Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.) Module Five: Working with the community (introduction...) Session 13 - The impact of culture on diarrhea (introduction...) Handout 13A: Sample diarrhea questionnaire Handout 13B: Methods for gathering information Handout 13C: Identifying helpful and harmful practices Handout 13D: Role of traditional healing in diarrheal diseases control Session 14 - Working with the community to prevent and control diarrheal diseases (introduction...) Handout 14A: Questions to ask about involving the community in a project Handout 14B: Skills for development facilitators Handout 14C: A checklist for use in identifying participatory components of projects Handout 14D: Helping the people to organize Handout 14E: Meetings Handout 14G: Ways to involve women in health projects Trainer Attachment 14A: Factors affecting participation in rural development projects Trainer Attachment 14B: Examples of problem situations

Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)

Module Five: Working with the community

OVERVIEW

This module provides a review of basic skills in community development applied to diarrhea and associated health problems. Session 13 leads participants into the community to learn about cultural practices related to diarrhea. Session 14 reviews skills in community organization that can be applied in promoting ORT in the community.

OBJECTIVES

· To correctly use a questionnaire to identify at least six local beliefs and practices that affect the occurrence and treatment of diarrhea, using the guidelines stated in Session 13.

· To identify and prioritize helpful and harmful practices affecting the occurrence of diarrhea in the community, in terms of which should be modified or reinforced through health education activities, following the criteria stated in Session 13.

· To describe three techniques to use in motivating community members to participate in projects to prevent and control diarrheal diseases, following the criteria stated in Session 14.

Cross reference with the Technical Health Training Manual:

Module 3: Community Analysis and Organization
Session 7: The Role of The Volunteer
Session 8: Factors Affecting Health

Session 13 - The impact of culture on diarrhea

TOTAL TIME

4 hours

OVERVIEW

An understanding of local knowledge, beliefs and practices associated with diarrhea is critical to any work done as a part of CDD. During this session, participants reflect on their own perceptions of diarrhea-what causes it and how to treat it. Then, using a questionnaire, they go out into the local community to gather information about local perception and treatment of diarrhea. When they return, participants analyze the data to identify practices which are helpful and harmful, and discuss how they might begin CDD and ORT projects that build on the traditional health care beliefs and practices in the culture.

OBJECTIVES

· To gather information on local knowledge, beliefs, and practices associated with the causes and treatment of diarrhea.
(Steps 2- 4)

· To identify helpful and harmful local beliefs and practices that affect diarrhea and have highest priority for change or encouragement.
(Step 4)

· To compare the local traditional approach to diarrhea treatment with the Western medical approach.
(Steps 1-4)

RESOURCES

Community, Culture and Care, pp. 173-242 Helping Health Workers Learn, Chapters 7 and 14

Handouts:

- 13A Sample Diarrhea Questionnaire
- 13B Methods for Gathering information
- 13C Identifying Helpful and Harmful Practices
- 13D Role of Traditional Healing in Diarrheal Diseases Control

MATERIALS

Newsprint, markers and any herbs or other items associated with the treatment of diarrhea you may want to show the group (optional).

PROCEDURE

Trainer Note

Before the session, try to find out as much as you can about local beliefs and practices for the treatment of diarrhea. Also collect any herbal remedies and evidence of other cures to show participants. Use this information during Step 4 to help participants validate what they learned from their interviews with local community members and provide additional content to the session.

Nave someone translate Handout 13A (Sample Diarrhea Questionnaire) in the language used in the local area. Make any necessary arrangements for the community visit for interviews and observations. Some possible kinds of arrangements include' permission from local officials and families, as well as transportation.

It is assumed that participants have already had training and experience in how to gather information. For preservice training or other situations where participants lack these skills use Sessions 10-13 in the Technical Health Training Manual to provide the background needed.

Step 1 (20 min)

Cross-Cultural Perspective On Diarrhea

Open the session by explaining that they will be gathering information about local knowledge, beliefs and practices related to diarrhea. To do this effectively it is helpful to begin by looking at their own beliefs and practices as well as their assumptions about local beliefs and practices.

Ask participants to recall the last time they had diarrhea. Write the following questions on newsprint and ask them to write their answers on a sheet of paper.

- How did you explain the cause of that diarrhea?
- What did you do treat the diarrhea?
- From whom did you seek advice or care?
- What did you do to prevent future episodes of diarrhea?

Ask a few participants to share their answers with the group.

Now ask participants to:

- Assume the identity of a local woman,
- Think in terms of her cultural, religious and social background,
- Consider how she would feel and react to having a baby with recurrent diarrhea, - Answer the same questions as above but from her perspective.

Have the participants write these answers beneath their initial answers. Encourage the group to use their imagination and guess if they don't know the answers.

Ask a few participants to share their answers with the group and briefly discuss how different or similar the perspectives appear to be both between cultures and among individuals. Discuss how those differences could affect CDD projects in their communities.

Step 2 (20 min)

Introducing and Adapting the Diarrhea Questionnaire

Explain to participants that during the next 90 minutes they will visit members of the local community and gather information related to the local knowledge, beliefs and practices about the causes and treatment of diarrhea. Distribute Handout 13A (Sample Diarrhea questionnaire, and ask participants to look it over.

Ask the group to discuss and delete, odd to, or modify the questions in the sample questionnaire so that they reflect the local situation.

When the questionnaire la ready, ask participants to pair off. Have each pair interview and address their questions to at least two different people or families in the community and, if possible, borrow or collect any stems associated with diarrhea treatment they may encounter during the visit (items such ass utensils, containers, herbs or medicines used in treatment or ORS solution substitutes found in the home).

Before participants leave, ask them to briefly review Handout 13B (Methods for Gathering information and ask any questions they have about how to gather the information

Trainer Note

You may want to spend some time reviewing the vocabulary needed for collecting information about diarrhea.

You may want to have participants use pictures such as those in Trainer Attachment 3B (A Story About Diarrhea from Session 3) along with their questions to make the interview more concrete and more interesting.

If a visit to the local community is impossible, an alternative is to invite in 3-5 community members to act as cultural resources. Divide participants into small groups and assign a community member to each one. Have each group do some parts or all of the diarrhea questionnaire and collect as much information as possible about local beliefs and practices.

You may want to add questions about nutrition and sanitation depending on the interests of the group.

For preservice training it may be necessary to enlist the help of first or second year volunteers to accompany participants during the visits and help out with the interviews (but not to conduct the interviews for the Trainees).

For inservice training, it is effective to have Volunteers pair off with their counterpart for this activity.

Step 3 (90 min)

Information Gather log in the Community

Have the participants conduct the interviews in the community. If appropriate, suggest specific places to visit and/or people to talk with to find the information.

Trainer Note

If this session is done at the end of the day, you might consider giving participants the evening to do their interviews and information gathering. Then, the next morning, you can reconvene and complete the remaining steps in the session.

Because visits to homes in the community are likely to stimulate interest and questions about ORT, you may want to ask participants to be prepared to tell a picture story about ORT at the end of the interview

Step 4 (20 min.)

Processing the Community Visit

When the participants return from their visit, reconvene the group and ask two or three pairs to report on what they learned from asking questions and any other general information on cultural beliefs and practices, Ask the others to add to what these pairs report.

Ask participants to compare and discuss the differences between their own approach to the treatment of diarrhea from Step 1, the traditional, country-specific perceptions also from Step 1, and the points of view encountered during the interviews

Step 5 (30 min.)

Identifying Harmful and Helpful Practices

Affecting Diarrhea

Divide participants into four or five small groups, Distribute Handout 13C (Identifying Helpful and Harmful Practices) and give the following instructions to explain how to fill in the sheet:

- Identify practices that affect diarrhea.

- Indicate whether they are harmful, or helpful and who in the community does these things,

- Examine the harmful practices and identify those which you feel you cannot change. Briefly explain why you cannot change them.

- Rank the remaining harmful Practices in terms of priority for change. Take into account, severity of effect on health and ease of changing the behavior. Explain your ranking.

- For the Practices with the highest priority far change, describe ways you might motivate people to adopt healthier practices building on existing beliefs, practices and values in the community.

- Examine the helpful practices and list ways to encourage people to continue them.

- Describe the people or groups with whom you could first work to motivate people to change harmful practices and continue helpful ones.

