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Protocol procedure

Part I: Training exercises
Part II: Data collection
Part III: Applying data to programs

Part I: Training exercises

To be Conducted During the Two Week Training Period

Exploring the context of women's health
The domain of women's illnesses
Exploring women's health-seeking behaviors

Exploring the context of women's health

Unit 1. Direct Observation: Community Mapping and Resources

Purpose

The purpose of this unit is to examine the context of women's health in the study locale. Doing direct observation is also an easy first step in getting to know the people of the community and their living conditions.

Data Collection

1. Take a Walking Tour of the Study Area. You may consider using a knowledgeable local person as a guide. With a note-pad and pencil in hand, walk around the area. If the study area includes several communities or one large community, severe trips may be necessary. Depending on the size and complexity of the community to be investigated, different research assistants may be assigned to tour the various parts of the study area, or to focus on specific features.

2. Make Brief Notes During the Walk. These notes should comprise a running description of the walking tour. This data set is exploratory in nature and all observations should be recorded. You may wish to count some items (number of health providers, herbalists, shops, etc.). In particular, record information on the following features:

a. Community Type: (urban, suburban, semirural, rural, dispersed, compact).

b. Public Transportation: type, availability, and cost (train, bus, waterway, other).

c. Distances: (e.g., from residential areas to the central plaza, local schools, markets, health clinic, source of water, firewood, agricultural fields, etc.).

d. Weather conditions during day of observation.

e. Local Health Resources: doctors' offices, herbalists' shops, clinics, etc. (including those located outside of the community that are used by community members). Describe the types of medicines displayed in different shops.

f. Major buildings and other features (schools, government offices, central parks, health facilities, hospital, etc.).

g. Condition of streets, pathways, walls, local buildings, and houses.

h. Evidence of economic variation (house sizes, number of windows, roofing materials, etc.).

i. Evidence of sanitary and unsanitary features (standing water, presence of human/animal waste, etc.).

j. Sources of water (lake, river, well, pump, faucet, etc.).

k. Religious buildings (churches, temples, mosques).

l. How are houses grouped? By ethnic group? Religion? Economic status?

m. Did you meet anyone? How did they interact with you (friendly, suspicious)? Be sure to write down names and descriptions. All contacts are potentially important.

3. Sketch a Map. Produce a map of the research area/ community, using two facing notebook pages. If the community is small, you may be able to draw every house on the map. Later on, as part of a key informant exercise, ask a local informant (or group of informants) to draw a map of the community. This technique can provide many insights in terms of local people's perceptions of what features are important.

Data Analysis

Microcomputer Application (optional)
The expanded notes (except the map) can be typed into the computer and accessed using text management and searching software (see Appendices C1-C3).

1. Write Up Expanded Field Notes. This will mainly take the form of a redrawn map. Expand on specific features of the map in greater detail.

2. Code the Observations. Coding for topics. What are local markers for differences in economic status?

3. What types of local healer/health practitioners did you observe?

4. Draw a preliminary version of the map of the community. You may wish to draw several versions, each emphasizing different important features. Use Form 1.1 to record your community diagram. Use additional (larger) pages if necessary. Make a key for selected important features.

Interpretation Suggestions

1. The analysis should allow you to formulate some of the questions to be investigated in other units of this protocol.

2. Which kinds of people appear to have greater or less access (in terms of distance or other parameters) to different resources?

3. What physical groupings of different types of people do you observe? How does this relate to housing type? To location of nearby resources?

4. How does the type/availability of health resources vary by section of study area?

Unit 2. Key Informant Interviews with Local Healers and Other Knowledgeable Persons

Data Collection

1. Develop an Ethnographic Field Guide concerning Local Healers (see Form 2.1 for example). An ethnographic guide is simply a series of questions organized by key topics. These questions are used to guide interviews, but the interview should never become a formal "question-answer" session. The interview guide should not be followed precisely, but rather the topics in the guide should be introduced into the conversation in an informal manner. The interviewer should move to a new topic when the previous topic is completed.

Some suggested key topics for the interview are:

• Community/household organization

• Women's status/power

• Female "ethno-physiology" and "ethno-anatomy" (physiology and anatomy from the emic point of view)

• How women perceive their bodies, health

• Illnesses - general

• Illnesses - women's (by developmental stage, cause, symptoms, treatment, etc.)

