Explore the Health Issue and Set Priorities

Beginning the dialogue: sample questions for the core group

Once you have been able to bring the core group together, it’s time to start learning what they know and how they feel about the health issue. The questions that are asked here (see below for examples) should be very open, and participants should be free to describe what they know and do without fear of being corrected. Leading this kind of session is often hard for facilitators who are new to this role, particularly for health workers who have been trained in a more prescriptive approach to health education. But it is critical to establish a safe environment in which participants can express themselves freely and learn from each other. Facilitators and other project team members should be listening carefully to the words used, noting specific practices and, most importantly, identifying the reasons given for why these practices are used.

A Need is Not Necessarily a Problem

It is important to remember that a need is not the same as a problem. A need is a lack of or deprivation of something that should normally be a part of a person's, group's or community's life. Other names for needs are aspirations, desires, dreams. Problems, on the other hand, are obstacles or barriers to satisfying a need or desire.

Take an example: The people in a neighborhood felt the need to apply hygienic and nutritional practices so that their children would grow up healthy, avoiding illness and death. But, to satisfy this need, they encountered two problems:

Many parents were unemployed so there were few resources to buy food and shoes for the children; nor could they afford to buy materials to build latrines; etc. The need is healthy children but the problem is economic.
The fathers and the mothers cannot read pamphlets that have been distributed by health promoters. The need is healthy children; the problem is not being able to access and use the information.

Another example: An autodiagnosis was carried out in a project that aimed to increase rural women's participation in community development. The women identified problems of health, education, transport, etc. They formed groups to discuss women's participation and the resolution of their problems. For a few months many women came to meetings organized by project promoters. Suddenly, they stopped coming to the meetings. When they were asked why they stopped coming, they responded: "Our husbands complained that we spend all this time discussing and don't resolve anything." They were then asked what they really wanted to do for the project and they answered, "We want sewing courses because we want to learn how to make clothing for our children."

Needs perceived by the community may be different from problems that are the focus of external projects. Technicians tend to see problems and ignore needs. If someone does not feel the need for something, not having it does not represent a problem for her/him.. For example, for many people the fact that they cannot read does not present a problem when they don't feel the need to read. Similarly, if parents believe that their children are growing normally, they will not see the problem of malnutrition.

The diagnosis, then, should emphasize discovering the felt needs of the people. It is in the felt needs where energy and motivation reside.

Juan Diaz Bordenave

Before you start asking the questions, you will need to spend some time helping the group develop a common vocabulary to talk about the health issue. To be able to understand each other when they talk about a topic, participants need to use language that is understood by everyone. Health issues have their own local lexicons that all participants need to be familiar with. Some questions that a facilitator might use to help the core group establish a common vocabulary are:

What are all the words we know that are used to refer to this health condition/problem?
Are there other local words? What do they mean?
What kinds of words do we use to describe this health condition?
How many different terms are there? What do they mean? (For example, in some communities there may be many words for diarrhea, each describing a different consistency or color.)

If the CM goal is broad, such as reducing deaths of children under five years old, you may ask what are the conditions and illnesses that children die from and then use the questions above to elicit local terms for these conditions or circumstances (e.g., diarrhea, respiratory infections, accidents).

Finally, if the health issue is an intimate topic which participants may not feel comfortable discussing directly, you may want to help participants project their thoughts and feelings onto others. For example, you could ask: “Who knows of someone who has experienced this problem?” Or: “What do you think it would be like to experience this health condition? Why?” Picture cards, drawings, stories, songs, videos, puppet shows and other techniques based on real experiences can help participants express their thoughts and feelings about the topic in a safe and entertaining way. Don’t underestimate the importance of emotional identification and commitment to the health issue and to building a sense of community, support, and trust within the group. This is an important step! You can begin to see trust building when participants feel safe enough to share their own personal experiences, particularly when the topic is one that is not normally discussed in public.

