1.01

Priority health problems and educational objectives

1.02

The aims of this first chapter are to show: that the health problems of the community must be taken as the starting-point for the construction of a relevant educational programme; the advantages of defining educational objectives on the basis of professional tasks; that if the precision and clarity of these objectives are important, their relevance to health problems is even more so; and that an approach based on objectives will ensure that health personnel are better prepared to perform a role that is relevant to the health problems of society.

Those interested in this approach should read the following works by R.F. Mager:

Preparing instructional objectives (1962).

Goal analysis (1972).

Measuring instructional intent (1973) (Chapter III, pages 15 to 46) Fearon Publishers, California, USA.

And the following publication by the World Health Organization:

Criteria for the evaluation of learning objectives in the education of health personnel (1977) WHO Technical Report Series No. 608.

After having studied this chapter and the reference documents mentioned you should be able to:

1. Define the following terms: professional task, activities, functions, role, institutional objectives; specific objective; domains of practical skills, communication skills and intellectual skills.

2. List the health problems in your own community in order of priority.*

3. Analyse the causes of these problems.*

4. Identify the parts of the system of which your establishment is a part and list the actors (organizations or people) who either utilize or collaborate with the health services.*

5. Define the professional functions of a member of the health team whom your teaching institution is responsible for training (general educational objectives) so as to deal with the health problems of society.*

6. Analyse a major professional function by defining the various intermediate components (activities) making it up.*

7. Define a professional task and identify its components (domains of practical skills, communication skills and intellectual skills).*

8. Draw up a list of the specific educational objectives relating to a professional task, stating explicitly what you feel the student should be able to do after a given course of instruction (that he was not able to do previously) and corresponding to the domains of the communication skills or practical skills involved in this activity.*

9. Taking a specific objective in a non-cognitive domain (i.e. practical skills or attitudes), define in terms of contributing educational objectives what theoretical knowledge you feel the student should possess if he is to attain that objective.*

10. Make a critical analysis of specific educational objectives (listed by a colleague), indicating in particular whether they include all the requisite elements (act, content, conditions, criteria).*

11. Draw up a list of the possible reactions of colleagues with whom you work in your faculty to the idea of having to define educational objectives derived from professional tasks, and propose strategies for overcoming those reactions.*

* Work in small groups is recommended for these objectives. Individual work will usually be appropriate for the others.

If you are not certain of where you are going you may very well end up somewhere else (and not even know it) Mager 1.03

1.04

Every individual should have access to a type of education that permits maximum development of his potential and capabilities.

¯

Education is a process, the chief goal of which is to bring about change in human behaviour.

¯

The result of education is an expected change in the behaviour of the student in the course of a given period.

This “behaviour” will be defined explicitly in the form of educational objectives derived from professional tasks that respond to the priority health problems of the community.

An evaluation system will be planned so that better educational decisions can be taken.

A programme will be prepared and implemented to facilitate attainment of educational objectives by the students.

The evaluation process will be used to measure the extent to which the objectives have been achieved... it will measure the student's final abilities ... and the effectiveness of programme and teachers.

This is the Educational Planning Spiral

The educational planning spiral

1.05

Figure

The object of education is not to shape citizens to the uses of society, but to produce citizens able to shape a better society.

The educational planning spiral

1.06

Programme reform has been a source of concern for many years to those training health personnel and the alarm has often been sounded. However, the strength of the traditions impeding necessary reforms has been such that it has not been possible to avoid serious disturbance in many universities throughout the world, always caused by a reaction in face of the apparent diehard conservatism of the system.

It would, however, be negative and dangerous merely to accuse of incompetence those at present in positions of teaching responsibility. They should be offered help.

Societies change and have always been changing, but until the present century their evolution was relatively slow and adaptation to change was possible without unduly violent disorders.

The form of teaching has remained unchanged for centuries. The university has wrapped itself in its privileges and remained deaf to the cry from without. The needs of society, the practical side of the matter, have been left to chance, whereas specific features of the situation in each country are changing ever more rapidly. Hitherto, unfortunately, little or no account has been taken of those features and the training of health personnel has followed traditional systems. What is required now is to make sure that educational programmes are relevant.

There can be no question of continuing to copy the models of the past or, in the case of developing countries, foreign models.

The educational system leading to the development of health personnel, at all levels, must be re-examined within the context of the needs of the country concerned¹

¹ Those who are interested in a more detailed analysis of needs, organization of health services, and the definition of tasks and functions than it is possible to give in this Handbook should consult specialized texts on these aspects (see Bibliography, p. 7.01).

There are a few health sciences institutions in different parts of the world that have not only succeeded in introducing significant changes over the past two decades but have also amply demonstrated that the effort has been worth while. No educational system can be effective unless its purposes are clearly defined. The members of the health team must be trained specifically for the tasks they will have to perform, taking into account the circumstances under which they will work.

The sum total of these tasks, or professional profile, can only be defined in accordance with a plan in which the nature of the services to be provided is specified, priorities are allotted, the staff needed to provide these services determined, etc.

Professional training programmes must then be tailored to meet these needs.

There is room for some degree of optimism in this sphere, for no financial assistance is needed for a move in the right direction. All that is needed is a resource distributed more or less equally around the world: mental ability. The management of that resource is the art of organizing talent and of coping intelligently with change.

Defining the professional tasks of health personnel to be trained, the very basis of the educational objectives of training centres, is of crucial importance.

Thus an educational programme, instead of being the result of a non-selective accumulation of knowledge built up over the centuries, must be shaped selectively in terms of the goal to be achieved. If that goal is modified in the course of time, the programme must also be modified accordingly.

Definition of professional tasks must proceed from a study of needs, take account of available resources and indicate clearly and precisely what various categories of personnel will be called upon to do during their professional careers in a given type of health service.

The first step is to map reality.

The road to relevance

1.07

Mapping reality

Mapping reality means identifying the factors that have an impact on the health of the community; in other words, getting on the road to relevance.

Identifying the health problems of the community
Identifying the overall goals of national health policy
Identifying support systems
Identifying institutional goals
Identifying the “players” in activities relating to health

Personal notes

1.08

What is meant by relevance?

1.09

The most important quality in an educational programme is its relevance. Training programmes for health personnel must enable the graduates to cope effectively with the problems they will encounter in the context of their work.

The first step is therefore to identify and analyse the health problems of the community so as to be able to define the community's health needs. These elements will serve as the starting point for the design of an educational programme.

A first comprehensive assessment of health problems will bring to light so many complex problems that it would be impossible (and probably futile) to include them all in an analysis of the health situation. It will therefore be necessary to define priorities and select those that are regarded as most important for an educational programme.

These factors should then be examined to see how they interact, or in other words, to make a causal analysis.

EXERCISE

Rank (in order of priority¹) the health problems in your own community.

¹ Use criteria 1, 2 and 3 given at the top of page 3.52.

High-priority community health problems

EXERCISE

1.10

Make a causal analysis of the priority health problems you have identified.

