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Participatory health appraisal (health profile) The health status in a given locality affects and is affected by the community's population profile and its patterns of using natural resources. A comprehensive local environment and population appraisal will thus elicit information also on the local health situation. In particular, the nutritional status, the most common health problems and health risks present in the community, and the available medical and public health services will need to be investigated. In the last 15 years, rapid, qualitative and participatory methods have been tested and accepted in many countries as an important aid for health services decision-making. Labeled 'rapid epidemiological appraisal' or 'qualitative health services research', these methods can be useful for dealing with the health-related aspects of participatory action research. The following, in particular, are good as entry points for interest groups assessing their health needs and linking those to environmental and population variables:
Health-risk mapping is a variant of participatory mapping in which community members:
The best length of time for the recall period may take some discussion with the group. In many regions of the world, six months is too short a period of time to reflect seasonally related health patterns. For example, diarrhea is often worst in rainy seasons when ground water contaminates water sources, or meningitis is most common during the Sahelian dry season when dust is blowing in the Saharan harmattan. At the same time, research has shown that the longer the time period covered by the recall request, the lower the reliability of the information about the reported events. See Figure 4.4: Example of a health-risk map (prepared by health-care staff) As shown in Figure 4.4, pictures or graphic symbols can be used to facilitate understanding of the exercise among participants (especially the non-literate ones). As women are often the primary caretakers of the home, risk mapping of vital events and household contingencies may be best carried out by women, especially mothers and elderly women. If time permits, complementary perspectives about health events and risks can be obtained by conducting the same exercise with different gender, age and status groups (e.g., male elders, adolescents, local men working in migratory occupations such as mines or estate farms, etc.). This can help in discovering differences in health beliefs and behaviors within the community, as well as triangulating results to test their validity. Risk mapping relies very much on local perceptions about the determinants of health and disease. It is thus a powerful entry point to identify and discuss local (indigenous) medical beliefs and practices, and a challenge to health professionals with limited acceptance of different cultural understandings of health conditions. A medical anthropologist may help the PAR support team to interpret the findings and understand them within their (likely) bio-medical and 'scientific' system of reference. The local point of view expressed by risk-mapping exercises can be compared with conventional epidemiological and health services information from existing documents. This blending of viewpoints may yield a new, integrated perspective on the community health profile and help improve communication between various kinds of health service providers and users. The support team should facilitate the drawing of connections between the identified health issues and other phenomena and features encountered while assessing the environmental and population situation in the area. In fact, many environmental and demographic features may be health-risk factors in themselves. For instance small-size household plots and poor productivity of the hillside land can be risk factors for child malnutrition and high mortality. Large-size households or seasonal male migration can be risk factors for tuberculosis. A child nutrition assessment will enable the community to get a grasp on the prevalence of child malnutrition. The standard means of assessing malnutrition is to measure children's height and weight and compare those among themselves and to average heights and weights of children of the same age in a comparable group of reference (e.g., the country as a whole). In communities where this kind of nutritional monitoring has never taken place (for lack of equipment or trained personnel), the methods presented below can be used to gain an approximate measure of local malnutrition. They also accompany the community into the identification and analysis of the problem, thereby bringing them a step closer to devising potential solutions.
The two methods we describe here are seasonal analysis of food availability and brief, structured interviews with mothers. The seasonal analysis method involves using sticks of varying lengths for each month of the year. Together with a group of villagers, place 12 small stones in a line, each separated by a few centimeters. Having at their disposal sticks that can be broken off for varying lengths, villagers select a long stick and place it close to the month that has the greatest food availability. Then, they place progressively smaller sticks close to months that have less food availability. Typically, the 'leanest' month will be just prior to harvest of the new crop. The result is a histogram that visually represents the good and the bad months. Using this diagram as a basis for discussion, a facilitator can elicit from the participants some of the implications of this seasonal variation for child health and nutrition, the gathering of edible plants in the fields and forests, the spread of infectious diseases and the household coping strategies. This informal discussion can prepare for more detailed interviews involving all (or a sample of) mothers with children under age 10. The questions should be few in number and sufficiently straightforward. Ideally, the members of a 'mothers of a family' interest group would be involved in collecting the information. Examples of questions that might be asked can be found in Box 4.8. The responses can be tallied and converted into percentages in order to develop a composite picture for the village, and also by different household characteristics (see Table 4.5 below). Table 4.5
A better mutual understanding of the dynamic relations between communities and the health services available to them can be facilitated by a strengths, weaknesses, opportunities and limitations (SWOL) analysis (see Table 4.6(below) and Annex B, section B.10). Many action research practitioners consider a community SWOL analysis to be a good way to promote a frank discussion of the positive and negative sides of local service availability, linking past experience with desired improvements to be achieved in the near future. As health services are often the subject of sharp and contradictory (either enthusiastic or distrustful) judgment by actual or potential users, the use of this technique is especially effective to investigate the quality of the provided services in specific terms. Table 4.6