Ask the groups to answer each of the questions as thoroughly as they can using the information collected from the questionnaire and interviews. Where appropriate, provide any additional information you may have on local beliefs and practices related to diarrhea to help the group complete the task.

Step 6 (30 min.)

Reporting on Small Group Analysis

Ask one group to report their answers. Have the other groups add additional answers

When the questions are answered, have the Trainees). focus on their conclusions about which behaviors are considered to be important to change first. Have them comment on why they arrived at these conclusions, how their perceptions may differ from their communities, and how they would attempt to resolve such differences.

Trainer Note

This discussion should address the fact that different people in the community have different knowledge, practices and degrees of influence over others. Because it is necessary to recognize these differences in their later work on planning health education projects and deciding with whom to work, it is important to emphasize these differences here. This point will be discussed more in Session 14 (Working with the Community).

Also make certain that participants recognize the difference between knowledge and actual practice. People in their communities and they themselves may know what to do, but may not always do it. Note that people must take into account many things in deciding what actions to take, For example lack of money or social pressures can lead to actions harmful to children's health even though individuals or families "know better".

Step 7 (10 min)

Identifying Nays to Learn More About Local Beliefs and Practices

To close the session, ask participants to briefly discuss their experience of interviewing people about their beliefs and practices - What was easy about the interaction? What was hard? Have them discuss and list in their notebooks other ways to gather and validate information about cultural beliefs and practices in the treatment of diarrhea and how they can use that information to make their health education for CDD, particularly ORT, more effective. Finally, distribute Handout 13D (The Role of Traditional Healing in Diarrheal Diseases Control) for supplementary reading.

Trainer Note

You may want to recommend additional general reading in Community Culture and Care (Traditional and Modern Health Systems) pp. 173-242.)

Handout 13D (The Role of Traditional Healing in Diarrheal Disease Control) discusses a number of Brazilian cultural beliefs and practices related to diarrhea. Because there are many similarities in traditions associated with diarrhea cross-culturally, much of the information may be directly applicable to your local culture.

Handout 13A: Sample diarrhea questionnaire

Date ___________________________

Location ___________________________

Name of Person interviewed ______________________________________________________

Occupation ____________________________________________________________________

Number of Children ___________________________ Age ___________________________

1. When did your child last have diarrhea?

2. What names do people use for diarrhea?

3. How did your child get diarrhea?

4. Do children in the village die from diarrhea?

5. Do you know a child that has died from diarrhea?

6. What did you do when your child last had diarrhea? Why did you do this?

7. Do you give liquids to your child when he or she has diarrhea? Why? What liquids? How ouch?

8. Do you give food to your child when he or she has diarrhea? Why? What foods?

9. Do you continue breast feeding when your child has diarrhea? The same, more or less than usual?

10. Who in your community helps you when your child has diarrhea? (*Probe: Can the traditional healer help? Can the community health worker? Your mother? etc.)

11. Are there particular medicines that you give your child when he or she has diarrhea? What medicines? Where do you get them?

12. Does hand washing help prevent diarrhea? Can anything help prevent diarrhea?

13. Observe and ask what utensils can be used to measure water, salt and sugar (for oral rehydration).

14. Observe and note sanitation around and inside the home.

15. Observe and note the physical condition of the child in the home. Look for signs of malnourishment or dehydration.

Handout 13B: Methods for gathering information

Who Should Gather Information?

Involve community people when you can.

How to Get Started

Look and listen before asking and acting.
Explore the community's attitude toward "being studied.
Find out if you should follow any special rules of protocol.
Put human relations before getting answers
Ask questions that set people thinking in a positive way.

General Methods You Might Use

In-depth interviews
Simple surveys
Observations
Case studies

Find a close confident - someone who may help you bridge the gap between cultures.

Be cautious in choosing a close confidant - is he or she still in touch with the local culture.!

Find other informants:

Get to know local leaders, residents who are widely respected
Talk with those considered "wise" within the community
Talk with the "ordinary" workers and community people
Get to know the patients, the recipients of care
Talk with the critics of the system

Learn through informal conversations

Just sit and talk over a cup of coffee or a calabash of millett beer
Learn from gossip
Be alert to jokes and their meanings
Listen to stories and learn from them
Learn about the system by asking how to solve problems

Learn through observing

Participate in community activities
Go out and see what it's really like
Learn by looking at what's going on around you

How to Ask Questions

Explore peoples' attitudes toward questioning
Check your questions before starting out
Learn how to interview within the local area
Learn when to ask questions and when not to ask them
Learn what questions to ask, and which ones not to ask
Adapt your questions to the culture

Some Typical Problems in Gaining information or "Why You May Have Difficulty in Getting the 'Truth".

People may not trust you yet
Respondents may wish to tell you what they think you want to hear
You nay be asking the wrong people
People may have difficulty in reflecting on what is second nature to them
What a respondent says might be altered during translation
You own characteristics nay influence the response
Your respondents may mistake the "ideal" for the "real"
Beware of the Pitfalls of Making Stereotypes and Generalizations

Consider the Effects of Your Information Gathering on the Community

Consider whether your findings will make any real difference
Develop methods that can be used by local personnel or community members when you leave.

Handout 13C: Identifying helpful and harmful practices

1. Who does things that increase the problem of diarrhea? Can we change these practices through health education? Why? or How? Which Practices have the greatest priority for change?

Harmful Practices	Who does This?	Can We Change the Practice? How?
	·	·
	·	·
	·	·
	·	·

2. Who does what things that help reduce the problems of diarrhea? What are some reasons for these Practice? How can we encourage people to continue these Practices

Harmful Practices	Who does This?	Can We Change the Practice? How?
	·	·
	·	·
	·	·
	·	·

3. What groups and individuals can we work with in the community to help people change harmful behavior and encourage helpful behavior? Why? and How?

Groups and Individuals	Why and How They Can Help
	·
	·
	·
	·

4. Summarize your conclusions on a large sheet of newsprint so you can share them with the other groups.

Handout 13D: Role of traditional healing in diarrheal diseases control

DR. MARILYN NATIONS
Assistant Professor of Internal Medicine/Anthropology
University of Virgina Medical School
Division of Geographic Medicine
Charlottesville, VA

In northeastern Brazil, infant mortality from diarrhea and dehydration is an among the highest in Latin America. It is estimated that 159 out of 1,000 children born in urban northeast Brazil die before their first birthday, with diarrhea as the primary or contributing cause of death in 54% of the cases. And, because unrecorded early deaths are common. particularly in rural areas of Brazil, actual childhood fatalities most certainly climb even higher. Regardless of which statistics are cited, it is fair to say that in this arid region gastrointestinal illnesses take an enormous toll on infant lives, resulting in immeasurable losses for poor Brazilian families.

Faced with the serious and direct threat diarrhea and dehydration pose for infant survival, it is not surprising that natures throughout the world have evolved their own locally adapted healing systems to help them combat this major child health problem. I will first discuss the elaborate traditional rnedicine system in northeastern Brazil as it relates specifically to enteric diseases. Next, I will show how these longstanding indigenous health approaches are rapidly changing, sormetimes for the worse, with the recent widespread introduction of biomedicine in northeastern Brazil. Finally, I will discuss the implications of traditional healing for the delivery of primary medical services, particularly oral rehydration therapy and related diarrheal diseases control interventions.

This exercise is important if we are to increase the understanding between the people who struggle with diarrheal illness and death on the one hand, and health proffesionals who aim to treat and prevent it on the other. Confronted with data that document the existence of radically different view points pertaining to childhood illness, we can appreciate restore fully the important role human culture plays in shaping the diarrheal episode. That other health ideas and healing ways exist and are embraced by countless poor families living in rural and serve urban areas in developing countries will hopefully aid health profession to move beyond their own explanatory models of disease, including enteric infections. This awareness hopefully will stimulate a reassessment of the limitations and strengths of the biomedical approach to diarrheal diseases and lead to the development of culture-sensitive approaches to control which skillfully articulate the biomedical and popular spheres of care.