Problem	Cause

You may now wish to reconsider the order of priority you had established.

Identifying health policy orientation

1.11

Most countries have developed some sort of policy orientation to address health problems. But they may not have formulated any explicit goals. If your country has not set itself any health goals, it would be useful to review existing national plans in areas with some relation to health, such as nutrition, agriculture or education, in order to derive an idea of the country's general goals for health.

You should now obtain copies of your country's relevant documents on these questions.

EXERCISE

On the basis of your country's plans, identify the general national goals that relate to the health situation. Compare them with the health problems you have already identified (page 1.09)

General national goals for health

System?

1.12

The word “system” is used frequently in the Handbook. Let us take a few minutes to explore its different meanings.

A system is often defined as a set of interacting components or elements aimed at a common goal.

Support system

A support system refers here to an institution, organization, administrative structure, or other community structure that facilitates the effective implementation of a health care activity (e.g. the education system).

Health system¹

¹ Glossary of terms used in the “Health for All” Series No. 1-8. Geneva, World Health Organization, 1984 (“Health for All” Series No. 9).

A health system is the complex of interrelated elements that contribute to health in homes, educational institutions, workplaces, public places and communities, as well as in the physical and psychosocial environment, and the health and related sectors. A health system is usually organized at various levels, starting at the most peripheral level, also known as the community level or the primary level of health care, and proceeding through the intermediate (district, regional or provincial) to the central level.

Educational institutions - one of the support systems for health care activities

1.13

Taking these definitions and the objectives of your institution as an element in society, you should regard your institution as one of the support systems for health care activities.

Any programme of action intended to improve the health situation in a society (at the national, district, local, family or individual level) must be able to draw support from different sectors. Various fields of action may be delineated or left open by overall national policy. The political system will therefore have a crucial role to play if general policy decisions are needed for programmes of action to be implemented.

The authorities and administrative structures, with the powers of decision that are delegated to them, often have a strong influence on health care at various levels, for although they can facilitate initiative and action, they can also hamper them and be a source of constraint.

For the right decisions to be taken, both in terms of policy and administration, it is essential to have a database designed in the light of the information requirements of the users, that is, of the general public. This database is also important for the formulation of training programmes or for more limited educational activities. The circulation of information among different users often leaves much to be desired. A proper system of communication between the different sectors is essential for the information needed for decision-making to be circulated and for the various sectors to be able to keep each other informed of their activities. This will prevent unnecessary overlap, duplication and errors, thus making for better use of resources. This is often the weakest link in a support system.

In many countries the infrastructure is inadequate. This weakness is evident in transport, communications, water supply, waste disposal, etc., which are clearly vital sectors and which have varying degrees of influence on the health situation.

There are many other sectors that might be mentioned, but we shall confine our attention to the support system which is the subject of this Handbook, namely, the education system. This system is responsible for education and training from the primary level to the university and beyond. It is important that it should function well, as it must supply human resources with the skills needed by the other support systems. It is fair to say that the existence of an efficient education system is a prerequisite for any action to improve the health situation in a country. Here we shall deal only with the part of the system that is concerned with education for the health professions.

Figure 1 (p. 1.14) represents the support systems for the health system:

- the political system;
- the structures and authorities of the administrative system;
- the general system (or general infrastructure);
- the education system.

Unfortunately, it all too often happens that most of these systems act as a constraint rather than a support to health care activities. However, by regarding them as support systems, we will force ourselves to see their positive side and the ways in which they can provide support.

Figure 1. Position of the educational system in relation to all the elements that have an influence on the system which must respond to the health needs of the population.

1.14

The actors involved in activities related to health care

1.15

The participants involved in activities related to health care (whom we shall call here the actors), both in the health system itself and in the support systems, may be institutions, public or private agencies, or individuals. Some of them directly provide health services (e.g. nurses or doctors). Others work in areas in which certain aspects are relevant to health - they are indirect providers of care. They may belong to interprofessional groups which include health personnel, or occupy positions in which they are natural partners in dialogue or collaboration with health professionals (e.g. agronomists).

Then there are the users of the health services. Some will have occasional recourse to competences in the area of health (e.g. school-age children) while others will be more regular users (e.g. diabetics). Dialogue between all these users and providers will produce valuable feedback for those whose task it is to design training programmes for health personnel.

These actors are very numerous. We shall nevertheless attempt to identify them, simply in order to understand how important and necessary it is that there should be dialogue between them and how difficult and complex this is likely to be.

Personal notes

1.16

EXERCISE

1.17

For each of the high priority health problems (column 1) you listed previously (page 1.09), state the support systems concerned in your country (column 2); the providers of direct (column 3) or indirect (column 4) care and the occasional (column 5) or regular users (column 6).

High priority health problems	Support systems	Actors
		Providers		Users
		Direct	Indirect	Occasional	Regular
(1)	(2)	(3)	(4)	(5)	(6)

There are nearly always more actors involved than you might expect! Compare your list with the list on the next page... and draw your own conclusions.

EXERCISE

1.18

Now examine the long list of actors¹ reproduced below (for an example comprising only two health problems).

- Underline those you mentioned in the previous exercise;

- Place brackets round the actors you did not mention and relate them to the particular health problem(s) which concern them.

¹ Drawn up by a group of participants in the Community Health Course, Faculty of Medicine University of Geneva, Switzerland, 1989.

		Actors
High priority health problems	Support systems	Providers		Users
		Direct	Indirect	Occasional	Regular
(1)	(2)	(3)	(4)	(5)	(6)
Resulting from internal aggression (lifestyle) e.g. - obesity - hypertension - diabetes - stroke - heart attack - dental caries - alcoholism - smoking - anorexia - suicide - cancer	- all citizens - general infrastructure - education system	- doctors - nurses - dentists - pharmacists - health educators - gynaecologists - psychiatrists - psychologists - paediatricians - nutritionists - dietitians	- teachers - journalists - media specialists - publicists - caterers - chefs/cooks - food industry - farmers - industrialists - tobacco and alcohol regulatory authorities - agronomists	- healthy individuals - parents - infants - school-age children - pregnant women	- groups at risk - diabetics - elderly people
Resulting from external aggression e.g. - transport, work, home, school accidents - air and water pollution	- political system - public administration - education system - general infrastructure	- surgeons - physio-therapists - radiologists - veterinarians - emergency medical workers - occupational physicians - school doctors	- opticians - oculists - laboratory technicians - sanitary engineers - ambulance drivers - meteorologists - driving instructors - architects - planners - civil engineers - teachers - civil administrators - elected representatives - politicians - trade unions - ergonomists - insurers	- healthy individuals - parents - school-age children - workforce (industry and agriculture)	- handicapped - asthmatics - allergic

Importance of defining professional tasks

1.19

If we stress the importance of the prior definition of professional tasks, it is because this is a precondition for ensuring that training programmes are really designed to meet the population's health needs. Over the last 20 years or so, teachers, under the cloak of an educational revival, have used the title of educational objectives to disguise what they had been in the habit of teaching in the past. Such educational objectives have favoured the creation or continuation of training programmes which all too often seem hardly relevant to the needs of the population.

