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Participant manual chp for trainers mar 09-1 Participant manual chp for trainers mar 09-1 Document Transcript

  • COMMUNITY HEALTH PROMOTIONFOR TRAINERS_______________________________________A CAWST PARTICIPANT MANUALMarch 2009 Edition
  • 12, 2916 – 5th Avenue Calgary, Alberta T2A 6K4, Canada Phone + 1 (403) 243-3285 Fax + 1 (403) 243-6199 E-mail: cawst@cawst.org Website: www.cawst.orgCAWST is a Canadian non-profit organization focused on the principle that clean waterchanges lives. Safe water and basic sanitation are fundamentals necessary to empowerthe world’s poorest people and break the cycle of poverty. CAWST believes that theplace to start is to teach people the skills they need to have safe water in their homes.CAWST transfers knowledge and skills to organizations and individuals in developingcountries through education, training and consulting services. This ever expandingnetwork can motivate individual households to take action to meet their own water andsanitation needs.One of CAWST’s core strategies is to make knowledge about water commonknowledge. This is achieved, in part, by developing and freely distributing educationmaterials with the intent of increasing its availability to those who need it most.This document is open content and licensed under the Creative Commons AttributionWorks 3.0 Unported License. To view a copy of this license, visithttp://creativecommons.org/licenses/by/3.0/ or send a letter to Creative Commons, 171Second Street, Suite 300, San Francisco, California 94105, USA.You are free to:• Share - to copy, distribute and transmit this document• Remix - to adapt this documentUnder the following conditions:• Attribution. You must give credit to CAWST as the original source of the document (but not in any way that suggests that CAWST endorses you or your use of this document).CAWST and its directors, employees, contractors, and volunteers do not assume anyresponsibility for and make no warranty with respect to the results that may be obtainedfrom the use of the information provided.
  • Community Health Promotion for TrainersTable of ContentsAcknowledgmentsAcronymsProjects and OrganizationsSection 1 Introduction1.1 Introduction1.2 CAWST Dissemination Model1.3 Role of Community Health Promoters1.4 Role of Trainers1.5 Summary of Key PointsSection 2 How to be a Community Health Promoter2.1 Introduction2.2 How to Change Behaviour2.3 Participatory Learning and Action2.4 What Makes a Good Community Health Promoter?2.5 Key Skills2.6 Key Attitudes2.7 Key Knowledge2.8 Social Marketing2.9 How to Work with Households2.10 How to Work with Community Groups2.11 How to Work with Schools2.12 How to Create a Field Kit2.13 Additional Resources2.14 ReferencesSection 3 How to Train Community Health Promoters3.1 Introduction3.2 Project Planning3.3 How to Recruit Community Health Promoters3.4 How to Develop the Training Program3.5 How to Evaluate the Training Program3.6 How to Monitor Community Health Promoters3.7 How to Monitor Behaviour Change and Progress3.8 Additional Resources3.9 ReferencesSection 4 Case Studies4.1 Nigerians for Pure Water4.2 School Hygiene Promotion4.3 Late Adopters4.4 Hygiene Promotion in Burkina Faso4.5 Life of a Hygiene Educator in Uganda4.6 School Sanitation and Hygiene Education in India4.7 School Hygiene Promotion in Pakistan4.8 Health Education for Malaria Control in India4.9 Safe Water Supply and Latrines in Ethiopia4.10 Communities Take Ownership of Hygiene in Bangladesh i
  • Community Health Promotion for Trainers4.11 From Smelly Yards to Happy Husbands4.12 ReferencesAppendicesAppendix 1: Participatory Learning and Action ToolsAppendix 2: Water, Hygiene and Sanitation PostersAppendix 3: EnergizersAppendix 4: Training Tools ii
  • Community Health Promotion for TrainersAcknowledgmentsOrganizations and individuals have been developing and using participatory learning andaction tools over many years and in many countries. The original source of each tool israrely known or acknowledged. However, many of the tools featured in this manual havebeen adapted and referenced from the following sources:• SARAR (Self-esteem, Associative Strengths, Resourcefulness, Action Planning, and Responsibility). This methodology was first conceived by Lyra Srinivasan in the 1970s. Over the years, Srinivasan and her colleagues worked to develop participatory activities that would increase the self-esteem of individuals and community groups and help them to acquire skills to contribute effectively to decision making and planning for meaningful change.• PHAST (Participatory Hygiene and Sanitation Transformation). The PHAST initiative undertaken by the UNDP/World Bank Water and Sanitation Program and WHO in 1992 adapted the SARAR methodology more specifically for sanitation and hygiene behaviour change. The methods were field tested in four African countries (Botswana, Kenya, Uganda and Zimbabwe) and have since been adopted by several countries within and some outside the African region.• Tools Together Now. In 2006, the International HIV/AIDS Alliance put together a selection of 100 participatory learning and action tools to use for HIV/AIDS programmes. A common theme of the Alliance’s work has been encouraging community participation in the assessment, design, implementation, monitoring, evaluation and scaling up of HIV/AIDS activities.CAWST would also like to thank our many clients who have provided case stories,photos, and examples of their training and education materials. iii
  • Community Health Promotion for TrainersAcronymsCBO Community based organizationCHW Community Health WorkerCTC Child-to-ChildHTH High test hypochloriteHWT Household water treatmentITA International Technical AdvisorKPC Knowledge, practices and coverageNADCC Sodium dichloroisocyanuratend No dateNGO Non-governmental organizationPAC Polyaluminum chloridePHAST Participatory Hygiene and Sanitation TransformationPLA Participatory learning and actionSARAR Self-esteem, Associative Strengths, Resourcefulness, Action Planning, and ResponsibilitySODIS Solar disinfectionUV UltravioletVIP Ventilated improved pitWASH Water, sanitation and hygiene iv
  • Community Health Promotion for TrainersProjects and OrganizationsACTED Agency for Technical Cooperation and DevelopmentCAWST Centre for Affordable Water and Sanitation TechnologyCDC Centre for Disease ControlCHC Community Health CellDFID UK Department for International DevelopmentEAWAG Swiss Federal Institute of Aquatic Science and TechnologyENPHO Environment and Public Health Organization of NepalIFAD International Fund for Agricultural DevelopmentIRC International Water and Sanitation CentreMIT Massachusetts Institute of TechnologyNIMR National Institute of Malaria ResearchNPW Nigerians for Pure Water (fictitious)PWW Pure Water for the WorldSANDEC Department of Water and Sanitation in Developing CountriesSAPWII South Asia Pure Water Initiative, Inc.UNDP United Nations Development ProgramUNICEF United Nations Children’s FundWERA Wera Development AssociationWHO World Health Organization v
  • Community Health Promotion for Trainers Section 1 Introduction1.1 IntroductionCommunity Health Promoters are essential for the successful implementation of anyhousehold water treatment, sanitation or hygiene project. This manual helps to provideTrainers with the knowledge and skills to effectively organize, train and monitorCommunity Health Promoters as part of a new or existing project.After working through this manual, you will be able to:• Describe how to prevent illness through improved water, sanitation and hygiene• Describe the multi-barrier approach to household water treatment• Describe the different roles of Community Health Promoters and Trainers• Identify skills, knowledge and attitudes required of Community Health Promoters and Trainers• Discuss factors that influence behaviour change• Apply various participatory learning and action tools to effectively work with households, community groups and schools• Design appropriate social marketing messages and choose effective communication methods for different target audiences• Plan and implement a training program for Community Health Promoters• Apply participatory learning and facilitation techniques to train Community Health Promoters• Monitor behaviour change and progress 1
  • Community Health Promotion for Trainers Section 1 Introduction1.2 CAWST Dissemination ModelThe Centre for Affordable Water and Sanitation Technology (CAWST) started with thebelief that the poor in the developing world deserve safe water and basic sanitation. Wealso believe that the place to start is to teach people the skills necessary to have safewater in their homes. The goal of the CAWST Dissemination Model is to pass knowledgeand skills to organizations and individuals in developing countries through education,training and consulting services. They, in turn, can motivate households to take actionand meet their own water and sanitation needs.This model is sometimes called “technology transfer” because it enables and developsthe capacity of local populations to meet their own needs for safe water and basicsanitation. Most people that CAWST reaches are not water and sanitation professionals.CAWST training programs and educational materials are designed to be appropriate fora wide variety of non-technical audiences.As shown in the following diagram, there are different roles within the CAWSTDissemination Model that are important in making household water treatment andsanitation projects successful and sustainable. This model promotes a sharedresponsibility between everyone involved. Collaborating Other Organizations Stakeholders Product Manufacturers Local Project CAWST End Users Trainers Implementer Community Health Promoters1.2.1 Centre for Affordable Water and Sanitation TechnologyThe Calgary-based Centre for Affordable Water and Sanitation Technology (CAWST)provides technical training and consulting services, and acts as a catalyst bringingtogether the right partners and funders to make water and sanitation projects a reality forthe poorest of the poor in the developing world. 2
  • Community Health Promotion for Trainers Section 1 IntroductionCAWST has taken a different approach to the problem of water and sanitation for thepoor. Instead of starting with technology solutions, CAWST starts with education andtraining to build local capacity. CAWST sends International Technical Advisors (ITAs) todiverse and often remote locations around the world to deliver training directly to thepeople. Training is customized for each of the roles shown in the Dissemination Model.After providing training, CAWST follows up with ongoing technical consultation to helpthem with project development, overcome problems to implementation, and makeconnections with other local organizations. ITAs provide support to organizations andindividuals working around the world by telephone, e-mail and in-country visits.1.2.2 Collaborating OrganizationsCAWST recognizes that it is important to work with and create effective relationshipswith other organizations who work in the water and sanitation field. CAWST is an activemember of the World Health Organization (WHO) Network to Promote Household WaterTreatment and Safe Storage and has Special Consultative Status with the Economic andSocial Council of the United Nations. CAWST also supports universities and others toconduct research that would be useful for technology development and projectimplementation.1.2.3 Local TrainersExperienced in-country organizations can act as Local Trainers and provide ongoingconsultation and technical support. These Local Trainers are capable of training othercommunity organizations in the various roles required to implement household watertreatment projects. The Local Trainers also facilitate networking between projectimplementers and ensure that lessons learned are shared.The Local Trainer should be knowledgeable about the subject matter and technologyappropriate to each of the various roles. An individual or organization becomes a LocalTrainer through participating in trainings, and later by apprenticing with other qualifiedtrainers. Once fully-trained and competent, these individuals and organizations can thenact as local centres of expertise to pass on their knowledge and skills to othercommunity organizations.1.2.4 Project ImplementerThe Project Implementer is the person or organization who initiates and organizes ahousehold water treatment or sanitation project. They are the key driver and providesupport to all of the others who are involved in the project. The Project Implementershould have a reasonable level of knowledge on water and sanitation issues and may bevery knowledgeable about the local situation. They are generalists and know a little bit ofeverything, but don’t need to be an expert on all aspects of the project.The Project Implementer is the center of the activities and needs to keep things movingto ensure an effective and successful project. Strong planning, management,organizational and communication skills are essential for this role. To successfullyimplement a project, the Project Implementer should be able to: 3
  • Community Health Promotion for Trainers Section 1 Introduction• Understand how to construct the household water treatment or sanitation technology• Develop project plans and write funding proposals• Put together a team of individuals (Product Manufacturers, Community Health Promoters) and work with other stakeholders (government agencies, funding organizations, community groups, etc.) needed to implement the project• Teach some skills to Product Manufacturers, Community Health Promoters and End Users• Perform monitoring and evaluation activities1.2.5 Product ManufacturerThe Product Manufacturer is responsible for constructing and installing the householdwater treatment or sanitation technology and is the local expert on production andtroubleshooting. The Product Manufacturer may also be the first person to teach the EndUser about how to use and maintain the technology. They are sometimes called by othernames, such as Filter Technician in the case of a biosand filter project.It would be an asset if the Product Manufacturers already have construction skills relatedto the type of technology being produced, such as a mason for building biosand filters orpotter for making ceramic filters.A competent Product Manufacturer should be able to complete the following tasks:• Explain how and why the technology works, its advantages and limitations• Assemble and prepare the required tools and materials• Construct and install the technology using appropriate quality control steps• Teach other workers how to construct and install the technology• Teach End Users how to use and maintain the technologyThe Product Manufacturer role can also be taken by a microentrepreneur and it can berun as a profit making business. These individuals should have or be able to developbusiness skills such as:• Production planning• Budgeting for production costs and selling price• Accounting of money• Customer service• Marketing to promote the technology1.2.6 End UsersEnd Users are the people who are interested and willing to adopt and use a new watertreatment or sanitation technology for their home. End Users should be informed aboutwater and health issues, and practical options to improve their quality of life, includingthe following topics: 4
  • Community Health Promotion for Trainers Section 1 Introduction• How water is contaminated and diseases are transmitted• Proper hygiene• Basic sanitation options• Household water treatment options• How to protect their water source• How to use and maintain a technology• Options for safe water storageEnd Users should be supported by Community Health Promoters and ProductManufacturers following the installation of their new household water treatment orsanitation technology. Education materials targeted for the End Users must be culturallyappropriate and suitable for the local situation. Participatory learning activities and visualmaterials are often used so that all members of the community can take part and learntogether. Educational materials should also be adapted for women, men and childrenbecause they may have different priorities and views about water, hygiene andsanitation.1.2.7 Other StakeholdersThere are usually several stakeholders that play different roles at various times in ahousehold water treatment or sanitation project. Potential stakeholders may includegovernment officials, funding agencies, health staff, academic personnel, religiousorganizations, and schools.GovernmentSupport and endorsement from the local and national government can be useful; eventhough they are not often directly involved in the implementation of household water andsanitation projects. Governments can benefit from household water and sanitationprojects since they reduce the burden on their resources and contribute to the localeconomy. Household projects also contribute to reaching the water and sanitationtargets of the Millennium Development Goals which generally fall under the responsibilityof government. In many cases, a local government can provide some in-kind resourcesto support a project, such as a centralized workspace and transportation.Funding AgenciesFinancial support from local and international community organizations, foundations,agencies and individuals is usually a critical element in starting and sustaining a newproject. End Users are often supported financially since they may not be able to affordthe cost of adopting a new technology.Health Departments and Educational InstitutesHealth departments and educational institutes tend to be very knowledgeable about thelocal situation and the issues related to water and sanitation. They can support projectsby sharing their expertise and knowledge with the Project Implementer. Health staff andacademic researchers often rely on local projects for data to support their investigationsand studies. 5
  • Community Health Promotion for Trainers Section 1 IntroductionReligious OrganizationsReligious communities often support household water and sanitation projects since theyshare a common goal of helping those in need. Religious organizations can often reacha large number of people through their regular activities and events, such as dailyprayers and weekly gatherings.SchoolsWater, sanitation and hygiene education can be incorporated into formal school curriculaor informal child education programs. Children tend to be more open to adopting newpractices, and they can influence the hygiene behaviour of their families, peers, andneighbours. Once convinced, children can teach others about improved water,sanitation, and hygiene practices. There have been many successful programs usingchild-to-child programs; where one group of children is educated and then goes on toshare what they’ve learned with other groups of children.Exercise – What is Your Dissemination Model?Complete the following model by filling in the names of the people or organizations thatdo each job. Sometimes, the same person can have more than one role or more thanone person can share a role, in which case, you would enter that individual’s name morethan once. As well, there may be nobody who performs a specific job so you wouldleave that space blank. CAWST End Users Community Health Promoters 6
  • Community Health Promotion for Trainers Section 1 Introduction1.3 Role of Community Health PromotersThe Community Health Promoter is essential for the successful implementation of anyhousehold water treatment, sanitation or hygiene program. Their main role is to facilitatethe learning process and help others improve their behaviour. They are sometimescalled other names, such as Community Steward, Health Worker, Village Worker,Extension Worker, Animateur, or Hygiene Educator, depending on the organization,language and country.Community Health Promoters will usually report to the Project Implementer. They can bea volunteer or paid position, and could be a newly created job or included as part of anexisting job description within the implementing organization.The primary responsibility of Community Health Promoters is usually to visit withhouseholds to help people learn about how to treat their drinking water, improve theirhygiene and sanitation practices, and answer questions that they might have aboutwater in general. They may spend their whole day or only a few hours a week to docomplete these tasks.Another role that the Community Health Promoter may have is to help schools andcommunity groups with education programs about water, sanitation and hygiene. Theycould act as the principal organizer of activities or as a resource person to teachers andcommunity leaders.Depending on the implementing organization, there may be additional responsibilitiesthat are assigned to Community Health Promoters. This might involve visiting a certainnumber of houses in a given time period, performing monitoring or evaluation activities,and recording information that might be required by the organization.Almost anyone can become a Community Health Promoter. They can be communityrepresentatives, members of a local NGO or community based organization (CBO),health workers, nurses, or teachers. It doesn’t matter what age or socioeconomic statusthey are. What is more important is that they have the ability to acquire the rightknowledge, skills and attitudes, and be able to apply these confidently towardshousehold water treatment, hygiene and sanitation.Community Health Promoters should ideally be:• Trusted by the members of the community or group they are facilitating.• Able to speak the local language of that community.• Able to understand the culture of the group or community.• Able to communicate effectively and listen to others.• Committed to addressing water, hygiene and sanitation needs in their community.• Able to have a basic knowledge of water, hygiene and sanitation issues.• Skilled in using participatory learning tools.• Possess the appropriate attitudes and behaviour to facilitate participatory learning activities.• Demonstrate good water, hygiene and sanitation practices within their household. 7
  • Community Health Promotion for Trainers Section 1 IntroductionCommunity Health Promoters don’t necessarily have to be experts in water, hygiene andsanitation. This is knowledge that they can learn through your training sessions. It ismore important for Community Health Promoters to be trusted by the local communityand have the capacity to learn new skills and communicate.1.4 Role of TrainersThe Trainer is responsible for recruiting, training and supervising Community HealthPromoters; monitoring behaviour change in the community; and reporting to theorganization.Trainers are generally the technical and health staff of the Project Implementer. TheTrainer could be a newly created job or included as part of an existing job description.The following are some suggested knowledge, skills and attitudes required for aneffective and successful Trainer:• Has experience in water, hygiene and sanitation, community development, or health education projects.• Aware of the need for safe water and have some familiarity with household water treatment, good hygiene and basic sanitation.• Able to communicate effectively and train others.• Skilled in using participatory learning tools.• Possess the appropriate attitudes and behaviour to facilitate participatory learning activities.• Responsible for organizing projects and making decisions.Exercise – Who is the Trainer in Your Organization?List the name(s) of people in your organization who could be the Trainer of CommunityHealth Promoters. Sometimes, the same person can have more than one role (ex.Project Leader is also the Trainer of Community Health Promoters) or more than oneperson can share a role. Or you may be the Trainer! 8
  • Community Health Promotion for Trainers Section 1 Introduction1.5 What Makes a Good Community Health Promoter?A Community Health Promoter does not need to be an expert in everything; howeverthey do need to have some basic professional and personal characteristics. Examples ofthese can be divided into three categories: knowledge, skills and attitudes. CommunityHealth Promoters do not have to have all of these characteristics. However, they shouldaim to have at least some from each area and to be open to developing more as theygain experience. Skills • Active listening • Effective questioning • Facilitating group activities Knowledge • About water, hygiene and sanitation • About the local community context • About PLA tools Community Health Promoter Attitudes • Friendly • Patient • Respectful • Committed to helping people (Adapted from International HIV/AIDS Alliance, 2001)Exercise – Knowledge, Skills and Attitudes of Community Health PromotersUse Tool 8: Knowledge, Skills and Attitudes to identify the expectations of CommunityHealth Promoters for your project. Remember that they don’t necessarily have to beexperts in household water treatment, hygiene and sanitation. This is knowledge andskills that they can learn through your training sessions. 9
  • Community Health Promotion for Trainers Section 1 Introduction1.6 Summary of Key Points• The Community Health Promoter is essential for the successful implementation of any household water treatment, sanitation or hygiene program.• The main role of Community Health Promoters is usually to conduct household visits to help people learn about safe drinking water, good hygiene and basic sanitation.• Community Health Promoters may also deliver education programs to schools and community groups.• Community Health Promoters are generally community representatives, health workers, nurses, or teachers who are responsible for training local people.• It is very important that respected local people and leaders from the community are selected as Community Health Promoters.• Trainers are responsible for recruiting, training and supervising Community Health Promoters; monitoring behaviour change in the community; and reporting to the implementing organization.• Trainers are generally the technical and health staff of the implementing organization. 10
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.1 IntroductionThere are many programs around the world to improve drinking water, hygiene andsanitation. However, these programs often fall short of changing behaviour over the longterm. Why do they not succeed? Emphasis is often placed on the technology, ratherthan educating people on how to use and include the technology into their lives. Publicawareness and education programs are usually an after thought. By the time theirimportance is finally recognized, the project money has already been spent. Thecommunication methods used by many projects tend to be unsuccessful and they don’treach the target audience.Community Health Promoters are key agents in helping the learning process andpromoting behaviour change with different groups of people. They play an important rolein raising awareness and helping people learn about water, hygiene and sanitationthrough participatory learning and action.The approach outlined in this section explains how to be an effective Community HealthPromoter and work with different target audiences, including households, communitygroups and schools. It also provides activities and exercises to help you develop the keyknowledge, skills and attitudes. This will help you to support behaviour change and thesuccessful implementation of any type of water, hygiene and sanitation project.Community Health Promotion at the Grass Roots LevelSustainable household water treatment cannot be established with a single informationevent in the community. The knowledge of pathogen transmission routes that causediarrhea and an awareness of the importance of treating drinking water are quite oftenlacking and have to be established before information on household water treatmentoptions can be passed on. To establish awareness and to achieve behaviour change isa slow and demanding process. This involves a long and multi-facetted contact with theconcerned people and experience in the application of appropriate community healtheducation tools. (Paraphrased from EAWAG/SANDEC, 2006) 11
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.2 How to Change BehaviourBefore going on to practical issues, it is important for us to understand the factors thatinfluence our behaviour. Human behaviour is the way people act, especially in relation tothe situation they are in or the people they are with. Habits are ingrained and sustainedbehaviours, often developed in childhood, which are not easily lost.You can only help people to change their behaviour if you understand how they thinkand feel. You have to look through the eyes of other people (put yourself in theirposition), so that you can figure out how to help them change. The only way to changelong-held habits is to understand the factors that shape the behaviour and intentions ofany individual. Once we understand why people act the way they do, then we can focuson their needs. Having their perspective in mind will determine the kinds of promotionactivities we do. Model of Behaviour Change Why Do People Act As They Do? Roots of Behaviour • Beliefs • Norms • Motivation Helping People to Change Behaviour Intention • Individuals • Families • Groups Factors That Influence Change • Knowledge, attitudes, skills • Support • Positive environment • Facilitating factors Relapse Behaviour Change (Adapted from Network Learning, 2003) 12
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.2.1 Why Do People Act As They Do?BeliefsYou have a set of beliefs were learned when you were very young. These probablyinclude religious beliefs and beliefs about behaviour, but they cover almost everything.Some beliefs lead you to healthy behaviour. For example, many people believe that fruitis good for you – and it is. Some beliefs may not lead you to healthy behaviour. Forexample, you may think that at the end of a day of hard work, a plate full of rice is goodfood; it fills the stomach. In terms of meeting nutritional needs, it is indeed appropriatefor people doing hard outside work. However if you sit behind a desk all day, you mayput on weight.NormsNorms are the normal ideas and behaviours in your society or community. A norm maybe to pray before dinner, or to go to the mosque, church or temple once a week. ForMuslim women the norm may be to cover their heads. In some communities it is thenorm to eat with one’s hands, in others it is the norm to eat with a knife and fork.MotivationIf you are motivated to do or have something, you are likely to take action to accomplishit. If you are not motivated you will not take this action. For example, earning a goodsalary and having chances for advancement will motivate you to do your work properly.If you are not paid and recognized for your efforts, you probably will put less effort intoyour work. In school, getting compliments for doing your best will motivate you to workeven better. For parents, knowing that if you give your children safe water to drink, theywill be sick less often - this will motivate them to treat their water.You have just learned how behaviour is based on beliefs, norms and motivation. Nowlook back on your last exercise. Do you recognize more clearly why some activities areeasier to include in your life than others?Exercise – Courage to ChangeUse Tool 6: Courage To Change with the group to discover how easy or hard it is tomake changes in your life. Looking at the Model of Behaviour Change, you can see thatany behaviour is deeply rooted in beliefs, norms and motivations. How easy or hard it isto change depends partly on these roots.Exercise – Hot SeatUse Tool 7: Hot Seat to get people to put themselves in others’ shoes and think throughthe implications and pressures faced in different situations. 13
  • Community Health Promotion for Trainers Section 2 How to Be CHPExercise – Looking At OthersNow you have considered the roots of your behaviour and how these make you act asyou do. So now think about how this works for others. Have a group member read of thefollowing story:A woman who lives in a poor, rural community confides to you that she has threechildren who are constantly sick with diarrhea. Her friends who are also young mothershave told her to take her children to the nursing clinic to help make them feel better.However, she is reluctant to because the local healer and some older women think it iswrong to use western-style medicine. They believe the children are sick because evilspirits are haunting her for a past wrong. She is scared to approach her husband forsupport because his mother also blames her for the children’s illness. As well, going tothe clinic takes all day. It means that the weeds in the garden will not be pulled and thefamily dinner will be served late.As a group, think of this individual and discuss the following questions:• What is her belief system concerning western medicine?• How normal is it in this community to seek help from the clinic?• Looking at her motivation, what encourages her to go to the clinic? What might discourage her? 14
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.2.2 Factors That Influence People to ChangeA good way to think about behaviour change is in the form of a continuum, as shown inthe following illustration Understanding Resistance to Change. You will be trying to reachpeople at different stages of beliefs, norms and motivation about the problem. Your roleas the Community Health Promoters is to try to influence people to change byunderstanding their existing beliefs, norms and motivation.While habitual behaviours are often learned at an early age, there are opportunities forchange, especially at life changing events. A key event for women is the birth of a babyor moving to a husband’s home after marriage and learning the habits of the newhousehold. Understanding Resistance to Change (UNICEF, 1997) 15
  • Community Health Promotion for Trainers Section 2 How to Be CHPKnowledge, Attitude and SkillsWhen faced with people who need to adopt a more healthy behaviour, you can ask thefollowing questions to yourself:• What do these people need in order to change their behaviour?• Do they need to know more about the subject or do they need to adopt a different attitude?• What about skills?• Where do they need assistance?• Will this behaviour require more time or money?Exercise – What is Needed to Change?Have a group member read out the following story:A woman, who lives in a poor neighbourhood, has told you that she is tired of her familybeing sick with diarrhea. She believes that it is because of the drinking water she fetchesfrom the local pond, but is unsure why. Her mother has told her it is because the waterhas been poisoned by an evil spirit. There is no other water supply available withinwalking distance of her community so she does not know what else to do. You haveobserved that the family’s latrine is in poor condition and they lack water for basichygiene, such as washing hands. Both she and her husband work hard all day tosupport their four children.Use Tool 8: Knowledge, Skills and Attitudes to help identify the information you shouldgive her to make it possible for her family to be healthier.Knowledge:Attitude:Skills: 16
  • Community Health Promotion for Trainers Section 2 How to Be CHPSupportWith proper support, Community Health Promoters can influence the motivation ofpeople, so that you can help them change behaviour. Some people can only beconvinced to change their behaviour when someone they know well and trust tells themthat it would be beneficial to make the change.Positive EnvironmentTo stimulate healthy behaviour, it helps when your services meet the needs of thepeople. This seems obvious but is not always true. As Community Health Promoters,you need the right attitudes that help people to listen to you. You have to show respectfor each and every person. People may bring problems to you that involve your ownbeliefs, feelings or point of view. You may have to put your own personal feelings asidewhen helping people.Behaviour change does not happen until people experience the benefits resulting fromthe change. If a person has an early negative experience with the new behaviour ortechnology, it can hurt the person’s desire to change. You need to make sure that aperson’s first experience is positive.As well, hearing positive stories about benefits that other people have experienced canalso act as a catalyst for someone to change their own behaviour. It is easier to convincepeople if they are told stories of benefits already achieved elsewhere. An example is,“Children are not getting diarrhea every month after water filters were installed in thevillage” or, “People in 8 out of every 10 villages are not losing so many working days anymore because last year they built household water filters and they get sick less oftennow.”Facilitating FactorsThese go beyond the individual’s own environment and affect everybody. They includepolicy and laws that support healthy behaviour. For example, fines for defecating in theopen public.2.2.3 Helping People to ChangeCommunity Health Promoters can help people as individuals, as members of families, oras part of a group. In some cases, it is possible to help people on an individual basisonly; in other cases it may be more useful and even necessary to help through the familyor group, or to use all three levels at the same time.We need to understand that the adoption of a new behaviour or technology in acommunity does not happen all at once. Instead, adoption starts with a few people, andgradually spreads to the rest of the community over time. For this reason, you should notfeel bad if everyone does not immediately start changing their behaviour.The next graph shows how different types of people will adopt a new behaviour ortechnology earlier or later than others. 17
  • Community Health Promotion for Trainers Section 2 How to Be CHPThe innovators and early adopters are open to new ideas and ready to take action. Theyare the generally opinion leaders who are willing to try out a new behaviour ortechnology. The early majority tend to be careful, but more accepting to change than theaverage person. The late majority are sceptics who will adopt a new idea after themajority are already using it. The laggards are traditional people who are satisfied withthings as they are and see no reason for change. They tend to be critical towards newideas and will only adopt a new behaviour or technology if it has become mainstream oreven tradition (Rogers, 1995).Category Values Communication behaviour • Obsessed with new ideas • Actively seeks new information throughInnovators • Risk taker various channels • Not constrained by the community • Open to new values • Informal influence over the behaviour ofEarly • Favourable to change othersadopters • High aspirations for advancement in the • Active contact with those who positively community influence decisions • Deliberate in their actions • Frequent interaction with local communityEarly majority • Skeptical to new ideas • Passively receive information from localLate majority • Cautious community • Unwilling to take risks • Resists change • Somewhat isolated from the local communityLaggards • Traditional, conservative • Suspicious of innovations (Adapted from Rogers, 1995) 18
