Ministry of Health-Ethiopia

Health Extension and Primary Health

Care Directorate

Health Facility based

Health Education and promotion
Implementation manual

November 2019
Table of Contents
Acknowledgment ........................................................................................................... ii
Preface ...........................................................................................................................iii
Abbreviations .................................................................................................................iv
Purpose of the manual .................................................................................................... v
1.Introduction ................................................................................................................. 1
1.1 Why health facility-based health education/Rationale ........................................... 2
1.2 Objectives of the manual ....................................................................................... 3
1.3 Who are Health Educators? ................................................................................... 3
1.4 What is Health Facility Based Health Education setting? ..................................... 3
2.Setup and components of Health Facility- Based Health Education Program............... 5
2.1 The Physical environment for health education ..................................................... 5
2.2 Resource ............................................................................................................... 6
2.3 Institutional arrangement and capacity to coordinate HEPr activities ................... 6
2.4 Engaging different actors/stakeholders .................................................................. 8
3.Planning for health education and promotion intervention in health facilities ............ 10
4.Health Education Methods for health facilities .......................................................... 16
4.1Counseling ........................................................................................................... 17
4.1.1 Principles of Counseling ............................................................................. 17
4.1.2 Clinical Communication Skills for Counseling ........................................... 17
4.1.3 Counselling steps ........................................................................................ 19
4.2 Health Education with groups ............................................................................. 20
4.2.1 Setup for group health education ................................................................. 20
4.2.2 Group health education techniques for health facilities ............................... 21
4.3Provision and distribution of health learning materials ......................................... 24
5.Monitoring and Evaluation of the Health facility Based Health Education Manual .... 26
6.Roles and Responsibilities ......................................................................................... 29
7.References ................................................................................................................. 32
 Acknowledgment

Ministry of Health- Ethiopia gratefully acknowledges the contributions of individuals

and organizations in the manual development process. We would particularly like to
thank the members of the manual development group and the technical resource
persons for their serious and dedicated effort.
In addition, the ministry of health would also thank the following participants from
the Ministry of Health, non-governmental organizations Universities, public hospitals
and health centers, and other governmental organizations for their commitment to
enrich this manual.
 United Nations Children‟s Fund
 USAID Transform: Primary Health Care Project
 John Hopkins Center for Communication Programs
 Addis Ababa University School of Public Health

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Preface

This manual is part of a series that aims to help implement health education and
promotion interventions at health facilities. This manual uses a human centered
approach in order to develop and implement health education and promotion
activities by considering clients and health care provider‟s inspiration. It also
hoped, this approach will help both health care providers and clients produce
greater benefits on health on more sustainable basis.
This manual is developed by health extension and primary health care directorate of
Ministry of health – Ethiopia based on the experiences of the health facilities at
national level. Health extension and primary health care directorate is pleased to
present this health facility- based health education and promotion manual aiming at
supporting health facilities to place greater emphasis on health promotion and
disease prevention, rather than on diagnostic and curative services alone. Therefore,
this manual presents guides and approaches how to perform health education and
promotion activities at health facility.
This manual is only a beginning. We look forward to receiving suggestions and
ideas on how to improve this manual in particular, and to strengthen health
prevention, promotive, curative and rehabilitative services.

Temesgen Ayehu
Health extension and primary health care directorate director
Ministry of health-Ethiopia

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 Abbreviations

DHIS District Health information system

FMOH Federal Minster of Health
HC Health center
HCP Health care provider
HEP Health extension program
HEPHS Health extension and primary health service
HLM Health learning materials
HMIS Health management and Information system
IEC Information education and communication
M&E Monitoring and evaluation
NHEC National Health Education and Communication
OPD Outpatient Department
IPD Inpatient Department
PHC Primary Health Care
RHB Regional Health Bureau
SBCC Social Behavioral change and communication
TWG Technical Working Group
WHO World Health organizations

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Purpose of the manual

This manual is mainly intended to provide guidelines and ideas for health facilities
to implement health education and promotion interventions at their health facilities.
It is also designed to help them ensure the quality and effectiveness of health
education programs. Moreover, this manual is aimed at helping and supporting
health facilities and professionals to place greater emphasis for design, implement
and monitor health education and promotion intervention to achieve intended health
outcome.
Generally, this manual is specifically intended to help health facilities and health
care providers:

o To integrate effective health education methods and approaches into the

planning, delivery, and monitor of primary health care services and make
health education and promotion an integral part of health service delivery.
o To design, carry out, and evaluate heath education activities, working with
individuals and groups using appropriate methods based on the local
culture and available resources.
o To transfer educational and planning skills to community health workers
and the community at large.
o To promote effective interaction between health care provider and clients
at health facility, community level and communication to larger audiences
through different health learning materials.

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 Definition and concepts

Health education: “consciously constructed opportunities for learning involving

some form of communication designed to improve health literacy, including
improving knowledge and developing life skills which are conducive to individual
and community health.” It encourages behavior that promotes health, prevents
illness, cures disease, and facilitates rehabilitation. The need and interests of
individuals, families, groups, organizations, and communities are at the heart of
health education programs.