Indeed, if educational objectives are based on faulty principles, then the “best” system of training may well give “bad” results. There is even a danger that a “bad” message will be “better” communicated, and this is certainly not the goal sought.

We therefore propose to demonstrate that the professional profile of a member of the health team and the educational objectives providing a basis for construction of his training programme must be almost identical.

We shall also be stressing two principles that are of fundamental importance for education. Principle no. 1: it must be oriented towards the community as well as the individual, taking account of the health needs of each particular collectivity, i.e. education must be community-oriented. Principle no. 2: it must keep students in an active situation, gradually helping them to become the architects of their own learning activities, i.e. education must be learner-centred.

Another important point to bear in mind is that it can be useless to try to change a programme or teaching methods without also changing the system of evaluation (particularly examinations). Experience has shown that if, on the other hand, the evaluation system is modified, this has a much greater impact on the nature of learning than has modification of the programme unaccompanied by any change in the evaluation system. Evaluation provides a sound basis for programme planning. Therefore, an evaluation mechanism should be set up before proceeding to any reform of the programme. This makes it possible to measure the level at the outset (prerequisite level) and the level at the finish and thus to determine whether the change has been positive or not. This process can be represented by what is called the educational planning spiral (page 1.05).

If the teaching staff are given an opportunity to gain the new knowledge they need and to acquire the appropriate modern teaching skills, they will feel more secure and instead of being confined to limited personal experience they will accept the use of more formal educational research methods.

This can be a powerful stimulus for institutional change, particularly when used by faculty members whose experience in the educational process has already alerted them to the ways in which educational innovation can be accomplished with the greatest possible enthusiasm and the least possible hostility on the part of their colleagues. Such innovation, based upon carefully gathered information and developed according to sound educational principles, could enable some medical education institutions to explore, in particular, non-traditional means of preparing the members of the health team for the professional tasks they will have to undertake. Without the encrusted educational tradition that long adherence to a single system creates, the opportunity for innovative experimentation is far greater.

This is a very difficult task which may well have daunted the most conscientious. We consider that teachers should be offered assistance in this field.

That is the main reason why this Handbook has been prepared and used during workshops on educational planning.

Organizational diagram of the educational system for health professionals

1.20

Selection of training goals1

¹ Adapted from “An overview of applied research in medical education problems, principles and priorities”. Christine H. McGuire, WHO Report on the Workshop on the Needs for Research in Medical Education, Alexandria, March 1974.

1.21

Traditionally, this selection has been made by relying on the judgement of experts to determine what a neophyte in the profession ought to know and ought to be able to do. In the past we have relied almost exclusively on this method. As a result curricula are crammed with an ever-burgeoning amount of new and highly specialized knowledge which the student often perceives as irrelevant to his own goals and which, in fact, may be of little value to other than the super sub-specialist. Certainly expert opinion is an important source of information about the knowledge and skills which trainees should be able to demonstrate, but it is also possible to make this decision on the basis of scientific evidence about what competent health personnel need to know and need to be able to do in order to fulfil their responsibilities. A number of procedures have now been developed for collecting such data which provide an empirical basis for working out a behavioural description of the essential components of professional competence. This is of great assistance to faculties in setting goals and designing curricula. Three of these procedures are of special interest: the critical incident technique, task analysis and analysis of epidemiological data.

The critical incident technique

This method consists of collecting data about specific types of behaviour that characterize professional effectiveness and ineffectiveness and using these data to make an objective, empirical assessment of the essential performance requirements of the profession. This technique is an outgrowth of studies in aviation psychology made in the United States during the Second World War. In that programme it was found that in reporting the reasons for eliminating a trainee, pilot instructors and check pilots frequently offered such cliches and stereotypes as “lack of inherent flying ability”, “poor judgement” or “unsuitable temperament”. In an effort to determine the specific characteristics of personnel that contributed to success or failure, combat veterans were asked to report incidents observed by them that involved behaviour which was especially helpful or especially inadequate in accomplishing the assigned mission. This request concluded with the statement: “Describe the officer's action. What did he do?” The several thousand incidents submitted in response to this inquiry were analysed and categorized to provide a relatively objective and concrete description of the “critical requirements” of combat leadership.

To apply this method to the health professions, several thousand incidents describing observations of especially effective or ineffective colleague behaviour are collected from several hundred health workers representing various age groups, geographical areas, professional categories and specialty interests. For example, in a critical incident study of intern and resident performance (i.e. of the general practitioner) commissioned by the US National Board of Medical Examiners, the American Institute of Research collected over 3000 incidents from physicians across the country. The incidents submitted involved all areas of behaviour: practical, communication and intellectual skills. They identified, for example, such general requisites of competence as “Skill in gathering clinical information,” i.e. in taking a competent history and in performing an adequate physical examination, or “Skill in relating to the patient and in gaining his cooperation in a treatment plan”. In a similar study conducted by the University of Illinois Center for Educational Development of the critical performance requirements in orthopaedic surgery, over 1700 incidents were collected from more than 1000 orthopaedic surgeons representing various practice settings and sub-specialty interests. An empirical classification defining 94 critical performance requirements, grouped into nine major categories of competence, was derived from the incidents. This operational and prospective definition of the essential components of competence could then be used to determine the goals of specialty training, the design of programmes for their achievement and the criteria and methodology for their evaluation. If educational planning were regularly based on such operationally defined, empirically derived goals, educational programmes would look quite different.

Task analysis

1.22

A second method of determining the essential components of professional competence which should define educational objectives consists in detailed task analysis of what various categories of health personnel actually do, and in deriving from that list of tasks a statement of the knowledge and skills (what should be done, not merely what is done) which they must have to perform competently. Such a task analysis should be based on careful, systematic observations of the activities of a representative sample of various categories of staff or on the daily logs of a representative sample who report in minute detail the way in which they spend their working days over a specified period of time, or on some combination of these two approaches.

Wherever this method has been employed, the results have been most enlightening. For example, in a limited pilot study of paediatricians in a typical small US city, researchers found that all the physicians had different but consistent patterns for taking a history and performing a physical examination. Of the 481 patient visits observed, 222 were well children; an average of 10.2 minutes was spent with these children (range: 7.5 minutes to 13.6 minutes) in contrast with an average of 8.1 minutes spent with ill children (range: 7.4 minutes to 10 minutes). Of the 259 ill children, 104 (i.e. 40%) were diagnosed as having an infection of the upper respiratory tract, 15 had chronic illnesses and five had potentially dangerous diseases. For the total group of 481, optic fundi were examined only nine times and rectals were performed in only six cases; two physicians did not percuss the lung fields for any patient. The greatest amount of time was spent in discussion of nutrition and child development. The single most frequent topic on which advice was rendered in well-child care concerned toilet training. The authors of this study concluded, “Few aspects of well-child care appear to require the skill of a physician... the question is also raised as to whether current training programmes are aggravating the physician manpower shortage by overtraining in relation to community health needs.”¹

¹ Bergman, A., Probstfield, J. and Wedgewood, R. Performance analysis in pediatric practice: preliminary report. Journal of Medical Education, Vol. 42: 262 (1967).