  • Community Health Promotion for Trainers Section 2 How to Be CHPThere does become a time in the process when enough people in a community haveadopted the new behaviour or technology that the rate of adoption becomes self-sustaining. We call this the “critical mass” or “tipping point”. When this happens, thesocial pressure is great enough to encourage the late majority and laggards to change.They feel that they have no choice but to adopt the behaviour or technology or else theywill be excluded from the community.We can use the “tipping point” to our benefit when trying to encourage positive behaviourchange in a community. A good strategy is for Community Health Promoters to initiallyidentify and help the innovators and early adopters. Providing incentives for earlyadoption can help to create a critical mass in the community needed for the tipping pointto take place. After these people have adopted the behaviour or technology, you canthen change your focus to helping the late adopters and laggards.Exercise – Low Hanging FruitUse Tool 9: Low Hanging Fruit to identify the innovators, early adopters, majority, andlaggards in your community or project.2.2.4 How to Monitor Behaviour ChangeOver time, you should be able to see that the community’s habits are improving. Regularmonitoring allows the project to be modified and improved over its lifetime. This is bestdone by keeping records of some key indicators and observing an improvement in theseindicators.It is important that a list of indicators (or indicators by questions) is developed with all ofthe project partners. Once the indicators have been identified, you will need differentmethods to find out the information so that you can establish to what extent behaviourchange and progress is taking place in the community.There are many different methods that can be used to monitor behaviour change.• Structured observations• Focus group discussions• Interviews• Questionnaires and surveys• Participatory activitiesStructured ObservationsStructured observation is a way of observing and recording particular practices. It letsyou measure specific water, hygiene and sanitation practices directly. Structuredobservation is carried out by a team of trained observers. The observers ask permissionto visit the households, and often come very early in the morning as people get up. Theysit as quietly as possible in a space where they can see what is happening. Each timethey see a practice of interest they note down what happens on a form.Tool 34: Structured Observations provides information about how to use this method. 19
  • Community Health Promotion for Trainers Section 2 How to Be CHPUsing Observations in ZambiaDirect observation was used to evaluate a drinking water project in Zambia. Researchersobserved training sessions for women and children on hygiene. The study revealed thatproject staff used very academic terms and language in the hygiene training. Thesessions were useless because they were not understood by the villagers. With thisinformation, the training sessions were modified to become more locally appropriate. (IFAD, nd)Focus Group DiscussionsFocus groups are a good way of gathering information on peoples ideas, beliefs,practices and behaviour. They gather together people with similar backgrounds for adetailed discussion about a subject. Focus groups work best with people from the samesocial group or economic background. The technique is now widely used in healthresearch and there are a number of helpful manuals, such as that by Dawson et al(1993). This manual provides a step-by-step, easy to read and follow, set of instructionsfor the proper use of focus group methods to learn more about social and cultural issuesrelating to infectious diseases.Tool 35: Focus Groups provides more information about how to use this method.InterviewsConducting interviews is a way to explore what people think about an issue without theformality of a questionnaire or survey. Instead they employ a discussion guide, such as achecklist. The interviewer guides the conversation by asking detailed questions.Interviews can be especially helpful when conducted with key informants, such ascommunity leaders, health workers, teachers, government officials, women, etc.Tool 36: Interviews provides more information about how to use this method.Questionnaires and SurveysQuestionnaires and surveys are used to gather data from a large number of people in astructured way. A questionnaire is a simple form with questions used to gatherinformation from people. A survey is a more structured term that might be one or twosimple questions or could even be a long questionnaire.Tool 37: Questionnaires and Surveys provides more information about how to use thismethod. 20
  • Community Health Promotion for Trainers Section 2 How to Be CHPParticipatory ActivitiesTool 38: Most Significant Change can be used to understand the results that an activityor project is having on people, what a person thinks about the change, and the reasonsfor the change. It can be used to monitor on-going activities or at the end of a project toevaluate its impact.Tool 39: Before and Now Diagram can assess the impact of a community initiative. It isuseful for exploring change over time in a particular situation and the reasons forchange. It can also show how significant events have affected people differently.Tool 33: Monitoring Matrix is a chart that shows what activities are working well and whatneeds improving according to those who are participating in it. It is useful to monitor theprogress of activities with members of the community or project and understand whatdifferent people think about activities that were done. 21
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.3 Participatory Learning and ActionParticipatory learning and action (PLA) is a way to help people to participate together inlearning, and then act on that learning. It is a group of approaches, tools, attitudes andbehaviours that can be used by Community Health Promoters to:• Demonstrate the relationship between water, hygiene, sanitation and health• Increase the self esteem of community members• Help people to share information, learn from each other, and work together to solve common problems• Empower communities to implement their own household water treatment, hygiene and sanitation improvementsThis section gives an overview of PLA, answers frequently asked questions, andpresents advantages and disadvantages of participatory approaches in learning.2.3.1 What is PLA?PLA encourages people to think for themselves. Participants actively contribute toteaching and learning, rather than passively receive information from outside experts,who may not have local understanding of the issues. It encourages the participation ofindividuals in a group process, no matter what their age, gender, social class oreducational background. PLA is especially useful for encouraging the participation ofwomen who in some cultures are reluctant to express their views or unable to read andwrite.Participatory methods are designed to build self-esteem and a sense of responsibility forone’s decisions. They also try to make the process of decision-making easy and fun.The fundamental principles of participatory learning and action are:• participation• valuing local knowledge and experience• empowerment• group analysis and planning• using visual tools• actively seeking the unheard voice• using the right attitudes and behaviours2.3.2 Why Use PLA?PLA has succeeded where other strategies have failed. While participatory activities takemore time to conduct, they are much more likely to be successful than those whichimpose solutions on communities. Experience shows that when everyone contributes tothe learning process, then people feel more ownership of the problem and developbetter solutions for their context.The participatory techniques used in the PHAST initiative proved to be very successfuland rewarding for both communities and for facilitators. So much so, those communityworkers who took part in the initial pilot study to test the use of participatory techniquesfor improving hygiene behaviour did not want to go back to their previous methods. Theywanted to continue with the participatory approach because results were much betterand the process was more enjoyable (WHO, 1998). 22
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.3.3 Who Can Use PLA?Anyone who is willing to try it can use PLA. The tools are flexible and adaptable; theycan be used with different types of people, in different situations and for differentpurposes.2.3.4 When Can PLA Be Used?Participatory approaches are used when a number of people must work together tosolve a problem. PLA can be used at every stage of community mobilization. It can helpyou to:• get a community together to address water, hygiene and sanitation issues• analyze a situation together• decide what needs doing together• make plans• act on those plans• check on how those actions are going• evaluate those actions• reflect on what needs to be done next2.3.5 Where Can PLA Be Used?PLA can be used in both rural and urban settings and rich and poor areas. It has beenused in different countries around the world.PLA is best used wherever people feel most comfortable discussing the topic of water,hygiene and sanitation. This may be in formal workshops, offices, religious meetings orhealth facilities, or in informal meeting places such as people’s homes or under a shadytree.2.3.6 How Can PLA Be Used?PLA is guided by a facilitator, who helps people to use the tools and ensure thateveryone is able to participate equally. As such, Community Health Promoters who arefacilitating PLA need to adopt the right attitudes and behaviours to become a facilitator.The role of the facilitator is a very important one and is discussed in the followingsections of this manual. 23
  • Community Health Promotion for Trainers Section 2 How to Be CHP Advantages and Disadvantages of Participatory Approaches to Learning Advantages Disadvantages They use inexpensive resources. They are difficult to plan because planning often depends on what participants want to do. They can be used in any physical setting. Involving stakeholders takes time. They are interesting and fun – helping toinvolve people in the subject. It can take time for people who are used to being “pupils” rather than “participants” to feel They help people to build self-confidence. comfortable with these approaches. They help people to learn about themselves. Facilitator techniques can be difficult to master and use effectively. They help people to understand theperspectives of others. They can make people feel uncomfortable, for example about drawing or role playing. Participants with different degrees ofexperience and literacy can use them. They can be difficult to document in a report format but can be documented well using They prevent individuals from being singled photographs or by keeping flipcharts.out for what they know or don’t know. Some people may not consider them to be They are less intimidating for less confident valid ways of working.participants. Participants may be more focused on the They can help people to analyze complex creative, rather than the learning aspect of thesituations. activity. Outcomes are often documented during the It can be difficult to establish clear actionprocess and do not depend on jargon. points or conclusions from the activity. They are memorable. Lessons learnt can be brought back to localcommunities or organizations. (International HIV/AIDS Alliance, 2001) 24
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.4 Social MarketingSocial marketing uses commercial marketing tools to target different groups of people topromote habit change and health benefits. Social marketing often reduces the timenecessary to change poor habits. Tools include house-to-house education programs,community events such as theatre performances, and training school children to teachtheir parents to adopt these new habits. People may not readily accept anyimprovements in their water, sanitation and hygiene situation without targeted andculture-specific education and social marketing programs (Oldfield, 2007).The following sections describe how to identify your target audience, design keymessages, and use different tools to work with households, communities and schools.2.4.1 Who is Your Target Audience?Primary target audiences are those who carry out poor water, hygiene and sanitationpractices. Mothers and girls are often chosen as the primary target audience, since theyare usually the main caregivers for young children and are most influential in a familysetting.Importance of Educating Girls“Once you educate the boys, they leave the villages and go search for work in the citiesbut the girls stay home, become leaders in the community, and pass on what they’velearned. If you really want to change a culture, to empower women, improve basichygiene and health care, and fight high rates of infant mortality, the answer is to educatethe girls.” (Mortenson, 2006)While targeting mothers may be useful for influencing change at the household level,there is also a need to involve secondary target audiences who influence their behaviour(e.g. fathers, children, mothers-in-law). There is also a third target audience which isvery important: opinion leaders such as religious, political, traditional leaders and elders(UNICEF, 1999; WHO, 2002). (UNICEF, 1999) 25
  • Community Health Promotion for Trainers Section 2 How to Be CHPEach segment of your audience can be addressed separately, so while you may arrangefor house-to-house visits to reach mothers, street theatre may be more effective inreaching fathers and youths, and leaflets might be appropriate for local opinion leaders(UNICEF, 1999).Exercise – Who is Your Target Audience?Use Tool 20: Targeting to identify those most vulnerable to unsafe water, poor hygieneand inadequate sanitation. Discuss the benefits of using targeted social marketing toolswith these people, and explore how to increase the impact of your activities.2.4.2 Designing the Right MessageCommunication can be more effective if it focuses on benefits that are important to thetarget audience. Any promotion strategy needs to be based on an understanding ofpeople’s needs and local motivations. These could be as diverse as convenience,safety, privacy, health improvement, or money saving. While good health may seem anobvious need from the public health point of view, it may not be the main concern of thelocal community. A targeted promotional strategy based on local motivating factors willbe more successful than the standard public health based promotion (World Bank,2002). Focus on Local Needs Focus on Public Health• Perceptions of community members. • Perception of people outside the community, such as health staff.• Motivating factors are directly related to • Motivating factors are related to the life in the community. prevention of disease.Example thoughts on hand washing: Example thoughts on hand washing:“If I wash my hands more often, it means “People will get sick more often if theythat I have to carry more buckets of water don’t wash their hands.”from the well.”“Clean hands smell nice. I’m embarrassed “Hands are a link in the fecal-oralif my hands smell after using the toilet.” transmission route and the key to breaking that is by hand washing with soap.” (Adapted from Nam Saat Central, 2001)It is also good to focus on positive and useful ideas about safe water and health (e.g.clarity, taste, good health, ease of use) rather than negative ones. It is not a good idea tocreate messages around the fear of disease and the death of children. Messages aboutdiarrhea don’t always make sense to people, and can disgust people because they areunattractive. The tone of the message should be upbeat and encouraging, especially ifthe ultimate goal of the behaviour change is a happy and healthy family. 26
  • Community Health Promotion for Trainers Section 2 How to Be CHP (UNICEF, 1999)Every society already has explanations and words to talk about disease, water, hygieneand sanitation, so messages should be based on existing practices and beliefs. Avoidcontradicting traditional beliefs. Try to integrate and include these beliefs into yourmessages. As well, try to use common words and situations that are familiar toeveryone.Too many messages at one time are confusing to people. Look at the lists of messagesbelow. These are all common in water, hygiene and sanitation education projects. Butthere are so many! You need to keep it simple and focus on two or three key messagesfor good communication. Which ones would you choose? (UNICEF, 1999) 27
  • Community Health Promotion for Trainers Section 2 How to Be CHPExercise – Designing the Right MessageHave a group member read out the following case study:Between 1993 and 1996, research was conducted in Zou Department in the Republic ofBenin, West Africa. The goal was to find out why some households had decided tochange from open defecation, and install a pit latrine at home, and why most others hadnot.Interviews with many households identified that prestige and well-being were the mainmotivators for installing a latrine. Owning a home latrine allowed the owner and theirfamily to: - Display their connections with the urban world; - Show modern views, goals and new values gained outside the village; and - Imitate some of the privilege, wealth and status of the Fon Royalty.People also wanted to protect their family’s health and safety from dangers, accidents,snake bites, and crimes associated with open defecation. There was also a desire forincreased convenience, comfort and cleanliness associated with using a latrine. As well,people wanted to protect themselves from supernatural dangers associated with opendefecation.Preventing fecal-oral transmission of diseases (the classic health benefit used in mostmessages) was hardly mentioned. When infectious diseases were mentioned, they weretraced to smelling or seeing human feces. Beliefs that the smell of feces made a personsick and weak, and that seeing it in the morning brought misfortune and bad luck, werewidespread in the study area. (World Bank, 2004)Based on the information provided in the case study, design two or three key messagesto encourage households to install a pit latrine. Try to focus on people’s needs and localmotivations. Remember to keep it simple and focus on the positive.Message 1:Message 2:Message 3: 28
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.5 How to Work with HouseholdsDoor-to-door household visits can be a good method for awareness building andeducating about water, hygiene and sanitation issues. However, visiting individualhouseholds requires time and is not always practical for organizations with limitedhuman resources.Generally, mothers and child caregivers are your target audience during householdvisits. The following are some things to consider for conducting an effective householdvisit:• Appearance. This is very important. For example, when working in a rural community, try to identify with local people and by wearing simple clothes and using appropriate language.• Introductions. Introduce yourself and ask the person you are addressing to introduce them self, in a locally acceptable manner. This will help to assure the individual that you are genuinely interested in learning about them.• Terms of Address. When asking questions, use the individual’s name. This helps the visit to remain informal or conversational rather than formal or interrogative. The person being asked questions should not feel that they are on trial or being given a test about what they know.• Establish confidence by stressing to the individuals that you are interested in her/his/their opinions, knowledge and beliefs. Make it clear that your intention is to learn and not to judge.• Be positive by focusing on what a household is doing well rather than what they are doing wrong. It is best to start a conversation from a positive point or achievement.• Establish confidentiality by assuring the individual that your conversations will not be repeated to others and that when you write a report, they will not be identified by name.• Privacy. You should be very careful about intruding in people’s privacy. Private and sensitive questions such as asking to see people’s latrines can cause embarrassment. This can be minimized if the person is well-informed about your motives and interests. If people understand why you are asking them such questions, they are more likely to cooperate with you.• Timing. Visits to people’s homes should take into account local patterns of activities. For example, you should avoid arriving for visits at meal times. 29
  • Community Health Promotion for Trainers Section 2 How to Be CHPExercise – Household Visit ChecklistMake a checklist of important attitudes and behaviour that you think a Community HealthPromoter should have when they conduct a household visit. Remember that the targetaudience is usually mothers and child caregivers. An example checklist could look likethe following…Did the Community Health Promoter…1. Greet people politely? Yes A bit No2. Introduce them self? Yes A bit No3. Explain the purpose of the visit? Yes A bit No4. Etc.5. Etc.Record your checklist in the space below. 30
  • Community Health Promotion for Trainers Section 2 How to Be CHPExercise – Role Play a Household VisitUse Tool 21: Role Play to help with this activity. With the whole group, pick a topic that isrelevant to your project that you would like to discuss with a household. Work with apartner to rehearse what a Community Health Promoter should say and do about thistopic. Sometimes it helps to write down your thoughts and prepare a script. The water,hygiene and sanitation posters provided in Appendix 2 can be a helpful tool to facilitateyour discussion with a household.Next, one partner will play the part of the household while the other plays the CommunityHealth Promoter. It is fine to use your notes and posters as a guide during your role play.Afterwards, the partner playing the household role should complete the checklist createdin the previous exercise. Did the Community Health Promoter demonstrate the importantattitudes and behaviour? Share with each other what went well and what part of the visitneeds more work. Switch roles and practice the household visit again.Remember that it is OK to make mistakes - that is why we are practicing! It may take lotsof practice before you are comfortable with the topic and how you will act during ahousehold visit.Pure Water for the World Successfully Working with HouseholdsPure Water for the World (PWW) has installed about 14,000 biosand filters in Hondurassince 2001. The initial focus was to distribute as many filters as possible, however overtime, the project team realized that more household education was needed to ensurelong-term use and proper maintenance of the filters.PWW now has a successful Community Health Promotion program to work directly withhouseholds. Early adopters volunteer to support 10 to 15 homes in their community andhelp monitor the filters. PWW covers the cost of their training and provides freeeducation materials, such as posters, pamphlets and stickers using CAWST designs.PWW is pleased with the outcomes of the program, including improved use andmaintenance of the filters, as well as a stronger connection with the local communities. 31
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.6 How to Work with Community GroupsThe following steps outline how to successfully work with community groups to raiseawareness and promote behaviour change:• Identify the target groups you want to reach;• Design key messages;• Choose effective communication methods;• Prepare the communication materials and activities;• Deliver the activity and message.We have already discussed how to identify target groups and design the right messagebased on local needs and motivations, so now we will focus on the remaining steps.2.6.1 Choosing Effective Communication MethodsThere are many methods that have been used toengage and educate communities around theworld. When selecting a communication method fora particular audience, consider the followingquestions:• Who are the members of each target group?• Where are they?• How many of them are there?• What languages do they speak?• Who listens to the radio or watches television regularly?• What proportion can read?• Do they read newspapers?• To which organizations and groups do they belong?• Which methods of communication do they like and trust? (UNICEF, 1999)By finding out how many of the target audience reads papers, listens to the radio, belongto social groups, etc. you can see which methods are most suitable for your messages.For example, using printed information in the form of pamphlets or posters is notappropriate if the majority of the community cannot read.Partnering with Existing Community OrganizationsBoth formal and non-formal community-based organizations (CBOs), clubs, self-helpgroups, religious communities and political organizations exist in many communities tobring about positive changes. Such groups may be unknown until you talk with thecommunity. Whether the organization is legally recognized or not, they can be animportant resource and should not be overlooked or ignored. You can explore thesituation and mission of any existing organizations and see if there is potential to worktogether to meet a common goal. 32
  • Community Health Promotion for Trainers Section 2 How to Be CHPLocal LeadersLocal leaders are the prominent people in the community who can influence thebehaviour of people. This group includes opinion leaders such as religious, political,traditional leaders, teachers and elders. You can approach and inform local leaders tohelp promote safe water, hygiene and sanitation in the community.DemonstrationsPeople often believe more what they see than what they hear. Seeing othersexperiencing benefits is a powerful motivator. People observe the benefits thatneighbours have with a household water filter or latrine and want the same thing forthemselves and their families. A small number of successful installations of householdfilters or latrines can have a positive influence among the families without the facilities.Mass MediaMass media campaigns usually focus on a few key messagesfor the general public. Simple messages can be disseminated toa wide audience using television, radio, and newspapers. Massmedia can be very timely (eg. Just before the rainy seasonabout cholera) and does not require a high number of personnel.The limitations of using mass media are: • Provides only one-way communication; • May only reach select audiences (i.e. only wealthy households may own a television or radio); • Not very effective for promoting long term behaviour change; and • Centrally produced, so it may not be appropriate for diverse ethnic/linguistic groups within a region.Radio has been frequently used to pass on information since it can be an efficientmeans for wide coverage in a short time. Information can be broadcasted in the forms ofa radio drama, news item, information bulletin, contests or other formats used by thecommunity.You can also try to publish local newspaper articles about issues that are relevant to thecommunity on water, hygiene and sanitation.Radio Competition in Lao PDRIn cooperation with the Centre for Health Education, Lao National Radio has beenbroadcasting information about good personal hygiene and prevention of diarrhealdiseases across the country. Every week, following an informative talk, a question isgiven to the public. People write in their answers and the correct ones are put into adraw. The winners are announced every week and prizes are sent out. The radiocompetition gets hundreds of answers from all over the country. The organizers are verypleased with the response that they get from listeners. Some of the answers are verystrange, which gives the radio people feedback on how clearly they gave theinformation. (Nam Saat Central, 2001) 33
  • Community Health Promotion for Trainers Section 2 How to Be CHPPublications, Posters and PamphletsThere are numerous examples of publications, posters and pamphlets that have beencreated on water, hygiene and sanitation. Appendix 2 provides CAWST posters whichcan be adapted to fit the needs and language of the community.Pure Water for the World has adapted the CAWST posters from Appendix 2 to create apamphlet that is given to households and stickers that are placed on safe water storagecontainers. The cartoon illustrations remind people how to use and maintain theirbiosand filters.Participatory ActivitiesUsing community level participatory activities allows people to contribute to teaching andlearning, rather than passively receive information from outside experts. It encouragesthe participation of all individuals in the community, no matter what their age, gender,social class or educational background. Participatory activities also make learning funand interesting.There are many different participatory activities that can be used in the community,including the following:• Tool 21: Role Play• Tool 22: Story With a Gap• Tool 23: Case Studies• Tool 24: Community Drama• Tool 25: Participatory Photography• Tool 26: Participatory Video• Tool 27: Picture Story• Tool 28: Storytelling (International HIV/AIDS Alliance, 2006) 34
  • Community Health Promotion for Trainers Section 2 How to Be CHPExercise – Create Your Own Participatory ActivityThe facilitator will divide you into small working groups. Each group will be given adifferent community scenario. Your task is to create a product or activity to inform,educate and communicate specific knowledge, skills or attitudes to the community.To start off, discuss the following questions within your group:• Target Audience – who will be the specific audience for the product/activity?• Topics – what specific issues and topics should the product/activity cover?• Communication method – what form of product/activity would be most appropriate for that audience and topic?Next plan the content of your product/activity in detail, including the:• Exact message• Roles and responsibilities• Materials required• Location where the activities will take placeBe prepared to share your results with the entire group. See Tool 29: Production ofInformation, Education and Communication Materials if you need more information.Communication TipsThe best key messages and communication methods:• are attractive: so that they pull people in• use local language and situations: so that people feel it concerns them• are repetitive: so that messages are retained• are easy to understand: so nobody gets confused• are participatory: an exchange of views is most effective• are provocative: so that they are memorable and discussed• show by example: so that the new practices are seen to be possible. (Hiam, Kotler and Graeff cited in UNICEF, 1999) 35
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.6.2 Facilitating Group ActivitiesGroup SizeGroup size is important. For the group to take on its own identity, everybody must knoweverybody else. If groups are too big, then it is difficult for everyone to participateequally. If the group is too small – for example below 8 members – it can forget what itstask is and just become a friendship group.Group NormsNormally the group can suggest its own “ground rules” and participants will generallymention things like respect, punctuality, attendance, and use of cell phones.Exercise – Ground RulesUse Tool 31: Making Ground Rules to establish the group expectations that will guideeveryone’s behaviour during the session.Gender MixThe gender mix should depend on the group task. Having a gender balance can be goodfor everyone to understand both perspectives on an issue. If a group is all female or allmale then there is a tendency to reinforce stereotyped values like “Isn’t it terrible the waymen/women behave – they’re all the same”.Physical ArrangementsIn informal groups, you should sit with the other participants; sitting in a circle issometimes the most appropriate. Rooms should be quiet and free of interruptions. Ifapplicable, nurses or other official facilitators should probably change out of uniform intoordinary clothes.Whole Group Versus Small Group ActivitiesDepending on the objective of the activity it may be necessary for people to work on theirown, with people from the same community or organization, or in mixed groups.Activities can also be carried out with the whole group or with several small groups.Working with the whole group is best when dealing with an activity in which participantsgive each other positive feedback.Working in smaller groups is recommended when every participant has to participatemore than once or if the activity is longer. Using small groups gives every member achance to fully participate and exchange opinions. At the end of small group work, atleast a few minutes should be dedicated to work with the whole group. A spokespersonfrom each small group then responds back to everyone about what the group was doingand what conclusions and results they reached. 36
  • Community Health Promotion for Trainers Section 2 How to Be CHPDividing People Into Small GroupsThere are many ways to divide participants into groups. When there is no logical groupsnecessary for the activity (for example, same gender, same organization, same age),participants can be divided by:• Random mix (for example, all those wearing brown shoes or have names beginning with the letters A to M).• Mixing levels of work experience (for example, those with lots of experience with those with little experience).• Counting 1, 2, 3, 1, 2, 3 etc. or different fruits (for example, apple, orange, mango) so that each group includes those that have not been sitting together.• Mixing gender and ages (ensure that people’s ages are not discussed openly if this is inappropriate). (International HIV/AIDS Alliance, 2006)Keeping Records of ActivitiesThe group should keep a record of its answers and decisions along the way. Usually,these answers and decisions will be clear from the product of the activity. The results ofeach activity can be displayed on walls. How records are made will depend on severalfactors, including the literacy level of the group and available writing materials. Keepingrecords means participants can quickly review their progress when they need to.Generally, it is best if the group selects one or more volunteers to keep records. If noone volunteers, you could ask someone whom you think would do the task well. Makesure the records are brought to each meeting so that the results of previous meetingscan be easily reviewed. If the group is unsure of what to do, confused, unable to reachan agreement, or if participation is slowing, you may need to help the group reviewdecisions reached in past meetings.Evaluate Each ActivityIt is important to receive feedback on the relevance of activities, on what the groupthought was good or bad, and on where improvements could be made in the future.Each activity or the end of each meeting should be evaluated. They can be carried outby using questionnaires or participatory activities. See Appendix 4 for differentevaluation methods. 37
  • Community Health Promotion for Trainers Section 2 How to Be CHPTips for Facilitating a Participatory Activity1. Have all materials for each activity ready before starting.2. Make sure the materials are large enough to be seen by all participants.3. Make sure that people can talk to one another easily; use a circle where possible.4. Introduce yourself and the purpose of the session. Ask each person to introduce themselves to the group.5. Begin each new session with an energizer activity, such as a game, song or dance movement. Examples of different energizers are provided in Appendix 3.6. Agree on the “ground rules” with participants, including the need to respect opinions and confidentiality. See Tool 31: Making Ground Rules for more information.7. Go through each activity one step at a time and give exact instructions.8. Encourage and welcome the input that individuals make. Be careful not to find fault or make critical comments when you respond to people. Remember that there are no wrong answers.9. Try to facilitate the group, do not direct it.10. Try to encourage the active participation of everyone by paying attention to who is dominating discussions and who is not contributing.11. Take into account the participants’ literacy level and work out ways in which they can keep records of what is discussed and agreed upon.12. Have the group keep the materials and records in a safe place.13. At the end of each session, ask the group members to evaluate each activity on the basis of what they have learnt, what they liked and what they did not like. See Appendix 4 for different types of evaluations that can be used.14. At the end of each session, summarize the main points, decisions that have been made, and action points that have been agreed. Thank the participants for their effort and explain briefly what will be covered in the next session.15. At the beginning of each new meeting, get the group to review what it has done so far and the decisions it has taken. 38
  • Community Health Promotion for Trainers Section 2 How to Be CHPAceh’s Very Own Broadway ShowWhile Raju and Era weren’t opening a Broadway show, they did not let that detail comein the way of their daily theatre practice in a tsunami-affected region of Indonesia. Theyare part of a cast of four tsunami survivors staging a drama promoting safe waterhandling practices for their friends and families. Their Aceh community was in an areanearly wiped off the map by the 2004 tsunami waves.At the opening performance, the actors nervously walked onto the makeshift stage in thecommunity centre. Within five minutes, the crowd of mostly women and children werelaughing and clapping. “The topic was interesting. I wanted to take part in this dramabecause I want to encourage all my friends in the community to keep our environmentclean and healthy,” says Raju.Despite the simple set and wardrobe, the actors received an encore from the audience.“We know that we are supposed to wash our hands. But many times we don’t do itbecause we are busy or because we don’t think it’s that important. Our children see thisand they imitate us. Then when our children get sick or we get sick, we wonder why,”says Mauliadar, a community member who saw the play. “Health campaigns like theCanadian Red Cross’ safe water play makes us realize how important safe hygiene is.But in an entertaining way!”This is one of the many ways in which Canadian Red Cross is working to improve thelives and living conditions of tsunami survivors across Aceh province. The environmentalhealth program of Canadian Red Cross in Indonesia supports volunteer groups indeveloping health campaigns to promote safe hygiene and sanitation practices in theircommunities. One of the most effective ways is by using traditional methods ofcommunication to deliver educational messages.“By communicating hygiene information through this infotainment method, my hope isthat community members will be more engaged in learning and implementing thisinformation in their everyday lives,” says Meiry, a Canadian Red Cross hygienepromotion coordinator.After the drama, through the use of games and quizzes, the Canadian Red CrossHygiene Promotion team determines if the audience understands the messages on safewater handling.“Behavioural change is very difficult to measure. We continuously conduct follow-upvisits to ensure that the families who participated in the hygiene campaigns are puttingthe information to good use. Even if 30 per cent of families have changed theirbehaviour, I consider it a success story. Small steps can make a difference,” says Meiry.After the play ends, the women leave to prepare supper before evening prayer time. Twochildren stayed behind in the hall and asks Meiry when there is going to be anotherdrama. “I want to be the chosen again for the next drama,” says Era, her eyes shiningwith excitement. (Mardiati, 2007) 39