As shown by the example provided in Table 4.6, SWOL analysis can help people to systematize their opinion of what is good or bad in service delivery, to identify what improvements can reasonably be requested from the providers and to see what external constraints could be expected. The SWOL approach can also be useful for helping communities to think about potential solutions to local problems. Obviously the SWOL approach can be used to analyze other kinds of services besides health, such as forestry extension, education or agriculture. There are some potential difficulties in the implementation of a SWOL exercise. Good facilitation, for instance, is essential for managing the sensitive issues that may arise. In fact, SWOL exercises are usually easier to conduct with homogeneous groups. Gender analysis focusing on reproductive issues In addition to biological differences, men and women in every culture have different roles, needs and responsibilities in fertility control, reproduction and child-rearing. These gender-based differences can vary from country to country, depending on traditions and on social, economic and environmental conditions. Gender analysis is a method used for identifying and discussing the most important features of male and female roles within the local culture. This method can be applied for assessing gender divisions of labor, gender-specific knowledge and practices related to natural resources management, and reproductive behavior. Its use is especially recommended, in the framework of this manual, for all those mentioned aims, as well as for appraising existing knowledge, attitudes, needs and expectations related to fertility, reproductive health and family planning. It is also recommended that, wherever possible, a gender-based collection of information and analysis is carried out for the prior environmental, population and health profiles. Here we will focus on reproductive issues to provide an example of how this can be done. In most rural communities, relationships between men and women, sexual behaviors and beliefs, and practices related to conception, pregnancy and delivery are extremely sensitive issues. Applying a gender analysis to these topics requires a good understanding of local culture and well-developed facilitation skills. A satisfactory outcome to this exercise is more likely if it is not attempted until the participatory process is going well and a smooth relationship has been established between insiders and outsiders. Facilitators of gender analysis exercises will need to practice some cultural relativism, i.e., they will need to put aside their own ideas about how men and women 'ought to' relate to each other. Outsiders need to be prepared to accept beliefs and behaviors which may be very different from their own. For example, insistence on promoting equality in women's conditions with respect to men's can be resented and disrupt the process of community-based exercises, unless such a need is clearly spelled out by the locals themselves. On reproductive knowledge and behavior, the principal actors could be small gender-based interest groups supported by a facilitator of the same gender (e.g., five to six women with a female facilitator, a similar group of men with a male facilitator). In many regions of the world, traditional culture, especially in rural areas, subordinates female involvement in public settings, such as meetings. Dividing men and women into separate groups for discussion can be an effective way of coping with this social norm. In a separate group, women can have the opportunity to organize their thoughts, prepare their own presentations and refine their opinions and wishes before meeting again with men. In this way, gender-separated groups can help ensure that women's insights are integrated into the discussions of the entire community. There are two basic methods, suggested for gathering and appraising information, which are specifically relevant to a gender analysis of reproductive behavior:
Women's reproductive history obtained through semi-structured interviews (see Annex B, section B.6) can be useful for collecting basic quantitative information on numbers of pregnancies, deliveries, potential problems, etc. These interviews are generally best carried out by literate members of the female interest group. While the ideal respondents for these interviews would be elderly women, there may be substantial differences in reproductive values and behaviors between generations of women. Therefore, a sample of female informants representing different age groups is suggested, e.g., some adolescents, some young women, some middle-aged and some elderly.
Examples of interview guides and summary forms are presented in Boxes 4.9 (above) and 4.10 (below). Organizing quantitative data in simple summary forms may help to identify locally useful indicators of reproductive behavior. The next step is tallying (consolidating) the data to look for patterns in the community (see Box 4.11 below).
Focus group interviews (see Annex B, section B.5) are an appropriate strategy for eliciting women's and men's expectations, attitudes and needs with respect to fertility and parenting. They can provide qualitative data useful for interpreting the quantitative data collected from reproductive histories. A couple of cautions about focus groups: 1) the facilitator will need sensitivity in discussing sexually related topics in most communities; and 2) there will be a need for analytical skill in extracting the key points from the large amounts of data likely to be generated. Training and practice with the support of an experienced facilitator can help to conduct the interview and to process and consolidate the raw data. In a small village, two focus groups, one of five to ten males and the other of a similar number of female participants, should be sufficient to obtain a reasonably representative view of insiders' perceptions of fertility and parenting. The participants should be adult, married persons with some parenting experience. This perspective could be enhanced by obtaining opinions and perceptions also from adolescents and from elders. Table 4.7 (below) provides an example of a focus group interview guide (and a sample of hypothetical responses from two groups) for an exercise on expectations and attitudes on fertility and parenting. The results are a composite of replies from real settings, showing a plausible set of concerns from women and men in a rural community. Table 4.7
The final results of a gender analysis on reproductive health and fertility can be communicated to a broader community audience for review and discussion. Care should be taken to maintain a strict anonymity of sources. The local situation will influence whether to hold separate feedback meetings by gender, or report on the results in a general meeting. Although comparing the results from male and female groups could create a delicate situation, it can also be useful in identifying possible gaps and inconsistencies, and help to elicit any felt needs about changing the situation. To make the meeting more effective, the support team could prepare a list of questions to promote discussion and orient the meeting towards action (see Box 4.12 below).
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