Methods

The research was carried out from July 1979 to June 1980 with a three-month follow-up in 1981 in Pacatuba, a rural town with a population of about 7,000 in the Brazilian northeast, about thirty-two kilometers from Fortaleza, the state capital. Field observations were occasionally extended beyond Pacatuba; I accompanied village mothers and their sick children to the Marieta Calas Rehydration Center and to a number of hospitals located in the capital when neccesary. When I utilized quantitativer methods, such as formal questionnaires, medicinal plant collection and botanical identification, and recording of diarrheal illness episodes in children, I relied most heavily upon qualitative anthropological techniques including participant-observation and informal, open-ended interviews with key informants, particularly traditional healers. To the extent possible, I participated actively in the lives of village families in order to understand what diarrhea meant to them. I saw, in a sense, childhood diarrhea and death through the eyes of a village mother by participating fully in the women's sphere of village life. I learned by involving myself and my family directly in the lives of Brazilian peasants plagued by this ubiquitous threat.

The role of traditional medicine in diarrheal diseases

Diarrhea is an illness of poverty in Pacatuba; it flourishes among the poorest village families with low incornes, faulty nutrition, poor living conditions, and inadequate clean water supplies. Their infants, ages seven to twelve months; are at highest risk for both the most total days and episodes of diarrhea, which climbs on average to a staggering fifty days, or over nine episodes, per person per year. To cure their ailing children, poor village parents in northeast Brazil for hundreds of years have relied solely on their own folk medical wisdom. Ancestors borrowed many of these healing ways from Dutch and Portugese colonizers and the West African slaves they captured and brought with them. Other medical beliefs and practices evolved as direct responses to specific illnesses and environmental conditions in Pacatuba. Through trial and error experimentation, people developed their own explanations about the causes of illness, diagnostic techniques, therapeutic practices, a pharmacopeia, preventive strategies, and carefully selected healers to assist them with major health problems, such as diarrhea and dehydration. Enhanced childhood survival, perhaps, reinforced the continued use, generation after generation, of a large number of these popular medical practices.

Traditionally at least three types of indigenous healers treated children with enteric infections: the rezdaira or rezador (prayers); the raizeiro (herbalist); and the Mae de Santo (voodoo healer). These "doctors of the poor", however, differ significantly in their training, powers, and healing ways. Rezadeiras (-dors), the most common type of lay healer in Pacatuba, are deeply religious women and men who are endowed with the power to heal from God, a special healing force that they inherit either directly from the deity or from an elderly folk healer shortly before his/her death. Because most rezadeiras are illiterate, they must learn healing skills not from books, but from their mothers. fathers, or elderly neighbors; they imitate a practicing healer with whom they associate, watching, reciting prayers, and learning, to prepare home remedies under the expert eye of their mentor. Unlike rezadeiras, who rely primarily on god-given healing powers, the raizeiros de-emphasize the supernatural role in illness. As herbalists, they cure with chemical substances extracted from medicinal plants and, more recently, with modern pharmaceuticals. The Mae de Santo head of the religious sect, Umbanda - a voodoo-like religious synchronization of ancient African, Brazilian, and Catholic belief - is distinguished from the other traditional healers in several important ways. As a spirit medium, she has direct contact while in trance with supernatural beings from whom she receives the power to heal. This voodoo healer, unlike the prayers or herbalists, also has the power to cause harm in the form of sickness and even death. Because of her tremendous supernatural power, flirtation with the underworld, and demands for food and money offering, she is feared, respected, kept at a social distance, and often unacceptable to more pious clients.

These healers' skills are in particular demand by village parents, since according to popular thought diarrhea and dehydration are symptoms of a number of folk-defined illnesses including evil eve (guebranto mau olhado) fright disease (susto) spirit intrusion (sombra, encosto) intestinal heat (quintura do intestino) and fallen fontanelle (caido da mohera). An envious glance at a beautiful child by neighbors. friends. or strangers; a sudden, unexpected fright from, say, a passing train or barking dog; intrusion of a dead person's spirit into a child's body; heat that accumulates inside the intestine and upsets the hot-cold humoral equilibrium can all result in diarrhea just as a fall or blow on the head is believed to cause the child's fontanelle to sink into its skull. a signal of grave illness and almost certain death.

Healers and parents arrive as a definitive diagnosis by recalling recent social events believed to trigger diarrhea and noting the child's symptoms and the consistency, color and smell of his stool.

The course of treatment, although quite foreign to most Western medical professionals, follows logically from this popular diagnosis: the appropriate healer is sought among available alternatives, standard confirmatory techniques are used; and, finally, rituals and treatment are directed at ameliorating the folk-assigned cause of illness. The evil eve. for instance, is drawn out of the child's body by passing three leaves over the victim's body whit' praying. The evil enters the large, fragile leaves. which will quickly; and the rezadeira, careful not to spill their evil contents, flings them out an open window. The evil disease forces, including diarrhea, are thought to disappear with the leaves, leaving the child's body "clean" and disease-free. In the case of fright disease, the header must lift and realign the dislocated internal body parts that have fallen out of place with a sudden start in order to stop the diarrhea. This the healer does by reciting a verse and then lifting the infant's buttocks and hitting them lightly three times. When a child has been possessed by a spirit, the healer must talk to and negotiate with the spirit an acceptable payment of food, candles, or money in order to appease it and coax it out of the child's body. For intestinal heat. the healer (often the herbalist or parent) must re- establish the child's humoral balance by counteracting :he excessive heat with "cold" remedies, foods, or baths, and in extreme cases the "heat" must be flushed out of the body by frequent purges - therapies based on the Greek Principle of Opposition described by Hippocrates. Lastly, to effect a cure for a sunken fontanelle, the healer attempts to raise it to its original position by holding the child upside down by its ankles and tapping the stoles of its feet or by pulling the infant's hair upward and pushing on the hard palate.

To prevent childhood illness, specific prayers, amulets, and behavioral strategies were advised for each folk illness But the best protection against infant diarrhea was the traditional pattern of prolonged breastfeeding. Mothers almost always initiated the vital flow of milk without complication shortly after birth. After establishing a milk supply, they continued nursing - the only source of the infant's nutrition - for about the first six to twelve months of life. Even after this, village mothers supplied a significant but diminishing amount of breastmilk for several more years. That breastfeeding played a critical role for infant health in Pacatuba's past is evident from the number of folk medical practice evolved, such as the forty-day resting-in period (resquardo) high caloric and protein-rich postpartum diets, and wide use of plant galactagogues to stimulate milk flow, to insure that mothers not only initiated but continued lactating.

Prolonged breastfeeding did not, of course, sweet all infant diarrhea; the sources of infection were everywhere. Parents in Pacatuba, like members of other peasant communities, were able to draw upon an extensive herbal pharmacopeia in time of illness. Local healers identified some twenty-one plant remedies they retinely used to treat childhood diarrhea, of which fifteen were identified by Brazilian botanists. A computerized search revealed that of these fifteen, eleven have been recognized by medical researchers as specific to some aspect of gastroenteritis. Specifically, these plants possess amebacidal, anticholinergic, antihelminthic, antibacterial, or antiviral qualities and perhaps, in the case of coconut water act as an oral rehydration.

The impact of modern medicine on traditional practices.

The traditional health beliefs and practices described above, however, are not static; they are being rapidly modified as modernization sweeps through Brazil and biomedicine makes in-roads into the northeast. Western-style hospitals, rehydration centers, medical schools, and special clinics increasingly provide health care in major cities and, to a more limited extent, in rural communities, such as Pacatuba. Clearly, rural families stand to profit from modern medical miracles: antibiotics that cure tuberculosis, meningitis, and pneumonia, and vaccinations that prevent polio, diphtheria, and measles. However, modern medicine's effect on the rural poor is paradoxical. While sophisticated technology exists; it is often ill-adapted to rural conditions inaccessible, and unable to effectively treat diarrhea, Pacatuba's commonest childhood illment. Moreover, beneficial traditional medical strategies are often not recognized until they have been completely undermined.