Health promotion: the process of enabling people to increase control over their
health and its determinants, and thereby improving their health.

Patient education: a term for education in health facility settings linked to

following of treatment procedures, medication, and home care and rehabilitation
procedures.
Counseling: - is defined as a process where clients who are in need and health care
providers meet and support and encouragement provided to the clients that enables
clients raise understanding, ability and confidence to find solutions by themselves.

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 Chapter one

1. Introduction
At the time of Alma Ata declaration of Primary Health Care in 1978, health education
was put as one of the components of Primary Health Care and it was recognized as a
fundamental tool to the attainment of health for all. Adopting Alma Ata declaration,
Ethiopia utilizes health education as a primary means of prevention of diseases and
promotion of health.

In addition, the 1993 Health Policy of Ethiopia boldly indicated priority health issues
and the significance of Information, Education, and Communication (IEC), as well as
health education and community mobilization as priority interventions to address
health problems and encourage participation of communities in efforts to take control
over their own health. The policy also recommended strengthening of health
education by targeting specific populations through mass media, health facilities,
community leaders, religious and cultural leaders, professional associations, schools
and others.
The importance of health education and promotion and behavioral change
communication, are also highlighted in the HSTP as key components of the health
extension program to help achieve increased demand of health services and
community empowerment for the sustainability of health outcomes. In addition, the
HSTP gives emphasis on strengthen health facility-based education in order to
enhance the skills and knowledge of individuals and communities to take control over
their own health, as well as the skill and knowledge of health care providers to
provide quality health information.
Ministry of Health has developed Health Promotion and Education strategy to achieve
the above-mentioned goals and put in place different implementation guidelines
including Health Learning Material Development Guideline, Quality Assurance
Guideline and other different Health Communication Message guides to support
health education and promotion interventions at different level. Although lots of
progress has been made so far, the implementation of health facility- based health

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education activities have slowly been introduced to health facilities and its
implementation has not been progressive as compared to the increasing health facility
visit by the community.
Therefore, this manual has been developed to accelerate the pace of implementation
and makes sure that health education and promotion interventions gain more
importance within the health facility setting. Moreover, it helps health facilities and
health professionals to prioritize and implement health promotion through introducing
practical concepts and implementation tools that will allow better implementation of
health facility based health education nationally in integration with manuals,
guidelines and guides developed mentioned above.

1.1 Why health facility-based health education/Rationale

Health professionals in health facilities have a lasting impact on influencing the

behavior of patients and relatives, who are more responsive to health advice in
situations of experienced ill-health. Based on the observation conducted by MOH at
different health facilities and practical experience of health facilities, there are many
challenges that health facilities and HCP facing to providing health education at health
facilities. Lack of structures and assigned personnel for health education, less
attention and infrastructure given for health education, lack of budget and resources to
facilitate HE are most common challenges seen in health facilities so far.
In addition, lack of skills how to plan, implement and monitor HE interventions,
taking health education as an additional duties, lack of uniformity, Fear of educating
clients as a group, negligence‟s and ignoring rights of clients for health information,
less motivation and commitment to provide HE, communication barriers and less
attention given for people in need are also mentioned as a barrier for implementing
facility based health education and promotion program.
Therefore, MOH intended to develop standardized health facility-based health
education manual to guide health facilities in order to provide proper way health
education and promotion interventions healthy behavior, prevent readmission and
maintain quality of life of patients.

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1.2 Objectives of the manual

The main objective of this manual is to guide health facilities and health care
providers with standardized health facility-based health education and promotion
interventions at national level.

1.3 Who are Health Educators?

According to WHO definition health educators are all health care providers who are
concerned with helping people to improve their health knowledge and skill and
practice health education in their day to day jobs. Therefore, Health education is the
duty of everyone engaged in health and community development activities to
promote health and prevent disease through provision of health education.

1.4 What is A Health Facility Based Health Education setting?

According to the definition of a health promotion setting by WHO, a health facility-
based health education setting is „ the place or social context in which people engage in
daily activities in which environmental, organizational, and personal factors interact to
affect health and well-being. A setting is also where people actively use and shape the
environment and thus create or solve problems relating to health. It can be also
identified as having physical boundaries, a range of people with defined roles, and an
organizational structure.‟

Among the settings/locations that health education and promotion interventions takes
place, health facilities are mentioned as one of the set ups, where all members/health
care providers work together to provide patients/clients with important health
information which promote and protect their health.

A health facility-based health education needs to be set up in a way which ensures

positive health behaviors of clients and improve their health status. A facility-based
health education and promotion program should be incorporated into the organization
culture of the health care facilities that promote the health of patients/clients and create
supportive healthy environments through continuously engaging the community.

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 Health facilities that
value health education
Effective communication
process Proper Planning,
implementation
Best practice Monitoring and
health education Evaluation
Appropriate resource and
and promotion
facilities
environment
Appropriate set up for
health education
An effective health care
providers relationship
during health education
provision

figure1Health Facility- based health education framework

Adopted from Health.VIC

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 Chapter two

2. Setup and components of Health Facility- Based Health Education

Program

In this manual a facility- based health education set up refers to the physical
environment of the facility, institutional leadership (including structure,
management involvement, and capacity building.) and community engagement at
facility level. For the above-mentioned reasons, the following sub sections are
prepared to propose components for improving facility- based health education and
promotion programs in all primary health care units and hospitals at national level.