This is a question that could apply to all members of health teams in every country; only task analysis or comparable empirical studies will give us the answer.

Epidemiological studies

One of the most interesting of the newer approaches to the use of such studies consists in combining three arbitrarily weighted factors - disease incidence, individual disability and social disruption - to define priorities in health care needs and, hence, in educational effort. As initially developed by Dr John W. Williamson², the three factors are computed as follows: disease incidence consists of a simple tabulation of the frequency of the disease (e.g. pneumonia) or other medical condition (e.g. pregnancy) in the target population. Individual disability involves a determination of the extent of patient disability or risk associated with a given medical condition; an Individual Disability Weight (IDW) is calculated for each condition from three elements: the average length of hospital stay, mortality rates and complication rates. Social disruption represents an estimate of the disruption that would be produced by a given disease or condition in the social group of which the patient is a member; it is based on such factors as cost of illness, age of patient and number of dependents, socioeconomic standing and the like. For each discharged patient a Total Priority Weight (TPW) is calculated combining these elements. This Total Priority Weight is then arbitrarily apportioned among patient diagnoses. Finally, a cumulative total for each diagnosis is calculated from the total patient sample. The resultant ranking represents a quantitative estimate of health care needs or priorities for the population at risk.

² Williamson, J. et al. Journal of the American Medical Association, Vol. 201: 938 (1967) and Vol. 204: 303 (1968).

It is clear that even with unlimited resources not all of these needs could be met in the present state of our knowledge. The next step therefore consists of determining what portion of total health care needs can be met, given our present understanding of disease and our present treatment possibilities. This portion indicates the target area for application of professional skills and helps to define educational priorities. The goals of education for health service staff can therefore be defined as encompassing those areas of health care needs that cause the greatest total preventable disability - i.e. those that cause the greatest total disruption that could be reduced or minimized by early diagnosis and appropriate intervention.

In his early studies using this method to review hospital practice in two large community hospitals in widely separated metropolitan areas in the United States, Dr Williamson found that pregnancy, including uncomplicated delivery, ranked first or second in priority in both hospitals, that cerebral vascular accidents ranked among the first five diagnostic categories in both hospitals and that fractures of the lower extremities ranked among the first five in one hospital. These particular conditions are mentioned because in certain educational institutions there is a general tendency to reduce the amount of clinical instruction for the general medical student in some of these areas. For example, instruction in orthopaedic surgery is often elective despite the fact that trauma in general accounts for a very significant proportion of total preventable disability.

While the study reported above was limited to hospital practice, the same method could easily be applied to any level of health practice. In addition, while the findings from such epidemiological studies and the particular weights to be assigned to such factors as individual disability and social disruption will, of course, vary markedly in different parts of the world, the approach is clearly applicable to any society for which health personnel are being trained.

In all parts of the world, use of such data will modify the goals and priorities of educational institutions and the emphases in curricula by focusing far greater attention on ambulatory medicine and on the more common causes of disability.

Implications of applied research on goals and priorities

It can be seen from the above that the means are now at hand for supplementing expert judgement with data derived from empirical studies to assist us in defining the roles and, hence, the skills required of students on completion of programmes. If such studies were carried out as a matter of course and if the findings were used to develop explicit educational objectives for the health professions, we should see revolutionary changes in the kinds of health professionals produced and in their training programmes. Furthermore, such changes would have a far greater impact on meeting health care needs than would simple expansion of educational facilities of the conventional type.

Here we should mention some simpler but also more rapid and less costly techniques which can be used to complement or replace other methods. These methods are not mutually exclusive:

- Interviews with members of the profession, who are asked to describe what, in the light of their experience, should be the functions and tasks of any member of the health team.

- Questionnaires, made up of either open-answer questions (what are the functions of...?) or closed-answer questions (which of the tasks listed below...?).

- Personal log-books kept by health professionals, describing the actual work carried out each day and recording the time spent on each activity.

- The simplest method consists of asking each of a group of colleagues to put himself in the shoes of a person needing care and to describe the functions and tasks that he would wish a given member of the health services to be able to perform. Comparison of the lists submitted will lead to rapid agreement on a common list of sufficiently high quality to provide a basis for a productive discussion on the relevance of the programme, for example.

The following pages (1.25 to 1.27) describe the services provided by a health unit in one country. This list was obtained using the questionnaire method in a survey carried out in Egypt in 1969.

1.24

Transformation of the present professionally oriented technologically dominated health system into a patient-oriented system is the needed ingredient for any successful curriculum change. The patient should be the primary concern of both education and service. George A. Silver

Example of services provided by rural health units1

¹ Adapted from “Three approaches to the analysis of health manpower functions”. Unpublished WHO document HMD/79.1, pp. 69-72.

1.25

Each health unit is meant to serve a population of 5000 persons, normally in one village and maybe a few smaller settlements around it. The health team of each of these rural health units is made up basically of:

One physician (in charge)
One assistant midwife
One assistant sanitarian, and
One laboratory assistant.

The rural health unit provides the basic health services for the population it serves, i.e.:

A. Maternal and child health work
B. Communicable disease control work
C. Vital and health statistics work
D. Environmental sanitation work, and
E. Medical care work.

A. Maternal and child health work

(a) Prenatal care activities:

1. Comprehensive examination of new patients.
2. Follow-up examination of patients.
3. Urine analysis (sugar and albumin, microscopic examination).
4. Taking blood samples and determination of haemoglobin level.
5. Weighing of pregnant women.
6. Measurement of blood pressure.
7. Prescription of treatment.
8. Referral of patients to hospitals.
9. Giving subcutaneous, intramuscular and intravenous injections.
10. Supervision of cleanliness of pregnant women.
11. Carrying out health education activities.
12. Home visiting for non-attenders and during the ninth month.

(b) Natal care activities:

13. Preparation of delivery bags.
14. Conducting normal deliveries at home.
15. Conducting abnormal labour, and transfer to hospital where necessary.
16. Giving intramuscular and intravenous injections.

(c) Postnatal care activities:

17. Home visiting for puerperal cases.
18. Detection and treatment of fever.
19. Giving subcutaneous, intramuscular and intravenous injections.
20. Carrying out health education and family planning activities.

(d) Child care activities:

21. Weighing of children.
22. Supervision of child cleanliness.
23. Vaccination against diphtheria, tuberculosis, etc.
24. Taking temperature.
25. Carrying out medical examination.
26. Prescribing treatment.
27. Referral of patients to hospitals.
28. Isolation of communicable disease cases.
29. Giving subcutaneous, intramuscular and intravenous injections.
30. Taking blood samples.
31. Circumcision of male children.
32. Prescribing the diet.
33. Home visiting for non-attenders.

