Supervision can be an important and, indeed, sole means of improving performance, competence, and quality of health workers. It can be used to help health workers improve their performance, identify and solve problems, create a better working environment, identify training needs, identity available or required initiatives and resources, and assess whether the training serves community needs. Effective supervision is hindered by a lack of supervisory guidelines, a shortage of staff, a lack of resources, unclear roles and responsibilities of supervisors, and inadequate staff training and motivation. The process approach to training allows people to work through problems and find solutions for themselves by basing learning on their own experiences, knowledge, and skills and by relating theory to practice through workshops and fieldwork. Based on the principle of empowerment, process learning has 4 steps: 1) to ensue that participants understand what they will be learning and why it is important, 2) to encourage participants to describe, analyze, and exchange individual experiences, 3) for participants to compare their different practices and study the gap between what they actually do and what they should do, and 4) to place experience and new knowledge into a system which provides a frame of reference for future education and training.
The AIDS Educacao and Prevencao (AIDS Education and Prevention) project in Fortaleza, Brazil, is an attempt to find new approaches to working on sexual health education with vulnerable young people. The project aims to develop a learning system focusing on the mental and physical well-being of youths that is appropriate for their age, context, and needs. The project, which was developed by nursing lecturers and students studying for nursing degrees at the Federal University of Ceara, works with young people between ages 11 and 17. The project reaches young people through its biannual workshops where facilitators learn about the problems encountered by young people regarding sex and sexuality, sexual behavior, condom use, unwanted pregnancies, STDs and HIV/AIDS. Facilitators are not counselors, but work with small groups to promote participation and collective learning. Factual information and case studies are introduced gradually to teach participants ways in which they can protect themselves and help them decide what choices are right for them. However, lessons learned from the workshops are not reinforced because teachers and parents are afraid and ignorant of AIDS. As a result, while it continues to target young people, the project now attempts to involve schools and students' families.
Family planning workers seeking to improve sexual health in the community need to learn how to provide a service that is more responsive to people's needs. In doing so, they must first meet with, and listen to, a range of different community-based groups to find out how people view their sexual health, and how problems identified could be addressed. The IPPF's member planning associations in Ghana, The Gambia, and India have used a number of exercises in their staff training workshops to help develop the skills necessary to explore sexual health needs in their communities. The described exercises include: exploring sexual experience; the sexuality life line; sexual health needs in communities; needs assessment; encouraging people to talk; and community mapping. These exercises should, however, be used with care. Workshop facilitators must establish a high level of trust with all participants before starting the exercises. They should be confidential and judge carefully whether participants are capable of coping emotionally with some of the activities.
The author, a nurse at a rural hospital in Sierra Leone, offers several rationales for a community development approach to women's health. Rural women in particular face a lack of access to education and literacy, and ideology that disapproves of women working outside of the home, a culture that prevents men from viewing their wives as equal partners, and a religious value system that prohibits contraceptive use for child spacing. As a result of all these factors, Sierra Leone has high rates of maternal and infant mortality. The problems for women and children are further magnified by war, which leads to population displacement and malnutrition. Until the importance of social justice for women is recognized and a community development approach implemented, the health of the entire population will continue to be compromised.
In South Africa, the University of Western Cape started a project in August 1991 in the poor and isolated settlement of Mfuleni. Mfuleni has 30,000 people but no public transportation, no post office, no public telephone, and a single school. It does, however, have a community health center with a health committee composed of community representatives. Participants in the University project included pharmacists, nurses, physiotherapists, and dentists, all of whom pledged to follow the principles of primary health care and to change their familiar attitude and ways of working to achieve democracy, participation, collaboration, equity, and transformation. The first change that was necessary was in attitudes and language; the formal terms which resulted from a medical education seemed hostile to the people to be served. Participants also learned that they could not keep a usual 40-hour work week but had to work the hours that fitted in with the community needs and in places where the people felt comfortable. Participants also had to learn to break down the professional barriers which existed among them and work together on an equal basis. The staff of the community health center was instrumental in pointing out to project participants that they were clinging to old ways of doing things which prevented them from working in partnership with the community. Monthly tutorials attended by university staff, students, community members, and health center staff provided a forum for discussion in the community. This project will provide community-based work for students at the University's new school of public heath and will become an integral part of the undergraduate curriculum.