2.1 The Physical environment for health education

Physical environment for health education refers to units, spaces, furniture‟s and
equipment‟s that are comfortable and safe to provide health education sessions at
health facilities.
 Health Education Units and Spaces: -the overall appropriate offices and
space created to provide health education session at a given facility. These
includes: -
o Information desk and directory for people living with disabilities
o Health education office/department,
o A resource center/library for health education,
o Waiting areas (OPD, IPD, and other preventive service areas, wards and
around card room) that helps to provide health education activities at
individual and group level.
 Furniture and Equipment: -this refers to
o Chairs with back rest for clients at waiting area,
o Shelf/table to display materials at service delivery points and wards,
o audio visual materials like Television, video tapes, microphones to
watch at waiting areas

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2.2 Resource
The Health facility should have linkage and good relationship to mobilize the resource
required to strengthen the health education programs. The following points should
also be used to identify and solicit resources to strengthen facility based health
education program: -
 Identify health facility resources and barriers
 Identify individuals, institutions, associations, and corporations etc. that
work in your catchment areas.
 Identify agencies/organizations/peoples with skills such as
materials/machines….
 Map available resources stakeholders including community
 Develop a proposal based on the identified barriers and communicate these
stakeholders to support/strengthen the health education program at health
facility level.

2.3 Institutional arrangement and capacity to coordinate health

education and promotion activities at health facilities

Health facilities have great opportunities to serve as source of health information and
education as they reach millions of people with awareness raising and behavior
change communication interventions. In order to do that there is a need to strengthen
the health education and promotion arrangement at health facilities as follows: -

Health Education and Promotion Expert and Health Educators: -All health
facilities should assign a health education and promotion focal person who can lead,
coordinate, monitor and evaluate the overall activities at the facility level as follows:
o Select evidence - based health education topics based on services provided at
individual and group level.
o Create proper setup to provide health eduaction.
o Get ready on the topic area that is going to be provided by refering different
guides, case senarios or related practical stories and having health learning
materials.
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 o Recognize,build good relationship and take account of cultural diversity and
the influence of social factors in order to adjust client‟s behaviour in to value
o Assess patient's ability to understand the information imparted by question
and answer and must be able to modify his/her approach accordingly. Care
should be taken with health education where understanding is likely to be a
problem.
o Assist and facilitate conversation considering the questions you ask, the way
you listen and the content you gather during counselling that will empower
and clearly understand their concern to meets the expectations of the patient
and fulfils your obligation as a clinician.
o Encourage informed decision-making and cover basic concepts related to
medicines action; how to choose when to self-medicate and when to seek
medical advice.
o Observe whether clients are paying attentionand ensure that patients are
understand. You may observe problems you can then help to solve
thembefore they receive any service like medications that they are to self-
administer.
o Create opportunities for the clients (Attendees) to summarize what they have
learnt
o Record, document, and report health education activities.

Health Education and Promotion Focal at the service delivery points/at

wards/OPD, IPD…: As health education activity should not be left only for health
education expert, who is responsible for the overall coordination and management of
health education activities at health facilities. Therefore, there needs to be assigned
trained focal persons at each service delivery points/wards who will perform the
following activities: -

o Facilitate/coordinate morning health education sessions at each service

delivery points/wards every morning before starting the service.
o Keep records of the health education and promotion activities daily

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 o Identify top ten diseases each week and report to the health education and
promotion expert
o Display and manage audio-visual materials at each service delivery
points/wards
o Avail health education and promotion materials at each waiting areas for
clients who prefer to take and read

Integrating Health Education and Promotion with Quality Improvement team: -

All facilities should integrate health education and promotion issues with the quality
improvement committee meetings to ensure the following points:-

o Enhance institutional leadership to make health education intervention

gain support at their respective health facility
o Create enabling environment for health education interventions (room,
HE materials, TV etc)
o Insuring patient‟s health education is under taking
o Assign /allocate budget for health education activities/program
o Monitor and evaluate health education program activities periodically.

2.4 Engaging different actors/stakeholders

Bringing different actors together helps to increase synergy and wisely coordinate the
actors to optimal use their expertise in effective implementation of health education
and promotion in health facilities. Such coordinated synergy at all level would have
enormous effect that helps design effective responses, lifted up public awareness and
increased community engagement.

Therefore, health facilities should identify and engage potential stakeholders whom
are working with in their catchment area to strengthen facility based health education
intervention/program.

