNING  THE
COURSE  CONTENT  (based  on  their  experience
and  the  needs  in  their  communities)

• Why  is  it  important  that  the  students  take  part
in  planning  the  course?

• How  can  the  students'  participation  in  planning
help  them  to  learn  about  . . .

• examining  and  analyzing  the  needs  in  their
communities?

• recognizing  both  the  strengths  and  the
weaknesses  of  their  people's  customs?

• ways  to  plan  and  organize  a learning  group?

• the  value  of  learning  by  doing,  and  of  respecting
and  building  on  their  own  experiences?

• shared  decision  making?

13.  REVISING  THE  PLAN  OF  STUDIES
(COURSE  CONTENT)  ACCORDING  TO
STUDENT  SUGGESTIONS

• To  what  extent  do  the  priorities  determined  by
the  students,  according  to  problems  and  needs  in
their  own  villages,  correspond  to  those  already
considered  by  the  instructors  and  planners?  (How
do  you  explain  the  similarities  and  differences?)

• How  important  is  it  to  revise  the  course  plans  in
order  to  better  meet  the  concerns  and  expressed
needs  of  the  student  group?

14.  PREPARING  INDIVIDUAL  CLASSES  AND
ACTIVITIES

• How  detailed  should  class  plans  be?

• How  far  in  advance  should  a class  or  activity  be
planned?  Why?

• Is  it  helpful  to  use  a particular  outline  or  formula
for  preparing  a class?  If  so,  what  should  it  include?

• Can  each  class  or  activity  be  planned  to  include  . . .

♦ all  of  the  basic  points  to  be  learned  or
considered?

♦ active  student  participation  and  interaction?

♦ use  of  appropriate  learning  aids?

• opportunities  for  the  students  to  explore
questions  and  discover  answers  for  themselves?

• practice  in  solving  problems  similar  to  those
health  workers  will  meet  in  their  work?

• a chance  for  students  to  summarize  what  they
have  learned  and  to  ask  questions?

• To  what  extent  can  students  take  part  in  the
preparation  of  classes  and  of  teaching  aids?  (Is
this  important?  Why?)

3-8

Helping  Health  Workers  Learn  (2005)

15.  CONTINUED  REVISION  OF  THE

SCHEDULE— to  make  room  for  new  ideas,
learning  opportunities,  needs,  and  problems
as  they  arise

• What  are  the  advantages  and  disadvantages  to
keeping  the  program  open  and  flexible?  (How
might  this  influence  a health  worker's  ability
to  work  toward,  or  tolerate,  change  in  his  or
her  community?)

18.  STARTING  OVER

The  whole  process  is  repeated:

1

PURPOSE

I

OBSERVATION

16.  EVALUATION  DURING  THE  TRAINING
PROGRAM  —to  consider  how  it  might  be
improved  (see  Chapter  9)

• I n what  ways  can  this  be  done?

• Who  should  be  involved?

• What  is  the  value  of  . . .

♦ round-table  discussions  in  which  all  students
and  staff  have  a chance  to  express  their  feelings
about  the  program  and  each  other?

♦ similar  discussions  with  members  of  the
community  where  the  training  program  takes
place?

♦ tests  and  exams?

♦ setting  specific  goals  and  seeing  if  they  are  met?

• If  evaluation  studies  (informal  or  formal,  ongoing
or  final)  are  made,  what  can  be  done  to  help
assure  that  results  are  useful  and  will  be  used?

CE

LU

>

o

a

z

I—

re

<t

l-

COLLECTION  OF  INFORMATION

ANALYSIS  OF  NEEDS

EARLY  DECISIONS  AND  OBJECTIVES

ACTION -

Twix;  CONTINUED  PLANNING

■ 1/5  V V ]

(S

to®  CONTINUOUS  EVALUATION

I 1

i < Sf  CHANGES  OF  PLAN

ice  mm  .-..i

ift®  CHANGES  OF  ACTION

-FOLLOW-UP  AND  FEEDBACK

C.  Planning  and  programming  after  the
course  is  completed:

17.  FOLLOW-UP  AND  FEEDBACK'  (see
Chapter  1 0)

• How  can  a supportive  learning  situation  be
continued  between  instructors  and  students,
and  among  the  students  themselves,  once  the
training  course  is  completed?

• How  can  the  following  be  involved  in  supporting
the  health  worker:

♦ members  of  the  community  (a  health
committee)?

♦ other  health  workers?

♦ program  instructors,  leaders,  and  advisers?

♦ other  support  groups  and  referral  centers?