For example, despite increasing numbers of modern health professionals in the northeast, they remain concentrated in distant cities, are expensive and often are removed socially from the culture of their poor rural patients. Instead, we learned from analysis of forty illness episodes that diarrhea in poor homes continues to be resolved for the most part, using local resources. Mothers were the first to diagnose and treat their children with a wide variety of herbal remedies shortly after symptoms appeared only a mean of 0.6 days into the episode; the mother then administered over-the-counter pharmaceuticals, on hand or borrowed. After 1.2 days, families consulted traditional healers. Shortly after beginning of the local ceremony. 2.7 days after onset, parents consulted pharmacy attendants to purchase additional drugs. But not until over eight days elapsed, when dehydration was obvious, did a small number of families consult local physicians; rehydration centers and hospitals, if resorted to at all, were not sought until 9.6 and 12.5 days, respectively, when the chances of severe dehydration are marked. That traditional healers continue to play a significant role in the early management of diarrhea! illnesses, even in the face of modern medicine, became apparent in our subsequent study of sixty-two infants admitted to an intravenous rehydration center in Fortaleza: 57 (91.9%) infants had already been treated by indigenous healers for a number of folk illnesses prior to admission. Moreover using standard microbiological culture and bioassay methods, we determined that these common folk illnesses treated by healers were associated with enteric pathogens such as enterotoxigenic E. coli (ST and LT) (24.5%), rotavirus (10.5%), Campobacter fetus subsp. jejuni (3.5%), and Entamoeba histolytica (1.8%).

Besides the introduction of new healers, modern disease etiologies such as "enterite" and "microbes" are occasionally referred to by village mothers, yet the poorest parents continue to define diarrhea in folk-disease terms and believe that the underlying cause, often supernatural, must be tended by indigenous healers. By no means, however, does this belief keep them from simultaneously seeking help from doctors for the same or different problems. Similarly, the traditional practice of prolonged breastfeeding is being dramatically replaced by bottle-feeding; we have reported sharp declines in both the total numbers of Pacatuba's women initiating breastfeeding and the length of time they lactate, trends most apparent among wealthier village women, but also occurring among the poorest women since 1964. This modification of traditional preventive wisdom has had a significant detrimental impact on children's health, since we have also shown that a bottlefed infant in Pacatuba suffers twelve times more days of diarrhea than an exclusively breastfed infant. Finally, parents are increasingly looking away from their sweetened herbal teas for therapy towards an almost limitless number of modern "anti-diarrheal" drugs. These include antibiotics like chloramphenicol and tetracycline, cathartics, antimotility agents, and pectin-containing antidiarrheals, the majority of which have been judged by the World Health Organization to be ineffective, unindicated, or, indeed, harmful.

Implications for diarrheal diseases control programs

These insights from Pacatuba impressed on our minds two important facts. First, whether health professionals recognize it or not, villagers do not exist in a health care vacuum. Quite the contrary: they have their own health care system, based on tradition, with deeply ingrained and culturally shared illnesses. beliefs, and practices relating to enteric diseases. Secondly, village parents nowadays no longer solely depend on folk-healing ways, but are eclectic in their help-seeking, behavior and readily integrate biomedicine when needed. As a consequence of these discoveries, we became convinced that what was needed was an innovative approach to diarrhea! diseases control, a health delivery strategy that would build on the strengths of the existing indigenous system while at the same time incorporating effective modern therapy.

Fortunately, there now exists a simple, safe, inexpensive, and effective medical therapy to treat diarrhea, regardless of its specific etiology: oral rehydration therapy. By simply drinking a solution of water sugar, and salts to replace the water and salt lost by the body during diarrhea, countless lives can be saved from diarrhea and dehydration. Although the solution advocated by WHO is judged most effective in rehydrating children, even simple table salt and sugar or cereal-based solutions made from rice water— readily available in rural village homes—are effective rehydrants. Despite the overwhelming acclaims for ORT in reducing infant mortality, getting the solution and methods to poor families most in need remains a major problem.

Our answer to the problem of accessibility has been to design an alternative oral rehydration program that mobilizes traditional healers, integrates ORT into the traditional healing ceremonies, and builds referral networks that link healers to communitybased hospital care for children judged to be at high risk. By spoon-feeding ORT as a supplement to medicinal teas and in the context of healing rituals, healers working together with and instructing village mothers can treat most diarrhea without ever resorting to outside help. When properly approached, we have found healers interested in ORT or any modern method that works, as long; as it can be easily incorporated without destroying their own medical tradition. Government officials have also given their tentative support, pending evaluation, to this lay-healing initiative on the grounds that the quality of health care would not be compromised when incorporated into the national health care delivery system.

While collaboration with traditional healers for the delivery of ORT and other primary health care services presents several problems, such as their practice of potentially harmful folk treatments (also present in modern diarrheal management), low literacy, and resistance from medical professionals, to name a few, we believe these can be overcome with creative approaches. The advantages of recognizing traditional healers as ideal providers of village-based ORT far outweigh these problems. from our viewpoint: they are already there, provide good coverage of poor children, are sought early in the course of illness; are trusted by village mothers; speak the same illness language; recognize clinical symptoms associated with diarrhea and dehydration even though they may call them by different names; and prepare accurate ORT, a skill we attribute to their life-long experience in preparing traditional remedies. In addition, indigenous practitioners follow up children during the three- to nine-day healing ritual and, perhaps most important, strongly advocate preventive breastfeeding.

In conclusion, if we take seriously the challenge of providing basic health care to all people within the next twenty years, it is time we look beyond hospital-based strategies to creative new delivery schemes. Traditional healers have been recognized by numerous social scientists to be critical providers of health care for many so-called hard-to-reach populations. And a number of international agencies, such as WHO. have also recently recognized their important contributions to world health: USAID and The World Rural Medical Association issued policy statements in favor of delivery strategies that incorporate traditional healers in 1979 and 1980, respectively. An alternative traditional healer-centered program, at least in the case of diarrhea! diseases control, offers great potential for the delivery of care that not only reaches poor families, but is also medically sound and culturally appropriate.

REFERENCES

1. Dra. Maria Auxiliadora de Sousa, Professor of Social Medicine, Federal University of CeEara, Fortaleza, Brazil, personal communication, June 9, 1983

2. Puffer, P. R., Serrano, C. V. Patterns of mortality in children. Washington, D.C.: PAHO No. 262, 19,'3.

3. Kleinman, A, Eisenberg, L., Good, B. "Culture, illness and care: clinical lessons from anthropologic and cross-cultural research." Ann.lnt.Med. 8 (1978):251 -8.

4. Shields, D. S.; Kirchhoff, L. O.; Sauer, K. T. Nations, M. K.; Araujo, J. G.; de Sousa, M. A.; Guerrant, R. L. Prosoective studies of diarrheal illnesses in Northeast Brazil: patterns of disease, etiologies and risk factors. Presented at ICAAC Meetings, Miami Beach, Florida, October 1982.

5. Chadwick, J., Mann, W.N., eds. The Medical Works of Hippocrates: A New Translation from the Original Greek Made Especially for English Readers by the Collaboration of John Chadwick M.A.. and W. N. Mann, MCI Oxford: Blackwell Scientific Publications, 1950.

6. Nations, M. K. Illness of the child: the cultural context of childhood diarrhea in Northeast Brazil. Berkeley, California: Department of Anthropology, 1982 (dissertation).

Session 14 - Working with the community to prevent and control diarrheal diseases

TOTAL TIME

3 hours

OVERVIEW

Knowing and involving the community Is necessary for effective health education for Diarrheal disease control Integrated with primary health care. In Session 13 (impact of Culture on Diarrhea participants learned abut and analyzed community beliefs, practices and knowledge related to diarrhea. In this session participants Identify techniques to use to Involve the community In CDD projects. They discuss techniques for working with local leaders and organizations as well as ways of ensuring women's Involvement In project decisions. They practice these techniques In role plays dealing with problem situations In community health work.

OBJECTIVES

· To Identify techniques for Involving and motivating the community In projects to control Diarrheal diseases.
(Steps 1-5)

· To practice techniques for Involving and motivating the community In problem situations.
(Steps 4, 5)

RESOURCES

Bridging the Gap
Community Culture and Care. Chapters 5 and 6. "Community Involvement" (WHO Supervisory Skills)
Helping Health Workers Learn, Chapter 6, pp.11-24, Chapter 26 pp.16-34.
Community Health Education In Developing Countries, (Peace Corps) pp.13-16.
The Role of the Volunteer in Development (Peace Corps)
Third World Women: Understanding Their Role In Development {Peace Corps)

Handouts:

- 14A Questions to Ask About Involving the Community In a Health Project
- 14B Skills for Development Facilitators
- 14C A Checklist for Use In Identifying Participatory Components of Projects.
- 14D Helping the People to Organize
- 14E Meetings
- 14F Problem Situations (to be developed by the trainer)
- 14G Ways to Involve Women In Health Projects

Trainer Attachments:

- 14A Factors Affecting Participation In Rural Development Projects.
- 14B Examples of Problem Situations

MATERIALS

Newsprint and markers

PROCEDURE

Trainer Note

If participants" background In community development and community organization Is weak, ask them to read the following sections In Helping Health Workers Learn: Chapter 6, pages 11-20 (Community Dynamics and Participation) and chapter 26, pages 16-34 (Paulo Freire's Method of Conscientization). Also distribute Handout 14D (Helping the Community to Organize) for reading before the session. Suggest that they think about the following questions as they read:

- Why Is It important to Involve the community In health projects?
- What are the best cays to Involve communities In projects?
- What problems could make It difficult to Involve communities?