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The following engagement mechanisms are proposed to enhance facility based health
education interventions:-

Working with Health - related associations, universities/health collages: -

Hospitals and health centers should work together with associations and
universities/colleges to strengthen facility health education activities through

o Celebrating health days- Maternity day, HIV day, diabetic, hand

washing day etc
o Providing health education materials, job aids and electronic equipment
o Providing Health education training for health care providers and
volunteers.
Working with youth centers/Schools/volunteers- Health facilities are expected to
provide health education and promotion services for youths at youth centers/schools
and volunteer in the way that they can provide health information. Hence, the health
education focal person will create awareness of the school community about the
importance of delivering health education in the school in collaboration with the
school directors to facilitate and create conducive environment for health education
program implementation. In addition, they also ensure and follow up the
implementation of the program.
Working with religious associations: -working with religious leaders is very
important through creating awareness and encourage them to educate the community
to have positive impact in health facility health education and promotion
interventions.
Working with local institutions ( Idir, Mahbre…):-These are important platforms
to educate and disseminate health education. In addition, we can use this platform as
earning forum among them by using their leader to educate their member of
association during their session after educating the leader.

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 Chapter Three
3. Planning for health education and promotion Intervention in
health facilities

Planning a health education program is very important in implementing heath

education and promotion activities in any health facilities. Planning enables health
educators to prioritize needs and activities, as the community may have lot of
problems and difficult to solve those problems as the same time. Planning also
enables to forecast resources and use them efficiently and effectively avoiding
duplication of activities and develop the best health education methods tailored to
specific group that helps to solve the health problems they have faced.
The current health situation of the community is the starting point for effective
health education activity at health facilities.

3.1 Steps in planning

The steps below are basic planning steps to follow while planning a health
education and promotion program at health centers and hospitals.

4.Selecting
Appropriate
Methods
5. Implement
3. Set the methods
Objective and develop an
action plan

2. Define 6. Monitor and

Problems Evaluate

1. Information 7. Re-plan
Gathering

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 Figure 1 Steps for planning health education and promotion

3.1.1 Collecting Information

As mentioned above knowing and understanding the current health problem of the
community is crucial to start planning a health education activity in health facilities.
Good health education is based on facts and should be evidence based. Gathering
information at the health center and hospital level is important to identify the most
important problem in the community as well as to know target population who are
affected. In addition, it helps to know and understand the reason why the target
population does the practice that lead to that specific problem.

Collecting the following information is very important to have clear understanding of

the community and their current health problem.

o Number of people who live in the area and size of population

o Their sex and age group
o Average size of a household
o Average number of pregnancies, children alive, and children died in the
last one year
o Available health care services traditional/modern
o Literacy status of the community
o Jobs and economic situation and its impact on health
o Existing clubs/organizations/society
o Religions practiced locally
o What the formal and informal channels and who the participants in those
channels
o The political structure in the community/power in the community
o Health beliefs and practices

All the above information could be gathered using the following ways:-

Data extraction at the health facility: -Health facilities can collect information for
the above-mentioned purposes by reviewing records and documents from the data
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 sources available in the health facility. In addition, integration of information
gathering with performance review committee meetings of health facilities is very
important. The committee meetings would help to identify priority health problems
that needs health education, based on the information gathered from the data
sources below:-

o Registration book
o Annual report (HMIS, DHIS)
o Written program plans
o Focal persons checklist at health facilities
o Monthly clinical attendance/register
o Lower level administration/sub city data
o Result of satisfaction survey
o Monthly ten top disease to identify determinants of health
o Weekly DHIS 2 morbidity data and aggregate to sort out
determinants
o Using top 10 morbidity and mortality data

Observation: - observation is one method to collect information in health facilities. It

is very important to know the timing and place of observation and write down the
observations on time. Observation can be made at every service delivery points and
wards at the health facilities and outside to the community to see the actual practices.

Conducting surveys: -conducting surveys using structured questioners is also

possible by interviewing and facilitating focus group discussions, which includes:-

o Client satisfaction survey

o Small group discussion at department level
o Exit interview
o Interviewing focal persons
o Interviewing leaders/managers

In general gathering information mainstreaming in the health facility sessions can also
be carried out developing integrated checklist/questioners, use of evaluation sessions,

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and use of opportunities like weekly EPI sessions, plan performance review meeting
and supportive supervision/Discussion with HCP.

3.1.2 Defining and prioritizing problems

People may have several problems at same time, there is a need to define and
prioritize specific health problems to decide which problem comes first, which is
setting priorities. During defining and prioritizing specific health problems, the
following points can help choosing priorities easier:-

No Identified Prioritizing Criteria

problems Magnitude Severity Feasibility Community Government
of the Concern concern
problem

It is also important to involve the community, during defining and prioritizing

specific health problems. The health educator at the facility level can use different
opportunities to involve the community including working with the catchment area
health extension workers, using meetings/gatherings conducted at the health
facilities (pregnant women conference, EPI sessions, and weekly meetings with the
health care providers) and others.

3.1.3 Setting objectives and goals

After deciding and setting priorities, an objective should be settled to have a clear
idea of what want to achieve by the end of the program or interventions. The
objective should be a statement that shows change over a fixed period of time. It
should measurable, relevant, possible to achieve and has to describe:

o What you want to change?

o How much change you want?
o For whom or for what you want the change? and
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 o When? By what time or date?

A given health facility may have many objectives at same time in a specific health
issue and can have health objective and education objective. A health objective is an
objective which focused on improvement of people‟s health. An educational objective
is focused on people‟s behavior that affects their health, so that they can carry out to
solve their health problems.

