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Nutritional anthropology

International conference on rapid assessment methodologies for planning and evaluation of health related programmes: Interpretative summary

Ellen Messer

Rapid ethnographic assessment procedures are now a reality in international health, nutrition, and development planning. The practice of consulting the people whose lives are to be changed by development projects is becoming widespread among international and national governmental and non-governmental (NGO) organizations. Moreover, the expansion of RAP (rapid assessment procedures) from the domain of health and nutrition programming to water management, credit, and other hazard management or economic development programmes more generally indicates a return to the principle of integrated rural development, with an additional set of tools to integrate local participation into project planning, implementation, and monitoring.

Integral to RAP methodology is the active involvement of community members in assessing what needs to be done, how existing projects are working and might work better, and how the community might take responsibility for reporting on progress. This means that successful RAP results in community organizing, or communities taking control of projects, as well as technology and infrastructural changes. Most RAP practitioners, however, still operate from a top-down or middle-management perspective and have not dealt seriously with the implications of letting go of control of health care, for themselves in the professional health care and development business, or for the local people who might be assuming control in national contexts where such expression might be viewed as threatening.

The representatives at the Conference on Rapid Assessment Methodologies from major UN-system organizations (UNU, UNICEF, WHO), international NGOs (Plan International, Helen Keller Institute), and national NGOs and government programmes (from Indonesia and India respectively) as well as academics associated with all of the above or concerned with the use of rapid assessment techniques in rural development more generally (Robert Chambers from Sussex doing rapid rural appraisal in India; Scarlett Epstein, retired from Oxford, pressing for market research) each had their own versions of RAP as they envisioned or had actually used it. This diversity of opinion and purpose provided an opportunity to explore the wide range of possibilities and some pitfalls, including issues such as how rapid is rapid? how relevant or reliable is information? how might frameworks from collecting information from one locality be made relevant to other locations and issues?

It was recognized that time, spatial, and issues frameworks all demanded scrutiny on criteria of validation and generalization (scaling up) of information. In addition, most of the studies represented one of three areas: they were projective studies of RAP possibilities, detailed descriptions of the design and use of RAP methods and techniques, or presentations of results, usually summaries of "ethnomedicinal" concepts from a given project area that helped improve the design and implementation of a particular health care delivery programme.

There were perceptible gaps in the reports from choice of methodology to acquisition, interpretation, and use of results. Even within these categories, most studies were in the realm of technical reports, as these might aid in the design, revision, and delivery of technical programmes. Almost no attempt was made to link RAP concepts and methods to general theories of culture or ideologies of development.

Key areas contain challenges for immediate or future RAP research. First is the relevance of RAP for understanding culture and development as construed by anthropologists or development planners, and as they relate to health, nutrition, and other processes and measures of economic change. Second is the question of the linkages between RAP concepts, methods, results, and programmes and between one area, such as health and nutrition, and the next. Finally, it is necessary to scale up from village or barrio to larger programmes.

Practitioners also have to address several methodological concerns. Trade-offs must be made between the standardization of techniques and flexibility in the use of RAP according to infrastructural and sociocultural circumstances. A question arises of how RAP can contribute to the identification of new indicators of, and interrelationships among, nutritional, health, or economic well-being. It also must be established how methods can be developed to unleash local creativity and participation without threatening repression by existing power structures.

On balance, it is amazing that the development community has operated almost 50 years of activities without RAP7 and also amazing how rapidly the method is catching on. It is still not clear, however, how much agreement there is on what the process is, or what we know as a result of its use.


What is rap?

This method began as an exercise to introduce ethnographic assessment rapidly into health and nutrition programme planning, revision, and evaluation. The idea of consulting recipient populations on their household-level perceptions of health care problems and the adequacies or inadequacies of primary health care obviously was not new, at least among anthropologists. We used to call this the "background ethnographic reconnaissance" that was preliminary to any health and nutrition project, but we never systematized a methodology. Moreover, in practice, ethnographic input was not widespread. Nor were systematic guidelines established on how to obtain information rapidly on how programmes might advance.

In Nevin Scrimshaw's case history, the idea of RAP was sown as long-term INCAP study of health and nutrition on a Guatemalan farming estate benefited from considering and integrating results of two methodologies. health and nutrition epidemiological surveying and ethnographic interviewing and observation. The UNU in 1982 used the RAP idea as a basis for commissioning a 16-country study on household-level perceptions of primary health care needs and programme effectiveness. To improve the comparability of these projects, Susan Scrimshaw and Elena Hurtado systematized a handbook of RAP methodology that provided guidelines on how to evaluate the impact of health programmes on health-seeking behaviour [1]. The results and methodological insights of these initial case studies were reported at a meeting in Bellagio, Italy, in July 1985. (The original researchers are hereafter referred to as the core RAPpers. )

Thereafter, core RAPpers adapted the guidelines to other health and health-related problems, particularly those having to do with water use and hygiene. They promoted RAP as a focused and flexible interview-observational technique that can rapidly and relatively inexpensively determine the effectiveness of programmes and contribute to useful modifications. Although RAP does not eliminate the need for quantitative assessment, surveys provide little guidance on programme impact. This must come from ethnographic assessments. Therefore, RAP is appropriate for all programme interventions.