Get help from a participant to adapt the problems In Trainer Attachment 14B (Examples of Problem Situations to fit the settings In which participants work.

Step 1 (20 min)

Factors That Help or Hinder Behavior Change

Introduce the session by explaining that the group will be looking at ways to work with the community to improve, prevent, and control diarrheal diseases and increase community self reliance. The first step is to look at reasons why people might be resistent to change.

Ask everyone to hold up one hand. Ask them to put their hand down if they cannot answer yes to one of the following questions:

- I always use a latrine.
- I always wash my hands with soap and water before and after I eat or prepare food.
- When I am sick I always do what the doctor or nurse tells me to do.
- I always drink plenty of liquids when I have diarrhea rather than taking something to stop it up.
- I always cover food to protect it from flies.

Ask participants to think about and discuss why they behave in ways that they know are harmful to their health.

List their reasons on newsprint and ask them to discuss questions such as the following:

- What keeps you from changing behavior that you know is harmful to your health?

- What kinds of questions do you ask when you are considering changing a habit?

- What conditions could help you change these habits?

- Do people in the community ask themselves the same kinds of questions before changing habits or deciding to participate in a health project?

- What keeps them from changing harmful habits?

- What conditions could help them change harmful habits?

Trainer Note

Some of the reasons for continuing habits harmful to health that you can expect from the discussion are:

- They do not perceive themselves as susceptible to any illness or accident.
- They do not realize the severity of the ilness
- The new behavior does not fit their social or cultural norms
- They prefer to use their resources In different ways.
- Friends or family would be angry or upset if they changed the old behavior

Be sure to make the point that people's behavior Is influenced by many factors, not Just knowledge alone. Social Influence, resources, attitudes, and perceptions also Influence behavior. You may want to refer to Trainer Attachment 14A (Factors Affecting Community Participation In Health Projects) for specific examples of factors.

Some of the questions people ask before changing a habit or adopting a new practice that should come out of the discussion are:

- What will I gain from this change?
- How soon will I enjoy this benefit?
- What can I lose from making the change?
- What kinds of economic resources, knowledge and skill are needed to make the change?
- How much of my time will It take - Will It conflict with other more Important activities?
- Will I get as much out of the change as my neighbor, my spouse, others?

Step 2 (20 min.)

Discussing Ways to Involve the Community

Ask participants to share some experiences, successes and failures they have had In Involving people on their community projects.

Use these shared experiences as a basis to discuss the following questions:

- Why Is It Important to Involve the community In planning and carrying out a health project?
- In what ways can community members participate In a health projects?
- What questions should we ask when deciding how to Involve the community In health projects?
- What techniques can we use to motivate community members to participate In projects?

Distribute Handouts 14A (Questions to Ask About How to involve the Community In Health Projects), 14B (Skills for Development facilitators) and 14C (A Cheeklist for Use In Identifying Participatory Components of Projects) as a review of skills covered in preservice training and as sources of valuable tips on bow to involve the community In health projects at all stages and how to assess to participate at each stage.

Trainer Note

Important points about community involvement that can be raised this discussion include:

- If people participate in a project they will be more interested in helping themselves in the future and less dependent on outside experts and resources (encourages self reliance).

- They will be more committed to taking the action necessary to carry out the project.

- Until people recognize and understand a problem they will not be interested in solving it

- Local knowledge and expertise should be included in the project planning so that the way the project is carried out will be better adapted to local needs.

Some important points to bring up in the discussion of ways to involve the community include:

- Continue learning about the community.

- Communicate clearly.

- Listen carefully to what people have to say.

- Estabilsh trust and credibility In the community.

- Gain the support of community leaders who can mobilize resources (money people and materials).

- Develop community cooperation and leadership at the village level such as establishing a health committee

- Start with a project villagers want even if it does not appear most relevant to improving health.

- Start with a project that will produce results quickly before going Into more long-tern efforts.

- Build on local self-help traditions, organizations, beliefs, customs and religious values.

- Practice what you preach (provide a good role model).

- Use teaching techniques that actively Involve community members {active discussion with open-ended questions, role play drama, peer teaching),

Also recommend Chapters 5 (The Family) and 6 (Politics) in Community Culture and Care as basic background on social organization in the community.

Step 3 (20 min)

Finding and Working With Local Leaders and Organizations

Ask two or three participants to share what they have learned about local leaders and organizations from their own experiences in the communities where they are working. Use this experience to lead a discussion on how to identify and work with local leaders, and organizations, including information from Handout 14D (Helping the People Organize).

Some discussion questions to ask are:

- How do you discover local formal and nonformal leaders?

- Does a leader necessarily represent everyone in the community?

- How can leaders and organizations contribute to the success of a project? How can they create problems?

- How do you motivate leaders and groups to participate in a health project?

- When and how should you organize a special committee for a project?

Trainer Note

The answers to the discussion questions are covered in Handout 14D (Helping the Community to Organize).

If the training is conducted in a facility with access to the local community, you may want to arrange opportunities for participants to meet with willing community leaders such as health workers and school teachers, as a part of planning the health education session they will conduct at the end of the training course.

If you decide not to use the Optional Step (involving Women in Community Projects), bring out some of those discussion questions in this step and refer to the example of the negative results when women were excluded from a project in Tonga, described in Handout 14D. Also distribute Handout 14G (Hays to Involve Women in Health Projects). Emphasize the great importance of involving women in water and sanitation projects.

Tell the participants that they will now practice some of these techniques for working with leaders and organizations. Distribute Handout 14E (Meetings) as an additional reference.

Step 4 (45 min)

Dealing With Problem Situations in Community

Health Work

Have the group divide into four small groups. Give participants Handout 14F (Problem Situations) developed by you and ask the groups to discuss each of the four situations. Ask them to spend no more than five minutes discussing each problem situation, identifying the problem, and deciding what techniques to use to try to solve it. Assign one of the situations to each group. Give them 25 minutes to prepare a 10 minute role play, demonstrating the group's solution to the problem.

Trainer Note

Ask one person in each group to serve as facilitator for the group. Ask another to be recorder. Explain that this activity will enable them to practice some of the techniques they have discussed during this session. Encourage them to use the handouts and ideas from the earlier discussions to develop their role plays. Circulate among the groups while they are working and answer any questions.

An alternative is to ask participants to list problems they have encountered and have not been able to solve. Assign these problems to the groups.

Step 5 (60 min.)

Presentation of Community Organization Solutions

Reconvene the forge group and have each small group present their skit illustrating their solution to the problem. Discuss each role play using some of the following questions to guide the discussion:

- What was the mayor problem in this situation?
- What community involvement techniques were used? Were they appropriate?
- in what ways did the group involve the community?
- What are the mayor strengths of the solution?
- How could the solution be improved?
- Did the activities during the session prepare you for dealing with the problem situations?
- Will you be able to apply any of these solutions in your own future work?

Close the session by discussing ways that participants could involve local community members in the health education sessions they will be conducting at the end of the training course.

Optional Step (30 min)

Involving Women in Community Projects

Ask a few people to share what they learned about opportunities and barriers to the participation of women in development projects in their local community. List the information from men and women separately.

Have participants look at the potentials and the barriers and discuss ways to involve women in health projects in this community. Distribute Handout 14G (Nays to involve Women in Health Projects) as a reference.

Trainer Note

If the participants will be focusing on Women in Development projects or have not covered Women in Development thoroughly in their other training you may cant to include this step after Step 3. You will find valuable resource material in Third World Women:

Understanding Their Role in Development, particularly the article by Judith Hermanson on "Women in Development: Defining an Approach", in Module V-8.