Here are some examples for health and educational objectives: -

If measles is a serious problem in the health facility, the facility may have the
following health and educational objectives: -

Health objectives: -

 All children who do get measles will recover quickly and suffer no disabilities
and will not die by the end of 2012.

Educational objectives: -

 Mothers whose children get measles will bring them quickly to the health
Facility.

3.1.4 Develop an action plan and selecting appropriate Methods

Having analyzed the situation, defines problems, prioritize and set objectives,
identify resources, an action plan should be developed which shows what to do,
when to do it, which will do it, and at what cost each step of activities. The Plan of
Action should include:

o Goal and objectives

o What steps are to be taken?

3 o List of activities including methods

o Who will be responsible for each step?
o What materials, equipment, people, funds will be necessary for each
step
o When each step is to be completed

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 During an action plan development it is also important to select appropriate
methods for health education and promotion considering the following basic
issues:

o How fast do people change?

o How many people are involved?
o Is the method appropriate to the local culture?
o What resources are available?
o What combined methods are needed?
o What methods fit the characteristics (age, sex, religion etc) of the
target group?

In general, use of mix of methods and repetition improves understanding and

people are more likely to remember them. Health education could be designed for
various groups of people: old, young, women groups, children and so on. Select
and adapt your methods (methods are listed in the next section) to fit the type of
people you meet is very important for successful implementation of a health
education program in health facilities.

Table 1:-Sample action plan template

S.no Goal/Objectives/ Type of Target Possible budget Time Material Responsi
Identified Problem activities/ audience educati frame s needed ble
strategy on person
List
method

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 Chapter Four

4. Health Education Methods for health facilities

Health education presents information to target clients on particular health topics and
provides tools to build capacity and support behavior change. Health education could be
designed for various groups of people: old, young, women groups, children and so on.
So select and adapt your methods to fit the type of people you meet is very important to
help clients make wise choices and decisions about their health.

The health education methods mostly used in health education and promotion
interventions in facility based health education setting are:-
o Counseling
o Health Education with groups
o Provision and distribution of health learning materials

As mentioned previously resource are also important while implementing health

education interventions while performing HE methods. This resource include every
health-related guideline, health education teaching aids that helps to facilitate both
individual and group health education.Therefore, health facilities leaders, health
education focal persons from each departments (OPD, IPD, and preventive service
areas) need to arrange and avail shelfs with health learning materials and teaching aids
like visual aids, broachers in order to maximize the awareness of the clients and care
givers.

This section guides health facilities and health care providers on how to apply
appropriate health education in the above listed methods, that help their clients for
positive behaviour change and improve their lives.

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4.1 Counseling

Counseling is one of the approaches most frequently used in health education at health
facilities individually. According to WHO health education manual, counseling is
defined as a process where clients who are in need and health care providers meet and
support and encouragement provided to the clientsthat enables clientsraise
understanding, ability and confidence to find solutions by themselves.The purpose of
counseling is to encourage individuals and help them think about their problems and
come up with a greater understanding of the causes so that they can take action and
solve their problems.
Topics for discussion points for individual counseling arise when health care
providers have contacts with their patients coming to the health facilities due to
various health problems. So the issues are mostly connected to the services that health
care providers are providing by the time.

4.1.1 Principles of Counseling

 Counseling requires establishing good relationship between the counselor and

the client.
 Counselors should assist people to identify their own problems.
 Counselors should have empathy. They should put themselves on their client‟s
shoe.
 Counselors should never force their clients to accept their advice.
 Counselors should always respect the privacy of the people they are helping.
 Counselors should share information and ideas on resources to help them
make a sound decision.

4.1.2 Clinical Communication Skills for Counseling

Good communication depends on careful observation, accurate listening and correct

interpretation of client‟s feelings. Proper utilization of communication skills in
counselling helps to meet the objective of counselling by helping the clients examine

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possible options by clients to explore solutions and their consequences. In this sub
topics will discuss about two clinical communication skills to guide health care
providers while providing counselling clients.

4.1.2.1 Prepare, Relationship building and Why-PRY

Prepare, Relationship building and Why (PRY) is a clinical communication skill used
in the first golden minutes of a consultation. The goal is to prepare for the patient and
build a relationship with the patient in order to get a comprehensive problem list
through the use of therapeutic interviewing skills (open questions, pausing, and active
listening, summarising).

 P- Prepare– Have a clear mind, make sure your space is clear, read history of
patient if possible,

 R- Relationship Building –how do you build the patient/clinician

relationship? Greet, use patient name, make sure patient is comfortable, and
introduce yourself to the patient

 Y- Find out why the patient has come to the health facility. Ask, probe,
listen actively, pause, be attentive to non-verbal languages.

4.1.2.2 Idea, concern and expectation (ICE)

ICE is clinical communication skill used to gather information which combines the bio
medical with patient perspectives. It also used for patient centeredness and
collaboration and developing an effective self-management plan.