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.7 How to Work with SchoolsWater, sanitation and hygiene education can be incorporated into formal schoolcurriculum or informal child education programs. Children tend to be more open toadopting new practices, and they influence the behaviour of their families, peers andneighbours.Child’s Play in BangladeshEleven-year-old Shobu Tara comes from Kallyanpur Pura Bastee slum in Dhaka,Bangladesh. Through WaterAid she has been learning about good hygiene practices."My name is Shobu which means Star and I come here to learn about good hygiene. Iwill be less ill if I learn well. I have already changed some of my behaviour by wearingslippers to the latrine to protect me from getting worms in my feet.”"I didnt even know about washing my hands before, but now I do. I tell my family andneighbours about hand washing and keeping things clean. If I see anyone using a badhygiene practice I tell them.”"The group I am with gets together and then goes and tells adults about good hygiene.We are braver in a group and feel like we can tell adults what to do with moreconfidence." (WaterAid, nd)The primary school age group (children who are approximately 5 to 14 years old) oftenmiss out on public health programs which tend to focus on children under five years old.Diarrheal diseases, hepatitis A, urinary tract infections, constipation and intestinal wormscause children to miss school and lack concentration (World Bank, 2007). All of theseillnesses are linked to poor water, hygiene and sanitation practices.School water, hygiene and sanitation programs need to go beyond the construction offacilities. They should also aim to improve children’s healthy behaviour and their qualityof life. Addressing water, sanitation and hygiene in schools is very useful since youngchildren are far more open to new ideas than adults. They can be stimulated to adopthabits of good personal hygiene which will last through their adult lives.However, getting children to practice hygienic behaviours is not that simple. Althoughhealth and hygiene education in schools may increase children’s knowledge aboutillnesses, this rarely translates into them practicing hygienic behaviours (World Bank,2007). 40
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.7.1 Designing the Right Message for ChildrenChildren often know all about the health problems associated with poor hygiene andsanitation. So education alone is not enough to help children change their behaviour.Similar to adults, we must also understand what motivates children to change theirbehaviour and how to effectively communicate messages to them. Children are not “littleadults” who model their behaviour after their parents and teachers. Most often theyfollow the lead of their peers and have a different perception than adults.Differences in the Perceptions of Children and AdultsIn one school, parents complained that pupils kept losing their underpants and theschool management had found soiled underpants in the toilets. During the researchproject, pupils finally revealed that it was shameful to ask for toilet paper in front of thewhole class before going to the toilet. The adults wanted to avoid toilet paper wastage,but it created shame amongst the students. The children resorted to using theirunderpants in place of toilet paper. (World Bank, 2007)A research project completed among primary schools in Dakar, Senegal gained thefollowing insights about children’s motivations to wash their hands:• If everybody is doing it, why not me? During the study, no child wanted to be left out and all washed their hands at the specified times.• My hands smelled nice. Children were keen to have nice smelling hands and they preferred the scented beauty soap to the odourless soap.• Avoiding diseases means more time with friends. Children were concerned about disease, because it meant missing time with their friends not because they were afraid of being sick.• Clean hands mean clean books, which mean better marks. Children were very worried about losing marks because their notebooks were difficult to keep clean without hand washing facilities. (World Bank, 2007)Why Don’t Children Wash Their Hands?When children were asked why their peers did not wash their hands they suggestedstubbornness, the rush during breaks, the time it takes away from their playtime, and thestate of the toilets. They explained that stubbornness arose from not wanting to do whatthey were told by adults. According to them, hand washing is an activity done alone,which takes time away from fun activities with friends. They also said that thetoilet/washing facilities are scary places that smell bad so they are in a rush to get outand prefer not to stay behind to wash their hands. (World Bank, 2007) 41
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.7.2 Developing Activities for ChildrenBased on understanding children’s need and motivations, the followingrecommendations should be taken into consideration when designing learning activitiesand programs for schools:• Make hygiene and sanitation “cool”. Children live in a social world where the approval of peers is often their highest goal.• Make hygiene and sanitation fun and part of a socializing activity. Children hate to waste socializing time. Activities that can make hygiene and sanitation playful and social are more likely to work in schools.• Find classroom-by-classroom solutions. Children’s school class is often the most important social unit after their family.• Build a sense of pride in belonging to the classroom and school. Building the feeling that “our classroom or school is the best” can work to encourage change. Inter-classroom and inter-school competition often works to motivate children.Children learn in many different ways. It is generally understood that they learn the leastfrom reading or memorizing and the most from experience. It is useful to have a varietyof learning activities which encourage children to actively participate inside and outsidethe classroom. There are many types of participatory activities that can be used inschools, from drama, art and songs to competitions and games.Some other things to consider when you are developing activities for school children:• First meet with the school principal and teachers to explain your purpose and find out their needs and expectations.• Make an agreement with the school and set up the logistics (e.g. time, place, how the visit will be handled, class size, age group).• Remember that teachers are very busy and usually have a lot of responsibility. You are trying to make their job easier, not give them more work to do. Try to integrate activities into the school curriculum or as an after school activity so that it won’t take away from class time.• All materials should be low-cost or free. Teachers and schools do not need to buy special materials or kits.There are several resources available to help you plan learning activities for childrenabout water, hygiene and sanitation:• The Joy of Learning: Participatory lesson plans on hygiene, sanitation, water, health and the environment by IRC (2005) is an excellent guide for people who want to design participatory learning activities. It is divided into two parts: theory and lesson plans. The lesson plans are organised into three sections: hygiene (including personal and food hygiene), sanitation and water. Each section contains a series of information sheets for planning, doing and evaluating participatory learning activities on a specific subject. Examples include personal hygiene, the safe transport and handling of water, protecting local water sources, and local disease transmission routes. 42
  • Community Health Promotion for Trainers Section 2 How to Be CHP The guide is characterised by its participatory activities, the possibility of adjusting each activity to local conditions and cultures, a combination of hygiene and health education with more formal education goals, a focus on socio-psychological life skills such as cooperation and mutual understanding, and the linking of learning activities in schools, homes and communities. Activities require the exclusive use of no- and low-cost materials which are easily available and affordable.• Life Skills-Based Hygiene Education is another manual developed by IRC (2004). Life skills-based hygiene education can help to create effective education and hygienic schools by giving children knowledge as well as attitudes and skills for coping with life (hence the term life skills). Part of this coping is in water, sanitation and hygiene and includes the learning of practical hygiene skills. Life skills-based hygiene education helps children to change behaviour and so reduce risks and prevents water and sanitation related diseases. Teaching children through life skills- based hygiene education materials involves the use of interactive and participatory methods with room for information-focused sessions and child-centred sessions. This document contains an overview of life skills-based education in general and the development of life skills-based hygiene education materials in school sanitation and hygiene education programmes in particular. Its focus is life skills-based sanitation and hygiene education for primary school children. As there are many adolescents in primary schools in developing countries, the age groups covered are from 6 to 14 years.• WaterAid’s Learn Zone website provides teaching and learning resources for use in the classroom, including teaching packs, online games, and videos. 43
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.8 How to Create a Field KitA field kit is the set of materials that a Community Health Promoter uses as visual aidsfor facilitating activities. It is recommended that a basic field kit include the followingmaterials:• Tool 1: Transmission Routes• Tool 2: Analyzing the Barriers• Tool 3: Three Pile Sorting• Tool 4: Sanitation Ladder• Appendix 2: Water, Hygiene and Sanitation Posters• ChecklistsThe ideal field kit consists of drawings that reflect the local culture and circumstances.CAWST has developed four sets illustrations for Tools 1-4 that represent differentregions and cultures:• Latin America• South Asia• Southeast Asia• AfricaThese materials are generally applicable over a wide cultural area where customs,housing and clothing are similar. The materials are open source and are available foryou to copy and use free of charge.In some situations, you may want to have a local artist modify the drawings to look morelike the specific setting in which you will be working. You can also translate the text sothat it is in the local language.Facilitators will generally need a number of sets of drawings. You should keep a masterset that can be photocopied when needed. It is also suggested to laminate or cover yourdrawings in plastic to help protect and make them last longer.There are different ways to keep your materials together. Some Community HealthPromoters put all of their materials into a binder or plastic folder that it easy to removeactivities when they are needed. Others use a cloth or plastic bag to carry theirmaterials.During an activity do not use glue or any other permanent adhesive to attach thedrawings to a surface because they will need to be moved around, removed and reused. 44
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.9 Additional ResourcesBehaviour Change:Network Learning (2003). Health Education for Behaviour Change: A Workbook toImprove Skills. Website: www.networklearning.orgParticipatory Learning and Facilitation Techniques:International HIV/AIDS Alliance (2001). A Facilitator’s Guide to Participatory Workshopswith NGOs/CBOs Responding to HIV/AIDS. Available at: www.aidsalliance.orgInternational HIV/AIDS Alliance (2006). Tools Together Now: 100 Participatory Tools toMobilise Communities for HIV/AIDS. Available at: www.aidsalliance.orgWorld Health Organization (1998). PHAST Step-by-step Guide: A ParticipatoryApproach for the Control of Diarrheal Disease. Available at:www.who.int/water_santitation_health/hygiene/envsan/phastep/en/index.htmlCommunication:UNICEF (1999). Towards Better Programming: A Manual on Hygiene Promotion.Available at: www.unicef.org/wes/files/hman.pdfSchool Activities:International Water and Sanitation Centre (2005). The Joy of Learning. Available at:www.irc.nlInternational Water and Sanitation Centre (2004). Life Skills-Based Hygiene Education.Available at: www.irc.nlWaterAid Learn Zone. Available at: www.wateraid.org/international/learn_zone/ 45
  • Community Health Promotion for Trainers Section 2 How to Be CHP2.10 ReferencesEAWAG/SANDEC (2006). Training Manual for SODIS Promotion. SANDEC Report No.13/06. Available at: www.sodis.ch/files/TrainingManual_sm.pdfInternational HIV/AIDS Alliance (2001). A Facilitator’s Guide to Participatory Workshopswith NGOs/CBOs Responding to HIV/AIDS. Available at: www.aidsalliance.orgInternational HIV/AIDS Alliance (2006). Tools Together Now: 100 Participatory Tools toMobilise Communities for HIV/AIDS. Available at: www.aidsalliance.orgInternational Water and Sanitation Centre (2005). The Joy of Learning. Available at:www.irc.nlInternational Water and Sanitation Centre (2004). Life Skills-Based Hygiene Education.Available at: www.irc.nlMardiati, F. (2007). Aceh’s Very Own Broadway Show, Canadian Red Cross, BandaAceh, Indonesia. Available at: www.redcross.ca/article.asp?id=024145&tid=094Mortenson, G. (2006) Three Cups of Tea: One Mans Mission to Promote Peace…OneSchool at a Time. Viking, USA.Nam Saat Central (2001). Towards Better Hygiene and Behaviour Change for the RuralWater Supply and Sanitation Sector in Lao PDR. Vientiane, Lao PDR. November 2001.Available at:Network Learning (2003). Health Education for Behaviour Change: A Workbook toImprove Skills. Available at: www.networklearning.orgOldfield, J. (2007). Community-Based Approaches to Water and Sanitation: A Survey ofBest, Worst, and Emerging Practices. Available at:mwww.wilsoncenter.org/topics/pubs/WaterStoriesCommunity.pdfRogers, E.M. (1995). Diffusion of Innovations. 4th ed. New York: Free Press. Cited at:www.valuebasedmanagement.net/methods_rogers_innovation_adoption_curve.htmlUNICEF (1997). Towards Better Programming: A Sanitation Handbook. Available at:www.unicef.org/wes/files/San_e.pdfUNICEF (1999). Towards Better Programming: A Manual on Hygiene Promotion.Available at: www.unicef.org/wes/files/hman.pdfWaterAid (nd). WaterWorks. Available at:www.wateraid.org/uk/about_us/wateraid_in_the_news/813.aspWorld Bank (2002). Learning What Works for Sanitation: Revisiting Sanitation Successin Cambodia. Water and Sanitation Program, East Asia and the Pacific Region. July2002. Available at: 46
  • Community Health Promotion for Trainers Section 2 How to Be CHPWorld Bank (2004). Who Buys Latrines, Where and Why? Field Note, Water andSanitation Program, Africa Region. September 2004. Available at:World Bank (2007). Can Hygiene Be Cool and Fun? Field Note, Water and SanitationProgram, Africa Region, March 2007. Available at:World Health Organization (1998). PHAST Step-by-step Guide: A ParticipatoryApproach for the Control of Diarrheal Disease. Available at:www.who.int/water_santitation_health/hygiene/envsan/phastep/en/index.htmlWorld Health Organization (2002). Healthy Villages: A Guide for Communities andCommunity Health. Available at:www.who.int/water_sanitation_health/hygiene/settings/healthvillages/en/index.html 47
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.1 IntroductionThis section provides information for Project Implementers and Trainers about how toplan, develop and implement a training program for Community Health Promoters. It alsotalks about how to evaluate your training to ensure that Community Health Promotershave gained the necessary knowledge, skills and attitudes to do their job effectively. Inaddition, this section discusses different methods that can be used to regularly monitorthe work of Community Health Promoters and assess behaviour change in thecommunity.3.2 Project PlanningAny type of water, hygiene or sanitation project should have an education component toensure behaviour change and a positive impact on people’s lives. Education objectivesand the role of Community Health Promoters should be included in the initial projectplanning phase to ensure that sufficient time and resources are allocated.It is often the case that the emphasis (and the majority of the financial resources) isplaced on the technology, rather than educating people on how to use and incorporatethe technology into their lives. Public awareness and education programs are usually anafter thought and by the time their importance is finally recognized, the project moneyhas already been spent.The education objectives and resources available will depend on the scale of the project.For larger projects (such as those working with more than 100 households), the first twoyears may be necessary to devote to the exploration of local awareness, assessment ofdemand and its underlying causes, and developing demand-generating interventions.The next few years could then be used for behaviour promotion, project implementationand follow-up monitoring of interventions including technical support to the families withnewly installed facilities.3.3 How to Recruit Community Health PromotersThe first step to recruit Community Health Promoters is to create a description of theposition based on the knowledge, skills and attitudes you expect them to have. The jobdescription needs to clearly communicate what responsibilities and tasks are expectedof the Community Health Promoter and the key qualifications of the job.It is useful to create a draft of the job description and then ask yourself the followingquestions:• Are we asking too much of these individuals?• Are the responsibilities and tasks realistic?• Do we need to provide additional compensation?Once a person is selected, the job description serves as a guide to the knowledge, skillsand attitudes that they will need to perform the job. Those skills that they alreadypossess should be refined and applied in the position, while skills or knowledge that theylack can be acquired through your training program. 48
  • Community Health Promotion for Trainers Section 3 How to Train CHPExercise – Create a Job DescriptionLook back at Section 4 and review the knowledge, skills and attitudes that you identifiedfor Community Health Promoters. Write a job description for your project using thisinformation to guide you.TitleSummary(Concise definition of the major responsibilities)Responsibilities or Tasks(List of duties that the person will perform. Begin each duty with an action verb, e.g., check, help, visit)•••••Qualifications(List the knowledge, skills or attitudes necessary to perform the job)•••••Compensation(Is this a volunteer or paid position?)Work Schedule(Is this a part-time or full-time position? What is the time frame?) 49
  • Community Health Promotion for Trainers Section 3 How to Train CHPThe next step is to advertise and interview people for the position. You can post the jobdescription in local newspapers or community boards and make announcements at localevents. Often the best way to find people is through word of mouth. You can speak withlocal leaders and other organizations to see if they have any suggestions for suitablecandidates.Offering Recruitment IncentivesThe Koshish Foundation is a non-profit organization working on biosand filter projects inPakistan. As part of their project, volunteer Lady Health Workers are recruited to providesupport to approximately 125 families in the village. Even though the position is unpaid,Koshish is able to successfully recruit Lady Health Workers by offering the incentive ofreceiving a free filter once the first 20 filters are installed in the village.Almost anyone can become a Community Health Promoter. They can be communityrepresentatives, members of a local NGO or CBO, health workers, nurses, or teachers.It is good to have a gender balance and ensure that you have enough femaleCommunity Health Promoters to connect with mothers and girls. It doesn’t matter whatage or socioeconomic status they are. What is more important is that they have theability to acquire the right knowledge, skills and attitudes, and be able to apply theseconfidently towards household water treatment, hygiene and sanitation.The number of Community Health Promoters needed will also depend on the housingdensity of the population in your community. A higher number of Community HealthPromoters are probably needed in mountainous regions where distances betweenhouseholds can be far, while more people can be reached by one Community HealthPromoter located in a dense urban area.You should plan to recruit more Community Health Promoters than are actually neededin case some change their mind and drop out of the project. For example, train fivepeople if only three are actually needed.Exercise – Potential Community Health Promoters for Your ProjectList the names of people in your project and community who could potentially berecruited as a Community Health Promoter. 50
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.4 How to Develop the Training ProgramCommunity Health Promoters will require training to ensure that they have the necessaryknowledge, skills and attitude to promote water, hygiene and sanitation for your project.Their training program will depend on your budget and time that is available. It can rangefrom one session at the beginning of the project to a series of sessions that are held ona frequent basis over the course of the project.As a minimum, it is recommended that you provide an initial training to CommunityHealth Promoters and a second refresher training shortly before the community work isscheduled to begin. You should also accompany and provide support to the CommunityHealth Promoters during their first activities in the community.3.4.1 Conducting a Needs AssessmentYour Community Health Promoters will probably come from different backgrounds andhave varying levels of experience. Before you create your initial training program, it is agood idea to conduct a needs assessment where you determine their baselineknowledge, skills and attitudes. The needs assessment is then used to plan the trainingprogram to ensure that the content is at the right level, and the materials and activitiesare relevant for everyone. A targeted and focused training program shouldn’t wasteanyone’s time, including your own. Conducting a needs assessment shows people thatyou are willing to invest time and effort to really understand their needs.Many needs assessments are developed based on a list of competencies required toperform a job well. Participants can be given a survey where they asked questions abouttheir competencies to help you determine in advance their knowledge and skills. Keepyour survey brief so more people will be willing to complete it and tallying the results willbe more manageable.Sometimes it is difficult for people to identify the skills or knowledge they lack to performtheir jobs adequately - in other words, they dont know what they dont know. In thiscase, you might not get back enough specific information from the survey or people mayignore the survey all together because they don’t know how to respond to it. As well, itmay not be feasible due to time and resource limitations for you to send out a survey inadvance.No time for a needs assessment? At the very least, it is a good idea to speak one on onewith a few of your new Community Health Promoters to get a better understanding of theculture, motivation, problems, needs and the types of solutions that will be mosteffective. Even a brief fact finding discussion can uncover some of the gaps in theirknowledge and skills and what is needed to fill them in.If your Community Health Promoters are already working in the field and you want toconduct on-going training, you can discuss what struggles they may be facing from day-to-day and what would make their job easier and more efficient. This is also anopportunity to identify any behaviour change challenges they are encountering andaddress those during on-going training. Remember to keep them focused on what theyneed rather than what they want. 51
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.4.2 Planning the ContentThe training program should be designed to help Community Health Promoters becomecompetent and do their job better. If you want this to happen, start by noting how youwant them to do their job afterwards. For example: “After the first training session, theCommunity Health Promoters will be able to conduct household visits and educatefamily members about household water treatment options.”This list of competencies then becomes the list of the training objectives. The objectivesare concerned with achievements by the end of the training session and should beSMART (specific, measurable, achievable, relevant and timebound). For example: “Bythe end of the training session, the Community Health Promoters will be able to…1. Identify different ways water is contaminated by human activities.2. Describe disease transmission routes related to water.3. Describe the 3 steps in household water treatment.4. Demonstrate how to use various participatory learning tools including the F-Diagram, Three Pile Sorting and the Sanitation Ladder.5. Identify skills, knowledge and attitudes required for Community Health Promoters.6. Discuss guidelines for working with households.7. Demonstrate how to use the poster presentation.8. Demonstrate how to use the contents of the field kit.Creating SMART ObjectivesUse Tool 32: Writing Aims and Objectives to help provide a framework for your planningand learn more about SMART objectives.3.4.3 Developing the FormatThe format of the training sessions will depend on several factors – the objectives, theavailable time, geographical location of the participants, and the budget.Creating an agenda for each day brings together all the different activities and exercises.It allows you to see if what you plan is possible in the time available. You will need toconsider each objective and ensure that they can be achieved with the plannedactivities. Often you find that there are too many objectives, so you must either design alonger workshop or cut back on your objectives. You may need to re-write the agendaand objectives a number of times to make sure that you have a format that works.The general structure of a training session includes the following activities:• Opening and introductions. To welcome people and enable participants and facilitators to get to know each other.• Housekeeping. To give information about meal times, facilities, expenses, and what to do in an emergency.• Learning expectations. To clarify participants’ hopes about the training session. 52
  • Community Health Promotion for Trainers Section 3 How to Train CHP• Ground rules. Participants develop ground rules so that everyone has a shared understanding of how people will work together. They are sometimes called a “group agreement” to emphasize the fact that the rules are not imposed by the facilitators.• Objectives and schedule. To outline the objectives, content, methods and timings of the training session. Although presented at the beginning of the workshop for the participants to see, schedules should be flexible to allow the planned activities to be reviewed and changed to meet the needs and interests of the participants.• Energizers. To help participants relax and get to know each other, and give them more energy and enthusiasm. See Appendix 3 for suggested energizers.• Field work. To provide an opportunity for participants to put new skills into practice. For people to learn new skills, they need to practice in situations as near as possible to reality. Though simulations can be helpful, field visits may be required for direct experience.• “Car park” flipchart. To give facilitators and participants a place to “park” issues that need to be covered at some stage, but are not appropriate for that moment in the training session.• Small and large group work. To do participatory activities and have focused discussions.• Recaps. To provide a summary (usually by participants at the beginning of each day) of what has been covered so far.• Follow up action plan. For participants to clarify what concrete steps they will take after the workshop in order to use the new skills and knowledge they have gained.• Evaluation. To enable participants to assess the strengths and weaknesses of the training session, including facilitation, methodologies used, materials, venue, accommodation, food, relevance of topics covered. They can be carried out by using questionnaires or participatory activities. Evaluations can be conducted at the end of every day, or at the end of the entire training session. See Appendix 4 for different evaluation methods.• Closing. The end of the training session can be official or unofficial depending on what is appropriate. Certificates may be expected in some countries. See Appendix 4 for different closings that can be used. (Adapted from International HIV/AIDS, 2001)The following is an example agenda that has been created for the previous objectives onhousehold water treatment. See Appendix 4 for an agenda template. 53
  • Community Health Promotion for Trainers Section 3 How to Train CHP Example Agenda Time Day 1 Day 2 2 hr • Introduction • Opening o Energizer o Recap Day 1 activities o Housekeeping o Energizer • Creating the learning environment • How to change behaviour o Ground rules • Skills, knowledge, attitudes of Community o Learning expectations Health Promoters • Workshop objectives and schedule o Active listening activities o Participatory learning o Effective questioning activities o Explain manual 15 min Break Break 2 hr • Global and local water, hygiene and • How to work with households 15 min sanitation issues • Develop checklist for household visits • Water cycle • Review poster presentation • Water quality and disease transmission o Traditional beliefs o F diagram activity • Improved hygiene and sanitation o Sanitation ladder activity o Three pile sorting activity 1 hr Lunch Lunch 2 hr 30 • Community versus household water • Role play household visits using checklist min treatment and posters • Household water treatment o Multi-barrier approach o Sedimentation o Filtration o Disinfection 15 min Break Break 1 hr 30 • Role of Community Health Promoters • How to create a field kit min • Evaluation • Follow up action plan • Closing • Evaluation • Closing and certificates Home • Read manual Work • Review posters 54
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.4.4 Choosing a LocationIt is important to find a place where people can express themselves freely and feelcomfortable. If possible, take the Community Health Promoters away from their work orcommunity and make it a residential workshop. People will share not only the classroomtime, but social time as well. As well, participants are much more likely to attend full-timesince they will not be distracted by other commitments from work and home.It may not always be possible to find a location outside of the office or community. Aneffective training session can still be organized regardless. In this case, you may want toinsist that participants attend the whole training sessions rather than coming and going.Also consider a location which is easy for all Community Health Promoters to get to.Remember, it is more important for it to be a place which is easy for participants to getto, rather than a place which is easy for you to get to.3.4.5 Identifying the ParticipantsIt is important to choose the right number of people. You may want to have a smallgroup to provide intensive training and support, or a larger group to have a wider rangeof participation.A maximum of 20 participants is recommended so that everyone has the chance to fullyparticipate in the training. If there are more people than this, some of the participants willkeep quiet and not contribute. A common reason for training sessions to fail in meetingtheir objectives is that more people than planned are added to the participant list. Theevent then turns into lectures rather than participatory activities and time for practice islost.3.4.6 Selecting the FacilitatorsYou will need at least one facilitator for a workshop of 20 participants. It is always a goodidea to have an assistant facilitator to help the main facilitator if you can afford a secondperson. It is always a good idea to have more than one person in your organization whocan deliver the training and an assistant is a perfect way to train somebody aboutfacilitation skills.It can also be helpful to have guest speakers or local experts on a topic to participate inthe training session. They can help everyone to deal with issues, such as how to puttheory into practice at a community level. Always talk to your guest speakers beforehandabout your expectations and be sure that they understand their role and timecommitment. 55
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.4.7 Working with the Facilitation TeamIt is important that the facilitation team works well together – both as professionals andas a group of people. Ways to build a strong team include:• Get to know each other as people. Use participatory activities to share information about each other. For example, share timelines showing key milestones in each other’s lives. Go out for lunch or dinner together the day before your training session.• Get to know each other as facilitators. Share information about your skills and the areas where you would like to develop more skill. For example, draw self-portraits and note facilitation strengths down one side and facilitation weaknesses down the other.• Get to know each other as colleagues. Different team members will have different working styles and preferences. These can be explored through activities such as “I like it when colleagues…I don’t like when colleagues…”• Get to know the subject matter together. Read through the resources to develop a common understanding and clarify points that are unclear.• Assign roles and responsibilities. Decide who will do what for each day and each session. Facilitators may prefer to design and conduct sessions in pairs for support. It is useful to clarify the role of the other facilitators when they are not actually leading an activity – should they be helping group work or be available to answer questions?• Enable continuity. Where possible, ensure that all facilitators are present during the entire training session.• Develop a facilitation team contract. Setting the ground rules can answer questions about how facilitators want to work together, such as: o What does the team want their training session to be like? For example, fun, interesting, challenging. o How does the team want to function together? For example, providing mutual support, working in pairs, having a leader. o What principles are important for the team? For example, being gender sensitive, respecting each other’s strengths and weaknesses. o How will you deal with potential problems? It is always useful to have a pre-arranged signal or a way of drawing each other’s attention. For example, raise your hand and the lead facilitator can call on you. (International HIV/AIDS Alliance, 2001) 56
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.4.8 Monitoring the TrainingFacilitators should debrief at the end of each day and at the end of the training sessionto discuss the overall strengths and weaknesses of the training session and to identifyimprovements for the future. The following are things that could be monitored anddiscussed to make sure that the training session is on track.• Is the agenda being followed? Are activities too long or too short?• Did participants learn what was planned during the activities?• Is the participant behaviour friendly and respectful towards each other?• Did any participant dominate the discussion? Should you leave it or take action?• Did any participant stay quiet and not contribute? Should you leave it or take action?• Were there enough breaks?• Is the training room ready for tomorrow? Is it tidy? Are visuals available? Are all the supplies present?• Are there any other problems that need to be dealt with? Accommodation? Food?3.4.9 Writing the Final ReportYou often have to write a final report on the training session for the funders and for yourorganization’s records. Writing a final report is a good way to reflect on what worked welland lessons learnt to improve the next training session. The following is a suggestedtable of contents for your final report.• Training Session Title• Host• Location• Dates• Funding agencies• Objectives• Facilitation team• Translators• Participants and contact information• Activities worth noting• Lessons learned• Recommendations for future training• Follow up action plan 57
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.5 Training Activities to Develop Skills and KnowledgeThe following sections describe the key skills and knowledge required of CommunityHealth Promoters. Various participatory learning activities are provided to help you trainCommunity Health Promoters to develop and enhance these skills and knowledge.3.5.1 Active Listening SkillsThis means more than just listening. It means helping people feel that they are beingheard and understood. Active listening encourages the participation of people and amore open communication of experiences, thoughts and feelings. In active listening, theperson listening:• Uses body language to show interest and understanding; in most cultures this will include nodding the head and turning the body to face the person speaking• Uses facial expression to show interest and reflect on what is being said; this may include looking directly at the person speaking, although in some cultures such direct eye contact may not be appropriate until some trust has been established• Listens to how things are said by paying attention to a speaker’s body language and tone of voice• Asks questions to show a desire to understand• Summarizes and rephrases the discussions to check on an understanding of what has been said and asks for feedback. (International HIV/AIDS Alliance, 2006) 58