Use Handout 14G (Ways to Involve Women in Health Projects) to guide the discussion of ways to involve women and distribute it as a reference.

Be sure to make the point that the way to involve women in projects varies with the cultural and social setting. There is no one way to involve women in projects. The approach must be community specific.

Handout 14A: Questions to ask about involving the community in a project

Leader support

Who are the important formal and nonformal leaders in the community?
Are there particular leaders that deal with health-related problems?
Should any of these leaders be contacted for permission before attempting to involve the community in a health-related project?
How could the leaders help involve the community?

Organizations, Groups, Individual Support

What individuals, groups, and organizations in the community would probably be interested in health-related activities? Why?
Are there any individuals, groups, etc. that might be opposed to efforts in this area? Why?
Are there any groups that might not have access to the benefits of the project?

Human Resources

What individuals, groups or organizations might have skills that would be useful in a health project?

Local Patterns of Communication

What types of social situations are most appropriate for exchanging what types of information?
How does the information spread in a community or group? (that is, between which people and in what ways?) Two different patterns are illustrated below:

What local gestures, sayings, clothing styles, and other traditions are used in sharing information or entertainment?
What objects, pictures or language are restricted or forbidden?
How do people teach children how to behave properly and to perform tasks?
What are the possible means of communication that could be used to involve people in the development of a project?
What means of communication are traditionally used for various types of messages?
Would use of these traditional means of communication be appropriate when trying to get people involved in a project?

Local Patterns of Cooperation

Do community groups traditionally work together on community projects? If so, how do they organize to work together? If not, why not?
Are there alternative ways to tackle problems in the community?

Handout 14B: Skills for development facilitators

Basic Skills

Throughout the stages of community development, the facilitator should:

1. Demonstrate an understanding of non-formal education through the use of:

· a variety of communication techniques.
· problem-solving activities.
· methods that motivate others to actively participate in the education process.

2. Stimulate planning and project implementation through the use of local skill, knowledge and resources during:

· needs assessment and planning.
· health education activities.
· follow-up.
· project review.

3. Use on-going methods of evaluation of community involvement.

Taking the First Steps

When the facilitator starts working with a community or group, he or she should:

1. Understand and be able to express his or hers

· motivation.
· expectations of the experience.
· strengths and weaknesses.
· role as a facilitator.
· Individual values.

2. Be sensitive and able to identify:

· expectations of the local community or group.
· local culture and resources, including customs, values, knowledge and ways of life.

3. Communicate in ways that demonstrate:

· active listening and observation skills.
· an ability to filter information
· skill in working cooperatively and in collaboration with others.
· an understanding of the participatory approach to development.
· on ability to promote local self-reliance, integrity and well being.

4. Use appropriate on-going techniques for evaluating community

Involvement.

Establishing a Dialogue

In the next stage of involvement, the facilitator should:

1. Demonstrate skills in facilitation and organization that include:

· an ability to work with existing local social structures and groups.
· stimulating active local participation.
· motivating others to contribute their skills and knowledge.
· planning and facilitating meetings, when appropriate.
· sharing techniques for effective problem solving, team building and negotiating.

2. Be able to examine analyze and prioritize issues, concerns and needs within the local context.

3. Understand and be able to discuss development issues in relation to local problems and strategies for change.

4. Continue to develop skills in interpersonal communications, including:

· encouragement of local leadership, when appropriate.
· building trust and confidence.
· consultation (e.g., active listening, conferring and feedback).

5. Continuation of community involvement.

Planning with the Community

In planning for active community participation, the facilitator should'

1. Collaborate with the local community or group to identify'

· health needs
· resources
· goals and objectives
· potential problems or limiting factors

2. Assist in the establishment of:

· project criteria
· plan of action
· methods of project evaluation
· relationships with appropriate organizations and agencies to form a supportive network,

3. Clarity the kind and extent of his or her involvement in the project.

4. Continue evaluation.

Evaluating the Process

In order to learn frog, and improve upon the experience of working with a community or other group, the facilitator should:

1. Work with community leaders to develop and use appropriate

evaluation criteria and techniques

2. Use a continuing process of evaluation to'

· review the level of local participation.
· review methods and approaches used during development work.
· assess the level of local self-reliance and well-being.
· generalize and apply the knowledge gained to increase the extent and benefits of community involvement in health projects.

Handout 14C: A checklist for use in identifying participatory components of projects

The following checklist can be used to assess project proposals as well as for project monitoring and evaluation.

A	Highly participative
B	Participative
C	Somewhat participative
D	Non-participative
E	Authoritarian

1. Project planning process:

- through initial open discussions with the community of its problems and how to solve them	A
- through a discussion of the project proposal with opinion leaders from the community	B
- through discussions with government/nongovernment organizations at district/block/project level	C
- project thrust from the outside without discussion	D
- project imposed in absolute disregard of community's wishes	E

2. Identification of the needs:

- by the people themselves	A
- by local opinion leaders	B
- by a government agency	C
- by a centrally sponsored scheme	D
- by fiat	E

3. Extent of resource mobilization for the project:

- by the community	A
- by the community and others	B
- through matching contributions	C
- through massive external assistance	D
- with no contribution from the community	E

4. Identification of project workers:

- by the community with its own criteria	A
- by the community with imposed criteria	B
- appointment of local persons by outside implementing agency	C
- appointment of outsiders	D

5. Development of social and/or technical skills:

- through short, local pre-service training, followed by regular, on-the-job, in-service training, in parallel with the training of trainers from within the community	A
- through short, local pre-service training, followed by regular, on-the-job, in-service training	B
- through pre-service training within the district/town followed by some in-service training	C
- through pre-service training in a remote institution without any follow-up in-service training	D
- no training or training in an unfamiliar language	E

6. Project implementation:

- under community control (especially the remuneration of project workers)	A
- under community supervision	B
- with some community involvement	C
- with no community involvement	D

7. Periodic evaluation/monitoring of progress:

- by the community	A
- some evaluation by the community	B
- outsiders' evaluation with results reported to the target community	C
- outsiders' evaluation not reported to target community	D
- no evaluation	E

This checklist needs not only initial but also continuous refining in the light of the growing understanding of the concept of community participation and its implications. It should be shared with those formulating and/or submitting project proposals-which means that there must be some common understanding of the conceptual framework of community participation between all those concerned with project formulation and implementation.

There are in addition certain general points to be looked for in assessing projects:

· Does the institution move out into the villages instead of expelling people to come to it?
· Is the project working with primary institutions?
· Has the government given its stamp of approval to agencies at the local level involved in the project?
· Does the project work with women?
· Is there a specific methodology suggested for community involvement?
· Does it include a specific methodology for involving people in monitoring/evaluation?
· Does an infrastructure exist for an exchange of information at the local level?
· Is there an acknowledgement of possible conflict areas by the project?

Handout 14D: Helping the people to organize

Now that you have some basic information about the community, the next step ~ to broaden your contact with the leaders of the community. Involve the local leaders as soon as possible in the project. Who are the leaders? Why are they important? How do you find them? What can they do to help?

Who are the leaders?

Anyone in the community may be a leader. A person is a leader when his or her ideas or actions influence others or he/she helps to get things done that the people want done. He/she is accepted by the people as a person of wisdom and sound judgement and one whose advice has been valuable in the past. He/she might be wealthy and powerful, or a person known to be very religious. Different people may be leaders in different areas such as agriculture, religion, politics or health. The leaders you are interested in should have some influence over people's actions which are related to their health.

Why are leaders important?

Community leaders usually make decisions that result in success or failure of a project. They are trusted and the people of the community will work with them more quickly than with you. If this is to be the community's program you must count on community leaders to take some responsibility for its success. You are the spark plug and the source of assistance. You can help bring together the other resources needed for improved community health. But the project will not be a success unless members of the community participate; their participation is usually decided by community leaders. The people to work with are those respected by the community and who are willing to learn and work.

Two kinds of local leaders

1. Formal leaders: Are generally paid for what they do. Projects sometimes fail or move slowly because these people were overlooked during the planning stage. Consult them often and request their advice and assistance. Gain their cooperation. Examples of formal leaders are:

- Political appointees (mayor, party representatives)
- Government officials (police, national guard)
- Village chief
- Religious leaders
- School teachers
- Heads of organizations

2. Informal leaden: May receive no money for what they do and have no official authority. They come from the local community and often have more influence than formal leaders. They are not necessarily the person' with the best houses or the best pieces of land, but they are liked, trusted and respected by their neighbors and are willing to help. A woman may be a leader in respect to the need for a better water supply while her neighbor may mainly influence vegetable gardening.