Since the initial studies, Michael Cernea emphasized, the use of RAP has expanded geographically and topically; the World Bank may be testing the cross-cultural validity of the method; and attempts have been made to tailor RAP to particular programmes to incorporate relevant community participation. Although the first decade has produced only piecemeal results, it has brought about a basic change in the planning process, which now (at least in Cernea's ideal model) "puts people first."

It has also launched the social sciences on a methodological revamping. Prior to this, anthropological studies could usually be characterized as either quick and dirty or long and late. Thus, RAP has contributed to integrating better research into programme planning and also helped to develop more creative ways to elicit and incorporate people's points of view. Moreover, it has a multiplier effect. Once community participation is organized for one type of study, it is there for others. The concept of community participation achieves new meaning and realization. Government programmes may be guided in the future not just by economic data but by better knowledge of people's society and culture. Many of the success stories so far have been in the areas of ethnomedicine and health and sanitation, but they should reverberate more widely.

However, problems of accuracy, representativeness, and cultural appropriateness remain. Time and accuracy are clearly relative to existing cultural knowledge on the research sites. The RAP method demands some judicious combination of formal and informal data, the use of short-cut methods to introduce a reasonable degree of formal rigour and comparability to what might otherwise be impressionistic observations and interpretations. The sample is always qualified and sacrifices the representativeness of a larger sample that takes more time.

In the best of all possible worlds. RAP can help community members to identify additional variables for programme planning, implementation, and evaluation. But success will depend on the skills of RAPpers in communicating their purpose to the recipients and donors. We still have little guidance on what works and why. Duncan Pedersen emphasized that there is no easy route to transferring power from those collecting information to the people. Ideally, RAP and rapid rural appraisal (RRA), a less targeted use of rapid assessment developed by Robert Chambers and others, are little more than organized common sense. Care must be taken to ensure that they are not quick and superficial and that the time released from more lengthy data-collection methods is used effectively to learn from the (rural) poor.

An additional dimension of RAP methods is advocacy. Chambers pointed out that RAP and RRA prove that illiterate people are quite capable of taking responsibility for their own assessment. They can estimate as well as quantify their conditions. One has to build rapport, develop the right materials, have patience, and have humility to lead to the democratization of knowledge.

Yongyout Kachondam, a Thai physician who was one of the core RAPpers, suggested a yin-yang analogy to the interdigitation of quantitative and qualitative information. All the core RAPpers emphasized the limitations of RAP and the need for proper training to involve the appropriate community members, collect necessary information, and avoid distortions. Over the four days, those with RAP experience seemed to agree that the people who are hardest to train are traditional government officials in supervisory positions, who find it difficult, if not impossible, to relinquish questions and answers to villagers. In addition, traditional anthropologists do not necessarily find themselves amenable to RAP methods.

Researchers (anthropologists) pointed out common questions that are useful in any study in a particular area. Especially those concerning average daily wages, access to social services, and principles of community organization may be critical for understanding any study that involves poverty measures. An additional relevant question relates to who helps people out and how in times of disaster. The right way to ask this question may be different in each culture but is critical to assessing various dimensions of vulnerability. Clearly, RAP will be harder to apply in some cultures-those that are resistant to talking to outsiders, for example, and ones with considerable intracultural diversity-than in others.

Overall, we can say that historically the technique is not new but that practitioners are better at packaging it. The numbers of guidelines and checklists that can be applied to an ever increasing number of problems -specialized health areas such as acute respiratory infections, epilepsy, onchocercosis, diarrhoea, and acquired immune deficiency syndrome (AIDS); environmental contaminants monitoring; water management; emergency relief monitoring of target population numbers, structure, and food habits; and dietary and nutritional assessments-are multiplying rapidly. UNICEF has a directive out to many, most, or all of its country offices to incorporate RAP into their programme monitoring. The technique is now spreading to all areas of programme interventions by all categories of programme actors-government, NGO, and intergovernmental agencies.


Who is using RAP?

The original core RAPpers have branched out to other health-related studies, such as water management and hygiene. International and national NGOs are employing RAP, particularly for ethnomedical studies on more appropriate intervention designs. Reports came from Plan International's use of RAP in Guatemala and an Indian programme, supervised by Johns Hopkins, that tries to coordinate NGO and academic efforts in health planning. The Heller Keller Foundation applied the technique for vitamin A screening through dietary monitoring, but with very questionable results. There are as yet no reliable indicators to monitor.