(e) Miscellaneous technical activities:

34. Preparing the clinic.
35. Sterilization of instruments and supplies.
36. Training of midwives and assistant midwives.
37. Preparation of drugs for distribution.

B. Communicable disease control work

(a) Activities related to cases:

38. Isolation of cases.
39. Disinfection of cases (during and after treatment).
40. Dusting of cases (for disinfestation).
41. Giving instructions at home (education).
42. Supervision of domiciliary treatment of tuberculosis patients.
43. Recording in communicable disease register.
44. Search for the source of infection.

(b) Activities related to contacts:

45. Surveillance of contacts.
46. Immunization of contacts.

(c) General preventive activities:

47. Vaccination against poliomyelitis, diphtheria and tuberculosis.
48. Noting names of non-attenders.
49. Preparation of list of families.
50. Carrying out periodic dusting.
51. Recording in disinfection and dusting registers.
52. Controlling insects and rodents.
53. Carrying out epidemiological surveys for case-finding.
54. Isolation of detected cases.

(d) Activities related to deaths:

55. Receiving notifications of deaths and search for relations.
56. Examination of the dead and establishment of death certificates.
57. Recording in the appropriate registers.
58. Issuing of burial permits.

C. Vital and health statistics work

59. Recording of births and deaths in the appropriate registers.
60. Making weekly and monthly reports.
61. Calculation of death rates, etc.
62. Making statistical studies and interpretations.

D. Environmental sanitation work

63. Numbering of houses and population census.
64. Mapping areas and facilities.
65. Ensuring cleanliness in and around dwellings.
66. Hygienic disposal of refuse.
67. Constructing latrines in village houses.
68. Control of bilharzial snails.
69. Identification of breeding places of mosquitos.
70. Mapping breeding places of mosquitos.
71. Checking hygiene of public latrines.
72. Carrying out measures ordered by doctor.
73. Supervision of environmental sanitation activities.
74. Examination of food in public places.
75. Taking samples from food.
76. Destroying spoiled food.
77. Surveillance of market and street vendors.
78. Taking water samples from public standpipes.
79. Enforcement of laws concerning cemeteries.
80. Examination and certification of food handlers.
81. Carrying out health education activities.

E. Medical care work

(a) Diagnosis activities:

82. Preparing the patient.
83. Taking the history.
84. Recording clinical observations.
85. Weighing the patient.
86. Taking the temperature.
87. Counting the respiration.
88. Counting the pulse.
89. Measurement of blood pressure.
90. Clinical examination.
91. Requesting laboratory tests.
92. Taking blood samples and administering transfusions.
93. Microscopic examination of blood and blood grouping.
94. Urine examination for parasites, chemical analysis and microscopic examination of urine.
95. Requesting X-ray examination.
96. Examination of stools.

(b) Therapeutic activities:

97. Prescribing treatment and/or diet.
98. Giving subcutaneous, intramuscular and intravenous injections and drips.
99. Giving oral medication.
100. Applying artificial respiration.
101. Catheterization.
102. Application of hot or cold compresses.
103. Administration of enemas and use of stomach pump.
104. Suction of mucus.
105. Making dressings.
106. Eye painting and irrigation.
107. Making surgical stitches and performing minor operations.
108. Removal of surgical stitches.
109. Carrying out health education and supervising patient's diet.
110. Observing patient's condition.
111. Application of external treatment (ointment).
112. Radiotherapy.
113. Physiotherapy.

F. Administrative work

114. Assignment of jobs and activities.
115. Checking attendance.
116. Giving leave permits.
117. Conducting legal investigations.
118. Management of equipment and supplies.
119. Management of financial matters.
120. Filling in forms.
121. Book-keeping.
122. Correspondence.
123. Preparation of monthly and annual reports.
124. Recording attendance in waiting-room.
125. Supervising housekeeping of the unit.
126. Supervising transportation.

Please Note! You are reminded that this list, drawn up in 1969, describes the services as they were and not as they should have been. It might seem that preventive activities deserved greater prominence.

A list of the “services” provided by health facilities is essential for verifying the relevance of the everyday work of the various members of the health team. It is from this that their professional profiles and their training programmes should be derived.

EXERCISE

1.28

1. Take one category of health personnel (e.g. physician, or nurse, or midwife, or medical assistant, or sanitarian) and circle the items on the preceding list corresponding to the activities which that category of staff is supposed to carry out in your country at present.

2. Then think of some activities which that same category does not undertake at present but which you feel, in the light of your personal experience, it should undertake to improve the level of health of the population it serves, Draw a square around each of the corresponding items on the list.

3. Describe below any unlisted activities that you consider relevant.

Educational objectives (derived from the tasks that make up the professional profile)

1.29

What the students should be able to do at the end of a learning period that they could not do beforehand.

¯

Educational objectives are also called “learning objectives” as opposed to “teaching objectives”. They define what the student, not the teacher, should be able to do (in accordance with principle no. 2, page 1.19 and 1.79).

¯

The definition of the objective of a course is that of the result sought, not a description or summary of the programme.

Relationship between professional acts in the health field and educational objectives

Note: The size of the circles relates to the number of objectives: the more specific they are the more numerous they are. The triangle indicates that at the general level objectives are “wide”, broad, vague, and that specific objectives are “punctual”, narrow, precise.

1.30

Types of educational objectives

1.31

1. General objectives: Correspond to the functions of the type(s) of health personnel trained in an establishment.

Example: Providing preventive and curative care to the individual and the community, in health and in sickness.

2. Intermediate objectives: Arrived at by breaking down professional functions into components (activities) which together indicate the nature of those functions.

Example: Planning and carrying out a blood sampling session for a group of adults in the community.

3. Specific (or instructional) objectives: Corresponding to (or derived from) precise professional tasks whose results are observable and measurable against given criteria.

Example: Using the syringe to take blood sample (5 ml) from the cubital vein of an adult (criteria: absence of haematoma; amount of blood taken within 10% of the amount required; not more than two attempts).

These three types of objectives, taken together, make up the
Professional Profile

To gain better understanding of these three levels of educational objectives and the relationship between them, study pp. 1.36 - 1.37 and 1.41 - 1.48

Data necessary for formulation of relevant educational objectives

1.32

Health needs, demands and resources of society.
Services to the patient (list of tasks).
Services to the community (list of tasks).
The profession itself.
The students.
Progress in sciences.
The scientific method.
etc...

For more details refer to: Criteria for the evaluation of learning objectives in the education of health personnel. Report of a WHO Study Group.¹ WHO Technical Report Series, No. 608, 1977; and pp. 4.10 - 4.14 of this Handbook.

¹ An annex to the report clarifies what different authors mean by educational objectives, examines the different levels and types of objectives, lists the potential benefits of taking the trouble to formulate objectives and reviews the data considered necessary for this. There is also a short section on how to word objectives properly.

EXERCISE

1.33

Take the time to list the main functions of the category of health personnel that interests you (dentist, nurse, sanitary engineer, physician, pharmacist, midwife, etc.). Where possible, refer to documents published on the subject in your country (national health plan, professional publications, etc.). If no such data are available, rely on your own experience.