How do you discover the informal leaders?

The first step is to consider the responses you received when asking villagers "Where would you go for help if you have a health problem?" Other questions you might use are:

"Who are the important people in the community?"

"Whose opinion do you respect?"

"Whose advice do you follow?"

"Who is wise?"

"Who settles arguments within or between families?"

"Whom do you think people would go to for advice when their children have fever? To organize a special trip or event?"

You will probably find that the people named are those with leadership qualities and that the named will differ according to the problem to be solved.

However, leaders may not be the persons who show the greatest interest at the beginning of a project.

You may not uncover obvious enthusiasm to help others, but people who express interest, friendliness, and willingness to work, or people whose name was mentioned often by neighbors, may be your key to potential leaders. In your quest to discover local leaders, do not bypass those who appear to be against your work. Give them special attention and try to win their support and cooperation.

Example of a local leader: the birth attendant

Birth attendants are the most widely distributed of any category of health-related person. The reason for this is that women usually wish some assistance at the time of delivery and they are unable to travel far or to wait long for some one to reach them when they go into labor. The birth attendant is also working at a time which is especially appropriate for maternal and child health education. Unfortunately, birth attendants are often untrained, but they are often very influential with mothers.

Identifying and working with local birth attendants can be very effective in health education. In fact, in some poor communities the entire standard of health, sanitation, infant and childhood death rates and family planning have been revolutionized primarily through the work of birth attendants.

What can leaders do for the community?

If an effort is made to give leaders a thorough understanding of how health problems affect community well-being and how these problem. can be solved, they can contribute immeasurably to better understanding among the people. They can also become a powerful motivating force for community unity and action. Through their own acceptance of improved health methods and practices, they become a motivating force for change.

But, care must be used when deciding which leaders are the influential ones related to the specific community problem. In Tonga, an enviornmental sanitation project was initiated after preliminary planning with the community leaders. In Tongan society the women rank higher than the men according to traditional Tongan Kinship systems; the men however, are the heads of the households. The organization of the project was based on the men's support, and, at the request of the men, the women were not involved in the planning. The health workers left the decisions about methods of work to the male leaders but conducted the evaluation themselves. The project failed.

When a second project was planned in another Tongan community, an analysis was made of why the first one failed. The conclusion was that both the male and female leaders should have been involved. Both groups were given full control of the activities under guidance of the health worker. The villagers were left to themselves to make the decisions and suggestions supported by the majority were encouraged and used. Evaluation of the second project showed that every goal was achieved.

Project success can be achieved through the efforts of the villagers themselves, providing the right approach is used in promoting the active participation of the most influential community groups and leaders.

Here are some other ways leaders can contribute to the success of a project:

1. Bring people to meetings.

2. Arrange for and meeting places.

3. Help reach more people by telling others.

4. Help people in the community know you and gain confidence in you.

5. Give general information about the program and help interpret it to the people.

6. Help identify problems and resources in the community.

7. Help plan and organize programs and community activities.

8. Help plan and organize any services which might be provided.

9. Give simple demonstrations.

10. Conduct meeting.

11. Lead youth groups and various individual projects.

12. Interest others in becoming leaders.

13. Help neighbors learn skills

14. Share information with neighbors.

15. Serve as an officer in an organization or chairman of a committee.

How can these potential resources of the community be mobilized? In discussions with leaders, what have you discovered that is important to them? Maybe it is the protection of children's health. Maybe it is convenience, privacy, or cleanliness? Maybe they are moved by competition - "Other communities are solving their health problems." They might express pride in their community "We have done so many other things in this village, but this problem remains." Capitalize on these motivations. Use them to guide you towards a better understanding of the people of the community.

The Health Committee

A health program must have some kind of organized group to make it work. The family, the church and the school all have primary purposes other than health. They can take part in the health program, but their separate efforts probably will not be able to make it work. Often, a health committee is organized which involves community leaders and other representatives of community life.

There are many ways to form a committee. Remember the reactions of the people you have talked to in the community. Who was interested in the health situation? Who was hopeful? Which people were recommended as leaders? Talk with these people. Suggest a meeting of the group of them.

In the meeting, discuss the purpose of organizing a committee; let them decide to make an organized attempt to solve community health problems.

In a small village in Nigeria, after a preliminary survey of the community, the village chief was approached and the suggestion for the formation of a health committee was made to him. He liked the idea and was requested to invite other influential members of the community, including women.

The chief requested that the objective of the meeting be presented by the health worker. The worker invited the members to go out on an inspection tour so that all would have a part in determining what their needs and problems were. This they did and it served as a starting point for the meeting. Both male and female members desired urgent solutions to the problems they discovered during the tour. The chief was elected chairman for a village health committee and a teacher was chosen as secretary. Decisions were made in that meeting about plans for solving some of the problems found.)

The community members must become involved from the beginning in the decision-making and planning for the community. To make changes, they must commit themselves. They may need to see health improvement projects of other communities. Suggest a field trip (or this purpose. They learn as they go along and will be better able to manage their own projects.

A separate health committee may not be the best choice for some communities. If an existing local committee or other structure appears to be an effective means for improving community health, then perhaps this group could add health to its other concerns.

Purposes of a health committee

A health committee can serve several purposes:

1. To discuss health problems and discover felt needs.

2. To plan ways to reach goals and objectives that promote new, sound health practices and attitudes.

3. To implement plans and organize projects.

4. To receive and consider new information about health and development of possible interest, and convey this to the community.

5. To encourage all members to gain skills and confidence in working in a group so that the work in the community will not depend on any one person.

For suggestions on planning and conducting a meeting, see Chapter V. Records of proceedings at each meeting should be kept and read at succeeding meetings and matters arising from them should be discussed. These records can always be referred to by any new member so that he/she can acquaint him/herself with the progress and history of the committee's work.

Members of the committee are usually elected, but its formal make-up will differ from one country to another, often from one village to another. The important thing is that you keep abreast of the committee's work and progress. Usually you will be invited to attend the meetings, and may even be chosen as a member. Because your position in the village is temporary, it may be best to decline any offer to be an officer. You are a resource person - one who assists and supplies information and guidance. Participate, hut do not become totally responsible.

After the creation of a Health Committee, initial projects should be simple in nature and should not demand a long period of time. Refer to the next chapter for further discussion of this point. The building of a latrine for a dispensary or school could be completed after only a few work days and would impress upon the Committee - and the community - what they are capable of doing. If a complicated project such as a water system or construction of a health post were chosen first, the problems of materials, technical assistance and the duration of the project would probably discourage the people and have a crippling effect on the Health Committee. More difficult projects can be attempted after the Committee has had some success with simpler projects.

Once a health committee or committees exist and have begun their work, they should always have a problem that they are currently working on. If committees remain stagnant for a period of time, they become ineffective and will cease to exist other than in name. There should also be lines of communication between the local health centers and the Health Committee to ensure recognition and cooperation between the two.

In summary, health committees can accomplish many things to improve community health if they represent key groups in the community, communicate and cooperate with other community workers, committees and institutions, are well-organized, and if they plan projects based on community needs and interests. Your role is to assist the committees in doing these things. The next two chapters will discuss steps in planning, implementing and evaluating a community health project.

Handout 14E: Meetings

There ore different kinds of meetings. Some involve general participation in the discussion and in making decisions (committee meetings, board meetings, public meetings on issue of concern to the community). Others, like the annual assembly of on association, use a few speakers who address a largely passive audience. In health education we are concerned with the first type of meetings.

Purpose

Meetings are held to gather information share ideas, make decisions and make plans to solve problems. Meetings are different from group discussions. A group discussion is free and informal. Meetings tend to be held for a special reason and are more organized. They have, for example, appointed or elected leaders. Meetings are an important part of successful self-help projects.

In meetings held by organizations and associations, 20 to 50 persons may come together. Community leaders may have small meetings where 5 to 10 persons take decisions about community needs. On the other hand, the whole community can come together in a meeting to learn about problems and express their views.