Patients come to consult with ideas and beliefs about what is wrong with them. They
also come up with more than one concern or worry and they come up with certain
expectations and hopes about what is going to happen in the consultations. Your role
as counsellor is to facilitate conversations to meet expectations of the patients and
fulfils your obligation. The question you ask, the way you listen and the content you
gather during counselling is key to meet the objectives.

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4.1.3 Counseling steps

Having in mind the communication skills mentioned above, it is also very important to
follow the following counselling steps while providing individual counselling at health
facilities.

o G- Greet the clients

o A- Ask them about their feelings
o L- Listen to what the clients says
o I- Identify the problem and resources
o D- Discuss on the problem and decide on the alternative actions that the client
agrees to undertake
o R – Recommend alternative doable solutions.
o A- Ask Agreement with the clients
o A- Appoint clients for the reassessment.

4.1.4 Setup for counseling

The areas for individual health eduction/counseling should be arranged or constructed
in such a manner that it provides:-
o Adequate space with available teaching aids
o Have professional look and ensure reasonable privacy that ensure confidentiality
to the patient at all times and
o Eliminate background noise as much as possible.

Sample illustrations

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 4.2 Health Education with groups

Health education with groups is a major health education activity applied in health
facilities. As mentioned in WHO health facility health education manual (1988),
groups can be divided in to two types as formal and informal groups.
Formal groups are a group of people who are well organized with some interest. In
this manual formal group at a health facility level includes mother forum, adolescent
and youth group, TB patient groups, HIV patient groups in different inpatient and
outpatient departments. Informal groups are groups that are not well organized and
having different interests including meeting attendants, people gather in a particular
event and etc.
Therefore, this manual incorporates both types of group as a target audience to
provide appropriate health education.
Topic for group health education should be selected based on the results of the
information gathering and problem identification process discussed in the previous
chapter. But, depends on the service delivery unit provided at each OPD, IPD,
preventive service delivery units it‟s good to assess needs of clients by information
collection/gathering steps that was discussed in previous chapter.

4.2.1 Setup for group health education

A health facility should provide services in accordance with standard and should
comply with the following requirements:-
 Appropriate space at each service delivery points (waiting areas) and at each
ward (OPD, IPD, Preventive service areas) for group education that helps to
provide focused health education.
 Appropriate media (TVs, video tapes) at waiting areas of card room,
outpatient, Inpatient, dispensing area and other preventive service area,
which are inclusive of people with disabilities.
 Appropriate health learning materials including brochures, leaflets,
posters…
 Free of background noises.
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 Sample illustration

4.2.2 Group health education techniques for health facilities

Health facilities can use different techniques and means for providing health
education in their health facilities. Some of them are discussed as follows:
Group discussions: -Groups allows people to say what is in their minds. They can
talk about their problems, share ideas, support and encourage each other to solve
problems and change their behavior. In health facility setting, number of people
participating in a health education session may depends on client‟s flow during the
given day and interest to take part in the discussion.
The following steps are helpful in specifically show how to plan and conduct a group
discussion in health facility based health education setting.
A. Planning a discussion- It involves:
o Identification of the discussants- that do have common need and interests.
E.g. pregnant mother
o Getting a group together - Talk individually to see if they would like to come
together in a group to share their problem, find out how others cope, seek help,
and in turn assist others.
o Where to Hold a Discussion - Identification of a comfortable place and time.
This will help people to talk more freely.

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B. Conducting the discussion: Health care providers need to do the following
suggestions while conducting group health education.
o Introduction of group members to each other
o Use questions to attract their attention and encourage sharing
o Encourage everyone to participate
o Limit those who talk repeatedly and encourage the quiet to contribute
o Limit the duration of discussion to the shortest possible
o Check for questions and satisfaction before concluding the session.

Time:-The time allowed for discussion depends on how much time members have.
People have work, family and other responsibilities. You yourself have other
duties. Even if people do not have other things to do, they will get tired and bored
if the discussion goes on for too long.

Demonstrations: -demonstration involve a mixture of theoretical teaching and of

practical work, which makes them lively. The main purpose of demonstrations is
helping people learn new skills. In health facilities there are different
demonstrations that can be done to help people learn new skills including condom
utilization, hand washing practice and etc.

A. Planning the Demonstration:-during this phase, the health educator needs

to: identify the needs of the group to learn, collect the necessary materials
such as models and real objects or posters and photographs, prepare adequate
space so that everyone could see and practice the skill and Choose the time
that is convenient for everyone. Use this method with small groups. If the
group is too large, members will not get a chance to practice the skills or ask
questions.
B. Conducting the Demonstration: The health educator needs to consider the
following procedures when conducting
demonstrations.

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 1) Explain the ideas and skills that you will demonstrate and the need for it
2) Conduct the demonstration (show one step at a time, slowly)
3) Ensure that everyone sees what you are doing.
4) Give explanations as you go along.
5) Encourage discussion either during or at the end of the demonstration.
6) Ask them to demonstrate back to you or to explain the steps.
7) Summarize/review the important steps and key points briefly.

Story Telling: -Story telling is a way of re-telling interesting cases that happened
throughout the process of providing health services. So, stories can entertain, spread
news and information so that people are encouraged to look at their attitudes and
values, and to help people decide how to solve their problems. Health educators can use
stories to get their messages across in a pleasant way. We can also use testimonies of
survivors or satisfied clients during this process.

