UnderstandingparticipationThe theme of community participationis explored in the next exercise. It isparticularly useful for showing theproblems of community participation,especially when a programme imposesa particular solution on a community.

One of the fieldworkers beingtrained is asked to wait in a separateroom while the remaining members ofthe group (which can be any numberfrom eight to twenty) are briefed. Theyare asked to imagine that they are

A common example of victim blamingis the singling out of women as thetargets for health education withoutproviding some means to help them.The cartoon from David Werner'sremarkable book Helping health work-ers learn (below) can be used to bringout this victim blaming.4 It can beshown to a group either on a slide oroverhead transparency. Participants areasked to say what they think theaudience in the picture are thinkingwhen they receive the message fromthe nurse. A simple role play can bedeveloped from this situation, whereparticipants take lip the exact positionsof the audience and voice aloud theirthoughts.

'Victim blaming''Victim blaming' is health educationwhich tries to make individuals changetheir own behaviour, but which takesno account of the outside forces, suchas money, time, and pressures fromothers, that can prevent a person fromacting even if he or she is convinced.

the many problems faced in promotinghealth behaviour.2•3 Furthermore, theteaching methods used often involveformal didactic sessions of one-wayteaching rather than alternative ap-proaches encouraging active participa-tion with discussion, dialogue, and asharing of experiences. This articledescribes a series of participatorylearning exercises that have been de-veloped by the author for training inwater and sanitation, and used incommunication courses for Southernfieldworkers held in Leeds, in theNetherlands, and in India.

COMMUNICA nON AND health edu-cation are essential in water supply andsanitation programmes in order toensure the adoption, use, and mainte-nance of water and sanitation systemsand accompanying hygiene practices.'It is recognized increasingly that theapproach used should move beyondpersuasion to include developing com-munity participation and helping peo-ple make informed choices abouttechnologies. Most programmes findthemselves having to mobilize aninfrastructure of fieldworkers, eitherwithin their own services or from othervoluntary or statutory agencies. A keyingredient of this mobilization is train-ing. A criticism of many of the trainingprogrammes carried out is that theytend to concentrate on giving facts andtechnical information on constructionskills only. Insufficient attention isgiven to developing both communica-tion and community participationskills, and strategies for dealing with

Participatory learning for waterand sanitationby John HubleyAppropriate training is essential if fieldworkersare to become effective catalysts in helpingcommunities to make informed decisions abouttheir water supply and sanitation systems.

YOUR C.HILDREN GET SICK BECAUSE OF 'YOuR OWN

DIRTY HA~'T5. OF COUR.SE You DON'T MEAN ANY

HARM,YOU JUST DON'T KNOW ANY aETTE.R. BUT I

WILL "TELL YOU WHAT TO 00.50 LISTEN

CAREFULLY!1.80/1_

""ATER1. W"'~H

HANDS3. &VILO

lAT" IN

f WE"'t.sUOES

, ""A~ •.•~oot>

-Figure: Cartoon from Helping Health Workers Learn usedfor role play.

WATERLINES VOL.12 NO.3 JANUARY 1994 23

Teaching methods should encourage actil'e participation with discussion.dialogue, and a sharing of experiences.

villagers. They have to assign them-selves typical roles of elder, mother,shopkeeper, farmer, chief, health-worker, and so on. By encouragingthem to decide what the communitylooks and feefs like - including theproblems, needs, and history of con-flicts and tensions - the group buildsup a real community which theyidentify with. They are told that aperson from the government is comingto speak to them and they shouldprepare to receive him or her. But theydo not know why the person is coming.

The individual person is given abriefing along these lines: 'You are ahealth educator attached to ChikokaDistrict. Your project manager has seta target that at least 30 per cent of the

villagers should have pit latrines builtand. in. use by the end of the year. Ahealth worker from the health centrehas reported that none of the house-holds in Choma village have built pitlatrines, and you are going to persuadethem to begin to build some. You arein a hurry as you have to go on toanother health centre 50 kilometresaway for a meeting and the roads arevery poor. You conduct your meetingsin a formal, distant manner and do nothave time to listen to the villagersproblems that do not involve sanita-tion. You know that if you do notmeet your target you may lose yourjob.'