The professional functions of .................... ¹ are as follows:

1. ___________________________________

2. ___________________________________

3. ___________________________________

4. ___________________________________

5. ___________________________________

6. ___________________________________

7. ___________________________________

8. ___________________________________

¹ Insert the name of the profession in which you are interested, e.g., “nurse”, “general practitioner”, “dentist”, etc.

Please read the following pages and then do the exercise on page 1.38

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

A health team is a group of persons who share a common health goal and common objectives, determined by community needs, towards the achievement of which each member of the team contributes, in a coordinated manner, in accordance with his/her competence and skills, and respecting the functions of others. The manner and degree of such cooperation will, of course, vary and has to be solved by each society according to its own needs and resources. There can be no universally acceptable composition of the health team.

The primary health care approach:

1.35

1. reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;

2. addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;

3. includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

4. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;

5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;

6. should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;

7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

General objectives: professional functions

1.36

There will be as many lists of these as there are categories of staff trained in the institution concerned.

The following examples of general educational objectives at the institutional level are real sets of objectives as formulated by health personnel training institutions.

They are only examples. Compare them with the functions you listed on p. 1.33. You may find that some of the items are almost identical. At this general level the acts required to meet the health needs of the population will have some points in common all over the world. This is quite understandable. At this level of general functions it is not surprising that nurses, physicians, midwives or dentists, for example, should exercise similar types of functions, such as treatment, prevention, planning, education of the public, training of colleagues, etc. The differences between the professions will emerge from the more detailed list of intermediate objectives, describing the activities of each category and from the even more specific list of tasks. The different types of objectives form a whole. They are given meaning by their relationships and interdependence. Taken together they make up the professional profile.

What should be noted at this stage is that all the examples are relatively short (one page) and rather vague. You will also note that they define everything the students should be able to do at the end of their training.

They do not define what the teachers do but rather what the institution's “end-product” is. They are also known as institutional objectives.

The fact that the examples that follow are numbered does not imply that they are classified in order of importance. Obviously each function can be more or less important as compared with another, depending on the health system in which the qualified student will work and on the overall stage of development of the country.

The prominence of the function “health education of the public” will depend on the population's general level of education. Similarly, functions relating to planning will be very different depending on the development context and degree of organization of the country. Physicians and nurses in less developed countries may have to assume greater responsibilities in this field than their counterparts working in more developed countries.

Whatever the relative importance of a given function, what counts at this stage is that it exists: you will find it useful to bear this in mind throughout the training process. Now read the examples that follow.

Professional profiles

Institutional Objectives (1)

The graduates of the M.D. programme¹ should be able:

1. To identify health problems in their totality and to show skills in collecting, processing and presenting data pertaining to health problems, and subsequently to resolve and manage them, from the individual level through the family level to the community level.

2. To diagnose and manage frequently occurring diseases in the community (including emergencies), to identify and provide primary care in serious diseases, taking account of their physical, emotional and social aspects.

3. To manage health centres at various levels and in a variety of settings and to work effectively and efficiently in health teams, in teaching, research and service, with available facilities.

4. To apply basic principles in health education in order to assist and lead the planning, implementation and evaluation of health programmes in promoting health, preventing disease, cure and rehabilitation, according to the needs of the community and local social, religious, customary and cultural values which can influence the state of health and disease.

5. To identify personal limitations, and to nurture the capacity and interest in enhancing their knowledge and developing personal characteristics required for professional advancement through an awareness of personal assets and limitations.

6. To function as an effective and efficient member of a team with a sense of responsibility and dependability.

¹ Adapted from Gadjah Mada University Faculty of Medicine, Yogyakarta, Indonesia.

Institutional Objectives (2)

At the end of his M.D. programme² the graduate will have acquired or developed the knowledge, abilities, and attitudes necessary to qualify for further education in any medical or related health career. The achievement of the general goals should enable a student:

1. To identify and define health problems at both an individual and a community level and to search for information to resolve or manage these problems.

2. To examine the underlying physical, biological and behavioural mechanisms of health problems. This includes a spectrum of phenomena from the molecular to those involving the patient's family and community.

3. To investigate community health problems and to recommend efficient and effective approaches to deal with environmental, occupational, behavioural, and public policy issues.

4. To develop the clinical skills and methods required to define and manage the health problems of patients, including their physical, emotional, and social aspects, within the context of effective health care.

5. To recognize, maintain, and develop the personal characteristics and attitudes required for a career in a health profession. These include:

a. Awareness of personal assets, limitations, and emotional reactions.
b. Responsibility and dependability.
c. Ability to relate to, and show concern for, other individuals.

6. To be a self-directed learner, recognizing personal educational needs, selecting appropriate learning resources, and evaluating personal progress.

7. To assess critically professional activity related to patient care, health care delivery, and health research.

8. To function as a productive member of a small group which is engaged in learning, research, or health care.

9. To work in a variety of health settings.

² From McMaster University, Canada.

Institutional Objectives (3)

The graduate of the new baccalaureate nursing programme³ will be prepared to function as a generalist with beginning competencies in a specialized area of nursing.

³ From the University of Washington School of Nursing.

The graduate will be prepared to function in a variety of settings and be able to:

1. Obtain health histories and make general health assessments.
2. Provide safe and competent care in emergency situations and acute illnesses.
3. Provide supportive care to persons with chronic or terminal health problems.
4. Provide health teaching, guidance and counselling.
5. Assist persons to maintain optimal health status.
6. Provide for continuity of health services.
7. Assume leadership responsibility for planning and evaluating nursing care.
8. Work effectively with all persons concerned with health care problems.

This baccalaureate nurse, as a practitioner of nursing, will be accountable and responsible to clients for the quality of nursing whether administered directly or indirectly.

These three examples of professional profiles are from both developed and developing countries. What is striking is the overall similarity between the functions listed, even if they are expressed in different terms: A. Professional profile: identifying and analysing health problems in order to: · provide treatment · provide preventive care · plan policies, activities and services (management) · participate in the health education of the population · collaborate with other services in the interests of overall development · train health personnel · participate in research B. Methodological functions: · evaluate one's own activities · develop one's own skills continuously They were gathered during a world-wide survey designed to collect general educational objectives for nurses and physicians. Identical results were obtained; that is, the same functions came up in practically every case. This collection of functions corresponds to the role that health services personnel are expected to fulfil. Throughout this Handbook you will be invited to use this list of functions (and others if necessary, depending on the health needs of the population in your country) as the basis for your future educational decision-making. To demonstrate how such an obvious list can in fact be a very effective instrument, you are invited to use it at once in making a quick analysis on the next page.

EXERCISE

1.38

After reading the previous four pages, revise if necessary your own list of functions.