Drama/Role Play: -It is a good means to entertain people in a message especially

during health events organized in health facilities and outside of the facilities. Their
preparation, practice and others may incur time. This means that it is somehow difficult
to prepare repeatedly. Yet, they are extremely useful for educating a group of people.
Dramas should have one main learning objective but can often include 2 or 3 other less
important objectives as well. Alike stories, dramas make us look at our own behavior,
attitudes, beliefs and values in the light of what we are told or shown.

Global public health days:- Global public health days offer great potential to raise
awareness and understanding about health issues and mobilize support for action, from
the local community to the international lvel. There are many world health days
observed throughout the year related to specific health issues or conditions. Health
facilities can utilize the opportunity to create awareness among their clients and the
surrounding community by using different teaching aids like banners as demanded.

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Health professionals can also play a part in these worldwide efforts to create a healthier
working environment in their respective health facilities.
The following are recommendations of some of the global health days celebrated all
over the world. Therefore, health facilities can utilize while educating and promoting
health issues depending on the service provided in their facilities.
Table 2 List of global health day
Health day and weeks Calendar Small doable actions
World Heart Day September 26 o Question and answer,
World Mental Health Day October 10 drama,
o Group education,
World Hand Washing Day October 15
o Integrate the issue in
World Breast Cancer Day October 1-31
routine counseling sessions,
World Diabetes Day November 14 o conduct community
World Aids Day December 1 conference, conduct
World Cancer Day February 4 outreach, service provision
campaign, Health talks,
World Kidney Day March 12
o Workshops, Talking to
World Tb Day March 24
clients about the issue
World Health Day April 7 o Organizing a mobile blood
World Vaccination Week April 17-24 collection in your
World Malaria Day April 25 facility/community,
contributing to the online
World Blood Donor’s Day June 14 conversation through social
World Breast Feeding August 1-7 media,
Week

4.3 Provision and distribution of health learning materials

Health learning materials are very important while implementing health education
interventions in facility-based health education setting. These include every health-
related guideline, health education teaching aids that helps to facilitate both
individual and group health education. Therefore, health facilities leaders, health
education focal persons from each department (OPD, IPD, and preventive service
areas) need to avail health learning materials and teaching to maximize the
awareness of the clients and care givers.

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The selection of the teaching aids depends on the type of message, the purpose, the
people addressed, availability of resources and availability of skills. The following
are types of health learning materials/teaching aids that can be employed in
facility-based health education and promotion activities.

4.3.1 Printed health learning materials

These materials include leaflets, posters, flipchart and etc. that can serve to remind
individuals or families of a health message, they have already learned in other
ways. They can provide additional information about a health problem or health
practice.
Health educators need to consider the time, place and engagement approach
whenever disseminating health learning materials in their respective health
facilities. This would have much contribution for effective health education which
requires delivering the right message at the right time and place for the right
clients.
4.3.1.1 Visual Aids
Visuals are objects that are seen. They are one of the strongest methods of
communicating messages; particularly when accompanied with interactive
methods. Visual aids enhance learning by providing a clear mental picture of the
message Visuals are more effective than words alone, and it will be more effective
for health facilities to reach more groups in each ward. So, health facilities can use
such visual aid at each waiting areas with TV to transfer health message the whole
days.

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 Chapter Five

5 Monitoring and Evaluation of the Facility Based Health Education

and promotion implementation Manual
All health facilities need to monitor and evaluate the implementation of this health
facility-based health education and promotion manual in order to ensure health
education and promotion interventions are strengthened at respective health
facilities.

After spending time and effort in implementing health education activities in a

health facility, it is important to know if the interventions were successful or not
through having a specific measures to check the progresses of the interventions
and the level of success needed.

Monitoring: - Referring the action plans developed during the planning process is
important in monitoring the progresses of the activities and check them weather
they are going as per the plan or not. This would help implementers to correct
problems or solve challenges faced during implementing the activities.

Evaluation: - Evaluation can be done through measuring successes based on the

educational and health objectives formulated during the planning process. By the
end of implementing the health education activities, it is possible to measure
successes based on the educational objectives comparing the current number of
specific cases in the health facility with cases recorded before starting the
program. This can easily be identified from records available at the health
facilities.

On the other hand for the health objectives, there should be a decrease in burden
of specific diseases reported in the facility in a given period of time, which may
take several months to show.

Evaluation can be carried out in a way we originally collect information when

starting the planning process through observation, interview and extracting
facility records. This can be done compare the information collected before the

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program started with the information collected after the program ended. Learning
from the monitoring and evaluation results and sharing them to the health facility
team by the end of the program is very important to enhance performances for the
future. This can be done through conducting meetings or use available gathering
held at the health facilities.

Table 3 Check points to ensure the implementation of the manual

The table below includes checklists that help health facilities to monitor and
evaluate their performances in implementing the manual as demanded.