  • Community Health Promotion for Trainers Section 3 How to Train CHPExercise – Nodders and ShakersYou will need to work with a partner to show how body language affects communication.Hold a conversation on any topic for five minutes. During this time, one of you has to nodtheir head repeatedly while the other shakes their head. About half way through, swapnodding and shaking your heads.Discuss the following questions with your partner and the entire group:• Did you feel that you were being listened to?• Were you distracted by the nodding and shaking?• How did making those body movements affect your conversation?• Can you remember what was said?Exercise – Practice Your Active ListeningUse Tool 10: Back-to-Front, Tool 11: Bad/Good Listening and Tool 12: Margolis Wheelto help you to develop active listening skills.3.5.2 Effective Questioning SkillsEffective questioning increases people’s participation in discussions and encouragestheir involvement in problem solving. In effective questioning, the person:• Asks open-ended questions that create discussion and encourage everyone to participate. For example using the six key ‘helper’ questions (Why? What? When? Where? Who and How?)• Asks probing questions by following up people’s answers with further questions that look deeper into the issue; continually asking, ‘But why…?’ is useful for doing this• Asks clarifying questions to ensure they have understood, which can be done by rewording a previous question• Asks questions about personal points of view by asking how people feel and not just about what they know. (International HIV/AIDS Alliance, 2006)Exercise – Practice Your Effective QuestioningUse Tool 13: Probing Deeper, Tool 14: Open and Closed, and Tool 15: Sensitive Topicsto help you to practice effective questioning skills. 59
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.5.3 Facilitation SkillsFacilitation means to “make things easy”. This skill is needed to ensure that everybodyfeels that they are part of the group and has the chance to participate in the activity.Good facilitation skills help to improve the quality of group discussions and problemsolving. In general, Community Health Promoters need to develop facilitating skills infour main areas:• Encouraging sharing and learning• Communicating well• Keeping material practical and relevant• Responding to group dynamicsThe following sections provide a checklist and some ideas of the techniques thatfacilitators use to make sure that participants have the best possible learning experience(International HIV/AIDS Alliance, 2001).Encouraging Sharing and Learning• Participation of each group member should be considered equally important. You must also be seen to be on the same level as participants. Do not present yourself as an authority figure who knows more than everyone else.• Ensure that everyone is comfortable and can see and hear each other.• Encourage two-way communication by actively listening to people and by using open, rather than closed questions.• Paraphrase or sum up to confirm people’s key points. Tips for summarizing include: o State the positive points first. o Highlight where there was agreement or differences. o Reflect on people’s comments rather than your own opinions. o Focus on the main points that have been made.• Confidentiality also needs to be stressed; participants must agree not to disclose embarrassing details about others. Or a group can agree that things can be talked about outside the group, but nobody can be identified.Exercise – Trust GameUse Tool 16: Trust Game to help people understand the issues of confidentiality andwhat is feels like to give people sensitive information about themselves. It also helpspeople to gain trust in each other.Communicating Well• Talk slowly and clearly. Use language that is simple and appropriate.• Provide clear guidance and instructions.• Be honest and clear about what you do and don’t know.• Use handouts, prepare flipcharts, and make examples to help explain activities.• Display the results. Put participants’ work on the walls, on tables, or on the ground where everyone can see them. 60
  • Community Health Promotion for Trainers Section 3 How to Train CHPExercise – Folding Paper GameThis exercise will help to show how simple instructions can be misinterpreted and theimportance of clear communication.• Four volunteers need to stand in front of the rest of the group.• Give each volunteer a square sheet of paper. They must close their eyes and not ask any questions.• Another person gives the following instructions: 1. Fold the paper in half and tear off the bottom right hand corner. 2. Fold the paper in half again and this time tear off the upper right hand corner.• Ask the volunteers to open their eyes and show everyone the unfolded paper. It is very likely that the results will not be the same.• Discuss as a group how the directions could have been clearer and what words could have been interpreted in different ways. How can people be encouraged to ask for clarification when they do not understand something?Keeping Materials Practical and Relevant• Focus on practice rather than theory. Include case studies of real community projects in action.• Talk about “we” and “us” rather than “they” and “them”.• Link the activities to participants own work or home. Ask “How could you use this in your day-to-day activities?”Responding to Group Dynamics• Cope with power imbalances. Encourage people with different social and professional backgrounds to work together as equals.• Avoid crisis. Deal with problems as they come up and work with the group to resolve them.• Deal positively with criticism. It is important to find a way for the participants to challenge each other constructively. Encourage discussion of the criticism, such as by asking, “Can you explain why you feel that way?” or “What do others think?”• Accept that you may not be able to please everyone all the time. It can be difficult for facilitators to accept the fact that participants do not always have to agree on everything. It is more important that they have shared different experiences and learned from them.• Balance participation. Encourage quiet participants to speak out and dominant ones to respect others. 61
  • Community Health Promotion for Trainers Section 3 How to Train CHPHow to Cope With Quiet and Dominant PersonalitiesFacilitators can build the confidence of quiet participants and encourage them to becomeinvolved by:• Encouraging them to start by speaking during small group work.• Asking them to share in a discussion about their area of specific interest or expertise.• Using activities where all participants are asked to make a small contribution.• Providing them with positive, but not patronizing, feedback when they contribute. For example, try and build on or reinforce what they have said rather than say “well done” or “very good”.Facilitators can work positively with dominant participants and support them to let othersmake a contribution by:• Giving them positive feedback and involving other participants in responding to them. For example, by saying “Thank you for that interesting viewpoint. What do other people think about it?”• Speaking with them privately during a break to ask them to allow others more time to participate.• Giving them a “job” to do within the workshop, for example providing the participants with a re-cap at the beginning of each day, or gathering and handing out the materials for the activity.• Drawing their attention to the established “ground rules” about allowing everyone to contribute or using games that encourage awareness of one’s own behaviour.• If the dominant person is a community leader, you can approach them formally or privately early in the planning phase, explain the process, and try to gain their support. Hopefully, you will be able to convince them that allowing community members to fully and equally participate will result in personal growth and betterment for all.Use Tool 17: Sabotage and Tool 18: Facilitation Challenges to help you to practice howmanage group dynamics.Exercise – Practice Your Facilitation SkillsUse Tool 19: Good Versus Bad Facilitation to consider what are good and bad practicesand help you practice your participatory facilitation skills. 62
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.5.4 KnowledgeCommunity Health Promoters should be able to provide basic and accurate informationon how to provide safe drinking water, good hygiene practices and basic sanitation. Thistype of information is provided in Section 2 Water, Hygiene and Sanitation and Section 3Household Water Treatment.The following tools can also be used to check understanding of basic water knowledgeand proper hygiene and sanitation practices:• Tool 1: Transmission Routes• Tool 2: Analyzing the Barriers• Tool 3: Three Pile Sorting• Tool 4: Sanitation LadderAs well, Community Health Promoters should understand and know how to use thewater, hygiene and sanitation posters that are provided in Appendix 2.It is beyond the scope of this workbook to provide specific details on how to use,maintain, and troubleshoot different household water treatment technologies.Community Health Promoters may require additional technical training depending on thenature of the project and activities they are expected to perform.Community Health Promoters also need know how to use a variety of PLA toolseffectively. This means knowing:• The range of tools and which work best in different situations with different people.• How to facilitate these tools effectively.The tools referred to in this workbook are all available in Appendix 1. It is a good idea tolook through and familiarize yourself with as many tools as possible.You will need to match the right tool to the issues you will be addressing. There are norules about which tools can be used for which issue. You also need to consider whichtools work best with the people who will be using them. Some tools work best withpeople who share the same characteristics, for example same gender, age group and soon. Some tools work better in large groups, others in smaller groups. As a general guide,tools that require a lot of detailed analysis, or are of a very personal nature, are bestused in small groups.You also need to think about how much time you have available to cover all of yourobjectives. Some tools can deal with a lot of issues at once, while others concentrate onjust one issue in depth. Time is the most important resource required in facilitatingparticipatory learning and action. However, the poor who you are trying to engage areoften very busy and suffer from “time poverty”. Time spent away from their regularlivelihood often means a loss of income. You need to be aware of people’s schedulesand time limitations when trying to plan a community activity (International HIV/AIDSAlliance, 2006). 63
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.6 How to Evaluate the TrainingYou need to know whether the training session has achieved its objectives. There aredifferent ways for you to evaluate if Community Health Promoters have the minimumknowledge and are competent in a certain skill set.3.6.1 Knowledge GainedIt is quite easy to find out whether participants know the facts after the end of a trainingsession, but this does not necessarily tell you whether they have learned anything new.They may have known them before they ever came into the session. They may alsoforget them before they ever have a chance to use the information in the field. If you canfind out what the participants know to start with it also helps you to plan your trainingbetter.You can evaluate participant’s knowledge gain by using a simple test before they haveundertaken a topic and then another one after they have finished it. Use exactly thesame questions every time.You can also test participants’ knowledge by giving them problems or scenarios andasking them to tell you what they would do. For example:• You approach a household for the first time and the door is slammed in your face. What would you do?• You are explaining how diseases are transmitted to a mother and she refuses to believe that she gets sick from drinking the water. What would you do?• You are visiting a household who received a new biosand filter two months ago. You notice that the filter lid is missing and that the outlet tube is very dirty. What would you do?Alternatively, participants can do the following informal self assessment of their learning.Often, people grade themselves harder than the facilitator would.• On a chart paper write the three or four topics that are going to be covered in the training session.• Under each heading draw a line with a 10-point scale (1 being low, 5 being medium and 10 being high).• On the first day for the pre-evaluation, have participants mark their knowledge of each category with a coloured sticker or marker. Explain that it is OK for participants to rate themselves low on the scale. This is just to get an idea of the group’s knowledge and demonstrate how much people will learn over the course of the training session.• On the last day for the post-evaluation, have participants mark their knowledge of each category with a different coloured sticker or marker. Discuss how participants have moved along the scale. 64
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.6.2 Skills LearnedFor each skill, a checklist can be used to help you evaluate a Community HealthPromoter’s performance. Checklists help you to judge the extent to which the new skillhas been learnt.First of all, decide on what the skill is going to be. For example, you may wantCommunity Health Promoters to practice talking with a household about how a biosandfilter is installed, operated and maintained; or you might want them to discuss basichygiene and sanitation practices with a family.Then have the group analyze the skill to be learnt and make a checklist with which theycan judge their own performance. An example checklist could look like the following…Did the Community Health Promoter…1. Greet the person politely? Yes A bit No2. Introduce them self? Yes A bit No3. Explain the purpose of the visit? Yes A bit No4. Use appropriate language? Yes A bit No5. Give useful information? Yes A bit No6. Find out how committed the individual and household is to change? Yes A bit No7. Agree on strategies to help change? Yes A bit No8. Design a plan for change with the individual, including a timeframe and future visits? Yes A bit No9. Say thank you for the individual’s time? Yes No10. Provide their contact information in case the household has questions at a later date? Yes No11. Etc.Notes:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 65
  • Community Health Promotion for Trainers Section 3 How to Train CHPThe checklist ensures that people know the standard they have to achieve. The standardcould be that “by the end of the training, each participant will score a “yes” tick on mostof the items on the check list” – perhaps eight out of ten or whatever you decide isappropriate.Have the participants work with a partner to rehearse what they are going to say and do.Sometimes it helps people to write down their thoughts in advance and prepare a scriptfor themselves. One participant acts the part of an individual household while the otherplays the Community Health Promoter.The role play can be done in partners, or held in front of the group depending on theparticipant’s comfort level. Afterwards, the partners or group can complete the checklistto determine what went well and what part needs more work. Tool 21: Role Play can beused to facilitate this activity.It might take several times of practice before Community Health Promoters scoreenough “yes” ticks on the checklist. People could change the partner or group they workwith after each practice. You may need more time for people whose performance,measured by the checklist, was not good enough.In some cultures it is difficult for people to make fools of themselves, as they see it, infront of their peers or supervisors. In this situation, it is better to have people practicetheir role plays in partners rather than in front of the entire group. In other cultures,people have problems separating the role from them. If they play a “bad person”, theyfeel they are being seen by others in that way. Where these attitudes exist, it is better ifthe “bad people” roles are played by facilitators or other staff.As the facilitator, you may notice that somebody shows inappropriate attitudes or thatthere is a common misunderstanding during the role play. One good way of challengingthis is for the facilitator to take the role of the Community Health Promoter in the roleplay and in front of the group exaggerate these poor attitudes or misunderstandings.After discussion, another item could be added to the checklist, such as “Did theCommunity Health Promoter demonstrate the right attitude towards the household?”The need to practice is especially important for technical skills. Imagine that you aretraining Community Health Promoters on how to use and maintain the biosand filter. Youwill need real biosand filters to practice on and a checklist with specific criteria to ensurethat the job is well done. You might decide that each Community Health Promoter shoulddemonstrate the maintenance steps at least three times and to receive a good score. (Adapted from Moynihan et al., 2004) 66
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.7 How to Monitor Community Health PromotersRegular monitoring of Community Health Promoter activities allows the project to bemodified and improved over its lifetime. It is recommended that the Trainer visit with theCommunity Health Promoters once per week during the first month after training, andthen meet once per month afterwards to monitor the progress of their activities.However, this may not be possible depending on your budget, so an appropriatemonitoring schedule should be created based on your organization’s needs andavailable resources.The Community Health Promoters should also be brought together once every month orwhen required to review their progress, exchange experiences, and discuss anyproblems or issues. Tool 33: Monitoring Matrix can be used with the Community HealthPromoters to see what activities are working well and what needs improving according totheir experiences.Follow Up with Community Stewards in IndiaThe South Asia Pure Water Initiative (SAPWII) supports a small factory in Kolar,Karnataka state to make biosand water filters. Their initiatives are designed to mobilizecommunities around the importance of clean water in three ways: provide clean point-of-use drinking water; educate children about better hygiene; provide community-basedemployment for project staff. Their five-year goal is to manufacture and install 15,000filters in South India by 2011 and provide ongoing water and sanitation education.To help meet their goal, SAPWII employs Community Stewards who are trained andpaid for a one year period to oversee the proper use of the filters by the villagers. Theyalso provide sanitation and hygiene education to make the link between clean water andhealth.SAPWII requires that Community Stewards get together at the Kolar workshop on amonthly basis to review their progress, exchanges experiences, and discuss any issues.Many of the Community Stewards must travel a great distance to attend the monthlymeeting, but it is worthwhile for the opportunity to interact with their colleagues.Community Stewards also receive their monthly pay at this time which is an extraincentive to attend the training session. (SAPWII, nd) 67
  • Community Health Promotion for Trainers Section 3 How to Train CHP3.8 Additional ResourcesInternational HIV/AIDS Alliance (2001). A Facilitators’ Guide to Participatory Workshopswith NGOs/CBOs Responding to HIV/AIDS. Available at: www.aidsalliance.orgMoynihan, M., Guilbert, J., Walker, B. and A. Walker (2004). How to Run a Workshop.Available at: www.networklearning.org3.9 ReferencesDawson, S., Manderson, L. and V.L. Tallo (1993). A Manual for the Use of FocusGroups. Available at: www.who.int/tdr/publications/publications/focus.htmFerron, S., Morgan, J., and M. O’Reilly (2000). Hygiene Promotion: A Practical Manualfor Relief and Development. CARE International.International Fund for Agricultural Development (nd). Managing for Impact in RuralDevelopment: A Guide for Project Monitoring and Evaluation. Available at:www.ifad.org/evaluation/guide/index.htmInternational HIV/AIDS Alliance (2001). A Facilitators’ Guide to Participatory Workshopswith NGOs/CBOs Responding to HIV/AIDS. Available at: www.aidsalliance.orgMoynihan, M., Guilbert, J., Walker, B. and A. Walker (2004). How to Run a Workshop.Available at: www.networklearning.orgSouth Asia Pure Water Initiative, Inc (nd). Personal communication. Available at:www.sapwii.org 68
  • Community Health Promotion for Trainers Section 4 Case StudiesSection 4 Case Studies4.1 Nigerians for Pure WaterInstructions:• Read the following case study. Note that all names and places are fictitious.• Complete the series of questions pertaining to the case studyNigerians for Pure Water (NPW) is a non-governmental organization that has beenworking in rural areas outside of Abuja, Nigeria for over five years. They are a grassrootsorganization working primarily in water, sanitation and hygiene in more than 20 localcommunities. The rural communities where NPW is working are underserved by thegovernment and are primarily using seasonal rivers, ponds, and open wells to supplytheir drinking water. Latrines and sanitation infrastructure are uncommon.NPW’s approach begins with constructing and installing biosand filters in householdswith the greatest need, charging each household a small fee for the filter. CommunityHealth Promoters are trained within each community to provide education on safe water,sanitation and hygiene practices as well as assist with any maintenance and operationneeds of the biosand filter users. NPW is planning to follow-up with a sanitation programto construct latrines, since open defecation is a common practice, but has not yetreceived the funding for such a project.NPW has seen an improvement in the health of biosand filter recipients, but realizes theneed to support a comprehensive water and sanitation program. Olajide, the ProgramDirector of NPW, has planned a visit to one of the villages to check on the progressmade by the organization. The Community Health Promoter, Yele, has agreed to showOlajide around the community and visit with several families that have received biosandfilters.They arrive at Desola’s house shortly before lunch and are invited to share some tea.The biosand filter is painted a bright blue color and prominently displayed in the cornerof the kitchen. Olajide notices there are several, open containers near the filter that areused to store water.Desola is anxious to demonstrate how the family drinks filtered water. Her son has justreturned with a bucket of water from the nearby pond and Desola pours the bucket intothe filter basin. She grabs an open container and places it underneath the outlet tocollect the filtered water. She explains that the water is then stored in a differentcontainer (without a tap or spigot) before the family drinks the water. Her son is thirstyafter fetching the water and takes a glass, dips it into the drinking water storagecontainer, smiles, and drinks from the glass of water.The kitchen is a busy room. Desola is cooking lunch for the day, chickens run in and outof the room, and a small goat is resting under the table. Yele asks Desola to talk aboutthe filter and if it has helped the family at all. Desola is pleased to report that she hasspent less money on medications in the past few months for her young children. Shealso says that her neighbors have been asking how they can get a biosand filterbecause they like the taste and appearance of the water. 69
  • Community Health Promotion for Trainers Section 4 Case StudiesAfter drinking tea, Yele and Olajide continue their visit in the community and are bothpleased with the progress NPW has made so far. He realizes that there are someopportunities to improve the Community Health Promoter program. He will incorporatethese changes into the next monthly training of the Community Health Promoters.Exercise – Project PlanAs a large group, discuss how NPW plans to solve the water problems in the rural areaaround Abuja. Write your response below.Exercise – Role of Community Health PromoterIn partners discuss, what is the role of the Community Health Promoters in the NPWproject? What are some activities that they would be doing to fulfill their role? 70
  • Community Health Promotion for Trainers Section 4 Case StudiesExercise – Community Health Promoter TrainingPersonal Reflection: If you were the Community Health Promoter, what type of trainingand tools would you want to perform your job? As a Coordinator, how would youprepare the Community Health Promoters to effectively complete their duties?Exercise – Future PlansIn partners, discuss what NPW could do to improve their current water, sanitation andhygiene program. Based on Olajide’s visit to the community, what would you change oradd to the Community Health Promoter program? 71
  • Community Health Promotion for Trainers Section 4 Case StudiesExercise – TrainingAs the Coordinator, how would you incorporate these changes into your trainingactivities with the Community Health Promoters? 72
  • Community Health Promotion for Trainers Section 4 Case Studies4.2 School Hygiene PromotionInstructions:• Read the following case study. Note that all names and places are fictitious.• Complete the series of questions pertaining to the case studyFulana is working as a Community Health Promoter with Water for All, an internationalNGO working in Peru. To complete her duties, she spends two days a week working inher own village and two additional villages nearby. Fulana has been working with Waterfor All for more than a year and began her work through the primary schools in each ofthe villages. The elementary schools had received funding through Water for All toconstruct latrines for the students and promote hand washing.Fulana held meetings with the school teachers to discuss ways to promote betterhygiene and sanitation practices with the students. She learned that the teachers wereoverworked and didn’t have enough time to focus on basic life skills with the children.The teachers reported that many students missed school on a regular basis due toillness and that many had short attention spans and lacked focus when they werepresent. Fulana also found out that many children didn’t know why they were getting sickand just accepted diarrhea as a fact of life. As well, she noted that the drinking watersource was an open, shallow well where children used a rope and bucket to fetch water.Fulana also had a chance to talk with a few of the students. They didn’t like being sickbecause it was embarrassing to have diarrhea and meant missing out on play time withtheir friends. The children also didn’t like washing their hands because they had to fetchwater from the well to do so. When they used soap, they preferred the brightly colouredand fragrant bars instead of the plain white powdered soap.Exercise – Designing the Right MessageOften, schools can be an ideal yet challenging setting for promoting sanitation andhygiene behaviours. Based on an understanding of the children’s knowledge andmotivations, what two or three key messages would you design to encourage bettersanitation and hygiene practices? 73
  • Community Health Promotion for Trainers Section 4 Case StudiesExercise – Designing the Right ActivitiesBrainstorm two or three activities that you could do to promote improved hygiene andsanitation practices with the children.Fulana decided to distribute handwashing equipment - soap and wash basins to each ofthe classrooms to promote ownership of the materials. Since the schools did not haveenough funds to employ an individual to clean and maintain the latrines, each classroomwas assigned a maintenance task every week. Children were protective of the soap fortheir classroom, whereas previously, soap often went missing from the common area.Latrines were kept clean by the students, ensuring more use of the facilities.Exercise – Taking Care of FacilitiesHow would you encourage maintenance and ownership of sanitation and hand washingfacilities in a school setting? 74
  • Community Health Promotion for Trainers Section 4 Case Studies4.3 Late AdoptersInstructions:• Read the following case study. Note that all names and places are fictitious.• Complete the series of questions pertaining to the case studyJoseph is a Community Health Promoter in the village of Lakeview. He has beenworking for the past few months in his own community to bring about better hygienepractices such as handwashing and proper disposal of children’s faeces. He visits eachhouse in the village once a month. On the first visit, he introduces himself and tellspeople about the new behaviour he is promoting.On the first visit to Sara’s house, she is very positive about the ideas that Joseph hasabout safe hygiene practices to help improve the health of the family. She says that sheunderstands that by washing her hands with soap at critical times (after defecating,before preparing food, and before eating) will result in a healthier family. Sara nods inagreement that she will begin to wash her hands at critical times.On Joseph’s second visit they create a handwashing station using materials from thehouse. He encourages Sara to use some soap from washing clothes for handwashing aswell. On the third visit, Joseph notices that the handwashing station does not have waternear it nor soap. It appears as if the facility is not being used at all. This seems to be thecase in several households in the village. He’s discouraged by the lack of participationby some of the villagers.Joseph is having difficulty understanding why people do not want to adopt these hygienepractices. He has made several visits and tried to negotiate improved behaviour duringeach visit, but he is not seeing results in some of the households.Exercise – Identifying BarriersWhat are some possible barriers to behaviour change in Sara’s house? 75
  • Community Health Promotion for Trainers Section 4 Case StudiesExercise – Overcoming BarriersWhat are some ways to address the barriers that you identified?Exercise – Providing SupportHow would you as the Coordinator encourage your Community Health Promoters whenthey face challenges in the community? What are some activities you could do withthem? 76
  • Community Health Promotion for Trainers Section 4 Case Studies4.4 Hygiene Promotion in Burkina FasoDescription of the programProgramme Saniya was carried out in Bobo-Dioulasso between August 1995 and July1998. The program was implemented by the Ministry of Health of Burkina Faso withtechnical assistance from the London School of Hygiene and Tropical Medicine andfunded by UNICEF. It aimed to promote a small number of safe hygiene practices, wasbased on the existing local motivation for hygiene, and used local channels ofcommunication to reach the target groups.The target behavioural practicesThe initial research showed that the incidence of diarrheal disease was more related tofailure to dispose of children’s excreta effectively, and failure to wash hands with soapafter contact with excreta, than to water quality. So the program focused on changingthese specific practices.The target groupsThe primary groups targeted for the intervention were mothers, older sisters and maids,who are the principal care givers of young children in Burkina Faso. School agedchildren were also keen to participate, so a curriculum for primary schools was added tothe program.Designing the messageThe content of the messages reflected the findings of the research, which suggestedthat mothers desired hygiene, not for the sake of avoiding diarrhea, but for aesthetic andsocial reasons. Messages were thus built around the respect they might gain from beinghygienic, and the improvements gained in quality of life when excreta were removed andcould not be seen or smelt. Germ theory of disease did not figure in any of themessages addressed to the adults, although it did form a part of the hygiene curriculumfor schools.Choosing effective communication methodsThe program used focus group discussions and a small questionnaire to identify localchannels of communication suitable for the specific target groups. Although two-thirds ofmothers regularly listened to local radio, the program staff decided that face-to-facehousehold visits would also be needed, because other people who cared for childrenhad little exposure to any type of communication except word of mouth. Messages werealso transmitted during a djandjoba (social event with music and dancing), whichprovided a good environment for transmitting information.Program implementationThe program was launched in August 1995 with a municipal ceremony, a mass clean-upof public spaces, and a phone-in on local radio. Subsequently six activities took placeover three years of the program: 77
  • Community Health Promotion for Trainers Section 4 Case Studies• Community volunteers conducted monthly household visits.• Health staff were trained to add participatory discussions related to hygiene to the normal program of health centre talks.• A theatre group created a play that was performed weekly.• A set of twelve radio spots was broadcast on three local radio stations.• Teachers were trained and a curriculum devised for six hygiene lessons in primary schools.• Schools received a starter box of soap and buckets to encourage children to wash their hands.Monitoring• Five project workers accompanied community volunteers in a rotating programme of home visits and reported on theatre activities.• Health centres completed forms that recorded their activities.• Volunteers listened to a specified sample of broadcasts from local radio stations.• Primary schools inspectors made visits to monitor progress. (World Bank, 2002) 78
  • Community Health Promotion for Trainers Section 4 Case Studies4.5 The Life of a Hygiene Educator in Uganda“I am John Robert, a hygiene educator from Ogwete Village in North East Uganda. In themorning I get up and clean my own compound. I look after my animals and give themwater."When WaterAids partner Wera Development Association (WEDA) came to thiscommunity, this village was identified as one that had a big sanitation problem. Therewere a lot of diseases and diarrhea. People could not wash and there was nowhere toclean utensils. The whole area was always dirty; the paths were very bushy with snakes.There were faeces along the side of the roads. No longer…"WEDA offered to train hygiene educators to sensitize the community to good sanitationpractices. The community nominated me to be one of the educators."I have an interest in this work; I like to live in a clean environment. Before WEDA camehere I could see how the roads and households were dirty with no place to clean cookingutensils. I wanted to help change this."I was given a bicycle by WEDA which makes it easy for me to travel around thecommunity. I visit 40 households a week."I use a cluster system to get people together so I can educate them about goodsanitation. There are 10 households per cluster. Each cluster has a cluster head who Iliaise with to arrange sanitation meetings. I work with them to organize communitysanitation workshops where we promote hygiene and sanitation to community members."I convince stubborn people to build latrines. I come to their place and actually start todig their pit. I start the pit and hope they feel shame to continue with it. Some peoplehave completed their pits. I show people examples of homes with clean facilities. I showthem how clean everything is."There are barriers to my work in this community. Mainly households run by men whodrink. They do not listen to sensitization. Sometimes the old do not have the strength toconstruct pit latrines and drying racks in their compounds. Where this is the case Iorganize days where community members can help the elderly construct facilities in theircompounds. WEDA and the community encourage these activities here and help tomobilize people."I am not happy that only 50% of households in this community have a latrine. I want it tobe 100%. I think we will have 75% of households with a latrine by the time WEDA installa borehole here. I am going to work hard to make sure the remaining 25% without alatrine set them up or are involved in setting them up."We have enforced bylaws to keep the paths and communal areas clean. They havebeen a big success. We are trying to agree further bylaws and get them approved by thecluster heads and the district authorities. These will stipulate that each household shouldhave a latrine and a drying rack for utensils. 79
  • Community Health Promotion for Trainers Section 4 Case Studies"Since these changes have been made here my children are not getting sick. Before Iwould have to take them to hospital regularly to get medication. This was an 8 km walkthere and back on foot."In the old days when sickness came we may not have had a cent in our pocket to payfor medication. We would have to borrow money from very many people."I would have to spend an average of £19 a month on medication. I do not need toborrow money any more but we are still paying back our debts from the old days. (WaterAid, nd) John Robert Anguira, Hygiene Educator, Ogwete village, Uganda. (Photo Credit: WaterAid/Caroline Irby) 80
  • Community Health Promotion for Trainers Section 4 Case Studies4.6 School Sanitation and Health Education in IndiaNew loos at two rural Indian primaries are having unexpected results in health educationIt is 11am, and the students of Marachipatti elementary school are queuing up in theircourtyard. Girls and boys in two neat crocodiles stand outside the schools white-paintedlatrine block. They disappear inside. There is some vigorous hand washing. One by onethey then emerge into the sunlight before filing back to the classroom, which isdecorated with pictures of the Hindu elephant god Ganesh, Indira Gandhi, the Buddhaand the saintly Tamil poet Thiruvalluvar.This is, of course, the loo break. On the face of it there is nothing remarkable here - untilyou remember that this is rural India where there are few facilities of any kind, let alonetoilets. The lack of proper sanitation is one of many obstacles Indian children face intheir struggle for an education. Other factors include too few books, teachers who fail toturn up and the requirement for children to work - like their parents - in the fields.Until recently, Marachipatti primary didnt have a latrine - nearly 85% of Indian schoolsare in the same dismal situation. Instead, the pupils would dash across the road andsquat down in the thorn bushes. It could be a scary experience: "Sometimes snakeswould come and disturb us. I would run away as quickly as possible", one 10-year-oldgirl, Vasanthi, explained. "This wasnt much fun."The lack of sanitation brought other problems too. Pupils frequently suffered fromdiarrhea. They also got hookworm. "In the past, as many as 10-15 children would beabsent because of illness," the schools assistant head teacher Mr Krishnan recalls.This lamentable situation ended three years ago when the British charity WaterAid cameup with an ingenious solution: it built a sanitation block for the schools 104 pupils - at thecost of £260 - complete with two Indian-style latrines and a girls and boys urinal. Moreimportantly, it asked the five- to 10-year-old pupils to manage the block themselves.The students organized themselves into different committee responsible for keeping theloos clean, fetching water from the hand-pump outside and ensuring all pupils washedtheir hands with soap. Other students on the "tidy committee" looked after the schoolsmodest grounds.In addition, WaterAid paid for a health educator to visit the school, which is in the lushsouthern state of Tamil Nadu, some 65km north of the temple town of Tiruchchirappalli.The scheme was extended to some 40 other local government schools, covering 8,000pupils.And it worked. "I tell the students to cut their nails, make sure their clothes are clean andto brush their teeth and comb their hair," Vasanthi, a member of the personal hygienecommittee, explains.The initiative brought startling results: pupils became healthier and suffered from fewerillnesses. "I havent got hookworm any more," said Vinod, a 10-year-old latrinecommittee member.But, crucially, the pupils of Marachipatti primary took the message of hygiene awarenessback into their homes. WaterAids local health workers discovered it was far quicker, and 81