The role play starts with the arrivalof the 'fieldworker' in his vehicle. The

community greets him or her and themeeting is allowed to run for at leasttwenty minutes or longer. The re-sponses of the community to thefieldworker can be very strong, every-one has fun, and it is explained that thefieldworker was acting to a brief. Ifthere are sufficient participants therecan be two groups, with the personselected to be the 'fieldworker' in thesecondgroup briefed to take a differentapproach, for example to spend moretime listening before raising sanitation.If a video camera is available it canbe useful to record the session and leteveryone watch afterwards. In thediscussion of the role play manyrelevant points about community par-ticipation are usually brought out bythe participants, especially the needfora systematic, planned approach involv-mg:6 showing respect for the community

and establishing rapport;o having a proper dialogue, not a

one-way conversation;o explaining honestly to the commu-

nity one's role ,\nd limitations;o finding out in advance what the

issuesof concern to the communityare; and

o understanding divisions and con-flicts which might affect the com-munity.In this discussion the point can be

made that community participation isa processwhich takes time to establish,and that targets should allow for theinitial phaseof establishing rapport andunderstanding the community.

Table 1. Statements on cards used in the role play.

Householder I would like to have a latrine but it costs too much. I am afraidto borrow money to build one.

Grandmother Children get diarrhoea because of the hot weather. We have toexpect that. It can't be helped.

Man I agree that a latrine is convenient and private. But what if itgets smelly and full of flies. People will laugh at me for buildingone.

Man You advise me to build a latrine for the whole family to use.That will not work. How can I be expected to use the 'samedefecation place as the women?

Man Somebody is practising witchcraft in the village. That is the realreason why so many of our people are sick.

Man Why should I contribute labour to this water scheme? Is it notthe responsibility of the government to build it?

Elder Why do we need latrines? There is enough room in the bush foreverybody. We are used to it. There is no need to change ourways.

Woman All children under five get diarrhoea. It is natural for them. Iwould not worry.

Woman You want us to build a latrine. If we do that it will mean morework cleaning and fetching water and I do not have enough timeeven now for my duties.

Woman I have to h_.ldle children's faeces all the time. They areharmless. Why do we need to force our children to use the latrineand dispose of their faeces in the latrine?

Developing skillsWhen looking at the technical aspectsof hygiene practices and water andsanitation it is easy to forget thatchange ultimately comes from ordi-nary people making decisions aboutthe things that will affect their ownlives. The more education and trainingwe have, the more difficult it can befor us to understand how the commu-nity thinks and feels, and this can leadto us giving irrelevant and unhelpfuladvice. This role play exercise helpsthe participants understand the realityof what is involved in influencingchange, as well as developing anunderstanding or empathy for thecommunity. The problems and possi-ble solutions become much more realwhen they are acted out rather thansimply intellectualized through ab-stract discussion. It is particularly goodto make men take the role of womenso that they realize the constraintsunder which women have to work!

A seriesof cards have been preparedeach of which makes a particular

24 WATERLINES VOL.12 NO.3 JANUARY 1994

Table 2. Content of cards used in communication stages exercise.

Communication stage(first set of cards)

Reaching intendedaudience

Gaining the attention of thecommunity

Being correctly understood

Convincing the community

Changing behaviour

Improvement in health

Examples of failure(second set of cards)

Only men were at the public meeting. Thewomen did not hear about the waterprogramme and did not participate.The sanitation exhibition at the agriculturalshow was boring, with only a few posters.People walked by without stopping and wenton to look at the other stuff.The sanitation fieldworker used complicatedterms such as faecal-borne diseases, stools,and bacteria. The community nodded politelybut did not know what he was talking about.The fieldworkers explained that latrines wereneeded because people passed on bacteriaand disease through their faeces. Thecommunity were polite and thanked thefieldworker for coming. Afterwards theylaughed at how anyone could be so foolishas to believe that something so small couldmake a person ill.The community was convinced of theimportance of pit latrines and wanted to buildthem, but it did not have any cement to buildthe slabs for the base.Everyone in the community followed thefieldworker's advice and built VIP latrines.But the children were afraid to use them, sothe levels of diarrhoea did not decrease.

Points to bring out in discussion

Ensure that your intended audience will bepresent, see the posters, listen to the radiobroadcasts.Make your communication sufficientlyinteresting to draw people's attention awayfrom other competing attractions.