We heard reports of rapid, and not so rapid, ethnographic assessments and survey results of various dimensions from UNICEF country studies in Nigeria, Egypt, Oman, and Chad. Several other studies had been postponed because of logistical difficulties, including civil unrest in one target study area. UNICEF staff participating used the conference not only to report results and compare experiences but to learn how to do RAP better in the field and to use the data more effectively for post hoc evaluation.

WHO was less well represented. A session had been scheduled on the use of RAP in relation to AIDS, which was to have been supported by the WHO Global Programme on AIDS; but, as the new director of the programme had disbanded the social unit and de-emphasized social behavioural activities. only one representative from WHO, Manuel Carballo, was present to talk on the subject, and the session did not occur as planned. David Nyamwaya of AMREF, Nairobi, gave an extemporaneous description of their project on AIDS education targeting truck drivers. Laura Ramos of UCLA also described a RAP programme that sensitizes women at risk. Clearly, RAP has critical potential for gaining information rapidly to develop educational and behavioural interventions for populations at risk for AIDS.

The Brown University World Hunger Program is looking for more and better indicators of malnutrition for rapid screening, especially ones that may not be conventional nutrition ones, such as children's school attendance.

Alternative development specialists use RRA to help design and implement more culturally appropriate economic programmes. RRA is a more general development information gathering, analysis, and monitoring method, whereas RAP is more targeted. Participants differed on whether and how they thought one could generalize RAP from one location or group to the next. The promise of the methodology at the local level, however, is that villagers can be brought into a development programme within five days if the appropriate rapport is established and the appropriate materials are used.

In the case of RRA, the idea is to involve villagers in the initial diagnosis of problems and designs of interventions. In RAP, the pattern so far has been to work at the middle-management level to diagnose what is positive or negative in health-related behaviours and programmes and then use this information to engineer programme changes. Thus, RAP is still very much top-down, although potentially empowering to the subjects of an intervention in two senses: First, it transfers power over programme decision making and data collection from the donors to the recipients. Second, it respects the power that is always inherent in the local people and ready to be released if it is not squelched by other forces.

In contrast, RRA is quite explicitly bottom-up. Scarlett Epstein provided a counterpoint to the "putting people first" ethno-methodology by suggesting that rapid appraisals and interventions might best be carried out by professional market experts, although preferably those coming from the local cultures. The audience, by and large, was hostile to this market mentality.

National programmes were represented indirectly through the UNICEF reports, and directly through the report from Indonesia, where Mahdin Husaini and colleagues have been using RAP procedures with great success to monitor health and nutrition conditions and programmes. Husaini indicated that Indonesian village organizations have been instrumental in demanding appropriate health programmes and contributing to their efforts. A USAID-funded Cornell Nutrition Surveillance project that used RAP to identify early indicators of malnutrition was also carried out in Indonesia.

The final two sessions of the meeting focused on training for rapid assessment procedures (led by core RAPpers) and the communication of results (led by a separate group of experts).



RAP staffers are expanding the numbers of manuals providing information about interviewing, focus groups, systematic observations, and checklists. They are "selling" RAP, and an enthusiastic group of buyers exists in the international intergovernmental and non-governmental communities that are anxious to have a rapid means of getting information to and from villagers and urban barrios. Right now, however, RAP is still many things to many people, and it will probably remain that way. The challenge for the core RAPpers is to provide a synthesis of the most important lessons they have learned in the last five years and to serve as resources for national and other programmes trying to implement RAP.

The method expands into new topical areas much more rapidly on a previously existing base. Thus, we can expect that it will enable more rapid programme planning and modification where community input has already been systematized in relation to the health planning. Clearly, the timing of RAP also depends on the cultural heterogeneity of those involved. geography, and the complexity of the issues being approached, as well as on the perceived importance of the issues from the perspective of target communities.

Implications for rapid assessment of health needs, monitoring, and evaluation

Potentially. RAP can contribute to the assessment of needs (what should be done), implementation (who should do it), and how local successes might be evaluated and scaled up. Scaling up includes extending a successful experience with RAP in one area to other topics or areas in a single location or expanding a successful programme built on RAP in a community to a region or nation. Several participants raised questions of scaling up, reliability sampling, and nutrition survey methodology which went largely unanswered. Answering these questions is clearly the next step in RAP in which we might be involved.

Identification of households at risk

We believe that RAP can provide reliable, rapid assessment for most of the hunger-monitoring issues about which concern was expressed at Bellagio. At this moment, however, the assessment procedures for most dietary-adequacy issues are questionable. Relevant reports to examine include an INCAP study reported by Isabel Nieves that used a combination of food-frequency measures and observation to validate seven-day recalls but which was flawed in that it did not have any measure of wastage. A key to this study, as well as others, is to design an appropriate set of RAP indicators to identify households at risk for hunger (or other health problem).