  • Community Health Promotion for Trainers Section 4 Case Studiesmore effective, to teach adults good hygiene practices via their children than to targetthem directly. "I told my mother and now she washes her hands with soap beforecooking vegetables," Vasanthi pointed out.The villagers of Marachipatti are poor. They live for the most part in mud housesthatched with coconut leaves, close to the lagoon-like Cauvery River. Nonetheless,several parents were encouraged to build their own latrines at the subsidized cost of Rs850 (£12). With better sanitation, they found that they were spending less money onmedicines. "I used to spend 1,000-2,000 rupees (£14-£28) a year on drugs," saidDhanam, a 30-year-old mother. "This figure has been considerably reduced. We dontget diarrhea so much."In the nearby government school of Udayakulamputhur, a short drive past fields of greenrice and picturesque oblongs of red chilies drying on the road, the pupils make use ofanother new WaterAid-funded latrine block. This one is painted red. The students herehave also become ambassadors of hygiene promotion - though in some cases theirefforts have not always gone down well with an obdurate older generation."Ive told my grandfather and grandmother what to do but they still dont wash theirhands," Isabella, aged 10, lamented. "My parents do what I tell them. But there is a lot offighting between my father and grandfather over hand-washing."The schools head teacher, Mr Mali, detects a new pride among the students andparents. "Even if they have to spend some money, they are happily spending. If a kidloses his tie they will replace it," he says. (WaterAid, nd) 82
  • Community Health Promotion for Trainers Section 4 Case Studies4.7 School Hygiene Promotion in PakistanSince November 2006, Agency for Technical Cooperation and Development (ACTED)has been working on a UNICEF funded program for Water and Sanitation and HealthPromotion in Azad Jammu and Kashmir. The program aims to provide water, latrines,hand washing facilities and hygiene education to approximately 8000 children in 90schools in the Neelum Valley by the end of July 2007.For the hygiene promotion component of the project ACTED has been implementing asix phase program using PHAST and Child-to-Child (CTC) methodology, which providesa framework for the active participation of children in the trainings and for turning thechildren into active agents of change within their families and communities.The hygiene promotion activities included:• Analysis of problems regarding the hygiene facilities and practices• Discussion of barriers (to help the children in finding ways of blocking the spread of diarrhea)• Choosing improved hygiene behaviors• Presentation of children to mothers about PHAST• Field visits where children and mothers point out good and bad hygiene practices in their own community• Hygiene competition with quizzes and debates• Street theatre with skits about hygiene practices, games and drama competition.The involvement of mothers and non-school going children has been an importantaspect of the hygiene promotion activities, avoiding focusing exclusively on schoolstudents. Whats more, UNICEF hygiene kits have been distributed to all children.The competitions and theatre have also been a great success, bringing togetherchildren, parents and teachers from different schools to share their knowledge abouthygiene while having a great time. The theatre group "Eye View" has been responsiblefor hosting the street theatre together with ACTED hygiene promoters.A Knowledge, Practices and Coverage (KPC) survey was conducted at the start of theprogram to determine the quality of the hygiene practices and identify specific needs interms of hygiene education. The survey will be repeated at the end of the program toassess the impact of the hygiene promotion activities on the knowledge and practices ofthe beneficiaries.And last, at the end of the program the water and sanitation facilities will be formallyhanded over to the Education Department to ensure sustainability in the long-term. Atschool level, School Environment Committees, consisting of 2 students and 2 teachers,have been formed and trained and will be responsible for maintaining the facilities andfostering continued proper hygiene practices. (Reuters Foundation, 2007) 83
  • Community Health Promotion for Trainers Section 4 Case Studies4.8 Health Education for Malaria Control in IndiaProject BackgroundThe National Institute of Malaria Research (NIMR) and Community Health Cell (CHC),Bangalore, jointly initiated the program. An inter-sectoral coordination committee wasformed involving ten governmental and non-governmental organizations for smoothfunctioning. The district health committee headed by the District Commissioner approvedthe proposal of the Kalajatha program. NIMR and CHC, Departments of Health,Education, Child and Womens Welfare, Rural Development and Panchayat Raj, TumkurScience Forum, local political and religious leaders actively participated in this program.Project PlanThirty local artists (15 males and 15 females) from different occupational backgroundswere selected. A local scriptwriter wrote 8 songs, two dramas and 4 rupakas (musicaldramas). The scripts were based on various aspects of malaria namely signs andsymptoms of sickness, treatment, health facilities, processes of transmission, role ofanopheles mosquitoes and names of the malaria vectors, breeding grounds ofmosquitoes especially the vectors, its control strategies focusing especially onlarvivorous fish and environmental management.Other control strategies like insecticide-treated nets, adopting measures for maintaininggeneral hygiene, keeping cleanliness in and around houses, and the role of thecommunity were also included in the script. These were then translated into skits usinglocal dialects, musical styles and theatre traditions. In the beginning, the artistsunderwent orientation training on the entire processes. Two troupes consisting of 15artists each were formed. Before the actual performances, they rehearsed the events inthe evening for two weeks in a religious trust of Kuppur Mutt. Each troupe was equippedwith a set of musical instruments and a performing wardrobe.The Kalajatha eventsThe Kalajatha events were performed in December 2001. One week before the events,wide publicity was given through the local village administration (Gram Panchayat) andthe community consent was obtained from the village headmen or Panchayatpresidents. The Minister-in-Charge of the district and the local elected legislativeassembly members inaugurated the program. The events were performed in theevenings so that maximum number of people could witness. Every day, each troupevisited two villages and spent two hours in each village. Villagers voluntarily attended theprograms. Local health officials and Gram Panchayats provided all the necessarylogistics and hospitality. A valedictory function was held at the end, which was presidedover by the Director of Health Services, Karnataka. Local media covered the events andhelped in spreading the key messages. (Ghosh, 2006) 84
  • Community Health Promotion for Trainers Section 4 Case Studies4.9 Safe Water Supply and Latrines in EthiopiaRobeshu lives with her husband, Gemechu Feyessa, and their eight children in thedistrict of Mulo, about 70 km south of Addis Ababa. Mulo is home to about 40,000people, almost all of whom are poor farmers eking out a living from the land, tendingcattle and growing teff, the grain used to make the flat pancakes that are the foundationof Ethiopia’s national dish, injeera.In September, the land is green, lush and fertile. Mulo’s rolling green hills remind yousometimes of Wales, or perhaps Somerset. But looks can be deceiving. During the rainyseason (mid-June to mid-September) over 1000 mm of rain falls, and this year has beenespecially wet, causing flooding and land erosion – more evidence, if any were needed,of a changing climate in a fragile landscape.But outside the wet season, it’s hot and dry. The land is parched, springs and streamsdry up and people have to work harder and walk further just to fetch water. This jobtypically falls on women and children, diverting time from school, family life and moreproductive activities.Protecting water at the sourceFor almost half of all rural Ethiopians, the nearest source of water is 1 to 4 km away. Butthanks to the Ethiopian Government’s national water, sanitation and hygiene (WASH)programme, Robeshu’s walk is shorter. "I can now collect 20 litres of water seven timesa day for my family," she says. "It’s a shorter journey than it used to be, as we havepermanent source of water less than 20 minutes away from our house." Robeshu takesher water from a protected spring tank, where the water is pure and safe, and free fromcontamination by human or animal waste.Ethiopia has one of the lowest levels of water and sanitation access in Africa. MostEthiopians consume less than 15 litres of water a day from nearby rivers or unprotectedsprings. Water-borne disease is one of the country’s biggest killers. In Mulo, the DistrictAdministration had only managed to construct ten water points in ten years. But throughthe national WASH program, 15 new water supply schemes - which have employedpumps, hand-dug wells and boreholes - have been delivered in the past year.Building better hygieneThe Local Governments renewed commitment to public health has also resulted in awave of household latrine building, with 1,700 simple pit latrines constructed in Muloduring 2005/06. Explaining the effect this has had on his family, Robeshu’s husbandGemechu says: "There is no more bad smell; no flies are coming to contaminate ourfood. We are able to save our cash which we used to spend on healthcare. My family isenjoying a clean environment and privacy."The Mulo woreda council has worked closely with the local health bureau to bring aboutthese achievements. Each kebele (a community of around 5,000) deploys two femalehealth extension workers, part of whose job is to go from house to house spreading themessage about the importance of hygiene and latrines. 85
  • Community Health Promotion for Trainers Section 4 Case Studies"We make house calls three times a week," explains Fantaye, a health extension workerin Thero Boro kebele, Mulo district. "Sometimes we have to walk up to two hours, but weare not discouraged by this."By encouraging community members to carry out some easy-to-follow actions, healthextension workers have brought about a real change in behaviour. Now, most people inMulo are happy to agree with Gemechu when he says, unequivocally: "No way of goingback to open field defecation!" (DFID, 2007) 86
  • Community Health Promotion for Trainers Section 4 Case Studies4.10 Communities Take Ownership of Hygiene inBangladeshMeet six-year-old Shirin. Shes washing her handswith soap and water. She knows it’s important towash her hands before eating and after using thelatrine. She knows she must wear sandals when sheuses the latrine. She knows poor hygiene can makeher ill.She knows all this thanks to Syeda Helena Akhter, aCommunity Hygiene Promoter (CHP). CHPs arehelping to change behaviour in Bangladesh to slowthe spread of waterborne diseases such as diarrheaand cholera. In 2004, 2.2 million cases of diarrheawere recorded in Bangladesh.UNICEF, with £11.8 million funding from DFID, has been pioneering the approach ofusing CHPs to promote good hygiene in rural communities in Bangladesh since April2000. Building a latrine isn’t enough. When it comes to changing ways of life, the entirecommunity must feel involved.How the community hygiene approach worksShirin lives in Shabajpur, a rural village in the district of Brahmanbaria, east of the capitalDhaka. With her mother and other village women and girls she is attending a discussionwith Syeda Helena Akhter.August 2005 is monsoon season and outside it’s pouring with rain. So 40 or so womenare huddled in one room, intently listening to what Syeda Helena Akhter has to say.They cover why it’s important to wash hands after cleaning a baby’s bottom; why it’simportant to use soap and clean water; why food must be kept covered. She uses awind-up toy chicken and little piles of sand on a white cloth to demonstrate how dirt canbe spread around the village.She shows that by washing hands in a white bowl, the dirt is visible. It’s a case of seeingis believing. The women then point out on a map which houses in the village havelatrines. Most have one of some sort but those that don’t share their neighbours’. All ofthis boils down to one message: the link between poor sanitation and gastrointestinaldiseases.Shabajpur has been certified as having 100% sanitation. The 2005 National SanitationStrategy defines this as: no open defecation, hygienic latrine available to all, use ofhygienic latrine by all, proper maintenance of latrines for continual use, and improvedhygienic practice.The hope is that as the younger generation grows up these important lessons will staywith them and be passed on to their children so that water-borne diseases become athing of the past. (DFID, nd) 87
  • Community Health Promotion for Trainers Section 4 Case Studies4.11 From Smelly Yards to Happy HusbandsA health worker wanted to find out about how to motivate people to dispose of childstools safely. This is what she did:The health worker and her team carried out four focus group discussions to ask aboutthe disposal of child stools. Mothers explained that they did not like to see stools on theground because they were ugly to look at and “they stop you breathing”. They said thatthey admired mothers who managed to keep their courtyards free of stools. But theysaid that it was hard to always keep an eye on the child so as to be able to clean upafterwards.The team interviewed some mothers who managed to keep their yards stool free. “Mymother-in-law gave me a potty for the child” said one woman, “I taught the child to use itso now the yard isn’t smelly anymore”.The team asked for volunteers to participate in behaviour trials. Each mother was givena potty, and asked to teach the child to use it. After two weeks they were asked whatthey thought. Mothers said that it had been difficult at first but that the child got used tousing the pot after about three days. Others said that the potty was convenient, othersthat their husbands had noticed that the yard was cleaner and free of smells. They allagreed that even if a plastic potty cost a bit, it was well worth buying one for the sake ofliving in a nice clean healthy environment.The health worker decided to build her hygiene promotion strategy around the idea thata happy, healthy family use potties to have a smell-free yard. (UNICEF, 1999) 88
  • Community Health Promotion for Trainers Section 4 Case Studies4.12 ReferencesDFID (nd). Bangladeshi communities take ownership of hygiene issues.Available at: www.dfid.gov.uk/casestudies/files/asia/bangladesh-sanitation.aspDFID. (2007). No going back to life without latrines in Ethiopia.Available at: www.dfid.gov.uk/casestudies/files/africa/ethiopia-water.aspGhosh, S.K., Patil, R.R., Tiwari, S. and A.P. Dash (2006). A community-based healtheducation programme for bio-environmental control of malaria through folk theatre(Kalajatha) in rural India. Malaria Journal 2006, 5:123. Available at:www.malariajournal.com/content/5/1/123Reuters Foundation AlertNet (2007). ACTED Pakistan: Hygiene Promotion in AzadJammu & Kashmir. Available at:www.alertnet.org/thenews/fromthefield/337869/118587600975.htmUNICEF (1999). Towards Better Programming: A Manual on Hygiene Promotion.Available at: www.unicef.org/wes/files/hman.pdfWaterAid (nd). Hygiene Education Making a Difference. Available at:www.wateraid.org/uk/what_we_do/how_we_work/integrated_projects/hygiene_education/784.aspWaterAid (nd). A Day in the Life Of. Available at:www.wateraid.org/uk/about_us/oasis/autumnwinter_07/5742.aspWorld Bank (2002). Hygiene Promotion in Burkina Faso and Zimbabwe: NewApproaches to Behaviour Change. Field Note 7, Water and Sanitation Program, AfricaRegion. August 2002. Available at: www.gtz.de/ecosan/download/WSP-hygiene-promotionin-burkinafaso-zimbabwe.pdf 89
  • Appendix 1Participatory Learning and Action Tools
  • Community Health Promotion for Trainers Appendix 1When you look at the Participatory Learning and Action Tools, you will see that they are alllaid out in the same way.• Number. Each tool is numbered to help you find the right tool quickly. The numbering on the tools does not mean that they should be used in this order!• What is it? This gives a brief summary of the tool and what it can be used for.• Why use it? This gives you an idea of what the tool is commonly used for. However, you are strongly encouraged to adapt the tool to suit your own circumstances and invent new ways of using it.• How to use it? Each tool provides step-by-step guidance on how the tool can be used. But it is only guidance, not strict instructions! Remember to be flexible. If something doesn’t work very well, we encourage you to use your own best judgment and adapt it to suit your own circumstances. Similarly, the questions you will ask will vary according to who you will be using it with, when and for what topic.• Facilitator notes. This provides useful guidance on what to remember when facilitating the tool or alternative ways in which it might be used. Please feel free to add your own notes to help you.• Diagram or illustration. Some tools have a diagram or illustration attached to it. These are examples only. You should not aim to recreate exactly the same diagram. And remember it is the discussion, learning and action which occurs while drawing the diagram that is more important than the diagram itself. So don’t worry if the diagram looks different from the example provided.It is a good idea to look through and familiarize yourself with as many tools as possiblesince you will need to match the right tool to the issues you will be addressing. There areno rules about which tools can be used for which issue. You also need to consider whichtools work best with the people who will be using them. Some tools work best with peoplewho share the same characteristics, for example same gender, age group and so on.Some tools work better in large groups, others in smaller groups. As a general guide, toolsthat require a lot of detailed analysis, or are of a very personal nature, are best used insmall groups.You also need to think about how much time you have available to cover all of yourobjectives. Some tools can deal with a lot of issues at once, while others concentrate onjust one issue in depth. Time is the most important resource required in facilitatingparticipatory learning and action. However, the poor who you are trying to engage areoften very busy and suffer from “time poverty”. Time spent away from their regularlivelihood often means a loss of income. You need to be aware of people’s schedules andtime limitations when trying to plan a community activity (International HIV/AIDS Alliance,2006). A1-1
  • Community Health Promotion for Trainers Appendix 1Index of ToolsCategories ToolsWater, hygiene, 1: Transmission Routessanitation 2: Analyzing the Barriers (use with Tools 1 & 3) 3: Three Pile Sorting 4: Sanitation Ladder 5: Pocket Chart (use with Tool 4)Behaviour Change 6: Courage to Change 7: Hot SeatDefining roles 8: Knowledge, Skills and AttitudesHow to work with 12: Margolis Wheelcommunities 21: Role Play 22: Story with a Gap 23: Case Studies 24: Community Drama 25: Participatory Photography 26: Participatory Video 27: Picture Story 28: Storytelling 29: Production of Information, Education and Communication Materials 40: BrainstormMonitoring & 33: Monitoring Matrixevaluation 34: Structured Observation 35: Focus Groups 36: Interviews 37: Questionnaires and Surveys 38: Most Significant Change 39: Before and Now DiagramTraining activities 10: Back to Front/Front to Backto develop skills 11: Bad/Good Listening 12: Margolis Wheel 13: Probing Deeper 14: Open and Closed 15: Sensitive Topics 16: Trust Game 17: Sabotage 18: Facilitation Challenges 19: Good versus Bad FacilitationLinkages and 22: Story with a Gaprelationships 45: Road Blocks 46: Seasonal Health and Disease Calendars 47: Division of Labour ChartWorkshop 30: Setting Learning Expectationsintroductions 31: Making Ground RulesIdentifying 2: Analyzing the Barriersproblems & 12: Margolis Wheelsolutions 20: Targeting 43: Problem Wall and Solution Tree 48: Problem Tree 49: Solution TreeAction planning 2: Analyzing the Barriers 9: Low Hanging Fruit 20: Targeting A1-2
  • Community Health Promotion for Trainers Appendix 1Categories ToolsAction planning 32: Writing Aims and Objectives 33: Monitoring Matrix 42: Vision Diagramming 43: Problem Wall and Solution Tree 44: Action Planning 45: Road Blocks 48: Problem Tree 49: Solution TreePrioritizing project 2: Analyzing the Barriersactivities 9: Low Hanging Fruit 41: Card Sorting A1-3
  • Community Health Promotion for Trainers Appendix 1Tool 1: Transmission RoutesWhat is it?This tool educates people about faecal-oral transmission routes using the F-Diagram andhow controls can be used to block the disease transmission routes. The name “F-Diagram” only works in English and stands for feces, food, flies, fields, fingers, fluids, andface. Call this game Transmission Routes or something similar in another language.Why use it?This tool can help participants discover and analyze how diarrhoeal disease can bespread through the environment.How to use it1. Cut the F-Diagram into individual components, including the arrows, before starting the activity.2. Introduce the topic and start with the pictures of feces and the child’s mouth. Explain that there are many ways in which pathogens can be “transmitted” from the feces to the mouth. Place the feces picture at one end of the table/floor and the mouth picture at the other end.3. Divide participants into groups of 5-8 people. Ask the groups to place the remaining pre-cut cards, including the arrows, between these two pictures to show how pathogens can find their way to the mouth.4. When the groups have made their diagrams, ask each group to show and explain its diagram to the other groups. Let them respond to questions raised by the other groups.5. Discuss the similarities and differences between the various diagrams. Encourage discussion to find out why participants placed the pictures in the particular order and ensure everyone understands what a “transmission route” is.6. Facilitate a discussion to help the group use this new knowledge to examine its own situation. Discuss and identify: • The transmission routes in the community • The problem areas and behaviours that are putting people at risk of infection.7. Then ask each group to identify practices that can break the transmission routes. Have them place the following pre-cut cards on top of the arrows: latrine, water treatment technologies, hand washing, good hygiene practices, good food handling practices and safe water storage. It is useful to have blank paper and pens so that the group can create its own blocks if the pre-cut cards do not cover all situations.8. When the groups have made their diagrams, ask each group to show and explain its diagram to the other groups. Let them respond to questions raised by the other groups.9. Discuss the similarities and differences between the various diagrams. Encourage discussion to find out why participants placed the blocking cards where they did and ensure everyone understands how that barrier works.10. Encourage discussion to ensure understanding.Facilitator Notes• The F Diagram only works in English so it should be called Transmission Routes or a similar name in other languages.• Some participants may at first be shocked at the content of this activity. There may be some disbelief that feces can be transmitted to the mouth. The best way to deal with A1-4
  • Community Health Promotion for Trainers Appendix 1 this situation is to get the group working together as quickly as possible. Those participants who are more receptive than others will help the disbelievers to become more involved.• Do not be concerned if the groups do not identify all the fecal-oral routes. It is enough if they have identified some of the routes.• Do not prompt or direct the groups when they are trying to create their diagrams.• If the whole group does not manage to clearly identify the transmission routes, try to find out why. It may be useful to hold a group discussion to evaluate the activity, which then can be tried a second time.• It would be a good idea to put the diagrams on the wall so it is easy for everyone to see and refer to later on.• This activity can be adapted to investigate other diseases such as intestinal worms, schistosomiasis, guinea worm disease, and dengue fever.(Adapted from WHO, 1998) A1-5
  • Community Health Promotion for Trainers Appendix 1Tool 2: Analyzing the BarriersWhat is it?This tool lets people analyze how effective the barriers are and how easy or difficult theywould be to put into place.Why use it?This tool can be used to follow up Transmission Routes and Three Pile Sorting to helppeople identify barriers they can implement to prevent the transmission of diarrhoealdisease.How to use it1. Have groups sort all the blocking methods from the Transmission Routes activity or the good cards from the Three Pile Sorting activity into three piles: those that have a “big impact”, “small impact” and “no impact” on disease transmission. Keep the three piles separate.2. Have people sort each pile of blocking methods into “easy to do”, “possible to do” and “difficult to do”. You now have a chart to rank the target behaviours. No Impact Small Impact Big ImpactEasy to Do These activities should be targeted first because people say theyPossible to Do are easier to do Better to avoid and have a bigger these activities impact. since they are harder to doHard to Do and have little impact.3. When the groups have completed the task, invite them to share their chart and discuss: • Which barriers the group would like to use in its community • The practicalities that would be involved in putting the barriers in placeAlternative MethodIf the activity seems confusing, it may be done as follows. Divide the group in two and giveeach a complete set of barriers. Ask one group to do a three pile sorting for “impact” (i.e.big impact, in between, no impact). Ask the other group to do a three pile sorting for “howeasy the barriers are to put in place” (i.e. easy to do, in between, difficult to do). Thencompare the two sets of cards. A1-6
  • Community Health Promotion for Trainers Appendix 1Another way of carrying out the activity is to do a three pile sorting of the barriers aimed at“impact”. Then take the “biggest impact” barriers and do another three pile sorting, thistime aimed at “easy to do”. Repeat with a three pile sorting for “in between” barriers.Facilitator Notes• This type of chart may be a new concept for the group so it might be a good idea to explain it step by step. Make it clear that this is only an explanation; participants should make their own placements.• If a group is unclear about the effectiveness of certain barriers, do not correct it. Instead, think of questions which might help it to come to a decision.• Do not be concerned at this stage if the group does not know enough to be able to judge how effective the barriers might be. There will be opportunities later in the process to introduce additional information to increase the quality of decision making.(Adapted from WHO, 1998) A1-7
  • Community Health Promotion for Trainers Appendix 1Tool 3: Three Pile SortingWhat is it?This activity allows participants to exchange information and discuss common water,hygiene and sanitation practices according to their good and bad impacts on health. Theaim is not to test people’s knowledge or to correct personal habits, but rather to provide astarting point for a discussion of local hygiene and sanitation beliefs and practices.Why use it?This tool can be used to:• assess people’s understanding of water, hygiene and sanitation practices and the impact on health• provide a way to explore issues about water, hygiene and sanitation• start discussions about local beliefs and practicesHow to use it1. If you intend to use this as a teaching activity with one group then one set of cards is suitable. If you intend to complete this using several groups at the same time, then print out as many versions as you need so that each group has a complete set of cards.2. Give out the sets of three pile sorting drawings, and three heading cards – one with the word “good”, another with the word “bad” and third with the word “in-between”. (Symbols to represent these qualities are also printed on each card i.e.: smile, sad, no expression.)3. Ask the participants to sort the pictures into three piles. • Good – those which they think show activities that are good for health. • Bad - those which they think show activities that are bad for health. • In-between - those which they think are activities that are neither good nor bad for health or which they are not sure about.4. After 20 – 30 minutes ask the participants to explain their selections and why they made these choices. Let the group answer any questions that the other participants raise.5. Facilitate a discussion on the way the participants have sorted the drawings. This discussion will provide a chance for participants to share what they know with the rest of the group. Clarify any misconceptions about disease transmission routes, and encourage the group to think carefully about the choices moving cards from one pile to another if necessary. The group may realize there are knowledge gaps and look for ways to fill these.6. Ask the group to consider and discuss the common behaviours in its own community. Ask the group to consider whether these behaviours are similar to any of the good and bad practices it has identified.7. At this stage or at a later session the group may start to discuss ways of eliminating the bad practices it has identified in its community. Encourage this discussion and have the group keep a record of suggestions made. A1-8
  • Community Health Promotion for Trainers Appendix 1Alternative method• If two or more sets of three-pile card sorting drawings are available and the group of participants is quite large, the group can be split into two or more subgroups. Each subgroup then carries out the exercise, and the facilitator encourages a debate between groups on why they made the choices they did.Facilitator Notes• It is good to include some drawings which can be interpreted in a number of different ways. This helps to make the activity more challenging and stimulates discussion.• Don’t prompt or direct the choices of the group by giving information. If people ask you specific questions, redirect the questions back to the group for a response. If the group is unable to interpret any one drawing, suggest that it is set aside.• If the group wants to know how many people practice good and bad behaviours, The Pocket Chart can be used to help find this information.(Adapted from WHO, 1998) A1-9
  • Community Health Promotion for Trainers Appendix 1Tool 4: Sanitation LadderWhat is it?The sanitation ladder helps people to identify options for improving sanitation in theircommunity and realize that this can be a gradual process.Why use it?This activity helps participants to:• Describe the community’s sanitation situation• Identify options for improving sanitation• Discover that improvements can be made step-by-stepHow to use it1. Depending on how many people and/or groups you are working with, print out as many copies as you need so that each group has a complete set of cards.2. Introduce the exercise to the participants. Give the participants the pictures depicting the various methods of excreta disposal. It may be useful to have some paper and pen so that participants can draw other methods which are not included in the set of drawings.3. Ask the participants to sort the pictures into steps according to improvements in sanitation practices. Participants can take 15 – 20 minutes for this work.4. When the groups have completed this task, ask the group to explain its sanitation ladder to the other participants.5. After the presentations, encourage a group discussion covering: • The similarities and differences in the way the options have been arranged as steps. • The options that have been identified as best for the community • The advantages of each option • The difficulties or obstacles that would make moving up the ladder difficult • How these decisions were reached6. Explain to the group that the next activity will help it to develop a plan to get from where it is now to the situation it would like to have in the future.Alternative MethodsIf the size of your group is almost the same as the number of illustrations you have (about16) give one illustration to each participant. Have the participants arrange themselves in aline, in order from worst sanitation practice to best. Starting from the worst end of the line,ask each participant to explain to the group why their illustration is a better practice thanthe previous illustration. The group and the facilitator can discuss whether they agree withthe order.This activity can also be used to deal with other questions and other problems. Forinstance the sanitation ladder can be adapted to make a water ladder. The activity wouldbe conducted in the same way, but using drawings showing different water options forimproving quality, quantity and access to water supply. The options shown would need torange from most simple to the more complex. Drawings of unsafe or unprotected watersources and collection would have to be included since some communities would bestarting from this step. A1-10
  • Community Health Promotion for Trainers Appendix 1Facilitator Notes• Before you begin this activity it would be helpful to have information on: o The design principles of different sanitation options o The effectiveness of different options o The use and maintenance of each option o The cost of different options o The durability and sustainability of each option• The sanitation ladder shows that improvements can be made step by step. The idea that a community can progress up the ladder at different rates can be very appealing to groups. They realize that changes can be made over time, at a pace that is appropriate and manageable to them. When groups discover this, it can inspire them to become more involved.• Some options are equally good. Two options can be placed side by side so the ladder has “branches”. The idea of progression and choosing for the future is more important than the shape of the ladder.(Adapted from WHO, 1998) A1-11
  • Community Health Promotion for Trainers Appendix 1Tool 5: Pocket ChartWhat is it?The pocket chart is a tool to help the group collect, organize and analyze information. Apocket chart can be set up in many different ways, depending on what the group wants tofind out.Why use it?Use a pocket chart when:• The group needs to collect information confidentially on what people are actually doing in the community.• The group has a question or point they want to examine.• The group wants to make a collective decision.How to make a pocket chartA pocket chart can be made of paper, plastic, cloth or with jars. If made of paper, plastic orcloth, the most practical size is to use 1-1.5 metres square (3-4.5 feet square). A pocketchart of this size can easily be rolled or folded for transporting from one place to another.1. Create a row across the top of the chart, with pockets in which drawings can be placed or pinned to. The drawings will represent subjects about which data needs to be collected, such as where people defecate or where people get their drinking water. There may be as few as three pockets, or as many as seven.2. Create a column along the left side of the chart, with similar pockets where drawings can be placed. These might represent the different people who use the options, or other variables. There may be as few as five pockets, or as many as ten.3. Attach rows of pockets across the chart so that there is one for each option, both up and down and across, to form a grid pattern.How to use it1. Explain to the group what a pocket chart is and how to use it.2. Ask the group to identify which behaviours or practices it would like to know more about. When these are clear, set up the column and row headings on the pocket chart.3. Provide participants with tokens or slips of paper for voting.4. Participants vote by placing their token in the appropriate pocket that represents their choice or information. During voting, the pocket chart is turned away from the group or put in a separate room so that voting is confidential. If transparent pockets are used, a blank card is placed inside each of them. Participants then place their tokens behind this card.5. When all the participants have given their information, the tokens are counted up by volunteers and the information is presented to the group. The tokens should be counted in front of the group so that everyone can see that the counting is done accurately. The tokens should be taped onto sheets of paper or directly onto the pocket chart to give immediate visual feedback of the results, and then counted so that none are lost or tampered with. If transparent plastic pockets are used, the tokens can be assessed visually by removing the card covering them.6. Discuss what this information reveals about actual practices in the community.Other ways to use itExample 1: Defecation sites A1-12