Planning a Meeting

Need - it is important that the members of the organization or the community see the need for a meeting. Does the problem require a meeting, or can it be handled easily by one or two members? The decision to hold a meeting should be made by the group members or community leaders themselves.

Time and Place - Many organized groups have regular times and places for their meetings. The village heads may meet once a week at the Chief's house. The neighborhood council may meet monthly in the community hall. The tailors' guild may meet every two months at a school or mosque.

Make use of regular meetings to solve problems and lay out plans for action. If a special meeting is necessary, have the leaders of the group decide on a suitable time and place that will be convenient for all.

Announcing the Meeting - Each group or organization has a way of informing members about meetings. This may be by posters, town criers or word of mouth. The group should make the announcement itself.

Word of mouth is often the best way to announce meetings in a village or small neighborhood. The need for the meeting can be announced by the leader to the people who cork closely with him. These people then spread the word to others who in turn tell others and so on.

Announcements will spread more quickly and reliably if a system is established to facilitate communication. In such a system, each member of the group has the responsibility of contacting certain people. The leader will contact tour or five people to announce the meeting, Each of these people knows the names of five other people whom he or she will contact. These people in turn will contact others.

One way to do this is to look at the different sections of the village or neighborhood. There should be someone in each section for the leader to contact first. If Mr. A is away when the leader tries to contact him, Mr. F could then fill in for Mr. A.

Meetings should be announced several days in advance to give people time to prepare. But do not announce the meeting too far in advance, people may forget.

Setting an Agenda - An Agenda is a list of topics or issues that will be discussed at the meeting. This should be planned carefully. People will lose interest if they come to a meeting where no one knows what is supposed to happen.

It the group already has leaders, see them some days before the meeting. Discuss the agenda. There may be issues remaining from the last meeting that must be discussed first. There may also be new topics to add. An agenda should not be too long. Ideally, it should include only one or two important topics. A long agenda means a long meeting. After one hour people start to get tired. After two hours they start to leave. If people leave before the work is finished, the group may not be able to solve its problems.

Also a long agenda may force people to make quick decisions which they may regret later. When the agenda has been agreed upon, look at the topics. What information will the group need to be able to discuss the topics carefully? If a women's group wants to meet to discuss ways of improving family nutrition through better kitchen gardens, they will need information on types of vegetables and grains with high nutritional value that grow well in local soil, their costs and effects. Some of the group leaders should volunteer to find out this information You can guide them to where to look. Do not do it all by yourself. It is useful for people to learn how to find information and resources.

When the meeting is announced, also tell people briefly what will be on the agenda. This will help them prepare. Members can look for information themselves. They can begin to think of ideas to be put before the meeting.

Leadership - Most organizations, associations and councils have their own leaders. These arc the people who should be in charge of the meeting. You will have already given them encouragement and suggestions during the planning of the agenda.

You should speak when the leaders ask you to folk, and occasionally give other comments. Be sure that the other group members hove the opportunity to speck their minds fully.

Participation - Participation in the meeting depends on the culture of the community. In some places leaders do most of the talking. In other , every member speaks. Encourage the kind of participation that is acceptable to the people. You can add comments like these to encourage more people to talk.

"It would be useful if we could hear more about this dirty water problem from the people who live near the stream."

"This problem of diarrhea worries us all. I am sure those members with small children must have some experiences to share with us."

Make Issues Clear - Before the meeting can reach intelligent decisions, everyone must understand the problems and suggested solutions. Comments like these can helps

"Is everyone clear about how much money this project will require?"

"Does anyone want us to explain again how this ORS works?"

"Does everyone understand what will be the responsibility of the community and of the sponsoring agency in implementing this project?"

Reaching Decisions

- Here are four ways in which decisions can be made in meetings:

- the group as a whole discusses on issue; after some time the leader or another member may say, "I think that we all agree to take this action. Does everyone feel tints way?" At this point anyone can object; if there are objections, then discussion continues until there is a final sense of agreement; this is called consensus decision-making.

- an issue can be placed before the group and members are asked to vote on whether they accept or reject the idea; action is taken on the idea that the largest number of people prefer;

- the leader listens carefully; when he or she senses that everyone is in agreement he or she announces a decision;

- the leader alone nay decide on what he or she thinks is best and announce that his or her decision stands for the whole group,

The first two methods are very similar. In both cases a decision is not taken until there is general agreement in the group. This may take longer than voting or the leader deciding for the group but it encourages participation. When everyone is in agreement, action is very likely to follow.

Taking Action

The purpose of a meeting is to decide on plans that will help solve a group or community problem. Simply put, the group must:

- set objectives (desired results);
- decide on strategies (ways to solve the problem);
- find resources;
- set a timetable for action;
- share tasks among individual members or small groups of members (committees);
- meet regularly to review progress and make improvements or changes in the plan as necessary.

Handout 14G: Ways to involve women in health projects

· Asking, listening and observing to identify women's needs.

· Identifying women's roles, opportunities and problems.

· Identifying cultural, social, family and other patterns which affect women positively and negatively.

· Getting womens' help in assessing the potential positive and negative effects of projects on women and children, particularly the likelihood of access to project benefits.

· Involving women in the decision-making aspects of project planning, implementation and evaluation. Encourage participation of women in village meetings when development projects are discussed; if socially unacceptable for women to attend with men hold meetings for women to discuss development project.

· Identifying, Training and working with women leaders and supportive men.

· Identifying and using local organizations traditionally supportive of women.

· Training and encouraging women counterparts to act as communication channels for information and resources generally controlled by men.

· Providing training and other programs or activities to improve the quality of life of rural women in traditional roles, (such as increasing status, income, income generating activities, social rewards).

· Helping government, other developers and community people understand and support the important role women can play in development.

· Sharing information and analyzing failures and successes of projects directed to women's needs.

Trainer Attachment 14A: Factors affecting participation in rural development projects

Trainer Attachment 14B: Examples of problem situations

Adapt the following example situations to fit the problems most encountered in the host country.

1. The local traditional healer is highly respected and cleared by members of the community. Health workers in the past have treated her disrespectfully, referring to her as a "dangerous quack." As a result, she has discouraged families from giving ORS to their children, saying it will poison them. Many of her herbal cures are effective, but many local children get diarrhea and die from dehydration that could be prevented by ORT. What should the new Volunteer and Counterpart do in this situation?

2. Community elites have dominated decision-making in previous development projects and, as a result have gained the greatest benefits from the projects. The traditional village structure is very hierarchical; all the major decisions are made by the village council which consists of elite males exclusively. The Volunteer and Counterpart want to work with the communittee to develop a water and sanitation project with a strong emphasis on communittee participation and health education, based on needs expressed by many individual farmers. What is the best approach in this situation?

3. The community recently had a bad experience with a development project intended to increase grain production through new seeds. The seeds were free but they were not well suited to the local soil and the crop yield was very poor. Many people had to sell some of their other crops and goods to buy grain last year. They were not willing to take chances with any government schemes again. The village has no latrines and many problems with intestinal diseases. The Volunteer end Counterpart would like to start a community project to properly construct and use latrines. What is the best approach in this situation?

4. Many children in local communities die each year from dehydration resulting from diarrhea. A very strong traditional health belief is that a baby with diarrhea is "hot" and it will "break" if you give it something "cold" like water. They continue breastfeeding during diarrhea because breast milk is "warm". The community water source is very dirty. Sugar is not available in the community. Salt is available but it is quite expensive and cash is scarce in the community. The local school teacher, Volunteer and Counterpart are concerned about this situation. What can they do?

5. The local community health worker (CHW) feels that the best way to do health education to improve community health practices is to inform people what they should be doing and why that will make thee healthier. The main techniques and materials used by this person include' talks during community meetings and in the school, posters in the market and other meeting places, and a display in the school which the CHW put up single-handedly. The health worker is very discouraged because all these efforts have had little impact on community health practices. The CHW has asked the Volunteer to make an attractive visual aid for the next talk so it will be more effective. What can the Volunteer or Counterpart do to help the CHW?

6. A Volunteer or Counterpart visits their sick friend, one Volunteer, in a neighboring village. They find that their friend is setting a poor example of hygiene practices' food is kept uncovered, the yard is cluttered, he or she does not usually wash their hands before handling food because water is scarce, he or she has not gotten around to building a latrine yet. What is one best action to take in this situation?