David Pelletier, from Cornell, identified specific qualitative indicators of nutrition risk at the household level. Such indicators as the shift from rice to uncultivated root crops, monitored by village head men in fortnightly reports (in Indonesia), allowed reliable identification of households at risk in time for interventions such as food for work, subsidized food shipments, or seed distribution. The research team did not calculate how widely such indicators might be used. They did, however, compare possible indicators with historical occurrences of food crises, using an interview technique.

In two other country studies, children's low weights for age were stratified by the fathers' occupations. The results stimulated investigation of the occupational conditions of those at risk (in this case, children of sugar workers in Costa Rica), diagnosed water and hygiene as a critical health and nutrition problem, and designed an intervention. In a third case, in Kenya, it was determined that stunting of children under five years of age was 50% greater in households where farmers farmed less than 1.5 hectares of hybrid maize. The investigators targeted the lack of drought resistance of the hybrid maize as a critical variable but need to ascertain through further research if this is the main problem. Cornell calls these qualitative-with-quantitative measures "TWIS": timely warning and intervention systems. They have yet to scale up, generalize, or validate their procedures.


Institutional issues

The RAP technique is another tool to organize communities to participate in improving their health and nutrition as well as sanitation and economic conditions. The NGOs are very interested in it as a way to intervene quickly and monitor. UNICEF sees RAP as a way to obtain standard, quick, short field reports on what is going on. Yet, if it works, it should take away from all non-community-based organizations' responsibility for and ownership of data collection. analysis, and action. This raises a serious question of how far the standard and non-standard organizations will accept such usurpation of their authority and raison d'être. Also, there is a question of how much power national governments would really like to see their villagers assume.

This issue also raises concerns about the standardization of methods. The best and most accepted methods are those developed with the community. These may not be standardized but rather tailored to the particular community's interests and needs. While such specificness takes away from the overall project the commonality on which comparability is built. it may result in more successful local use of methods. Growth-monitoring projects are a good example where tools tailored to local ideas of human development (physical, social, and psychological) have proved to work very well. There is also a delicate mix between RAP with a top-down orientation, RAP with a bottom-up orientation (which might also be construed as mildly paternalistic and romanticizing). and using the best efforts of these different cultural health perspectives to create a unified programme that benefits from diversity. Susan Scrimshaw summed this up by saying that RAP is flexible but perhaps the boundaries of flexibility have to be spelt out.

Several networks need to be established and strengthened, each around a particular type of hunger indicator. Thus, many organizations are trying to carry out rapid nutrition surveillance and dietary indications of malnutrition, but there is no coordination or agreement on the strengths and weaknesses of various indicators for different populations. In particular, such networks and discussions might focus on micro-nutrient deficiencies. The Brown University International Health Institute and World Hunger Program are in a position to try to bring together various actors and activities in RAP to press for better communication on appropriate indicates for diagnosing problems and monitoring improvements.

Future research

We need much more careful assessment of the potential advantages and dangers of RAP. Both RAP and RRA are techniques of social organization. and this social aspect is as important as the aspect of technology (health, nutrition, water) programme transfer, and perhaps much more rapid. What none of the speakers addressed is a sense of how this social-organization model has been adopted and adapted by different communities. They did discuss the fact that it might be threatening to higher-level service and decision making personnel, but it might also be threatening to governments. The promise of community empowerment varies with the issue; for instance. organizing mothers to report on the strengths and weaknesses of primary health care provisions differs from organizing villagers to identify rural agricultural, water, credit, and market needs. But such aspects of villagers' assuming power vis-à-vis those who would provide (top-down) programmes is important as an aspect of building sustainable programmes and building on local initiatives.

Finally, RAP should be able to provide some general criteria of scale and validation in health and nutrition projects.

Relevance for anthropologists

In addition RAP should provide some important data for anthropologists who seek to understand the dimensions of variability by which culture might be assessed rapidly. In the 1930s, American archaeologists and cultural anthropologists developed a checklist of culture traits by which they might describe and compare cultures in North and Middle America. This approach was soundly criticized and abandoned over the next 30 years. Today, with RAP, medical anthropologists are creating new kinds of culture trait lists that may or may not be appropriate for understanding health and nutrition behaviour over time, space, and other cultural dimensions. Clearly, the anthropologists who were part of the original core RAPpers, as well as other interested parties, have an important task as they seek to link RAP to the rest of anthropology.



1. Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care: anthropological approaches to improving programme effectiveness. Los Angeles, Calif, USA: UCLA Latin American Center, 1987.

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