  • Community Health Promotion for Trainers Appendix 1• Drawings of different sites or facilities used for defecation are used to create the row across the top of the chart. The drawings can be taken from Three Pile Sorting.• The column down the left-hand side shows a man, woman, boy, girl, etc.Participants will identify themselves in the left-hand side column and then indicate the siteor facility they normally use, and then place their token in the corresponding pocket.Additionally, participants can carry out the activity for urination sites. Give them two tokensof different colours or shapes (one to represent urination and the other to representdefecation). They place the appropriate token to indicate the options they use for eachoption.Example 2: Water sources and water uses• The row across the top of the chart is created using drawings of places where of the means by which water can be obtained; for example spring, river, well, tap, pond, rainwater, water vendor, etc. The drawings can be taken from Three Pile Sorting.• The column down the left-hand side shows different uses of water; for example, drinking, cooking, washing food, washing dishes, washing hands, bathing, watering garden, etc.Participants will use several tokens to indicate the water source for each use applicable tothem. For example, I drink water from the well, I wash my clothes with water from the river,etc.Facilitator Notes• Stress the need for people to be honest when placing their tokens, that this is a learning exercise and that, as such, it is important that the information collected be true to life.• Make sure that the pocket chart is set up in such a way that participants can place their tokens without being seen by others. Ensuring confidentiality is important so that participants are honest about their responses.• When the tool is being used for the first time, confusion can be avoided if only one drawing at a time is placed in the left-hand side column. Participants then place their tokens to identify their options. After this, the next drawing can be placed below the first one in the left-hand side column. Continue in this way until all the drawings in the left- hand side column are in place. This process will be slower than setting all the drawings up at once in the beginning.• This activity can also be used to collect more information by asking more than one question and using more than one type, colour or shape of token. If the group, for example, wanted to know which options were used occasionally as well as which were used frequently, each participant could use one type of token (say green) to answer the first question, and a different type of token (say red) to answer the second question.• Make sure the set of drawings reflects all the options present in the community. Be prepared to include or make additional drawings to represent other options mentioned or suggested by the group during the activity.• Be prepared with ways to keep the rest of the group busy while members are taking turns to place their tokens, since this process can be quite long. Or else, do the pocket chart activity during a break.• The pocket chart is a good evaluation tool. Information collected at an early stage of the project can be compared with information collected in the same way later on. By A1-13
  • Community Health Promotion for Trainers Appendix 1 comparing the two sets of information, the group can see whether changes in behaviour are taking place.(Adapted from WHO, 1998) A1-14
  • Community Health Promotion for Trainers Appendix 1Tool 6: Courage to ChangeWhat is it?This tool involves participants standing at different points along a line to show how easy orhard it is to make changes relating to water, hygiene and sanitation.Why use it?Using courage to change helps to:• provide a non-threatening way to identify the changes that people need to make in their lives and community in relation to water, hygiene and sanitation• assess how people feel about those changes, including which changes are easy or hard and why.How to use it1. Mark a line on the ground. State that one end means ‘easy’ and the other end means ‘hard’.2. Ask the participants to identify a way in which individuals or the community need to change in relation to water, hygiene and sanitation. Examples might include ‘We all need to wash our hands after using the latrine’ or ‘We all need to stop defecating in the open’.3. Ask a volunteer to stand on the line that you have drawn, according to how easy or difficult they think it would be for individuals or the community to make the change.4. Ask the volunteer to explain why they have chosen to stand where they are. Ask them what support individuals or the community would need to make the change easier. Ask the other participants if they agree.5. Ask the participants to identify another way in which individuals or the community need to change. Repeat the process for another six to eight changes.6. Record what is easy and what is hard to change in a way that all participants can see.7. When the activity is complete, encourage the participants to discuss what courage to change has shown. • What makes changes easy or hard? • What sort of support do individuals or the community need to make changes easier? • How could that support be provided? • By whom?Facilitator Notes• Talking about changes that need to be made can be difficult. Help participants to feel comfortable by agreeing that all information is confidential. Remind participants that the activity is about the changes that people like them can make. It is not necessarily about the changes that they, personally, must make.• Instead of a line, you can use a ‘secret vote’. This involves participants having voting cards and using a scale of one to five dots to show how easy or hard a change is. For example one dot (•) would show that it was very easy and five (•••••) that it was very hard. Read out an example of a change that is needed. Ask the participants to vote by putting dots on a card and putting it into a box or basket. Count up the votes and discuss what the total says about how easy or hard the change is. A1-15
  • Community Health Promotion for Trainers Appendix 1(Adapted from International HIV/AIDS Alliance, 2006) A1-16
  • Community Health Promotion for Trainers Appendix 1Tool 7: Hot SeatWhat is it?This tool is particularly effective for getting people to put themselves in others’ shoes andthink through the implications and pressures faced in different situations.Why use it?Using hot seating helps to:• provide a lively way to explore issues about water, hygiene and sanitation• identify what people already do and don’t do about water, hygiene and sanitation• explore how people feel about issues relating to water, hygiene and sanitation• address myths and misunderstandings about water, hygiene and sanitation• explore different strategies to address water, hygiene and sanitation issues.How to use it1. Before the activity, prepare four case studies for people to explore. These should be real-life dilemmas, written in the first person. For example, if you are exploring disease transmission a case study could read, ‘I am a woman who gets sick because I ...’ Alternatively, ask participants to think of dilemmas.2. Ask for a volunteer to sit in the ‘hot seat’. This means to sit down in a chair or on the floor in front of all the other participants.3. Ask the person to read out the case study as if they were the person in the case study.4. Invite the rest of the participants to ask questions addressing the person in the case study as if they are that person’s friend – for example, ‘Why do you believe…?’5. Where questions require information that is not provided in the case study, encourage the volunteer in the hot seat to fill in the details.6. Repeat the activity with other volunteers and other case studies.7. When the activity is complete, encourage the participants to discuss what they have learned. • Why was it easy or difficult to respond to the questions? • What choices did the person have? • What did the responses show about people’s knowledge and attitudes? • How do these affect a person’s risk of getting sick? • Clarify any misunderstandings that people may have.Facilitator Notes• Encourage a relaxed atmosphere. It can be less threatening if two people take the hot seat at once – for example, both the woman and her husband or child.• Stress that the case study does not necessarily reflect the experience of that person.• Don’t pressure people to take the hot seat if they don’t want to.(Adapted from International HIV/AIDS Alliance, 2006) A1-17
  • Community Health Promotion for Trainers Appendix 1Tool 8: Knowledge, Skills and AttitudeWhat is it?This tool involves participants identifying the knowledge, skills and attitudes for a personinvolved in action on water, hygiene and sanitation.Why use it?Knowledge, skills and attitudes diagrams are particularly useful for deciding what kind ofperson can best carry out a particular role or action with regard to water, hygiene andsanitation.• Knowledge means a persons understanding and information about key subjects, such as disease transmission or household water treatment.• Skills means a persons practical, technical and ‘people’ skills, such as good listening or project design.• Attitude means a persons feelings and approach, such as being empowering and non- judgmental.How to use it1. Explain the purpose of the tool to participants. Select a person who should be involved in action on water, hygiene and sanitation. Examples might include ‘mother in a household’, ‘doctor’ or ‘community health worker’.2. Draw a large picture of a person. Ask participants to think about the knowledge that person should have and write these around the head. Then get them to repeat this with skills written on the arms and attitudes on the body.3. If participants leave out important knowledge, skills, or attitudes, contribute ideas yourself and explain why they are important.4. When the activity is complete, encourage the participants to discuss what the diagram shows. • Was there agreement about the knowledge, skills and attitudes? • Which ones are most important? • How do knowledge, skills and attitudes link together? • How does the person compare to real people involved in action on water, hygiene and sanitation? • What support would help people to improve their knowledge, skills and attitudes? • Where can it come from?Facilitator Notes• Encourage participants to see that a balance of knowledge, skills and attitudes is needed for action on water, hygiene and sanitation to be effective. For example, a doctor might have a lot of knowledge about the importance of water, hygiene and sanitation, but without good listening skills their work will not be successful.(Adapted from International HIV/AIDS Alliance, 2006) A1-18
  • Community Health Promotion for Trainers Appendix 1Tool 9: Low Hanging FruitWhat is it?Low hanging fruit is a tool that involves drawing a tree and its fruits. The tree representsthe project. The fruits of the tree represent different activities or services within the project.If the fruits are ‘low hanging’, they will be easier to carry out. If they are ‘high hanging’,they will be harder to carry out.Why use it?• For project planning.• To discuss why certain activities or services would be easier than others to introduce or carry out.• To discuss both barriers and opportunities to carrying out or introducing new activities or services.How to use it1. Explain to participants the aim of the exercise: to identify which activities and services will be easier to start and which will be harder; and to discuss some of the barriers and opportunities to starting these activities and services.2. Ask people to draw a tree which has both high and low branches.3. Ask people to draw on separate cards new activities or services that they think should be introduced to tackle water, hygiene and sanitation.4. Explain the idea of low hanging fruit: ‘low hanging’ fruit is the easiest fruit to pick from the tree and links with the idea that some services and activities would be easier to introduce and carry out. Fruit that is hanging higher on the tree would be harder to pick.5. Ask participants to place the activities and services on the tree according to whether they think they are ‘low’ or ‘high’ hanging fruit.6. Ask participants to discuss things that will get in the way of carrying these out and opportunities that exist to begin these activities or services. If after discussion they wish to move the fruit lower or higher up the tree, let them do so.7. Ask one of the participants to present a summary of the tree and encourage others to ask questions and make any comments or suggestions.8. If the tree has been drawn on something which cannot be kept – for example, the ground – it is useful for someone, when it is finished, to make a copy of it onto a piece of paper for future reference.Facilitator Notes• Ensure that people are given the opportunities to discuss both barriers and opportunities before placing their cards on the tree.• This tool can follow any other tools that have been used to discuss the introduction of new projects and services.(Adapted from International HIV/AIDS Alliance, 2006) A1-19
  • Community Health Promotion for Trainers Appendix 1Tool 10: Back to Front/Front to BackWhat is it?Active listening means listening with the eyes as well as the ears. This exercise reinforcesthis message by helping people to experience the difference between listening tosomeone with your back turned to them and listening to someone who is facing you.Why use it?This exercise helps people practice active listening skills.How to use it1. Break participants into pairs. Ask the people in each pair to sit back-to-back.2. Ask one member of the pair to speak (on any subject) for three to four minutes while their partner listens.3. Then swap the roles.4. Debrief participants by asking what it was like to listen to someone when you could not see them. Ask what it was like to be listened to by someone whom they could not see.5. Go back into the pairs, but this time ask participants to sit facing each other. Repeat the exercise, with one person speaking and the other listening, and then swap the roles.6. De-brief the participants by asking: • What were the differences between listening to each other back-to-back and listening to each other face-to-face? • What do these differences mean in terms of active listening and what it involves?Facilitator Notes• See section 4 of this manual for the key points of active listening.(Adapted from International HIV/AIDS Alliance, 2006) A1-20
  • Community Health Promotion for Trainers Appendix 1Tool 11: Bad/Good ListeningWhat is it?This exercise makes the contrast between ‘bad’ listening techniques and ‘good’ listeningtechniques. It reinforces learning of the key points of active listening.Why use it?This exercise helps people practise and reinforce active listening skills.How to use it1. Explain that this section focuses on active listening skills.2. Break participants into pairs. Hand out Person A and Person B role cards to the pairs, reminding participants to keep their role a secret.3. Ask participants to play the role on their cards. Allow up to five minutes for the role play to take place.4. When this is done, debrief by asking what it felt like to be with a ‘bad’ listener. Ask what the ‘bad’ listeners were doing or not doing. Examples include: turning away, looking bored, distracted.5. Go back into the pairs and swap roles. This time instruct Person B to practice ‘good’ listening techniques.6. When this is done, debrief by asking what it felt like to be with a ‘good’ listener. Ask the speakers what the ‘good’ listeners were doing or not doing. Examples include: smiling, nodding your head in agreement7. From this discussion, draw out the key points about active listening.Facilitator Notes• See Section 4 of this manual for the key points of active listening.Role Play CardsPerson A: You have heard that Person B is really interested in ideas you have about whypeople are getting sick in your community and the need for safe drinking water. You seePerson B at a community event and approach them to share your thoughts.Person B: You are in a hurry to go somewhere and you are not really interested all thetime that Person A is talking to you. You look at your watch, look to see if a taxi is coming,and don’t really pay any attention to Person A.(Adapted from International HIV/AIDS Alliance, 2006) A1-21
  • Community Health Promotion for Trainers Appendix 1 A1-22
  • Community Health Promotion for Trainers Appendix 1Tool 12: Margolis WheelWhat is it?A margolis wheel involves participants consulting one another to find solutions to problems.Why use it?Using a margolis wheel can:• Help come up with new ideas about a topic• Give participants the opportunity to discuss real problems that they face• Help participants who prefer to discuss problems in smaller groups• Give participants the opportunity to find solutions to problems by talking to people who share their experiences and challenges• Show that everyone in a group has something to contribute.How to use it1. This exercise works best with about eight to twelve people in each margolis wheel. So first divide participants up into groups of about this size.2. Now divide each group into two equal halves, with an ‘A’ half and a ‘B’ half.3. Have the ‘A’ half sit in a tight circle facing outwards.4. Have the ‘B’ half sit in a wider circle around the ‘A’ half, with each person from the ‘B’ half directly facing another person in the ‘A’ half.5. Ask each person to think of an issue that they are having difficulty with.6. Instruct the ‘A’ half that they are going to be advisors to the ‘B’ half’s different issues. They will have three minutes to listen to the issues of the ‘B’ half sitting opposite them and offer any advice.7. When all of the ‘B’ half has decided on their issues, they can start explaining them to the ‘A’ half opposite them and the ‘A’ half can offer their advice back.8. After three minutes, shout ‘Change!’ Ask all the participants on the outside circle (the ‘B’s) to move around one place to the right. The ‘A’s stay still where they are in the centre. Everyone should now be sitting opposite someone new.9. Now repeat step seven and give participants another three minutes to explain their issues and offer advice to each other. Then shout ‘Change!’ again and repeat step eight.10. Repeat steps seven and eight until everyone from the ‘B’ half has received advice from everyone in the ‘A’ half.11. When this is done, reverse the whole process, with the ‘B’ half becoming the advisors and the ‘A’ half explaining their issues.Facilitator Notes• The inside circle stays still while the outside circle moves around!• If the group agrees that the discussion is about private problems, make sure that there is no discussion after the work in pairs. Do not discuss problems in the large group.• This exercise works well when participants have already had discussions of problems and constraints in a large group. Break up discussion by using the margolis wheel. This helps participants who prefer discussing ideas in private.• It is important to record solutions, unless discussion is about private problems.(Adapted from International HIV/AIDS Alliance, 2006) A1-23
  • Community Health Promotion for Trainers Appendix 1Tool 13: Probing DeeperWhat is it?This exercise practices the skill of probing deeper into an issue by asking follow-upquestions. Community Health Workers will begin a session with a set of key questions, butit is essential that they are able to respond flexibly to answers they are given and can useother questions to probe deeper.Why use it?This tool helps people to practice effective questioning skills, especially how to probedeeper to get to the heart of an issue.How to use it1. Give a short presentation on the six ‘helper’ questions (What? When? Where? Who? How and Why?) and their importance as open-ended questions.2. Break into pairs. Ask one member of the pair to think of a story or incident that their partner does not know about. Explain that their partner is going to ask them questions about it. Their task is to answer these questions as briefly as possible.3. Instruct their partner (the questioner) to try to use each of the six ‘helper’ questions at least twice to find out about this story or incident.4. After five minutes, end the questioning and debrief what it was like to try to probe deeper.5. Swap roles and repeat the exercise.Facilitator Notes• The most effective ‘helper’ question for probing deeper is to keep on asking, ‘But why…?’• See Section 4 of this manual for key points about effective questioning.(Adapted from International HIV/AIDS Alliance, 2006) A1-24
  • Community Health Promotion for Trainers Appendix 1Tool 14: Open and ClosedWhat is it?Asking open-ended questions, which cannot be answered with a ‘yes’ or a ‘no’, is animportant skill because it opens up discussion and helps in gathering more information.This exercise practices this skill.Why use it?This tool helps people to practice effective questioning skills – especially how to ask open-ended rather than closed questions.How to use it1. Prepare a brief (one-paragraph) case study of a typical local person living without safe drinking water, describing their life circumstances. Divide the participants into groups of six people.2. Explain that in each group of six there will be two teams (A and B) of three people: in each team, there will be a local person, the questioner and an observer. Give the local person in each team a copy of the case study to read, and ask them not to show it to their team members.3. Explain that in the A teams in each group, the questioner is only allowed to ask closed- ended questions and the role of the observer is to check that they do this. In the B teams in each group, the questioner is only allowed to ask open-ended questions and the role of the observer is to do the same.4. Explain that the questioners have five minutes to find out as much as they can about the local person living without safe drinking water in their team.5. At the end of the time, ask questioners in the A teams to tell the rest of the group what they learned about the person living without safe drinking water. Then ask the questioners on the B teams to do the same.6. Compare the difference between information gathered from asking closed and open- ended questions, and discuss lessons learned about effective questioning.Facilitator Notes• See Section 4 of this manual for key points about effective questioning.• If you want all participants to have a chance at practicing open-ended questions, prepare four more case studies.(Adapted from International HIV/AIDS Alliance, 2006) A1-25
  • Community Health Promotion for Trainers Appendix 1Tool 15: Sensitive TopicsWhat is it?This exercise helps people to develop the skills necessary to ask good questions aboutsensitive subjects.Why use it?This activity helps people to consider what topics and issues might arise when working incommunities, and to develop strategies to talk about sensitive topics with people.How to use it1. Ask participants to think which ‘sensitive’ issues may come up in session about water, hygiene and sanitation.2. Make a list of these sensitive issues and group similar issues together into topics.3. Identify three or four groupings of sensitive topics, and ask participants to break into smaller groups to look at one of these groupings.4. Ask each group to discuss their sensitive topic: • What might make it hard to ask questions about it? • What would be good questions to ask?5. Now ask each group to practice these questions in role plays6. Bring the groups back together to discuss what was learned about asking questions about sensitive subjects.Facilitator Notes• It might be a good idea to make a ‘sensitive questioning’ checklist from the results of this exercise. People can then use this checklist during sessions in the field.(Adapted from International HIV/AIDS Alliance, 2006) A1-26
  • Community Health Promotion for Trainers Appendix 1Tool 16: Trust GameWhat is it?This exercise helps people to understand issues of confidentiality. It also helps people togain trust in each other.Why use it?The trust game helps people to understand:• the importance of confidentiality in participatory activities• what it feels like to give people sensitive information about themselves.How to use it1. Ask participants to sit around in a circle. Explain to participants that this is a serious exercise about trust.2. Ask participants to think of a secret they have which they would not want anyone else to know. Ask them to write this down on a small piece of paper, fold it up and not show it to anyone.3. Now ask participants to pass their piece of paper with the secret in it to the person to their left.4. Ask each person around the circle how it feels to have their secret in someone else’s possession. You can record some of these responses on a flipchart if you wish.5. Now ask each person in turn how it feels to have someone else’s secret in their possession. Again, you can record these on a flipchart if you wish.6. Now ask participants to give the pieces of paper with the secret on them back to the person the secret belongs to. Once this is done, tell participants that they can all destroy their pieces of paper and relax! No one has had to share their secret.7. Debrief participants by asking them: • What does this tell us about confidentiality in PLA? • What kind of things might people share with us which should be kept confidential? • What rules should we have about confidentiality during PLA?Facilitator Notes• Remind participants that ‘trust’ is a verb! Trust is something you do rather than have. You have to earn and keep earning trust, and it can be taken away at any time if you break someone’s trust. We all like to think that we are trustworthy because of who we are or our position. But people are unlikely to trust you automatically just because you are a doctor or some other professional. Whoever you are, trust has to be built and maintained.• The point of this game is not for participants to share their secrets. If some do, that is up to them, but no one should feel pressured in any way to do so. A1-27
  • Community Health Promotion for Trainers Appendix 1From training of PLA facilitators in Ukraine(International HIV/AIDS Alliance, 2006) A1-28
  • Community Health Promotion for Trainers Appendix 1Tool 17: SabotageWhat is it?Sabotage is a tool to train people in some of the appropriate attitudes and behavioursrequired to facilitate participatory learning activities.Why use it?Sabotage helps facilitators to understand the different ways in which people can dominateor spoil an activity, and develop strategies for dealing with different personalities.How to use it1. Ask participants to divide into groups of three.2. Tell them that one person is going to interview another person (the interviewee) about an aspect of their life. The third person is going to try to sabotage the conversation in any way they can think of.3. Give each person three minutes in their roles, then ask them to change roles.4. Continue doing this until each person has performed the role of saboteur, interviewer and interviewee.5. Debrief participants in a group discussion by asking: • How did it feel to be sabotaged? • How did it feel to sabotage? • What different strategies did the saboteur use to try to spoil the interview? • What different strategies did the interviewer and interviewee use to try to stop the saboteur? • What strategies can we use to sabotage the saboteur during an activity, without disempowering or excluding them altogether?Facilitator Notes• Ask saboteurs to use types of sabotage which they are likely to come across, rather than extreme examples. A1-29
  • Community Health Promotion for Trainers Appendix 1 Passive Sabotage Facilitator Strategy Active Sabotage Facilitator Strategy Ask all participants to remain inGender Divide up males and females Speaking loudly or shouting silence for one minute to consider a question Have a conversation during a Do an energizer or give them aLooking bored Unconstructive criticism break and ask them for positive specific task suggestions to improve the activity Ask them what their thoughts are, have a friendly conversation Interrupting or speaking all the Use a “talking stick” which only theSaying nothing during a break to make them feel time person holding it can use more comfortable and get to know them better Do a lively energizer, then ask Bring people back to the mainConstantly moving around everyone to sit down and remain Changing the topic topic seatedDistracting body language Ignore Making irrelevant comments Ask how that relates to the topic Ask participants to suggest a Ask them what would help them toInappropriate setting Refusing to participate better place to meet participate Ask participants what time suitsInappropriate timing Being late Make them a timekeeper them best(International HIV/AIDS Alliance, 2006) A1-30
  • Community Health Promotion for Trainers Appendix 1Tool 18: Facilitation ChallengesWhat is it?This is a fun activity in which people get a chance to describe how to deal withchallenging situations that can happen while facilitating a participatory learning activity.Why use it?This tool helps people to consider different situations that may arise and discuss goodfacilitation practices with their peers.How to use it1. Explain to participants that facilitating participatory learning activities involves working with a range of different people. This activity focuses on challenging, but realistic, situations that can arise while facilitating and how to deal with these situations.2. Divide participants into groups of four or five.3. Give each group a set of facilitation challenge cards. One person in the group must choose a card and read it out to the rest. The others can suggest what course of action they would take to address the situation. The best suggestion wins the card. Groups continue in this way until all the cards are finished. The winner is the person with the most cards.4. Debrief with the entire group. Discuss a couple of the situations that groups felt were the most problematic.Facilitation Challenge Cards At the start of the meeting community members seem reluctant to talk. Some community members look very bored. Some community members say they are embarrassed to role play in front of others. A1-31
  • Community Health Promotion for Trainers Appendix 1 Most of those who attend the meeting leave before the end. At your first meeting, you are very nervous. You begin to stutter and lose your confidence. Some of the poorer and less educated community members make suggestions. However, the local leader does not take their suggestions seriously. Only the men are responding. The women are silent. One participant keeps dominating the conversation and frequently interrupts others. Participants complain that they can’t hear your voice. Create your own facilitation challenges! A1-32
  • Community Health Promotion for Trainers Appendix 1Tool 19: Good Versus Bad FacilitationWhat is it?This is a fun role play in which people get a chance to practice their participatoryfacilitation skills in a relaxed and safe setting.Why use it?This tool helps people to:• consider what are good and bad facilitation skills• practise their facilitation skills and receive feedback from their peers• learn how to ‘embrace error’ and learn from their mistakes without embarrassment.How to use it1. Ask participants to think about the best facilitator they know and list what made this person a good facilitator. Consider knowledge, skills, attitudes and behaviours.2. Now ask them to think about the worst facilitator they have experienced and list what made this person bad at facilitation. Again, consider their knowledge, skills, attitudes and behaviours.3. Now split participants into two groups.4. Tell one group of participants that they are going to perform a role play of a participatory learning session. Two people from this group will try to facilitate the rest of the participants in their group to do a tool as best they can. They should bear in mind the good and bad practices previously listed.5. The other group will sit around them and observe the two facilitators at work. If they think that one of the facilitators has made a mistake in some way, they should get up, tap the facilitator on the shoulder and take over facilitation. The original facilitator then joins the other group and becomes an observer.6. Each time either one of the facilitators makes a mistake, one of the observers should take over. Let the role play continue until all of the observers have had a chance to step in and take over the facilitation.7. Then swap group roles so that both groups have had a chance to facilitate, observe and be participants of the role play.8. Debrief participants about what they have learned about being a good and a bad facilitator.Facilitator Notes• See Section 4 in this manual for key points about facilitation.(Adapted from International HIV/AIDS Alliance, 2006) A1-33
  • Community Health Promotion for Trainers Appendix 1Tool 20: TargetingWhat is it?This tool sorts cards to identify who is most affected by a problem, and discusses thebenefits of focusing on activities with these people. It usually discusses problemsidentified during previous activities.Why use it?Using targeting helps to:• identify those most vulnerable to unsafe water, poor hygiene and inadequate sanitation• decide which groups of people most need assistance in coping with water, hygiene and sanitation• explore how to increase the impact of activities on a problem.How to use it1. Agree the problems around water, hygiene and sanitation to be discussed.2. Draw or write each problem on a separate horizontal line. Mark ‘not affected by the problem’ at one end of the line and ‘very affected by the problem’ at the other.3. Write on separate cards all the different types of people in the community. You will need to make several copies of these cards.4. Look at the first problem and discuss which types of people on the cards are affected by the problem, and to what degree. Go through each of the cards in turn, asking ‘Is this person affected by this problem?’ and ‘To what degree are they affected by this problem?’5. Place their cards on the line according to how affected they are. Participants may decide that more than one type of people is equally affected by the problem. This is OK.6. You may also want to ask and record ‘How are different types of people affected differently by this problem?’7. Continue to do this for each problem, asking, ‘Are they affected by this problem?’ and ‘To what degree are they affected by this problem?’ and placing the cards on the line according to this.8. Encourage the participants to discuss the benefits of targeting: • to the people targeted – for example, involving the people with the greatest need. • to the project – for example, the effective use of resources.9. Encourage the participants to discuss any negative effects of targeting or concerns about targeting. Discuss how these can be overcome.10. Decide which types of people should be targeted to help them cope with water, hygiene and sanitation, and how.(Adapted from International HIV/AIDS Alliance, 2006) A1-34
  • Community Health Promotion for Trainers Appendix 1Tool 21: Role PlayWhat is it?Role play involves participants acting out a situation that might happen in real life anddiscussing the issues that have been raised.Why use it?Using role plays helps provide a fun and non-threatening way to explore real-lifesituations; use those situations to help people explore their feelings and share what theyreally feel; and practice new skills or improve existing ones. For example, in a role playpeople can practice their negotiation skills or demonstrate how to use and maintain abiosand filter.How to use it1. Be clear about the objectives of the role play. Ask participants to prepare an outline of a common situation they would like to role play. Alternatively, write a situation beforehand, and include brief details of the roles and situation for participants to act out.2. Ask for volunteers to act out the role play and give them 15 minutes to prepare their role play.3. Ask the volunteers to do the role play. Encourage the other participants to watch and listen carefully.4. After the role play, ask the volunteers what it was like to act the parts, what they learned and how they felt. Then ask the audience what it was like to watch, what they learned and how they felt.5. When the activity is complete, encourage the participants to discuss what they have learned. For example, what were the challenges of the situation? Who had the most power in the situation? What might have been the effects of the situation? What could have made the situation better?Facilitator Notes• Encourage the volunteers to develop a realistic, everyday story rather than an extreme one. This will help you to discuss real-life situations and issues.• Role plays are not just about what people say, but what they do. Pay attention to the body language of both the volunteers and the audience.• It can be useful to ‘pause’ a role play at an interesting point and have a discussion. You can then restart the story afterwards. Alternatively, audiences can suggest different actions or endings at this point.• Role play often involves fun. This helps people to relax and talk openly. But sometimes the fun can take over and the point of the role play can get lost. Watch out for this and remind the group that the activity has a serious aim.• It can be useful to have a series of role plays that focus on the same situation but are slightly different. For example, in the second role play the key characters might be women rather than men, be children rather than adults, have positive rather than negative attitudes, etc.• It is always important to debrief participants after a role play.(Adapted from International HIV/AIDS Alliance, 2006) A1-35
  • Community Health Promotion for Trainers Appendix 1Tool 22: Story With a GapWhat is it?This tool involves community members drawing a series of pictures to tell a story aboutwater, hygiene and sanitation to highlight the issues involved.Why use it?Using a story with a gap helps to:• provide a visual way to explore situations about water, hygiene and sanitation• look closely at what those situations involve, including what leads a person to make certain decisions or to behave in certain ways• identify what choices people have and the factors that affect those choices• start to identify what would help people to make more positive choicesHow to use it1. Select a situation relating to water, hygiene and sanitation that community members might face. For example, ‘using a latrine’ or ‘drinking safe water’. This will become the end of the story.2. On the right-hand side of the page, ask participants to draw this situation. Encourage the participants to show who is involved, where it is happening, what is taking place etc. Label the drawing ‘5’.3. Now ask participants to make another drawing at the left-hand side of the page showing how the story started. Label this picture ‘1’.4. Now encourage the participants to think about the events that might have led to the situation in picture 5. Ask them to fill the gap in the story by drawing pictures 2, 3 and 4.5. Starting from picture 1, encourage the participants to identify the choices that were available to the person at each stage of the story. Ask them to identify the factors that led the person to move on to the next stage in the story. Ask them to write those factors below the picture.6. Repeat the process for pictures 2, 3, 4 and 5 until the story no longer has a ‘gap’ in it.7. When the activity is complete, encourage the participants to discuss what the story shows. • Why do some people have few choices and other people have many choices? • How could people be given more choices? • What other choices could the person have made? • How would those different choices have changed the story? • Who has power during each step of the story?Facilitator Notes• Encourage participants to think of a typical story rather than an extreme or ‘tragic’ one. This will help make the activity more realistic and useful.• Stories with a gap work best when the story leading up to picture 5 takes place over quite a short space of time (for example, hours or days) rather than a long one (for example, months or years).• If using paper and pens, it may be easier to use separate pieces of paper for each picture rather than one big piece of paper.(Adapted from International HIV/AIDS Alliance, 2006) A1-36