S.no Activities Performance rank

Met Partially met Unmet

1 Set up Availability of spaces for

health education
Health education office/
department
Information desk and
directory for people Health
education units
Resource center
Proper set up of OPD, IPD,
preventive service areas
where clients/patients access
health education.
2 Staffing Structure availability for health
and education
resources
Availability of health
education expert/focal
Health Education and
Promotion Focal at the service
delivery points
Availability of health
education coordinating PMT
Establish clear roles and
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 responsibilities for HCP and
focal
Orientation/training given on
health education for HCP
Budget allocation for health
education and promotion
interventions
3 Availability of furniture and equipment
(chair, shelf, and audio-visual materials
4 Planning Availability of planning
clear plan with objectives
and goal
Are planning done based on
the manual
Does the plan done by
engaging HCP and
stockholders
Do HCP aware of the plan
5 Health HE provisions based on plan
education Development, distribution,
Interventio
health learning materials
n
Health learning materials
(TV in placed where your
audience can view or access
ate each ward.
Registration availability,
Report tracking system in
placed
6 Performance M & E in placed for HE
7 Availability of stakeholder engagement
platform
8 Reward and recognition for best
performers

Note: Performance monitoring will be done based on HMIS Guide.

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 Chapter six

6. Roles and Responsibilities

Below is list of stakeholders‟ respective roles and responsibilities on implementing

health facility-based health education and promotion manual.

6.1 Federal Ministry of Health

o Introduce and promote the health -facility based health education and
promotion manual to RHBs, ZHDs, woreda health office Health facilities
and their partners and stakeholders.
o Support health education and promotion professionals in the region in the
use of health-facility-based health education and promotion Implementation
manual and other SBCC related guidelines.
o Ensure proper application of the facility- based health education and
promotion Implementation manual at health facilities.
o Assess the applicability and effectiveness of the health -facility based health
education and promotion Implementation manual and update as necessary.
o Support health facilities who need assistance in using the guideline.
o Avail and create access to the health -facility based health education and
promotion manual (hard and electronic copy) and corresponding tools for
respective RHBs, ZHDs, and health facilities.
o Provide technical and financial support for RHBs, woreda health offices,
and PHCUs for the implementation, monitoring, and evaluation of the
health facility based health education and promotion Implementation
manual
o Monitor and evaluate the quality of the health -facility based health
education and promotion interventions at all levels based on the standard.

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6.2 Regional and Administrative Health Bureaus
o Plan, monitor, and evaluate the implementation of the health -facility based
health education and promotion Implementation manual at health facilities
o Support health education and promotion experts in the region in the use of the
facility based health education and promotion Implementation manual and
other related guidelines.
o Coordinate the implementation of the health -facility based health education
and promotion manual at regional, zonal, woreda and health facilities levels.
o Provide technical assistance and guidance for the implementation of quality
the health facility based health education and promotion interventions in the
region, zonal, woreda, and PHCU levels.
o Ensure utilization of the health -facility based health education and
promotion Implementation manual by health facilities
o Provide technical and financial support for zonal, woreda health offices, and
PHCUs for the implementation, monitoring, and evaluation of the health
facility based health education and promotion Implementation manual.
o Participate in planning, monitoring, and evaluation of the implementation of
the health -facility based health education and promotion manual.

6.3 Zonal Health Departments and Woreda Health Offices

o Plan, monitor, and evaluate the implementation of the health -facility based
health education and promotion Implementation manual at zonal, woreda and
health facilities
o Coordinate the implementation of the health facility- based health education
and promotion interventions at zonal, woreda, hospitals, health centers, health
posts.
o Utilize health -facility based health education and promotion manual to
enhance behavioral change.
o Provide support to woreda health offices, health centers, and other sector
offices to adopt and implement according to the set standards.
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o Implementing health education and promotion manual in collaboration with
Partners and Stakeholders
o Provide technical and financial support for woreda health offices, and PHCUs
for the implementation, monitoring, and evaluation of the health facility based
health education and promotion Implementation manual
o Apply health facility based health education and promotion implementation
manual during any health facility- based health education and promotion
interventions.
o Participate in planning, monitoring, and evaluation of health -facility based
health education and promotion Implementation manual.

6.4 Roles and Responsibilities of the Health facilities and

governing board

o Provide the guidance and appropriate resources and setup to the health facilities
to implement health facility- based health education and promotion
interventions.
o Jointly supervise and identify areas requiring further capacity building in
related to health facility- based health education and promotion interventions at
health facilities.
o Ensure the health educators or health care providers are working properly to
implement health facility- based health education and promotion interventions.
o Provide technical and financial support for health facilities for the
implementation, monitoring, and evaluation of the health facility based health
education and promotion Implementation manual.
o Participate in planning, monitoring, and evaluation of health – facility based
health education interventions.

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7. References
 Ethiopian transitional health policy,1993.
 A manual on health education for primary health care, WHO,1988.
 Introduction to Health education, Jimma University and Carter center, 2004.
 Social and behavior change communication quality assurance guide, 2018.
 National Health promotion and communication strategy2016-2020,
FMOH,2015/16.
 The field Guide to human centered design, IDEO.org, 2015.
 Ethiopian health facilities standard,2012.
 Ethiopian Primary health care clinical guidelines, FMOH, 2018.

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