Use simple language and tryoutcommunication (pre-test) with a sample of theintended audience to make sure it isunderstood.Find out what the community already believeabout the topic and whether cultural beliefsare involved. Try and build in demonstrationswhere people will directly see the benefits oftaking action. Find out who are the trustedpeople in the community and use them ascommunicators.

Ensure that 'enabling' factors such asmaterials, money, and time are available andthat necessary skills are demonstrated.

Check that the actions you are recommendingin your communication messages will actuallylead to improvements in health.

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statement. These statements are shownin Table I and are based on bothpersonal experience and literature ontypical problems and obstacles to theadoption of new practices. It is alwaysuseful to keep some blank cards onhand in addition to the prepared cards,in case the participants raise anyspecial problems that they have en-countered in their health education.

Participants are asked to formgroups of four. One person selects atrandom one of the cards and then hasto represent the person making thestatement. Another person is assignedthe role of the fieldworker and has torespond to the situation on the card andgive appropriate advice. The other twoact as observers and will later be askedto comment on the interaction. Afterfive to ten minutes the role play isstopped and another participant selectsa different card, takes on that role, andreceives advice from another memberof the group.

Discussion and feedback from thisexercise can take place in a number ofways. Participants can summarize ona large sheet the characteristics ofhelpful advice that they saw beinggiven, and on another sheet, that of badadvice(!) In this way simple principlesof advice-giving and counselling canbe derived by the participants them-selves from observations, for examplethe importance of finding out whatpeople believe, making advice simpleand relevant, and avoiding imposing

one's own values on the other person.Discussion is encouraged about thereasons for the beliefs contained within

the statements and the factors whichunderlie traditions and customs. Theimportance of 'enabling factors' and

WATERLINES VOL. 12 NO.3 JANUARY 1994 25

Good communication results in learning that lasts for a long time afterfieldworkers are gone.

'"Q):stiii:.~cctI0->.Q)~ctII>-EQ)

Q;-,

'victim blaming' can be raised. Partici-pants can be invited to suggest howthey might respond to the issues raisedby the community and introduce newideas, while showing respect for thecommunity's beliefs. The discussioncan be broadened to cover general

barriers - cultural, social, and eco-nomic - to behaviour change.

Communication stagesThis final exercise is used to developgeneral concepts of communication

planning. It is based on an analysisdescribed elsewhere by the author2

which separates the elements of thecommunication process into a seriesof distinct stages starting with reachingthe audience, gaining attention, beingunderstood, changing beliefs, changingbehaviour, and finally influencinghealth. Communication failure canoccur at each of these stages andcareful planning based on an under-standing of the community is neededto ensure effective communication.

Each of the six communicationstages in the first column in Table 2and the statements containing exam-ples of communication failures shownin the second column are written oncards 12cm2, making 12 cards in total.The course participants are first askedto place the communication stages inthe correct order. Then they are askedto place the cards describing failuresnext to the stage at which the failuresoccurred. This exercise is followed upwith a discussion of how failures ateach stage can be avoided by carefulplanning. Some of the points that canbe brought out in discussion are listedin the third column of Table 2. Theseinclude:o the need to ensure that the message

actually reaches the intended audi-ence;

o the importance of making the mes-sage interesting so it attracts atten-tion;

o the need to test the wordings andpictures to make sure that they areunderstood;

o the importance of working withinthe local belief system whereverpossible and using respected mem-bers of the community as sources;and

o the importance of making adviceaffordable, practical, relevant, andbased on a sound understanding ofthe community .•

ReferencesI. Hubley, J.H. 'Communication and health

education planning for sanitation program-mes', Walerlines Vol.5 No.3.

2. Hubley, J .H. 'Barriers to health education indeveloping countries', Heallh EducalionResearch I, pp.233-45.

3. Hubley, J.H. 'Understanding behaviour -The key to successful health education',Tropical DoclOr, July ]988, 134-8.

4. Werner, D., and Bower, B., Helping heallhworkers learn, Hesperion Foundation, PaloAlto, California, 1982.

John Hubley is a Senior LecWrer in HeallhEducalion. Heallh Educalion Unil. LeedsMelrOpolilan Universily. Calverley Slreel.Leeds. LSI 3HE. UK.

26 WATERLINES VOL.12 NO.3 JANUARY 1994