  • Community Health Promotion for Trainers Appendix 1Tool 23: Case StudiesWhat is it?A case study is a true story about a real situation or person. Sometimes, the actualperson featured in the case study tells the story themselves.Why use it?Using a case study helps to:• start discussion about topics relating to water, hygiene and sanitation• explain how water, hygiene and sanitation affects the lives of real people, communities or organizations• reflect on what lessons can be learned from other people’s experiences• provide an opportunity for people to reflect and talk about their own situations.How to use it1. Case studies work best with small groups of participants. Case studies may also be of organizations as well as people.2. Before the activity, prepare a case study from real life.3. Explain to participants why you are giving a case study.4. Ask a participant to read out the case study. Alternatively, if there are several case studies, divide participants into groups and ask each group to read through a different case study. If participants are not literate, read the case study out loud to the group.5. When this is done, encourage the participants to discuss the case studies. • What do the participants feel about the situation in the case study? • What are the main issues in the case study? • What helped the situation? • What caused problems? • How does this relate to their own situation? • Would participants have acted the same way in this situation? • What options are available to deal with the situation? • What other support would have improved the situation?Facilitator Notes• Always gain permission to use the case study from the person or organization it is about. They must be informed about how the case study will be used and agree to this.• Sometimes, the person in the case study tells the story them self. If a person tells their own story, it is important that they understand the possible consequences beforehand. For example, participants may say things or ask questions that the person finds difficult or upsetting.• Participants may find it useful and helpful to share their own personal experiences that are similar to those illustrated by the case study. However, do not pressure people to discuss personal issues if they do not want to.(Adapted from International HIV/AIDS Alliance, 2006) A1-37
  • Community Health Promotion for Trainers Appendix 1Tool 24: Community DramaWhat is it?This tool involves participants acting a drama to highlight the issues and challengesfaced by real people in relation to water, hygiene and sanitation.Why use it?Using community drama helps to:• provide a fun and non-threatening way to explore issues about water, hygiene and sanitation• highlight real-life issues and challenges that community members face• start discussions about what can be done about those issues and challenges.How to use it1. Divide the participants into three or four groups.2. Describe three or four different community members whose lives are affected by unsafe drinking water, poor hygiene and lack of sanitation, example, ‘parent caring or sick child’ or ‘community health worker’.3. Give each group a description of one of the four different community members. Ask each group to develop a short drama about a day in the life of that person. Give them an hour to do this. Encourage participants to use the drama to show what happens to the person at home and in the community, who they see, what challenges they face and so on.4. Ask each group to perform their drama.5. When the activity is complete, encourage the participants to discuss what the dramas revealed. • What pressures and challenges were shown by the dramas? • Which community members faced the most pressures and challenges, and why? • What type of support would the community members need? • What can be done to increase that type of support?Facilitator Notes• There are many other ways to do community drama. Some examples include: – Tell the participants a short story about a community member. Ask them to add their own details and to act out the story. – Divide the participants into three or four groups. Tell each of them the same story, but with a slightly different ending. Ask them to act out the story and to compare their dramas.• Encourage participants not to act out their personal experiences as this can be too difficult and emotional. Instead, ask them to develop stories about ‘typical’ people and situations in their community.• Drama can be good fun. But it can also bring out emotions in people, including anger and hurt feelings. Be aware of this and provide plenty of time for discussion and debriefing. A1-38
  • Community Health Promotion for Trainers Appendix 1(Adapted from International HIV/AIDS Alliance, 2006) A1-39
  • Community Health Promotion for Trainers Appendix 1Tool 25: Participatory PhotographyWhat is it?This tool involves people learning how to use cameras to illustrate how water, hygieneand sanitation affects their lives.Why use it?Using participatory photography helps to provide:• a non-threatening way for people to express their opinions, ideas and feelings about water, hygiene and sanitation• a powerful way to allow people affected by unsafe water, poor hygiene and lack of sanitation to show the reality of their daily lives.How to use itParticipatory photography usually has five phases:1. Training in using cameras. People are trained in how cameras work and how to compose a picture. They can start by looking at photographs from newspapers and magazines, and discussing what makes a good or bad photograph. Good photographs usually tell a story all by themselves.2. Deciding what to photograph. Here photographers plan who or what they will photograph, where and how they will photograph and who they will present them to.3. Photographing. Photographers go out into the community and photograph according to their plan.4. Sharing and reflecting on the photographs taken. Photographers develop their photographs and allow each other to show what they have photographed and why. Photographers share what their photographs mean to them as individuals, identify the common themes emerging, and lessons they have learned about how water, hygiene and sanitation affects their community.5. Presenting the photographs to others. This can be done in different ways. For instance, an exhibition can be given in a public place like a school, hospital or workplace, or a book can be made of the photographs and sold to raise funds for the cameras or water, hygiene and sanitation projects.Facilitator Notes• Photography is an art, although children and adults can use cameras quite easily. For the best results, asking a local professional photographer to train participants is a good idea.• Always ask permission before taking someone’s photograph and ensure that the person knows what that photograph will be used for.• Cameras can be expensive, but cheaper cardboard cameras are now available in most big cities. Alternatively, people can share cameras.(Adapted from International HIV/AIDS Alliance, 2006) A1-40
  • Community Health Promotion for Trainers Appendix 1Tool 26: Participatory VideoWhat is it?This tool involves people learning how to use video cameras, storytelling and role play toillustrate to others how water, hygiene and sanitation affects their lives.Why use it?Using a participatory video helps to provide:• a non-threatening way for people to express their opinions, ideas and feelings about water, hygiene and sanitation• a powerful way to allow people affected by water, hygiene and sanitation to show the reality of their daily lives• a fun way for people to make their own information, education and communication materials.How to use itParticipatory video usually has seven phases:1. Training in using cameras. People are trained in how video cameras and sound equipment work, and how to make a film. Video making can be quite a skill. For the best results, asking a local professional video maker (like a wedding cameraman) to train participants is a good idea.2. Training in writing film scripts. Participants are trained in how to write scripts and scenes – see Storytelling and Picture Story.3. Deciding what to film. Here participants plan: • the key messages they want to show. • who or what they will film and why (participants may act in it themselves, • make a diary of their lives or film aspects of other people’s lives). • where and how they will film it. • who they will present the film to.4. Filming. Participants make and edit their video according to their plan.5. Sharing and reflecting on the film taken. Participants premiere their film to an audience of key stakeholders to show what they have filmed and why.6. Copies of the film are made and distributed to organizations.7. The film is shown to key groups and communities who may benefit from the film. This is a good way to start a discussion about the issue shown.Facilitator Notes• Always ask permission before recording someone on film and ensure that the person knows what that film will be used for.• Video cameras and editing equipment can be very expensive to buy, but it is possible in many places to hire or borrow this equipment.(Adapted from International HIV/AIDS Alliance, 2006) A1-41
  • Community Health Promotion for Trainers Appendix 1Tool 27: Picture StoryWhat is it?This tool involves participants drawing a series of pictures to tell the story of a ‘typical’community member and a situation related to water, hygiene and sanitation.Why use it?Using a picture story helps to:• provide a non-threatening way to identify the challenges and options that community members face in relation to water, hygiene and sanitation• explore how those challenges and options are or are not the same for all community members• begin to identify what can be done to address the challenges.How to use it1. Explain the purpose of the tool and divide large groups up to draw different picture stories.2. Describe different ‘typical’ community members – for example, a ‘14-year-old school girl from a poor rural family’, a ‘30-year-old male teacher in a village’ or a ‘40-year-old woman with 3 children’.3. Select three or four issues that might affect all of the ‘typical’ community members. Examples might include ‘having diarrhoea’ or ‘not having a latrine available’.4. Ask participants to choose one of the issues. Ask them to draw pictures telling the story of what might happen to the community member if they tried to address the issue.5. Repeat the activity for the other problems.6. Repeat the process for different ‘typical’ community members (or ask different groups to draw stories about different ‘typical’ community members).7. When the activity is complete, encourage the participants to discuss what the picture stories show. • Which community members have the most options for seeking help? • Who has the least? • How are different people treated when they try to get help? • Why is that? • What could be done to improve the situation?Facilitator Notes• Remind participants that the quality of their drawing does not matter. The activity is about sharing ideas and learning.• Encourage the participants to spend only a short time drawing their pictures so that they have much more time to discuss what the pictures mean.(Adapted from International HIV/AIDS Alliance, 2006) A1-42
  • Community Health Promotion for Trainers Appendix 1 A1-43
  • Community Health Promotion for Trainers Appendix 1Tool 28: StorytellingWhat is it?Storytelling involves participants discussing ‘typical’ stories about water, hygiene andsanitation in order to identify the issues involved and what can be done about them.Why use it?Using storytelling helps to:• provide a non-threatening way to identify the types of real-life situations and issues that affect people in relation to water, hygiene and sanitation• explore how people feel about those situations and issues• begin to identify how to take action on those situations and issues.How to use it1. Before the activity, prepare a ‘typical’ story about water, hygiene and sanitation in the community. For example, it might be about the ‘open defecation in our community’ or ‘people living with water related illness, such as diarrhoea’. Make sure that the story includes lots of detail (about the people, places and situations involved), but leave it without an ending.2. Share the story with the participants. Encourage them to listen carefully.3. Ask the participants what they think about the story. For example, is it realistic? How does it make them feel? What issues does it highlight?4. Divide larger groups of participants into groups of eight or less. Ask each group of participants to come up with an ending to the story. Encourage them to use speaking, singing, drawing and/or acting to communicate it.5. Ask the groups to share their endings.6. When the activity is complete, encourage the participants to discuss what the story showed. • What did the story show about relations between people in the community? • What did it show about people’s attitudes? • What did it show about the biggest challenges facing the community? • How could the situation be improved?Facilitator Notes• The storyteller can dress up and use props or different voices to make the story livelier.• There are many different versions of this tool. For example, you can: – Ask participants to make up their own ‘typical’ story about water, hygiene and sanitation in their community. Encourage participants to include lots of detail about the situation, people, places and attitudes involved. – Share the first two to three sentences of a ‘typical’ story about the community. Then ask a volunteer to suggest the next two to three lines. Then ask another volunteer to suggest the next two to three lines. Keep going until the story reaches an end or has covered several important points. – Divide a ‘typical’ story into three parts. Share the first part with the participants. Then stop and ask questions, such as, ‘How is the character feeling?’ ‘What do you think about what is happening?’ Then repeat the process for the next two parts. A1-44
  • Community Health Promotion for Trainers Appendix 1(Adapted from International HIV/AIDS Alliance, 2006) A1-45
  • Community Health Promotion for Trainers Appendix 1Tool 29: Production of Information, Education andCommunication MaterialsWhat is it?This tool involves participants producing their own information, education andcommunication (IEC) materials by themselves and for themselves and their peers. IECmaterials aim to inform, educate and communicate specific knowledge, skills or attitudesto people. This tool is particularly effective with key populations.Why use it?Participatory IEC helps to:• produce effective IEC material for specific groups or communities• build new skills, knowledge, confidence and social capital in individuals and groups• advocate for changes – for example, no open defecation, hand washing• provide general health information.How to use it1. Ensure everyone understands what IEC materials are and why they are used. Show examples.2. Discuss the purpose of the IEC material the participants are about to produce, and brainstorm the following questions: • Audiences – who will be the specific audience for the IEC product? • Topics – what specific issues and topics should the IEC products cover? Which solutions should it address? • Medium – what form of product would be most appropriate for that audience and topic?3. Record the results in a table. See the example below.4. Split the groups up into teams to plan the content of each product in detail: the exact message, roles and responsibilities, materials required and where the activities will take place. Facilitators should ensure that the messages are technically accurate.5. Produce the material by writing, drawing posters or pictures, filming, community drama, photographing, and so on.6. Display, reproduce and disseminate the products: • Products can be displayed or performed for an invited audience. • Visual products can be professionally reproduced for wider distribution. • Video and audio products can be put on CD or DVD for targeted distribution that may include television and radio stations, NGOs, government agencies and so on.Facilitator Notes• The IEC products belong to the participants who produced them, not the organization that facilitated or paid for the process. Ask participants for permission to use any IEC materials, and respect their wishes.• Experience has shown that participatory IEC materials do not need to be further field-tested if they have been produced by the same cross-section of a specific group who will use them.(Adapted from International HIV/AIDS Alliance, 2006) A1-46
  • Community Health Promotion for Trainers Appendix 1Tool 30: Setting Learning ExpectationsWhat is it?This tool allows facilitators to find out the learning expectations of the participants andlink these with the objectives of the activity.Why use it?Participants have the opportunity to state what they hope to learn from the activity whichallows them to take ownership of their learning. The facilitator can make sure that theirexpectations are reasonable and demonstrate that the participants’ needs are being met.How to use it1. Welcome participants to the session and introduce the facilitators.2. Ask participants to introduce themselves to the group. There are different ways that this can be done. See Appendix 3 for different ice breakers.3. After the introductions are completed, ask participants to discuss with a partner “When you were invited to this session, what did you hope that you would learn?”4. Ask each pair to share one or two learning expectations with the entire group. Write these on a flipchart or board.5. Ask if anyone’s expectations have been left out and write any additional points on the list.6. Talk about each of the expectations that have been written down and explain how it will be addressed in the session or whether it is outside the scope. If the expectation is not going to be met, provide the participant with alternative ways to learn about that particular topic (e.g. future sessions, book, internet, etc). A1-47
  • Community Health Promotion for Trainers Appendix 1Tool 31: Making Ground RulesWhat is it?Participants create the ground rules for how the group is expected to work togetherduring the session.Why use it?Setting expectations ahead of time is a proactive tool to create a positive learningenvironment for all participants.How to use it1. Introduce making ground rules by explaining these are expectations created by the group that will govern the session.2. Ask participants to suggest ways to create a positive learning environment for everyone. Check to see if the participants agree with what has been said.3. Write the expectations on a flipchart or board.4. Ask if anyone’s expectations have been left out and write any additional points on the list.5. If nothing is forthcoming from the participants, the facilitator may provide some suggestions, such as: • Respect what other people say • Only one person to speak at a time • It is OK to ask questions if you don’t understand • Turn off cell phones during the session6. Post the ground rules in a visible location for the entire session. Conclude by saying that these are the group’s expectations for working together. It is OK to add to the ground rules if other suggestions are brought forward later on during the session.Facilitator Notes• Refer back to the ground rules if the group or an individual is not meeting the expected behaviour. A1-48
  • Community Health Promotion for Trainers Appendix 1Tool 32: Writing Aims and ObjectivesWhat is it?The tool helps to write aims and objectives for a project.Why use it?Writing aims and objectives help to:• identify and summarize the purpose of a project or activity• identify and summarize what a project hopes to achieve• provide a framework for planning• provide information for monitoring and evaluation.How to use it1. Review the set of problems identified during a previous activity.2. Discuss the meaning of the word ‘aim’ (the overall purpose of the project).3. Look at all the problems. Discuss and agree the overall improvement that the project hopes to achieve by addressing these problems. Ask a participant to turn this into a short sentence. Ask other participants if they agree with this. Once agreement is reached, record this as the project aim.4. Discuss the meaning of the word ‘objective’ (a statement about specific activities of a project and what a project will achieve through these activities).5. Explain how objective writing helps to answer the following questions: • What will change as a result of the activity? • Who will be most involved in the activity? Who will benefit most from these changes? • How much will the activity change a problem? • When will the activity be completed? • Where will the activity take place?6. Explain that objectives should be SMART: specific, measurable, achievable, relevant and time-bound: • Specific – an objective should say exactly what will be achieved, with who, how, when and where. • Measurable – so you are able to tell exactly when the objective is achieved. • Achievable – it must be realistic given the circumstances you are working in and time you have available. • Relevant – it must relate to the problem being addressed. • Time-bound – it must be achieved by a certain date and not go on and on.7. Take one problem at a time. Using the ‘What?’ ‘Who?’ ‘How?’ ‘When?’ ‘Where?’ questions, decide on an objective that would address the problem.8. Ask a participant to put the objective into a short sentence. Ask other participants if they agree with this. Record this as one project objective.9. Repeat this process for each problem until a list of objectives is created.10. Read out the objectives one by one. Make sure that each objective will contribute towards achieving the aim.Facilitator Notes• It is important to be as precise as possible in the wording of objectives.(Adapted from International HIV/AIDS Alliance, 2006) A1-49
  • Community Health Promotion for Trainers Appendix 1Tool 33: Monitoring MatrixWhat is it?A monitoring matrix is a chart that shows what activities are working well and whatneeds improving according to those who are participating in it.Why use it?A monitoring matrix is useful to:• Monitor the progress of activities with members of the community or project• Understand what different people think about activities that were done• Explore the positive and negative results of activities• Explore who has been involved in activities, who has benefited from them and why• Explore what could be improved about the activities• Start to identify what other activities might be neededHow to use it1. Small or large groups can make a monitoring matrix. Divide larger groups into peer groups to explore different views.2. Agree what activities are to be discussed. Show the activities down the left-hand side of the chart (pocket chart, paper, or on the ground).3. Agree on important questions to be discussed about the activities. For example: • Has the planned activity taken place? • Have they happened according to the timeline? • Have all the people who wanted to be involved in the activity been involved? • Has attendance increased? • Has the activity had the effect people wanted?4. Show these questions at the top of the chart.5. Discuss each question for each activity listed on the left-hand side.6. Participants can use counters to score the degree to which an outcome has been achieved for each activity. For example, scoring out of 10, with 10 being “completely achieved” and 0 being “not achieved at all”.7. Discuss what is shown on the chart and the following questions: • Are there activities which were planned but not have taken place? • What is the most positive change? • What is the most negative change? • How can we improve activities?Facilitator Notes• If this tool is used to develop a community-level analysis, it is important to make sure that different views are well represented.• Discussing negative views as well as positive views will help show how to improve the activities. Discuss ideas for new activities.• If participants know less about the activities than expected, explore the reasons for this.(Adapted from International HIV/AIDS Alliance, 2006) A1-50
  • Community Health Promotion for Trainers Appendix 1Tool 34: Structured ObservationWhat is it?Structured observation is a systematic technique for observing and recording particularpractices.Why use it?To obtain useful and timely information by observing what people do, to help makedecisions on improving project performance, or for generating insights and findings formore focused studies. This method complements collected data and can be used tounderstand the context in which information is collected and can help explain results.How to use it1. Set the guidelines for what needs to be observed and the information required.2. Choose an appropriate observer or group of observers. • Observers can be community members and project staff who live and work full- time in the project area. These observer should be trained in observational skills • Observers can also be people from outside the community. Note that outsiders may need more time to know what is significant. On the other hand, they sometimes notice significant issues that local people no longer see or take for granted.3. Collect and record the data.4. Organize a time to discuss the recorded observations.Facilitator Notes• This method is also known as “participant observation” and is a common research method for social issues and processes.• People often forget this simple method. Everyone observes automatically. But you can make observations more effective by viewing it as a valid method and structuring its use. Much can be learned by watching what people actually do. Useful information and new insights can often be gained from observation that would otherwise not be obtained.• Observation can be used to cross check responses received by other methods.• There is always the potential to introduce bias into the results. Asking several people to undertake observations in the same way can help to confirm the results and improve the quality of the data.(Adapted from IFAD, nd) A1-51
  • Community Health Promotion for Trainers Appendix 1Tool 35: Focus GroupsWhat is it?Focus groups are an effective way of gathering information on peoples ideas, beliefs,practices and behaviour. They gather together people with similar backgrounds for adetailed discussion about a subject.Why use it?To collect general information, clarify details or gather opinions. It can also be used tobuild consensus. Focus groups are good for assessing opinions of change, assessingthe quality of project services, and identifying areas for improvement.How to use it1. Select the participants (four to eight people is ideal). Depending on your purpose, you can work with a group of people that are similar or different. Alternatively, use a number of focus groups, each one fairly the same, but the groups being different from each other. This allows interesting comparisons.2. Introduce yourself to the group and explain very clearly the object of the exercise and that you hope everyone will learn from each other. Explain that there are no right or wrong answers to the questions. Stress that people should try not to interrupt others when they are talking, and that everyone’s point of view will be valued.3. Present the group with a broad question. For example, What impact do you think a particular intervention has in changing the community’s behaviour?4. Discuss this question for a time period agreed upon beforehand. There should be minimal intervention by the facilitator other than to make sure that everybody has a say. Perhaps you might need to repeat the question using different words from time to time or to probe if something is not clear.5. Take detailed notes of the discussion. Focus groups are best facilitated in pairs – one person to facilitate the discussion and the other to take notes. The discussion can also be recorded to ease the review process, but only if the participants have consented and are comfortable with it.6. Bring the session to a close when you feel the subject has been exhausted (maximum of 1.5 hours). If problems have been identified try also to get people to consider any possible solutions and how they intend to implement them.7. Thank the participants for their time and participation.8. During analysis, take out any important quotes to emphasize certain points.9. Prioritize, summarize and analyze the information.10. Organize a time to discuss the results.Facilitator Notes• If facilitated well, this method can bring out detailed information. However, facilitation of focus groups requires considerable skill – both in moderating the group and in adequately recording the responses. They are less useful in the hands of a person who does not know how to actively listen or effectively ask open and probing questions.• This method can generate insights more quickly and generally more cheaply than through a series of structured interviews or surveys.(Adapted from IFAD, nd and Ferron, 2000) A1-52
  • Community Health Promotion for Trainers Appendix 1Tool 36: InterviewsWhat is it?Conducting interviews is a way to explore what people think about an issue without theformality of a questionnaire or survey. The interviews are open-ended and use adiscussion guide, such as a checklist.Why use it?To gain information from an individual or small group, using a series of broad questionsto guide the conversation, but allowing for new questions to come up as a result of thediscussion. Interviews can be especially informative when conducted with keyinformants, such as community leaders, health workers, teachers, government officials,etc. They are helpful for assessing unintended impacts, opinions about the quality ofproject services, etc.How to use it1. Set the guidelines for what information is required and create an interview checklist of open-ended questions. The questions should be such that interviewees can express opinions through discussion. A logical sequence to the questions will help the discussion flow.2. Select who should be interviewed, how many are required, and whether interviews should be with individuals or in a group.3. Choose appropriate people to conduct the interviews. Interviews are best facilitated in pairs – one person to perform the interview and the other to take notes.4. Make an appointment at a suitable time for them.5. Prepare beforehand what you want to find out, but try not to read out questions during the interview.6. Take notes of their answers.7. At the end of the interview, ask the person being interviewed whether they have questions to ask you. Be prepared to answer these as best you can, and when you don’t know the answer, offer to find out and return with a response.8. Summarize what you have discussed and agreed at the end of the interview and thank them for their time and participation.9. Produce a short summary of what each person said, including the main points.10. Look over the responses and once you have looked at about 25% of the interviews, note the points most frequently mentioned. Then read the remaining responses and record how many interviewees have responded to each of these main points. Alternatively, divide the responses into those “for” and “against” a certain issue or divide them to show various degrees of enthusiasm about an issue.11. Take out any important quotes to emphasize certain points.12. Prioritize, summarize and analyze the information.13. Organize a time to discuss the results.Facilitator Notes• Open-ended information is more difficult and time-consuming to synthesize well enough to obtain clear results. It can be difficult to keep interviews focused, making different interviews difficult to compare properly(Adapted from IFAD, nd and Ferron, 2000) A1-53
  • Community Health Promotion for Trainers Appendix 1Tool 37: Questionnaires and SurveysWhat is it?Questionnaires and surveys are used to gather data from a large number of people in astructured way. The terms questionnaire and survey are often used interchangeably butcan be distinguished as follows:• A questionnaire is a form with questions used to gather information from people.• A survey is a more general term that might be one or two simple questions to be answered or could even be a long questionnaire.Why use it?Questionnaires and surveys allow for focused data collection that can be used forstatistical analysis. They can provide precise answers to carefully defined questions.How to use it1. Agree on the purpose and information needs.2. Decide whether a questionnaire or survey format should be used. The formats can range from being very simple to quite complex.3. Create your questionnaire or survey. They can use a very specific and structured set of closed questions (yes/no or multiple choice) or they can also include open-ended questions. Closed questions are good for gathering data that needs to be statistically analyzed. Open-ended questions are good for determining people’s feelings or attitudes. For example, • Closed question (yes/no answer): Do you have enough water to satisfy your family’s needs? • Open-ended questions: Where do you get your water from? Do you have enough water for your family today? This week? How many months of the year do you have a water shortage? What do you do during this time?4. Determine who should be questioned and how many people should be included in the sample.5. Decide on the most appropriate manner of questioning. For example, a mailed out written form, telephone survey, individual interviews.6. Collect and analyze the information.Facilitator Notes• Often projects make the sample too big and ask too many questions. This makes analysis a tedious job and loses its usefulness. Long questionnaires and surveys are also time consuming for the respondent to complete.• Answers which must fit a certain set of options or format will also fail to pick up on deviating answers and opinions. Be aware that you might be missing out on important details and variations to the questions.(Adapted from IFAD, nd) A1-54
  • Community Health Promotion for Trainers Appendix 1Tool 38: Most Significant ChangeWhat is it?The most significant change tool is a story that describes an important change that hashappened due to project activity, and what a person thinks about this change.Why use it?The most significant change tool is useful to:• understand the impact the activity or project is having on people• understand what, if anything, has changed as a result of project activities• understand the reasons for this change• explore what people think about this change, for example, do they think it is a good change or a bad change?• identify what changes are seen as significant by communities and what are not• identify how to improve project activities.How to use it1. Agree how often to use the most significant change tool and with whom. For example: • at the end of the project with primary stakeholders to evaluate the impact of the activity • every three or four months with the all project stakeholders to monitor progress.2. Ask a stakeholder (or small peer group) to identify what they feel has been the most significant change related to the project during the time period.3. Ask the stakeholder to describe the significant change. Asking them to draw pictures of the most significant change can be used to help the discussion. Ask why the person thinks this change is significant.4. To find out about specific changes, you can also ask stakeholders what they think is the most significant change for: • themselves as individuals • the peer group they belong to • the community as a whole • the services in the community.5. You can use how people define significant change to set community-based goals for the project. For example, if people say that a significant change for them was ‘the community works closer together now’, then ‘the community works closer together’ can become a new goal of the project.6. Share most significant change stories with different people involved with the project.Facilitator Notes• Describe time periods according to local calendars.• Encourage participants to tell stories about negative changes or frustrating experiences in order to build up a balanced view.• If people have trouble identifying changes related to project activities, explore the reasons for this. Perhaps there have not been any significant changes.(Adapted from International HIV/AIDS Alliance, 2006) A1-55
  • Community Health Promotion for Trainers Appendix 1Tool 39: Before and Now DiagramWhat is it?A before and now diagram is a diagram that shows change. This might be change in asituation since a significant event, such as the start of a community initiative.Why use it?A before and now diagram is useful for:• exploring change over time in a particular situation, and the reasons for change. For example, changes explored might include changes in behaviour, knowledge and attitudes in a community• exploring the consequences of a particular event – for example, an important change in law• assessing the effectiveness (impact) of a community initiative• exploring how significant events have affected people differently.How to use it1. Explain the purpose of the diagram to participants.2. Agree what time period is described by before. This might be the time before an important event or development – for example, before an important change in law, before the start of a community initiative, or before safe water in the community.3. Draw or write about the situation as it was before the event or development. Examples of what participants might want to think about are changes in individuals’ attitudes and behaviours, the community, services, policies and laws, the economy or environment.4. Now ask participants to draw or write about the situation as it is now.5. Ask participants to compare and present the two drawings or descriptions. Discuss what has changed, what has not changed, and the reasons for this.Facilitator Notes• When discussing change at community level, it is important to make sure that different views are well represented, as people will have experienced change differently.• The before and now diagram is a useful tool for monitoring or assessing change – for example, what has changed as a result of community action?• Encourage a balanced assessment by discussing what has not changed, as well as what has changed.(Adapted from International HIV/AIDS Alliance, 2006) A1-56