The professional functions of ................... are as follows:

Everyone who uses a word knows what he means by it. The problem is that not everyone realizes that other people may have different meanings for the same word. Mager

EXERCISE

139

Tricky test to force you to think about the relevance of a programme

Take the functions you listed on p. 1.33

For each function that corresponds to one of those listed in the table below, ask yourself the following two questions:

In the institution where I work

1. are teaching activities organized to help students acquire skills corresponding to each function listed?

2. do the examinations (counting towards award of diploma) effectively measure the students' abilities in relation to each function listed?

- Where you can answer YES (without blushing), mark a cross in the + column,

- If no corresponding activity is organized by your institution, mark a cross in the 0 column,

- If you are not sure, mark a cross in the “+ or -” column.

	Teaching activities that help student to perform function			Examinations providing effective measurement of function
Function	+	+ or -	0	+	+ or -	0
Curative
Preventive
Planning
Health education
Collaboration within and outside the health services
Training of other personnel
Research
Self-evaluation
Self-training

Draw your own conclusions .........

General educational objectives provide a useful basis for preparation of a relevant programme

Personal notes

1.40

Professional activities and intermediate objectives

1.41

Intermediate educational objectives are obtained by breaking down each function (or general objective) into smaller components. These components are professional activities which in their turn can be broken down into more specific acts that are called professional tasks, as long as they can be measured against given criteria. (See p. 1.48 et seq. for specific objectives.) It can also be said that all objectives that are neither general nor specific are on the intermediate level. That is, there can be several intermediate levels rather than a single one.

The pages that follow give examples of intermediate objectives.¹ Unlike general objectives, whose vagueness makes them fairly universal, intermediate objectives should reflect the health needs of a population living in a given context. This professional profile would have been different in the case of a general practitioner in Finland or in Cameroon because of the special geographical epidemiology of each country. The social and political system and the type of health services provided will also have an influence. These are the factors that ensure the relevance of educational objectives. Another important point to be taken into consideration: this list, like any other list of educational objectives, is only a means or working instrument and not an end in itself. It was drawn up as a basis for choosing instruments of evaluation for measuring the skills of students during their internship.

¹ Prepared by a multidisciplinary group of teachers from Algeria. Workshop on docimology, Timimoun, Algeria, February 1977.

Examples of intermediate educational objectives

These intermediate educational objectives were derived from general objectives defining the functions of a general practitioner. They refer to the paediatric aspect of the work.

The general practitioner should be able to carry out the following activities:

1. Diagnose and treat major childhood disorders:

- abnormal development of the embryo or fetus
- infections in newborn babies
- emergency surgery on newborn babies
- jaundice of the newborn
- vomiting in infants
- cardiac insufficiency
- acute diarrhoea
- dehydration
- convulsions
- purulent meningitis
- tuberculous meningitis
- tuberculosis
- eruptive fevers
- viral bronchopneumonia
- bacterial pneumonia
- septicaemia
- childhood skin disorders
- urinary infections
- acute glomerular affections
- abdominal tumours
- enlargement of liver
- enlargement of adenoids
- enlargement of spleen
- kala azar
- malaria
- throat infections
- otitis
- orthopaedic problems in children

2. Carry out activities relating to patient care, taking of samples, laboratory work and use of equipment.

2.1 Sampling techniques:

- blood (including blood from umbilical cord)
- abscess
- cerebrospinal fluid (CSF)
- urine
- puncture of ascites, pleura

2.2 Techniques relating to patient care, preventive measures and laboratory work:

- immunization
- perfusion, intramuscular injection, transfusion
- catheterization, enema
- blood grouping
- haematocrit
- erythrocyte sedimentation rate
- CSF count

2.3 Use of equipment:

- sphygmomanometer
- otoscope
- aerosol spray
- aspirator
- electrocardiograph
- ophthalmoscope

3. Distinguish between normal newborn babies and those at risk; organize prevention and early detection of possible dangers.

3.1 Recognize growth anomalies.

3.2 Recognize anomalies of psycho-motor development.

3.3 Work out with the parents a diet suitable for the needs of their child.

3.4 Recognize dietary anomalies.

3.5 Plan a surveillance programme for a normal child and for one at risk.

3.6 Enter findings in the child's medical record.

4. Plan, in collaboration with the parents, individual and collective surveillance of growth, nutrition and psychomotor development in children (newborn babies, infants, children).

4.1 Plan care of a normal newborn baby.

4.2 Plan treatment of a newborn baby with a diabetic mother.

4.3 Plan treatment of a rhesus negative newborn baby.

4.4 Plan treatment of a newborn baby with kidney disease.

4.5 Plan treatment of a newborn baby with low birth weight.

4.6 Plan treatment of a premature baby.

4.7 Plan treatment of a baby born after abnormal labour.

5. Identify somatic problems (particularly relating to growth and nutrition), psycho-motor and emotional problems in a sick child on the basis of medical history and clinical examination.

5.1 Question parents of a sick child and make a record of the information obtained.

5.2 Examine a sick child.

5.3 Make a note of the findings.

5.4 On the basis of a clinical examination, determine the problems presented by a sick child (particularly relating to growth, nutrition and psychomotor development).

6. Protect children individually and collectively against the effects of hereditary conditions, communicable diseases and accidents.

6.1 Offer advice on genetic matters to parents.

6.2 Determine the mode of transmission of hereditary diseases.

6.3 Detect and treat hereditary diseases.

6.4 Investigate home conditions of a child with a communicable disease.

6.5 Examine contacts of a child with a communicable disease and apply preventive measures.

6.6 Carry out all immunizations.

6.7 Draw up a schedule for a child never or inadequately immunized.

6.8 List, in order of frequency, the accidents that happen to children in a given sector.

6.9 Organize and participate in a campaign to prevent accidents to children.

7. Identify mental health problems in children; propose measures and participate in their application.

7.1 Determine the priority mental health problems in children of his own health sector.

7.2 Coordinate health, administrative and educational resources available for dealing with mental health problems in children (particularly those relating to maladjusted or abandoned children).

8. Evaluate the effects on child health of the environment; propose appropriate measures and ensure that they are applied, individually and collectively.

8.1 List environmental factors in his own area of work.

8.2 Help improve environmental conditions in collaboration with the health authorities.

8.3 Identify a child seriously threatened by his environment.

8.4 Detect and treat a disorder caused by the environment.

8.5 Advise parents on drawing optimum benefit from a favourable environment.

9. Be accessible to the child and his family, providing health education and the support needed in case of disease or disability.

Organize his plan of work to ensure that:

9.1 He is accessible to the child and his family.

9.2 He has time to listen to them.

9.3 He has time to talk to them.

9.4 He has time to reassure them.

9.5 He has time and the ability to provide the child and his family with the necessary health education.

10. Organize prevention, detection and follow-up of deficiency diseases and chronic conditions.

10.1 Apply national regulations for the prevention of deficiency diseases.

10.2 Detect and treat the following deficiency diseases in a given population:

- protein and calorie malnutrition
marasmus
kwashiorkor

- hypovitaminoses
vitamin D deficiencies (rickets)
vitamin A deficiencies (hemeralopia, xeroma)
vitamin B complex deficiencies (beriberi, pellagra, megaloblastic anaemia)
vitamin C deficiencies (scurvy)

- iron deficiency (anaemia due to lack of iron).

