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CM4.1-4 | Health Promotion and Education Practice — PBL Case

CLINICAL SETTING

Prabhavati Nagar is a peri-urban settlement of 3,400 people on the outskirts of a district town in Rajasthan. The Primary Health Centre (PHC) for the area has a Medical Officer (Dr Suresh Mehta, a MBBS intern supervisor), two ANMs, and a team of ASHAs. The area has a persistently high diarrhoeal disease burden — the previous monsoon saw 47 acute gastroenteritis cases, three of which required district hospital referral for IV rehydration. Despite three years of IEC campaign posters on hand hygiene at the sub-centre, a health exhibition during World Health Day, and annual school competitions on cleanliness, there has been no measurable decline in diarrhoeal morbidity. Surveillance data from the last HMIS quarter shows: open defecation practice in 28% of households, ORS use in only 35% of diarrhoeal episodes (vs a district target of 80%), and handwashing before meals reported by 41% of surveyed adults. Dr Mehta decides that the standard IEC approach has failed and that a systematic health promotion strategy is needed before the next monsoon (6 months away). He assigns a team of four MBBS students posted at the PHC — Ananya, Ravi, Priya, and Sameer — to design and pilot a new programme.

Trigger 1: Diagnosing the Failure

Ananya reviews the past IEC reports and interviews three ASHA workers. She finds: the health exhibition was conducted in English and Hindi; a translated version in the local Marwari dialect was never produced. The posters use a photograph of a child from a stock image library — none of the depicted people look like local community members. The school competition rewarded drawing skills, not health knowledge. When Priya speaks to five randomly selected mothers at the sub-centre, none can name two symptoms of diarrhoeal dehydration requiring immediate care-seeking. Ravi checks the PHC's IEC budget: ₹18,000 was spent on printed materials last year; ₹0 was allocated for facilitator training or inter-personal communication activities. The Medical Officer's monthly report for the IEC component reads: 'All targets met — 3 sessions conducted, 500 pamphlets distributed.'

DISCUSSION POINTS

  • Classify the IEC methods used so far (individual / group / mass) using Park's framework. Which tier is entirely absent from the current programme?
  • What are the three most important reasons the existing IEC campaign failed to change community behaviour?
  • The ASHA workers were not consulted in programme design. How does this violate the Ottawa Charter principle of 'strengthening community action'?
  • Define the difference between IEC and BCC. Which approach was the PHC using, and what would a BCC-based intervention look like for this community?
Click to reveal Trigger 2: Designing the Programme (discuss previous trigger first!)

Trigger 2: Designing the Programme

Based on their assessment, the students design a 12-week community health promotion programme. They propose three components: (A) Training 8 ASHA workers as peer educators using a demonstration + return-demonstration model for hand-washing and ORT preparation (individual/family setting); (B) Facilitating 10 gram sabha sessions using role play and flip charts in Marwari to address community-level norms around open defecation (group/community setting); and (C) Continuing posters as a background awareness reinforcement (mass). Dr Mehta reviews the plan. He adds: 'Before we start, you need to write measurable objectives. And at the end, how will we know if this worked? Your previous team just counted how many sessions they held — that's not evaluation.' Sameer, who has studied evaluation frameworks, proposes a before-after design: a 25-item KAP survey administered to 60 randomly selected households before and 12 weeks after the programme. He also proposes direct observation of hand-washing behaviour in 10% of households at baseline and endline. The Medical Officer approves the plan and asks the team to pilot two gram sabha sessions before the full rollout.

DISCUSSION POINTS

  • Write two SMART learning objectives for the ASHA peer-educator training sessions (Component A).
  • The gram sabha sessions (Component B) use role play and flip charts. For each method, state one advantage and one limitation relevant to this specific setting.
  • Dr Mehta criticises 'just counting sessions' as not evaluation. Which Kirkpatrick level does session-counting represent? Which level does the KAP survey represent?
  • Sameer proposes both a KAP survey and direct observation. What additional outcome measure would correspond to Kirkpatrick Level 4 for this programme?
Click to reveal Trigger 3: Piloting and Evaluating (discuss previous trigger first!)

