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This article discusses the development of a simplified RAP (rapid assessment procedures) anthropological field guide for health care providers at the local level. The main purpose of the field guide is to help health care providers to learn what the people in the community know and do to maintain health and prevent and cure illness as well a' why they do it so that they can incorporate that knowledge into their health care activities in the community.
In 1987, 16 social scientists from the Central American countries and Panama gathered in Guatemala to exchange experiences using rapid assessment procedures (RAP), an anthropological methodology, in their research. One of the conclusions of the meeting was that, while low-cost, convenient medical services are needed, their physical availability and economic accessibility should not overshadow a concern for their cultural acceptability. Furthermore, a recommendation of that meeting was that health personnel should be acquainted with local conceptions of health and illness and patterns of treatment choice, and that a simplified RAP methodology should be designed and implemented for that purpose.
Involving health care providers in health behaviour studies could help them improve health care and nutrition programmes. This could be achieved because the problems studied would emerge from the communities and programmes themselves; information would be obtained on current conditions, not after the fact; feedback would be continuous; and the results could be applied to the programmes themselves.
In Central America, the ministries of health have become more interested in obtaining qualitative information that will improve the planning and process of public health programmes at the local level. This is partly due to research findings using RAP. In these countries, only a few persons are already trained in anthropological methodology, however, and fewer still in its application to the fields of health and nutrition. Thus, the current RAP guide [1] which is intended for use by persons already trained in anthropological or related field methods, is of limited use to health care personnel at the local level.
In conjunction with the Institute of Nutrition of Central America and Panama (INCAP) Child Survival Project [2], we initiated activities to design and implement a simplified rapid anthropological assessment manual for use by health workers at the community level. This field guide will enable village-level primary health care personnel to gather information needed to strengthen local capabilities for programming and implementation of health, nutrition, and other necessary interventions.
A simplified anthropological field guide for health care providers (health volunteers, health promoters, auxiliary nurses, and rural health technicians) in Guatemala has been designed in the form of a booklet, with drawings by health promoters. Its format follows the style of a series of educational booklets for health workers that were previously developed by the INCAP Child Survival Project. This guide is entitled "What Every Health Worker Should Find Out about the Community Where He Works".
The guide is organized into four sections: (1) the purpose of the simplified anthropological field manual and a guide to its use, (2) the relevant questions for health and nutrition programmes, (3) how to obtain the answers to those questions, and (4) what to do with the information once it is obtained.
The main purpose of this field guide is to help health care providers learn what the people in their community know and do to maintain health and prevent and cure illness and the reasons why they do it, so that they can incorporate that knowledge into their community health activities. The instructions given for using the field guide are simply to read each page slowly and carefully, to select a theme (a relevant set of questions in one of the health and nutrition areas) for investigation, and to follow the steps on how to obtain information and what to do with the information once it is obtained.
Since this field guide was designed under INCAP's Child Survival Project, the relevant questions outlined in the guide are included within the following child survival areas of information: pregnancy and delivery, infant and child growth, infant and child development, breast-feeding and weaning, food (availability, accessibility, preparation, and feeding), immunizations, diarrhoea! diseases, oral rehydration solutions, respiratory infections, feeding during and after an illness, and communication.
A minimum number of questions are posed under each theme. In addition, relevant questions focusing on key social, economic, and cultural variables are included under general themes such as "My Community" and "My People". Finally, questions regarding all existing health care resources in the community (popular, traditional, and modern) and health problems are grouped under "Health Providers" and "Health Problems".
To obtain the answers to these questions, a simplified RAP methodology is presented. First, the custom, or what the health care providers already know about people's knowledge and behaviours by virtue of being members of the community, is discussed, pointing out advantages and disadvantages of that knowledge. Techniques for qualitative data gathering, such as observations, interviews, and group discussions, are also presented in a simplified form.