Below you will find a series of questions that can be used to elicit important information from the core group. They are organized around the six key elements of this step: knowledge, feelings, attitudes, practices, beliefs, and facts about the core group itself.

Knowledge questions:

What is the problem/health condition called?
What causes this problem or condition? Why does this problem occur?
What prevents this problem?
What cures the problem?
How widespread is this problem?
Where do you go if you need help with this problem?
How many people die/get sick from this problem in your community?
How many people in the community/region/country/world are directly affected by it?
How many people have taken steps to prevent this health problem (if applicable)?
How many people seek health care services when this problem occurs?
How many people do not utilize formal health services?
How many people utilize traditional health services for this health problem?
What happens if you don’t treat the problem?

Questions about feelings:

How do you think people with this health condition feel? Why?
How would you feel if you had this condition?
How do other people in the family feel about a family member with this condition?
How do you think other people in the community feel about someone with this condition? Why?

Questions about attitudes:

What has been your experience with this health issue?
How do you feel about this problem/issue?
How do you feel about others who are experiencing this problem?
How does this problem affect you, your family, your community?
How does it feel to be healthy?
What does it mean to be healthy?
What is a healthy person?
What is a healthy family?
What is a healthy community?
How important is this issue to you? Why?
Are you interested in working on this issue? Why?

Questions about practices:

What do you do when this health problem/condition occurs? Why?
What do you see others doing? Why do they do it?
What are you/people in the community currently doing to prevent this health problem from occurring? Why?
Which of the practices that you/others do are beneficial? Successful? How do you know?
Which of these practices are (can be) harmful? How do you know?
How much agreement is there about these practices?
What do you do to keep yourself healthy? What do you do to keep your family healthy?

Questions about beliefs:

What factors influence whether and how a person will be affected by this health issue/problem?
What practices do you believe the community would approve of related to the health issue? Why?
Which practices would be met with disapproval? Why?

Questions about the core group itself:

Have members of the core group worked together on any issue in the past?
If yes, what was the result of their efforts? What did they learn through the experience?
Who were the leaders? How did they lead the group?
Has the core group worked on this particular issue in the past? If yes, what was their experience? What failures and successes did they have? Why?
Who are the leaders now on this issue? What do they say? What do they want people to do?
Which collective assets does the group have? (physical, financial, human, other resources, abilities, strengths)
Do others outside the group recognize the group as an entity within the community?
Does the core group have any affiliations with other organizations or groups related to this issue? If yes, what role does the core group play in these affiliations?
What do core group members want their group to be able to do in the future? Is there a common vision, mission, and/or objective that its members can articulate?
What role does the core group want to play in collecting and analyzing baseline data and raising community awareness about the issue? What skills does the group want to strengthen to play this role?

In addition to learning about specific beliefs and practices, it is helpful to try to understand these beliefs and practices from a systems perspective. Often practices and beliefs are tied together in a complex web of interdependent relationships. For example, many cultures base their medicine on beliefs about trying to maintain an appropriate balance between hot and cold elements or higher and lower elements that may be influenced by natural or supernatural forces. Ethnophysiology aims to understand how people view their bodily function, which elements affect them, and how. It is helpful not only to identify the practice and why people use it, but also to identify the relationships between the “whys”. Body mapping, where people draw pictures to demonstrate how they view their internal organs and systems, is a particularly useful technique to develop this understanding.

You may also want to give some thought to the sequence in which you ask these and other questions of the core group (and, later, members of the community). Usually it is more comfortable for participants when you start with topics that people are more accustomed to speaking about publicly before you introduce more intimate topics. Based on the experiential learning cycle, we also know that adults usually learn better when they start with specific experiences, reflect on them, generalize the learning, and then apply what they have learned. Applying this sequence to exploration sessions, it is usually better to start with questions about actual experiences (personal or observed) and then move on to the more abstract questions aimed at generalization. Often when you begin with abstract questions, participants’ responses remain abstract and removed and can lose personal relevance for the group.