  • Community Health Promotion for Trainers Appendix 1Tool 40: BrainstormWhat is it?This tool involves participants sharing their opinions, feelings and ideas about a topic.Why use it?Brainstorming helps to:• provide a non-threatening way for people to express their opinions and feelings• allow participants to explore new ideas• identify where there is, or is not, agreement about issues relating to water, hygiene and sanitation.How to use it1. Divide the participants into four groups and give each group a different coloured pen.2. Think of four challenging situations relating to water, hygiene and sanitation in the community. Examples might include ‘people are open defecating in the community’ or ‘children suffering from diarrhoea’.3. Write each of the situations on the top of a large piece of paper. Put the pieces of paper up on walls or trees in different places in your work area.4. Ask each group to stand by a piece of paper. Ask them to write down as many ideas as possible about how to improve the challenging situation. Before they start, stress to participants that at this stage any and all ideas should be written down without anyone judging them.5. After five minutes, shout out ‘Change!’ and ask each group to move to another piece of paper. Ask them to add to the ideas written by the previous group.6. After five minutes, shout ‘Change!’ again. Repeat the process until all of the groups have added to all of the pieces of paper.7. Bring the participants back together. Read through what they have written on the pieces of paper and ask them to explain anything that is unclear.8. When the activity is complete, encourage the participants to discuss what they have learned. • How difficult was it to think of ideas? • Did the groups have similar or different ideas? • Which of the ideas could be put into practice quickly? • What resources would be needed?Facilitator Notes• Brainstorms aim to help people to express themselves freely and openly. So it is important to create a ‘safe space’ where people will not be judged for what they say.• If some participants have difficulties with writing, ask all participants to use symbols.• There are many other ways of doing brainstorms. Some examples include: – Unfinished sentences: ask participants to suggest a way of finishing a provocative sentence; for example, ‘One thing our community could do to improve the situation is ...’ – Picture galleries: ask each participant to draw a picture of what a particular issue means to them. Display the pictures on the wall or on trees. Encourage people to ask each other about what they have drawn and why.(Adapted from International HIV/AIDS Alliance, 2006) A1-57
  • Community Health Promotion for Trainers Appendix 1Tool 41: Card SortingWhat is it?This tool is a simple way to sort issues when there is a lot of information.Why use it?Using card sorting can help to sort and organize information into categories. This mightinclude:• organizing information gained during an assessment into manageable quantities• sorting activities according to how feasible (do-able) they are• examining which activities have a risk of disease transmission and which activities have less risk.How to use it1. Card sorting works best with smaller groups of people.2. Agree the issue to be explored – for example, what helps mothers improve their hygiene practices in the household?3. Ask participants to write down or draw on separate cards all of the different things which relate to the issue4. Ensure all the cards are face up so that all the cards can be seen by all the participants.5. Now ask participants to sort the cards into different categories according to their own criteria about the issue to be explored. For example, categories of things which help mothers to improve their hygiene practices might include good health, social support, education, and so on.6. When the activity is complete, discuss what it shows. • What is in each category and why? • Why did people use these categories? • Discuss how to use the information.Facilitator Notes• For information gathered from participatory assessments, participants can use the same technique to sort information by the assessment objectives – for example, people’s knowledge about proper hygiene, their attitudes towards it and their behaviour towards it.• For assessing feasible (do-able) activities, participants could sort them into different categories, from easy to very difficult.• For assessing risk of disease transmission, different activities can be sorted into categories, from high to low risk. The number of ways card sorting can be used is limitless. Think how you could use it.• Allow participants to come up with their own categories if these have not been established yet. This may look disorganized and slow at first, but have trust that they can do it!(Adapted from International HIV/AIDS Alliance, 2006) A1-58
  • Community Health Promotion for Trainers Appendix 1Tool 42: Vision DiagrammingWhat is it?In vision diagramming, people draw a picture of a positive future they imagine for theircommunity. This tool is useful when people are working together to identify newactivities, services and resources.Why use it?Using vision diagramming helps to:• imagine a positive future – a vision – where the water, hygiene and sanitation situation is improved• identify services, activities and resources that will help achieve this vision• identify who might be involved in providing these services and activities• identify possible difficulties in bringing about the vision• discuss how to solve these difficulties.How to use it1. Vision diagramming works best with groups of up to 12 people.2. Ask participants to think about the current water, hygiene and sanitation issues in their community. Who is affected, and how? What services exist? What is the quality of these services?3. Encourage participants to close their eyes and imagine a future in which all of the community has access to safe drinking water, proper hygiene and basic sanitation. In this future, people are preventing illness and supporting all community members affected by unsafe drinking water and lack of sanitation. Everyone in the community is involved in responding to the issues.4. Ask each participant to draw this vision. What services exist? What would their role in this vision be? What would other people’s roles in this vision of the future be?5. Ask the participants to share their pictures with each other in small groups.6. Encourage the participants to discuss their visions in detail, using the following questions: • In the visions, what new activities, services and resources exist? • Who is involved in carrying out the activities or services? • What would each of their roles be in this vision? • How did the vision come about? • In the visions, what difficulties were there in implementing these activities and services? How were these difficulties solved? What made things easier?7. Ask the small groups to share their visions and discussions with the larger group. Encourage participants to ask questions about the drawings and make any comments or suggestions.Facilitator Notes• It is important that participants feel relaxed in this exercise and that they take the time to imagine a very positive future.• Encourage participants to be as imaginative as they can. Remember that it may be difficult for people to imagine a service or a project that they have never seen.(Adapted from International HIV/AIDS Alliance, 2006) A1-59
  • Community Health Promotion for Trainers Appendix 1Tool 43: Problem Wall and Solution TreeWhat is it?These tools are drawing tools that look at problems and solutions related to a particulartopic.Why use it?Using a problem wall and solution tree helps to:• identify and discuss problems related to a particular topic• group together similar problems that may have the same solution• identify and discuss possible solutions for the problems.How to use it1. Problem walls and solution trees work well with large groups of people in public places.2. Cover a wall with paper and title one half of it ‘problem wall’. On the other half draw a large tree and title it ‘solution tree’.3. Agree a topic. For example, ‘What do you think of our drinking water?’ Put this title of the topic at the top of the wall.4. Cut up lots of ‘brick-shaped’ pieces of paper and ‘leaf-shaped’ pieces of paper. Put these in separate piles, with the bricks by the ‘problem wall’ and the leaves by the ‘solution tree’. Put something nearby for people to be able to stick the leaves and bricks to the wall, such as glue or tape.5. Invite people to think about the topic and write problems on separate ‘bricks shaped’ pieces of paper and stick these on the problem wall.6. Ask participants to group similar problems on the wall.7. Now ask people to consider these problem bricks and think of solutions to them. Invite people to write solutions on the ‘leaf-shaped’ pieces of paper and stick these on the solution tree.8. Group together any solutions that are similar.9. If this tool is being used in a workshop setting, agree which solutions would be easy to do and those that would be difficult to achieve alone. Use Low Hanging Fruit to help with this activity.10. Summarize the main points of the discussion.Facilitator Notes• These tools are very easy to set up and can be left for participants to complete anonymously. They can be left in places like health facility waiting rooms, at bus stops or any other place where people congregate and have a little time to spare. Clear instructions left by the problem wall and solution tree will help people to do the exercise themselves.• Use symbols instead of words if people are not confident writers. A1-60
  • Community Health Promotion for Trainers Appendix 1(Adapted from International HIV/AIDS Alliance, 2006) A1-61
  • Community Health Promotion for Trainers Appendix 1Tool 44: Action PlanningWhat is it?This tool uses a simple matrix to plan who will do what, by when and with whatresources. It is especially useful for planning with communities and groups of individuals.Why use it?Action planning helps to plan:• which activities to do• who will implement the activities• when the activities will be done by• what resources will be required to implement the activities.It is an especially useful tool to use after objectives have been set.How to use it1. Draw an action planning matrix (see illustration).2. Ask participants to identify solutions and objectives to address a problem.3. Ask participants to think about potential activities which will make those solutions come about, and put these in the left-hand column.4. For each activity, ask participants who should carry it out. Should it be done by them alone? With others? Or by other people or organizations? Write the names of each person or organization in the appropriate column.5. Now ask participants when each activity should be done by. Should it be done straight away (now)? Soon (within weeks/a few months)? Or later (a few months later)? When they have decided broadly when it will be done by, ask them to write a specific date in the appropriate column.6. Now ask participants to consider what resources will be required to implement each activity successfully. These could be physical (for example, tools, materials, transport), or financial resources. Write these resources in the last column.7. Agree with participants which individual people will take the lead responsibility for each activity to make sure it is done. Write the names of these people next to each activity.8. Ask participants to look at the action plan as a whole. Does it make sense? Is anything missing? Is it realistic?Facilitator Notes• It is important to be very specific when discussing activities. Help participants to break down large activities into small ones.• Remember, if a stakeholder is not present when their roles and responsibilities are being discussed, they must be fully consulted before plans are finalized! A1-62
  • Community Health Promotion for Trainers Appendix 1(Adapted from International HIV/AIDS Alliance, 2006) A1-63
  • Community Health Promotion for Trainers Appendix 1Tool 45: Road BlocksWhat is it?This tool involves participants identifying the barriers (road blocks) to something, andidentifying solutions to the most important barriers.Why use it?Using road blocks helps to:• identify the different barriers to something• explore how those barriers can be grouped and how they relate to each other• begin to identify solutions to the most important barriers.How to use it1. Select a subject in relation to safe drinking water, hygiene and sanitation which might present barriers – for example, ‘funding for our project’ or ‘lack of support from the local government’.2. Ask the participants to identify the different barriers to that subject.3. Fold pieces of card in half and draw or write one barrier on each piece of card.4. Place the pieces of card in a row on the floor, so that they look like a series of road blocks.5. Walk along the road blocks, and discuss why each barrier has been identified.6. Agree how to group the barriers. Examples of groups might include: organizational barriers, financial barriers, physical barriers (for example, lack of equipment), social barriers (for example, people’s attitudes), political barriers and so on.7. Draw a chart with a column for each group. Place each barrier on the chart under the heading that suits it best.8. Encourage the participants to identify the most important barrier of those listed. Ask them to write the barrier in the middle of a large piece of paper.9. Encourage the participants to identify possible solutions to that barrier. Ask them to write those solutions around the outside of the paper, with arrows linking them to the barrier.10. When the activity is complete, encourage the participants to discuss what they have learned. • How do the different types of barriers link together? • Which are the largest barriers? • Which can be addressed most easily? • What type of people and organizations need to address the barriers?Facilitator Notes• Encourage participants to be specific about the barriers. For example, rather than ‘lack of resources’, they might write ‘lack of tools’, ‘lack of money’, ‘lack of electricity’.• This tool can be overwhelming if it results in long lists of barriers. Emphasize that something can be done about every barrier and even small successes can make a big difference.(Adapted from International HIV/AIDS Alliance, 2006) A1-64
  • Community Health Promotion for Trainers Appendix 1Tool 46: Seasonal Health and Disease CalendarsWhat is it?Seasonal health and disease calendars show seasonal patterns of health and illness.The diagrams show when different illnesses are most common.Why use it?Seasonal health and disease calendars are useful to:• identify common illnesses and the relationship between well-being, illness and seasonal changes• explore different perceptions of illness and health• identify community priority health concerns• explore access to treatment and different health-seeking behaviours.How to use it1. Small or large groups can use seasonal health and disease calendars. Divide larger groups to explore seasonal health and disease patterns for different people, such as men, women and children.2. Discuss what calendar and seasonal landmarks are used locally – for example, months, dry or rainy seasons, festivals, religious ceremonies.3. Draw a horizontal calendar line (from left to right) marking seasonal landmarks.4. List illnesses at the left-hand end of the calendar line and show when each illness is most common. Participants can use counters to score the frequency of each illness.5. Discuss what is shown on the calendar. Discuss what different people do when they become ill.6. Ideas for useful questions include: When are illnesses are most common? Why? What do people do for treatment when they have an illness? Are there times of the year when illnesses are more common? Why? What illnesses are most serious? Are there times of the year when certain illnesses are more common? What do people do when they are ill? Are there times of the year when children are ill more often? What are the reasons for this? How do illnesses at different times of the year affect people and their families – for example, do they stop people working?Facilitator Notes• It is important for participants to use their own local calendar and seasonal landmarks.• Discussing key signs and symptoms of illnesses can help establish a common understanding of the illnesses that participants talk about. Local concepts of illnesses do not always match medical doctors’ definitions.(Adapted from International HIV/AIDS Alliance, 2006) A1-65
  • Community Health Promotion for Trainers Appendix 1 A1-66
  • Community Health Promotion for Trainers Appendix 1Tool 47: Division of Labour ChartWhat is it?This tool involves identifying what activities people carry out at different times of day. Inparticular, it helps to show how roles and responsibilities are divided between differentpeople, such as women, men and children.Why use it?Using a division of labour chart helps to:• identify how roles and responsibilities are divided between different community members, such as women and men or old people and young people• explore how different activities link to water, hygiene and sanitation• discuss the relationships between different community members (such as men and women) and how they link to water, hygiene and sanitation.How to use it1. Explain to participants the purpose of the tool.2. Divide participants into groups of the same sex, age, and so on.3. Ask the participants to identify symbols to represent different stages in the day. For example, a sun might be dawn and a moon might be evening. Draw these symbols down the left-hand side of the chart.4. Encourage participants to describe a typical day in the community, including what activities they do at what times. Ask them to write or draw the activities on the chart next to the appropriate symbol.5. Bring different groups of participants back together and encourage them to compare their division of labour charts.6. Encourage the participants to discuss what is shown on the charts. For example:• What activities take up most of their time?• What activities do they like most or least?• How do the charts vary – for example, between women and men?• What activities are connected to water?• What would happen if roles and responsibilities changed – for example, if a person, or several people, in a household became sick and others had to perform their roles?Facilitator Notes• Rather than using symbols, participants can write the hours of the day down the side of the chart.• The division of labour is likely to vary not only by gender, but also by age, ethnic group, wealth and so on. Sometimes it is useful to draw charts for several different types of people in order to get an overview of the community as a whole.• It is important to record when people are carrying out several tasks at once. For example, a woman might be working in the fields while also looking after children. This helps to give an overview of people’s full roles and responsibilities.• Sometimes, it is useful to ask participants to do a chart for the ‘other’ group. For example, you can ask women to do a division of labour chart for men. When each has done this, they can share what each thinks the other does – this usually leads to some humorous discussions! A1-67
  • Community Health Promotion for Trainers Appendix 1• This activity can also be carried out by drawing pie charts, either on pieces of paper or on the ground. This involves dividing the pie into different-sized slices to show how much of each day is given to each type of activity. For example, eating might be a small slice, while sleeping might be a large slice.This chart was used to explore the division of labour among men and women in a villagein Rwanda. It shows important information: women do most of the work and are in alarger number of different places throughout the day.(Adapted from International HIV/AIDS Alliance, 2006) A1-68
  • Community Health Promotion for Trainers Appendix 1Tool 48: Problem TreeWhat is it?This tool involves participants using a drawing of the trunk, roots and branches of a treeto identify a problem relating to water and the causes and effects of the problem.Why use it?Using the problem tree helps to: • Provide a visual and non-threatening way to look closely at problems relating to water • Identify the main causes and effects of the problem • Identify the issues that lie behind the main causes and effects • Begin to identify what can be done to address the causes and reduce the effectsHow to use it1. Explain the purpose of the tool and ask participants to identify a problem related to water. For example, ‘A lot of water-related diseases’.2. Make a large drawing of the trunk of a tree and draw or write the problem on the trunk.3. Encourage the participants to identify all the main causes of the problem. Draw these along large roots of the tree, indicating that they are ‘root’ problems.4. Select one of the main causes. Ask, ‘Why do you think this happens?’ This question will help participants identify the ‘secondary’ causes. Draw or write the ‘secondary’ causes as small roots coming off the larger root of the tree.5. Repeat the process for each of the main causes.6. Encourage the participants to identify the main effects of the problem. Ask them to write each effect as large branches of the tree.7. Select one of the main effects. Ask the participants, ‘Why do you think this happens?’ to encourage them to identify the ‘secondary’ effects. Ask them to write the ‘secondary’ effects as small branches coming off the larger branch of the tree.8. Repeat the process for the other main effects.9. When completed, discuss what the problem tree shows. For example, how do the causes and effects relate to each other? What are the root causes of the problem?10. Summarize the discussion.Facilitator Notes: • This tool can be used with the Solution Tree tool to identify the solutions to the root causes of the water-related problem.(Adapted from International HIV/AIDS Alliance, 2006) A1-69
  • Community Health Promotion for Trainers Appendix 1Tool 49: Solution TreeWhat is it?This tool involves participants using a drawing of the trunk, roots, and branches of a treeto identify solutions, such as what will bring about that solution and what effects thatsolution will have. It is usually used to identify solutions to problems that have beenidentified using problem trees.Why use it?Using the solution tree helps to: • Provide a visual and non-threatening way to identify solutions for water-related problems • Identify what will bring that solution about • Identify what effects that solution will have on a problemHow to use it1. If you have done a problem tree for an issue, participants can easily turn it into a solution/objective tree by turning the negative statements of the problem tree into positive statements. For example, the problem of ‘poor quality water’ at the trunk becomes ‘improved quality water’. This becomes our objective.2. To understand how that objective can be achieved, participants can look at the root causes and turn negative statements into positive ones. For example, if one of the root causes was ‘lack of knowledge among end users’, it can be turned into a positive statement, or objective, like ‘enhanced knowledge among end users’.3. We can continue down the roots until the ‘root’ solutions/objectives to creating ‘poor quality water’ have been identified4. We can now look at the possible effects that ‘poor water quality’ will have by (again) turning negative statements into positive ones.5. If you have not yet done a problem tree, ask participant to identify a goal they have for improved water quality in their community, such as ‘household water treatment use among end users’. Ask participants to make a large drawing of a trunk of a tree and draw or write the aim on the trunk.6. Encourage participants to identify all the things which will bring about that aim. Draw these along large roots of the tree, indicating that these are the main ‘root’ solutions/objectives which will make them achieve this overall goal.7. Select one of the main ‘root’ solutions/objectives. Ask, ‘But how does this happen?’ This question will help participants identify the secondary ‘root’ solutions/objectives required to bring about the overall goal. Draw or write the ‘secondary’ solutions/objectives as small roots coming off the larger root of the tree.8. Repeat the process for each of the other main ‘root’ inputs.9. Now encourage the participants to identify all the effects that fulfilling the objective will bring about. Ask them to write each effect as a large branch of the tree.10. When completed, discuss what the solution/objective tree shows. For example, what activities can be done to make the solution/objective tree happen?(Adapted from International HIV/AIDS Alliance, 2006) A1-70
  • Community Health Promotion for Trainers Appendix 1Tool 50: Design Your Own ToolWhat is it?Here is a chance for you to be creative and invent your own participatory tool. If youwant to share it with others, send it to CAWST and we will publish it in the next edition ofour Community Health Worker manual!Why use it?(Explain what this tool helps to do.)This tool helps to:•••How to use it(Provide step-by-step instructions on how to facilitate the tool.)1.2.3.4.Facilitator Notes(What are your top tips for facilitating this tool?)•••See Also(What other tools are similar to this or carry out the same role?)••• A1-71
  • Appendix 2Water, Hygiene and Sanitation Posters
  • Appendix 3Energizers
  • Community Health Promotion for Trainers Appendix 3Throwing AnimalsFor this game, you will need 6-8 little stuffed animals or small object that you can throwwithout hurting anyone. The 6 stuffed animals should be the same or should have asimilar shape. You should have another object of a different colour or shape. Have allthe animals in a bag.Invite everyone to stand up and form a circle. Ask everyone to raise their right hand.Take the bagful of stuffed animals in your left hand. Explain that you are going to saythe name of one person in the circle and throw a stuffed animal to that person. Whenthe person catches the stuffed animal, he or she lowers their right hand. He or she mustthen say the name of another person and throw the stuffed animal to them. Wheneveryone has lowered their hand, the stuffed animal comes back to you. Start throwingthe stuffed animal again and continue, throwing all the like stuffed animals one after theother. After a few stuffed animals have made it around the circle, take out the differentone and explain that you have to throw it in the opposite direction, to the person whothrows you the like-coloured ones.Clean Water FlowsEnsure there are just enough seats in a circle for everyone but you. Explain that you willcall out “Clean water flows for everyone who…” and then you will add a description.Everyone who fits this description must get up and change seats with someone else whohas that description. For example, “Clean water flows for everyone who wears sandals”or “everyone with two eyes”. You must carry the characteristic of what you call out (i.e.you must be wearing sandals if you are to call out that “clean water flows for everyonewho wears sandals”) In the exchange of seats, you try to get a seat for yourself and theperson who remains left standing, gets to be the “Clean Water” Caller.Once the group has gotten used to the game (after 6-8 Calls), introduce the concept of a“Flood”. When there is a flood, everyone moves. As you end the energizer, explain thatif at any time during the remainder of the workshop, participants feel they need a quickenergizer, anyone can call out Flood! and everyone needs to stand up and quickly findanother seat.Big MouthGet three volunteers into the centre of the circle. Ask a question. Each of the volunteerstakes a deep breath, answers the question seeing which one can keep going the longestwithout taking a new breath. Use semi-serious questions relevant to the workshop like“how do you collect your water?” People can come up with important sounding answers,in an atmosphere in which content is not important and fun is the object.Big SighGet into a circle or stand up where you are, leader in the middle or at front where can beseen by everyone. Everyone follows what the leader does. Leader crouches on thefloor, hands on floor, and slowly rises giving an increasingly loud sigh as s/he does sofinishing with arms stretched high and sigh becomes a shout. Very good for relievingtension. A3-1
  • Community Health Promotion for Trainers Appendix 3AdhesionGet into pairs, standing shoulder to shoulder, scattered around the room. You are stucktogether like a bacteria adhered to a particle in the water. Choose one pair and make onperson “It” and one person the runner. “It” chases and tries to tag the runner. If tagged,the runner becomes “It”. Runner may escape at any time by lining up with any pair“adhering” to someone else. The person at the other end now becomes the runner.BioLayerTake a long string or tape and make a line to divide the room into two. Get everyone tostand on one side of the line and ask two people to be volunteers. Explain that everyonein the large group are pathogens in a pot of water. The two volunteers are “good bugs”in the BioLayer. Pathogens link arms and move toward the line. If one of the good bugstouches any of the pathogens, they become part of the biolayer and help the good bugscapture the rest of the pathogens. Pathogens are trying to get past the good bugs.MachineExplain that we are going to invent the most amazing water treatment machine ever! Itlooks and sounds completely different from anything every designed before. Oneperson begins with any mechanical noise and motion, repeated in machine-like fashion.Others connect themselves when they see a place in the machine where they could liketo fit in.Slow FlowOne person volunteers to be “It” with the objective of tagging another participant. Thetagged person then becomes “It”. In Slow Flow, everyone must use slow exaggeratedmotions as if swimming through very very thick, muddy water.Touch BlueLeader calls a colour “touch blue” and everyone must touch something blue on anotherperson. Continue with other colours and descriptions.RainstormThe person in the centre of the circle directs, rubbing hands together and turning slowlytoward everyone in the circle. Imitate the director as the director faces you, andcontinue the action until the director arrives at you again with another action.The director goes around the circle eight times in this order: First time: rubbing handstogether, go all around the circle. When you get to the person you started with, startgoing around the circle a second time, this time snapping your fingers. Third time: slapthighs. Fourth time: slap thighs and stamp feet. Fifth time: stop stamping feet and onlyslap thighs. Sixth time: back to snapping fingers. Seventh time: back to rubbing palmstogether. Eighth time: return to silence. Rainstorm is over once you’ve completed theentire circle and everyone has stopped rubbing their hands together. A3-2
  • Community Health Promotion for Trainers Appendix 3Concentric CirclesAsk the group what they need to do to be a good listener. Form two circles, inner circlefacing out, outer facing in so people are paired up. Ask people in inner circle to speak tothe theme while participants in outer circle only listen. After 2 minutes you stop and askpeople in outer circle to speak to same theme while inner only listens. Once both innerand outer participants have spoken, ask outer circle to stand up and move over to thenext chair to their left. Next theme, outer speaks, then inner. Then ask participants ininner circle to stand up and move to their left. This can be a bit confusing the first fewtimes you facilitate, but the important thing to remember is that both circles, inner andouter, move in the same direction to them; participants in outer circle move to their left,inner circle to their left. Since they are facing each other, they move in oppositedirections.Themes1. A person I admire and respect, and why...2. Something Ive learned thats been important to me, and why...3. The reasons Ive chosen the work Im doing now are...4. An important goal I have in my life, and some of the things Im doing to achieve it...5. One time I laughed so hard my face and tummy hurt and I couldnt stop...After all have spoken on all the themes, get everyone back in large circle, no moreinner/outer, and ask a few questions about how it went. • How did it feel to speak uninterrupted, with an attentive listener, for 2 minutes? • How was it to be the listener? • How did you find the questions/themes? • Did you find out anything exciting or surprising about others our yourself? • What do the themes/questions ask the speaker to reveal about him/herself?This is a good community building activity that helps participants know each other muchbetter. You can add/substitute questions/themes to suit the particular workshop. Forexample, in this case I included something about the reasons we chose the work we do. A3-3
  • Appendix 4Training Tools
  • Community Health Promotion for Trainers Appendix 4Training Agenda Template Time Day 1 Day 2 Day 3 Day 4 Day 5MorningBreakMid-MorningLunchAfternoonBreakMid-AfternoonEvening A4-1
  • Community Health Promotion for Trainers Appendix 4EvaluationsPre and Post Evaluation• At the start of the workshop, it is worthwhile to do a pre-evaluation to assess the level of the group; it also indicates the progress of the group when it comes to the post-evaluation.• On a chart paper write the three or four topics that are going to be covered in the training session.• Under each heading draw a line with a 10-point scale (1 being low, 5 being medium and 10 being high).• On the first day for the pre-evaluation, have participants mark their knowledge of each category with a colored sticker or marker. Explain that it is OK for participants to rate themselves low on the scale. This is just to get an idea of the group’s knowledge and demonstrate how much people will learn over the course of the training session.• On the last day for the post-evaluation, have participants mark their knowledge of each category with a different colored sticker or marker. Discuss how participants have moved along the scale.Scales• Write the numbers 1, 5, 10 on a piece of paper and post them along the wall as a continuum• Inform the participants that a 1 is low, a 5 is medium, and a 10 is high.• Ask questions about the sessions that were conducted such as: How valuable did you find the behaviour change lesson? How useful was the listening activity? Did you enjoy the role play?• After each question have participants stand along the scale to indicate how they felt about each topic.• An adaptation to this would be to represent a scale with your hands. Two hands pressed together would be low, both arms somewhat spread a part would be medium and both arms spread wide open would be high.• Similarly, a scale can be used by sitting, standing, and standing with arms raised in the air.Apples and Onions• If possible purchase an apple and an onion or two types of food, one that people tend to like and the other that people tend to dislike.• Inform the participants that the apple represents something positive about the day; it could be something new they learned or something they enjoyed. The onion represents something they wish to change about the day: it could be something they found confusing or difficult to do, or it could be something they want to change or learn more about.• Sitting in the circle, give a participant an apple and an onion and have them say something about the day for each.• The apple and onion is than passed along the circle until everyone has had a chance to express themselves A4-2
  • Community Health Promotion for Trainers Appendix 4Written EvaluationsYou can also ask questions that you would like people to record their comments. Writtenevaluations can be used at the end of a day, or as a formal evaluation at the end of theentire training session.Example Daily Evaluation Questions1. The most important or useful points that I picked up today was:__________________________________________________________________________________________________________________________________________________________________________________________________________________2. The one unanswered question that I have from today is:__________________________________________________________________________________________________________________________________________________________________________________________________________________3. The time that I felt the best was when:__________________________________________________________________________________________________________________________________________________________________________________________________________________4. The time or section where I felt the most frustrated or uncomfortable was when:__________________________________________________________________________________________________________________________________________________________________________________________________________________ A4-3
  • Community Health Promotion for Trainers Appendix 4Example End of Training Evaluation1. Did the workshop meet your expectations? (Please check the appropriate box.) Completely [ ] Partially [ ] Not at all [ ]Please explain – why or why not?2. What do you think about the overall length of the workshop, considering the limits on your time and the topics discussed? (Please check the appropriate box.) Too Long [ ] Just Right [ ] Too Short [ ]Please explain:3. How relevant was the workshop to your organization or project’s needs? (Please check the appropriate box.) Very Relevant [ ] Somewhat Relevant [ ] Not Relevant [ ]Please explain:4. Rate the time allocation (balance) for (Please check only one box for each item listed below.): Far Too Too Just Too Far Too Much Much Right Short Short a. Presentations [ ] [ ] [ ] [ ] [ ] b. Full Group Discussions [ ] [ ] [ ] [ ] [ ] c. Small Group Discussions [ ] [ ] [ ] [ ] [ ] d. Games [ ] [ ] [ ] [ ] [ ] f. Role Play [ ] [ ] [ ] [ ] [ ] g. Breaks/Lunch [ ] [ ] [ ] [ ] [ ] A4-4
  • Community Health Promotion for Trainers Appendix 45. Which portion of the workshop was the most useful? Please explain.6. Which portion of the workshop was the least useful? How would you improve this portion? Please explain.7. How would you rate the following (Please check only one box for each item listed below.): Poor Fair Good Very Good Excellent a. Presentations [ ] [ ] [ ] [ ] [ ] b. Reference Manual [ ] [ ] [ ] [ ] [ ] c. Games and Posters [ ] [ ] [ ] [ ] [ ] d. Course Content [ ] [ ] [ ] [ ] [ ] e. Instructors [ ] [ ] [ ] [ ] [ ] f. Demonstrations [ ] [ ] [ ] [ ] [ ] g. Facilities [ ] [ ] [ ] [ ] [ ]8. Are there any topics on which you would like more information? Are there other topics that would be of interest for a workshop? Please explain.9. Other comments about the workshop or other issues in general? Please explain.Name: (Optional) ______________________ Organization (Optional) ________________________ A4-5
  • Community Health Promotion for Trainers Appendix 4ClosingsWorkshop OverviewFacilitators or participants draw a picture to represent the activities used for eachsession of the workshop and explain what was learned during the activity and why it isimportant to their work.Networking GameAsk the participants to form a circle and pass a ball of string from one person to anotherto form a web while stating how they can share information or work together in thefuture.Learning Ball GameHave the group standing in a circle. Ask a participant to throw a ball to anotherparticipant and say what they have learned from that person during the workshop.Imaginary PresentsHave the group sit or stand in a circle. Draw names and ask the participants to presenteach other with an imaginary present which they think they would like and say a few nicewords about working with them during the training session. A more formal alternative isto ask participants to present their certificates to each other and say a few words. A4-6