Emphasis is placed on the need for a written summary of the answers for each of the relevant questions. Since health care promoters in distant communities are usually not able to write well, however, it is recommended that they give oral presentations of their findings to the health team and that the answers be recorded when possible. Teamwork is encouraged throughout the field guide.
Once the information on one area is available, it is suggested that it be classified into positive (beneficial to health) and negative (harmful to health) knowledge and practices. Since it is not always easy to classify a given practice, team discussion is again recommended. Health education should be focused on changing inappropriate knowledge and harmful practices. The method recommended is through group meetings and trials to enable discussion and analysis of the feasibility of changing a certain practice. Also, the use of games, songs, other folk media, and role playing is suggested as well as the use of all communication channels identified in the community.
Communities often see other problems as more urgent than health problems per se. Therefore, health care providers are advised to become involved in community organizations and to participate in helping to solve the most urgent problems (even more so if they are health related, for example, lack of tap water or lack of latrines). Health education and other health activities can be started more effectively if they revolve around an issue people consider central to their needs and are linked to community development.
The manual was pre-tested with focus groups comprising health care providers from different parts of the country. The purpose of this testing was to answer the following questions: Is each page of the field guide easily and correctly understood by most health care providers in each group? Can health care providers readily identify what they are being asked to do? Do they think that they can perform what they are being asked to do? Would they do it? That is, do they have the interest, the time? Do they think the field guide is for health care providers like them or for someone else?
The text was modified based on the information provided by the health care providers, including the suggestions they offered, such as illustrating the field guide with pictures drawn by them.
The first and most important obstacle to the implementation of the field guide by health care providers is their previous health training. In general, training courses for health workers focus on the idea that they are agents of change, that is, that they have to change the ways of the people in regard to health and nutrition. They have seldom been told that they first need to learn what people believe, feel, perceive. and do; nor are they made aware that there are valuable things to be learned from what people traditionally think and do.
Therefore, no matter how explicitly the field guide states that the purpose of using it is to find out about people, not to advise them, health care providers tend to regard it, at first, as a reference guide on how to advise people while conducting home visits. In fact, the distinction between the home visits conducted to collect data for morbidity reports, follow-up, reference. or health education purpose and visits for obtaining qualitative information needs to be clarified. Home visits should be complemented by qualitative data collection.
With this purpose in mind, we observed and documented the interaction between community health workers and mothers during home visits. These observations revealed that both health promoters and families engage in a routine that is not conducive to health education, much less to obtaining relevant qualitative information. For example, health promoters gave the same advice to all the families visited, without asking about or noting current health problems, while mothers politely thanked them for the advice. Yet, once the purpose of the field guide is understood, health care providers can easily recognize that the issue is getting to know local conditions and local health and food customs. Furthermore, health care providers can readily point out emic/etic views (i.e., insider/outsider perspectives) of health problems and solutions and thus realize their unique position of being able to understand both as well as the dilemma that this sometimes represents.
Training in the field guide and conducting research can take place simultaneously. This works better if only one topic or area of information is selected at a time. The topic can be based on specific health problems present in the community. For example, pregnancy, childbirth, and the postpartum period could be the subject of choice in a community with high maternal, perinatal, and/or neonatal mortality, whereas immunization could be selected for a community with low vaccination coverage.
Once the topic has been selected, all the steps outlined in the guide are followed with that topic in mind. These steps include the following: determining the relevant questions; determining the relevant informants; studying and practicing the techniques used to obtain information, obtaining the information, writing it down, and presenting it orally or recording it; making lists of positive and negative knowledge and practices; and meeting and making decisions to incorporate the findings into local programming and personal plans of action.
The simplified field guide has been used by several private voluntary organizations in Guatemala. Its application is currently being monitored and will be evaluated. It is expected that the simplified RAP guide developed under the INCAP Child Survival Project will be used by community health care providers in other Central American countries and Panama to improve their primary health care programmes. The commitment by governments to local planning and decision-making is crucial, however.