• Childbirth - intrapartum, postpartum

• Diet - general, during pregnancy, during lactation

Note: These are very broad topics and would be far too much to cover in one interview. The best approach would be to schedule several interviews with each key informant and cover a smaller number of topics in each interview.

2. Select Key Informants. Select four to five knowledgeable key informants. These individuals may include persons who treat women's health problems. It is also important to select women who are not "specialists," but who are able and willing to discuss women's health problems perhaps because they have good social contacts with many people.

3. Interviewing. Form T1.1 presents a general guide for conducting key informant interviews. See the trainer's guide for detailed comments on how to conduct key informant/in-depth interviewing (Appendix A- 1).

4. Examples of Specific Questions about this Practitioner's Practice:

Follow-up comments made by the healer about women's health problems with probing questions. Insert the following questions into T1.1.

Data Analysis

1. Expand Your Field Notes. Write the notes out fully, using direct quotes and actual terminology in the local language whenever possible. In many cases, you will need to translate your notes from a local language (e.g., Rajasthani) into a language suitable for communication with a larger audience (e.g., English). When doing translation, it is important to record key terms (e.g., illnesses) in the local language while translating their meaning in English.

2. Identify Significant Themes. Make a list of important themes⁶ that will later be developed into codes.

3. Develop Data Presentation Matrices. For example see Form 2.2. Many different types of data can be presented in matrix form. Consider inclusion of significant quotations m the matrix to illustrate key findings.

⁶ Key Definition
Theme: An important generalization, recurrent feature, or special pattern of behavior or events. Examples: "Women mostly get sick because of problems they have with their husbands," "Only the poor women get sick here," "Most women's sickness starts after they have children," or "Women never go to get health care until they are too sick to work".

FORM 2.1
Ethnographic Guide: Interview with a Practitioner/Healer who Treats Women's Illnesses

Start with general, friendly talk about the town, crops, etc.

"How long have you been treating (healing) people here in the community?" "What kinds of women come to see you?"

"What are some of the main kinds of illnesses that you treat?"

"Can you give me a "case" - for example, the condition of a woman you have treated recently. What was her problem? What caused it? What was your treatment of it?"

"You mentioned the case of a difficult childbirth that you personally attended. Could you describe the entire event from the beginning?

The informant may talk about the clients, their illnesses, or some other feature that is most salient to him or her. Probe on issues that the informant brings up. In addition, probe about socioeconomic status, caste, clients s/he enjoys, clients s/he would rather not see.

Examples of probes:

"You just mentioned that women have illness x. Can you give me an example of that?"

Other probes:

"Is that case "one-of-a-kind," or are there many? Can you give me a contrasting case?"

Source of payment

Depending on the research questions, it may or may not be appropriate to find out about how this healer is paid by clients. This question might actually be better to ask of clients, because while exploring questions of payment, questions of motivation for going to different types of practitioners can also be explored. If the question about payment is addressed to the healer, it may be phrased as follows:

"What are the fees you charge for services? For treatments? For medicines? Can clients pay over time? In kind?"

Terminology for Talking about Women's Health

"How do you talk to a woman who comes to see you about her concerns? What is the best way to get her to tell you what you need to know about her concerns?"

"What might be something she would say (What words is she likely to use?): About her health? About economic problems? About family worries?

"Would a woman say or when talking about personal matters?"

"How would a woman talk to you about something if she is shy? What would you say to encourage her to talk about her problems?"

Interpretation Suggestions

1. Observe the work and treatment patterns of reported practitioner specialties. Are some individuals known for treating certain types of conditions? For instance, illnesses of the stomach, or illnesses caused by witchcraft. Do some practitioners treat a greater variety of illnesses than others?

2. Rank the practitioners in order of most likely to treat women's problems (a subjective view). Are there any of these practitioners you have trouble putting in order? Perhaps you need to do return interviews with these individuals to clarify your understanding of their practices.

3. What local terms best represent categories as recognized by women? What is the most appropriate term for "problem" to be used in the next unit on free listing? What terms best indicate "illness," "complaints," "symptoms," "signs"?