• How  can  the  experiences,  successes,  and
difficulties  of  the  health  workers  in  their
communities  be  recorded  and  used  to  make  the
next  training  course  better  than  the  last?  (Can
this  be  done  so  that  health  workers  know  they
are  contributing,  rather  than  being  judged?)

* FEEDBACK : helpful  ideas  and  suggestions
sent  back  to  planners  or  instructors  by  health
workers.

Helping  Health  Workers  Learn  (2005)

3-9

EARLY  DECISIONS
Location  of  training

It  is  best  if  training  takes  place  in  a situation  close  to  that  where  health  workers
will  work.  Closeness  in  distance  is  convenient.  But  closeness  in  terms  of  community
setting  is  essential.  Village  health  workers  are  best  trained  in  a village.  That  way,
they  can  practice  solving  problems  and  carrying  out  activities  under  conditions
much  like  those  in  their  own  communities.

If  possible,  training  should  take  place  in  a village  with  a health  center  where
students  can  gain  clinical  experience.  It  helps  if  the  health  center  is  run  by
experienced  local  health  workers,  and  has  strong  community  participation.  A

small  community-based  health  center  is  usually  far  more  appropriate  for  training
villagers  than  a large  clinic  or  hospital  (see  page  8 4).  The  closer  the  situation  of
learning  to  the  situation  in  which  health  workers  will  later  work,  the  better.

For  the  same  reasons,  it  is  important  that  the  building  in  which  training  takes
place— and  even  the  furniture,  if  any— be  similar  to  those  in  the  villages  of  the
health  workers.

In  this  book  and  in
Where  There  Is  No
Doctor,  we  often  show
drawings  of  health
workers-in-traimng
sitting  on  chairs  or
benches.  That  is
because  people
customarily  make  and
use  such  furniture  in
the  villages  of  Latin
America  where  we
work.  But  in  areas
where  people
traditionally  sit  on
the  ground  during
meetings  and
discussions,  it  makes
sense  that  the  same
traditions  be  observed
in  the  training  course.

In  places  where  villagers  traditionally  sit  on  the  floor,  it  is
appropriate  that  the  training  course  follow  the  same  custom.
This  drawing  is  from  Ang  Maayong  Lawas  Maagum,  a
Philippine  equivalent  of  Where  There  Is  No  Doctor.

In  the  same  way,  there  are  advantages  to  having  health  workers  live  with
families  in  the  community  rather  than  staying  in  a separate  'dormitory'.  This  is
discussed  further  in  Chapter  6.

3-10

Helping  Health  Workers  Learn  (2005)

Numbers

LESS  APPROPRIATE

Many  programs  have  found
that  from  1 2 to  1 5 is  a good
number  of  students  for  a
course.  A group  this  size  is
large  enough  for  discussions
to  be  exciting,  but  small
enough  so  that  everyone  can  take  part.

MORE  APPROPRIATE

Timing

1.  Continuous

2 to  3 months

Some  training  courses  are  taught  in  one  continuous  block  of  time.  Two  to
three  months  is  the  average  length  of  such  a course.  This  is  usually  long  enough
for  health  workers  to  learn  the  basic  skills  needed  for  primary  care.  Yet  it  is
short  enough  so  that  villagers  with  families  and  responsibilities  at  home  can
(sometimes)  afford  the  time  away.

2.  Short  blocks  of  training
alternating  with  practice

2 weeks

2 weeks

2 weeks

Other  training  courses  are  taught  in  a series  of  shorter  blocks  of  time.  Health
workers  may  train  for  blocks  of  2 weeks,  separated  by  periods  of  1 or  2 months
in  which  they  return  to  their  villages  to  practice.  This  way  health  workers  are  not
apart  from  their  families  for  so  long  at  one  time,  and  they  have  a chance  to
put  into  practice  what  they  have  learned.  The  experience  they  gain  and  the
problems  they  meet  in  their  village  work  add  meaning  and  direction  to  their
continued  training.  However,  if  health  workers  must  come  a long  distance  by
foot  or  on  muleback,  training  in  short  b
…[truncated]

Summary: Helping  Health  Workers  Learn  (2005)    Helping   Health  Workers   Learn   A book  of  methods,  aids,  and  ideas  for  instructors  at  the  village  level    David  Werner  and  Bill  Bower    drawings  by   David  Werner  Pablo  Chavez   Regina  Faul-Jansen  Marie  Ducruy    Helping  Health  Workers  Learn  (2005)    Library  of  Congress  Cataloging-in-Publication  Data   Catalog  Card  No.:  81-85010   Werner,  David  Bradford  and  Bower,  Bill  Lamed  Helping  Health  Workers …

RADICAL MEDICINE; PEOPLE'S HEALTH. DAVID WERNER; HERSPERIAN