Trigger 3: Piloting and Evaluating

The team conducts two pilot gram sabha sessions. Session 1 (attended by 22 women and 3 men): a 45-minute session covering hand hygiene, ORT preparation, and when to seek care. The medical student facilitator covered 14 points across all three topics, using a flip chart with text in Hindi, reading directly from a script. Audience engagement was low — only 2 women asked questions. Session 2 (attended by 19 women): the team revised the session applying the three-message rule — only three take-home messages were delivered. The flip chart was redesigned with simple local-language illustrations. The facilitator used a role-play where two community volunteers acted out a child with diarrhoea, and the audience guided the 'mother' on correct ORT preparation. Audience engagement was high — 14 participants responded to questions. After 12 weeks, the endline KAP survey shows: ORS knowledge increased from 38% to 74% correct answers. Direct observation of hand-washing before meals improved from 41% to 61%. HMIS data for the quarter shows diarrhoeal cases: 19 (vs 47 in the same quarter last year). However, open defecation practice reduced only from 28% to 24% — a statistically non-significant change.

DISCUSSION POINTS

  • Identify three specific facilitation errors in Session 1 that explain the low engagement. For each error, state the corrective principle applied in Session 2.
  • Using Kirkpatrick's four levels, map the programme's evaluation evidence: KAP survey (Levels?), direct observation (Level?), HMIS diarrhoeal cases (Level?). Which level is missing?
  • The open defecation rate barely changed. Which Ottawa Charter action area was under-addressed in this programme, and what additional intervention would target it?
  • If you were asked to write a one-paragraph report for the District CMO summarising programme effectiveness, what would you include and what would you caution against over-interpreting?

Group Task Assignments

Group 1: Method Classification and IEC Material Audit

  • Classify all IEC methods mentioned in the case into Park's three-tier framework with a structured table.
  • Evaluate the flip chart designed for Session 1 against Park's principles for printed IEC materials (literacy appropriateness, language, visual design).
  • Design a revised flip chart outline for Trigger 2's gram sabha sessions — specify: title, 3 panels (content + visual description), language, and literacy level targeted.

Competencies: CM4.1

Group 2: Ottawa Charter and Setting Analysis

  • Map every programme component (A, B, C) and contextual factor (budget allocation, ASHA exclusion, language choice) to one or more of the Ottawa Charter's five action areas.
  • Identify which action area is most under-resourced in the programme and propose one concrete additional intervention.
  • Design a 200-word community mobilisation plan for the gram sabha sessions that operationalises 'strengthening community action'.

Competencies: CM4.2

Group 3: Programme Evaluation Design

  • Create a Kirkpatrick evaluation matrix for this programme: for each of the four levels, specify the evaluation tool used (or proposed) and the evidence obtained.
  • Critique Sameer's before-after KAP survey design — identify one methodological limitation and propose one improvement.
  • Calculate the programme's impact on diarrhoeal morbidity: what is the % reduction from baseline? Is this sufficient evidence of programme effectiveness? Justify your answer.

Competencies: CM4.3

Group 4: Session Facilitation Comparison

  • Create a side-by-side comparison table of Session 1 vs Session 2 across: message count, facilitation technique, audience engagement, and adherence to the three-message rule.
  • Write a NAPED-based session plan for a 30-minute revised gram sabha session targeting ORT preparation for mothers of under-5 children.
  • Identify the three SMART learning objectives for the revised session and specify how each would be evaluated at Kirkpatrick Levels 1 and 2.

Competencies: CM4.4

Group 5: Integration — District CMO Report and Programme Scale-up

  • Write a 300-word executive summary for the District CMO presenting: baseline gaps, programme design, evaluation findings, and three specific recommendations for scale-up.
  • If the programme were to be scaled to all 12 sub-centres in the district, identify two IEC methods that would need to change and justify your reasoning.
  • Propose a GATHER-based counselling protocol for ASHA workers to use during household visits for families with a child aged under 5 who has not completed immunisation.

Competencies: CM4.1, CM4.2, CM4.3, CM4.4

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [CM4.1] Describe the three-tier classification of health education methods (individual, group, mass) with two examples, two advantages, and two limitations for each tier.
  2. [CM4.1] Compare and contrast IEC and BCC as strategies for health promotion. Give one example of each from India's national health programmes.
  3. [CM4.2] List the five action areas of the Ottawa Charter for Health Promotion (1986) and give a specific example of each from a PHC or district health setting in India.
  4. [CM4.2] Describe the GATHER framework for counselling. What are the six steps and what does each step achieve?
  5. [CM4.3] Describe Kirkpatrick's four-level evaluation model with appropriate tools for each level. Which levels are feasible to measure in a PHC-based health education programme?
  6. [CM4.4] Outline the NAPED framework for health education session design. What are the five steps and what does each involve?
  7. [CM4.4] What is the three-message rule in health education session facilitation? What cognitive psychology principle supports it and how does it improve audience retention?