10.3 Detect and treat chronic conditions in children:

- diabetes

- haemoglobinopathy

- thalassaemia

- rheumatic conditions

- metabolic disorders (phenylketonuria, glycogenosis, glucose 6-phosphate dehydrogenase deficiency, galactosaemia)

- congenital or acquired heart conditions

- chronic respiratory insufficiency (mucoviscidosis, bronchial dilatation, deformations of the thorax, asthma)

- epilepsy

- haemophilia

- chronic allergic conditions (eczema, allergies in the upper respiratory tract, asthma)

11. Organize, participate in, and evaluate treatment and preventive activities (medical and otherwise).

11.1 Allocate tasks among members of a health team in his area of work.

11.2.1 Carry out a paediatric consultation.
11.2.2 Decide to admit a patient to hospital.

11.3 Work in a ward as part of a team.

11.4 Organize reception and surveillance of emergency cases.

11.5 Take part in the activities of a maternal and child health centre.

11.6 Deal with problems relating to drugs and equipment.

11.7 Help organize an immunization campaign.

11.8 Propose and ensure application of non-medical measures required to back up medical activities in the field of prevention and hygiene.

11.9 Set up a mechanism of periodic evaluation by all team members of his own and the team's activities, in terms of their objectives.

12. Help families to use health and administrative bodies concerned with improving child health.

12.1 Ensure health coverage of all children living in the area.

12.2 Enumerate the health structures that exist in the area.

12.3 Enumerate the administrative, political and economic bodies in the area.

12.4 Assess the role played by each of the preceding in improving child health.

12.5 Organize optimum use of health facilities.

12.6 Promote and enforce measures aimed at improving child health.

13. Plan training and retraining of health staff.

13.1 Identify any insufficiency in the skills of members of the health team.

13.2 Organize the training and/or continuous education of members of the health team.

13.3 Evaluate the training and further education activities of health team staff.

The definition of educational objectives has become almost a fashionable subject of conversation... defining them is becoming a mark of modernity... but, as with all slogans, there is a danger that we shall get used to them without understanding their purpose, their nature, their advantages, their limitations and the risks involved. In drawing up educational objectives, what counts is not their formal definition but their relevance to the professional tasks of the personnel to be trained and to the priority health problems of the population.

EXERCISE

1.45

Preparing a Professional Profile

You have seen how others have formulated intermediate educational objectives. For each of your general objectives (functions) (page 1.33), list alt the intermediate objectives you consider necessary, using the following type of grid:

Figure

You now have the main components of a
PROFESSIONAL PROFILE
which can be used to start planning the evaluation process.

Building in relevance

1.47

Before going any further, think about the concept of relevance and about the fact that educational objectives are a means and not an end.

It seems reasonable to believe that an educational programme has more chance of being effective if its purposes have been clearly expressed. Experimental research in the field of evaluation indicates that it is not possible to measure the results obtained from an educational system if its objectives have not been explicitly defined. But a desire for precision should not divert us from a much more important concern: the need for relevance.

To be relevant an educational programme, rather than being the result of a non-selective mass of knowledge accumulated over the centuries, should be selectively shaped in terms of the aims to be achieved. Each time the goal is modified, the programme too must be modified accordingly.

Thus relevance is the degree of conformity that exists between training programmes on the one hand and the population's health needs and resources on the other.

When determining a professional profile, therefore, we must take into account the health needs and resources of society, the health professions, the progress of science, the capabilities of the students, the social and cultural context, etc. Moreover, the study made of these factors must be prospective¹ in nature since we are training personnel for the future.

¹ The epidemiological, sociological data, etc., and the operational research necessary for such a prospective analysis are not dealt with in this Handbook. For information on these matters the reader should consult specialized publications dealing with the organization of health services (see Bibliography, p. 7.01 et seq.).

The method traditionally used is to bring together eminent professors and the result of their deliberations is presented as a list of chapter headings. Often, existing programmes are used as the main source of data for the preparation of the new programme. The professors indicate the number of hours to be devoted to the various subjects to be dealt with: this generally leads to a conflict of personalities and it is the most forceful, the most persuasive, sometimes the most irascible or noisiest of the participants in the discussions who obtains the largest number of hours. The result is that the time factor becomes a constant and that competence remains an undefined variable.²

² For example, the length of medical studies may be fixed by administrative regulations at 6 years (or 7, 5, etc.): this is the time constant On the other hand, there is hardly any definition of the competence of graduates, and this can lead to great variability.

In the absence of a definition of relevant educational objectives, discussions on programmes, teaching methods and evaluation methods are difficult and often futile.

When educational objectives have been established at the intermediate level (lists of activities), it is then possible to determine with some precision which learning activities are likely to facilitate the attainment of an objective and which are not.

Methods of evaluation (of students, teachers and methods) will also depend on the objectives to be achieved. Evaluation consists in being able to say to what extent and how the specific objective (task) set has been achieved. If one has not bothered to lay down a measurable objective, it will be difficult to make any kind of evaluation. To select a type of examination (to use an old-fashioned term) without specific educational objectives (or the definition of an acceptable level of performance) makes no more sense than to try to choose a measuring instrument without knowing what has to be measured. Only over the last two decades have investigators in the field of testing and measurement begun to work out a solution to this problem. Here, too, the weight of tradition and emotional reactions make themselves felt.

Professional tasks and specific educational objectives

1.48

Having established the principal functions that outline the role of a health worker, we then went on to achieve a greater degree of precision by describing the activities corresponding to each function. Now we must go further and define each of the specific professional tasks corresponding to each activity. Let us continue with the example furnished by our Algerian colleagues.

They decided to define the tasks corresponding to activity 11.4: “Organize reception and surveillance of emergency cases” (see p. 1.43).

Here is the list:

11.4.1 Check the availability of equipment needed for emergencies (drugs, instruments, beds), using a checklist.

11.4.2 Treat, in order of urgency, several patients who arrive at once.

11.4.3 Support the vital functions of a child, in accordance with an ad hoc outline of procedures.

11.4.4 Avoid any action that could endanger the life of the child.

11.4.5 Handle the child gently.

11.4.6 Reassure the child.

11.4.7 Explain to the parents why the child must be kept in hospital.

11.4.8 Offer moral support to the parents.

11.4.9 Organize a surveillance schedule for an emergency case.

11.4.10 Decide to move the patient.

11.4.11 Plan the move.

11.4.12 Prepare a newborn baby for transfer.

11.4.13 Prepare a child for transfer.

11.4.14 Explain to the parents how the administrative structures involved in admissions and departures function.

11.4.15 Identify the various administrative structures involved in a referral.

11.4.16 Distribute work among health personnel assigned to the emergency service.

11.4.17 Elicit the reasons for various surveillance activities from nursing staff.

11.4.18 Explain the reasons for various surveillance a