DATA ANALYSIS FORM 2.2
Sample Data Presentation Matrix (sample)

Instructions: Fill out the following matrix on health providers interviewed in the community. Use local terms and expressions whenever possible.

Unit 3. Free Listing of Women's General Problems In the Community

Purpose

1. To determine the items that make up the domain of "women's problems." It is likely that health problems are only part of this domain. Other concerns that may be included are: "social" problems (e.g., divorce), drug problems (e.g., alcoholism), and/or "development" problems (e.g., lack of a local health post or primary school). Identifying the full range of perceived problems is important, because it will later allow us to see the relative importance women attribute to their own health problems.

2. To document locally used terminology about women's problems. This is the basis for further work, including more structured interviews. It is essential to compile a "working vocabulary" in order to employ language that is well understood by the local people. Also, the exploration of the systematic relationships among terms, the beliefs related to causes and solutions, and episode narratives that may be elicited will provide the basis for construction of the explanatory model(s) of women's problems.

Data Collection

1. Prepare Task Materials.

Translate the following questions into the appropriate local language(s) and use as shown in Form 3.1.

A. [Main Question] "What are the problems that women have here in (name of community/area) ?"
_______________________________________
_______________________________________
_______________________________________
B. [Probing Question] "Are there other kinds of (problem type)?"
_______________________________________
_______________________________________
_______________________________________
C. [Secondary Question] "How does a woman know she has (problem type)?" or "What does a woman do when she has (problem type)?"
_______________________________________
_______________________________________
_______________________________________

2. Select Respondents: Pre-test the procedure with four to five women. These individuals could be the key informants from Unit 2. Revise the questions if they are unclear, offensive, or if there are any other difficulties with them. Generate free lists of women's problems with 12 to 15 respondents. Select respondents who represent different sections of the study community. These women should be drawn from the client population and should represent a range of ages, economic status, ethnic backgrounds, and/or other relevant factors. Respondents should be relatively knowledgeable and willing to participate. Form 3.1 should be used for data collection.

3. Suggested Wording: There are several ways to begin a free listing of terms with informants. Starting with the general term for "problem," one might inquire about different types of women's problems. A good way of phrasing the question in English might be: "What are all the different problems that women in this community experience?" The selection of an appropriate term for "problem" is crucial and should have been fully explored earlier when doing key informant interviews during Unit 2.

If the informants are not accustomed to listing phenomena it may be necessary to probe. The interviewer might ask, for example, "You said that X and Y are different problems experienced by women in the community. What are some other problems?" (As a general principle of good eliciting style, don't ask "Are there other problems?," but rather, "What are the other problems?") You may also ask about the seasonal variation of problems or those faced by women of different ages.

Look for special words, or parts of words, that reoccur in describing different problems. For example, if a woman reports family worries, money worries," and "health worries," then ask "Are there any other kinds of worries?" A similar query might be, "Can you tell me - list for me - all the different kinds of worries?" This is an example of a probing question that may result in a more complete free list.

Some women may report women's problems only in terms of their own problems. Clues that informants are only reporting personal experiences would be if they say, for example, "Well, I have had (problem x)," or in response to a probe, "No, that's all the problems I have had." In this instance, it would be useful to also ask the woman for a list of women's general problems, or those faced by other women in the village, after she has fully listed her own problems.

In the initial free listing exercise it is valuable to generate as large a list as possible, in order to cover the full domain of terms and concepts that pertain to women's problems in the community. Within this broader domain, it is also important to clarify which problems most women have. Some women may list particularly severe or unusual problems. Do not, however, prematurely "censor" or restrict the list until a round of interviews with informants has been completed. It may be that the category "women's problems" is not sharply delineated in the culture.

The best results come from a flexible use of this method rather than rigidly following the interview. For example, an informant may spontaneously go on to give both causes and solutions in connection with a single term, once she or he understands what the interviewer is after. Remember this is a "free listing" process and a spontaneously elicited comment from an informant may be of critical importance, even if it does not "fit" with a preordained interview format.

Once you have compiled a complete list, you may ask a further question about each item. Selection of an appropriate "further question" will depend on the research thus far. Possibilities include "What happens when you have _?" or "What should a woman do when she has _?" Start with the first item and move down the list.

4. Recording the Data. Use Form 3.1 to carefully record the answers to the free listing. It is important to fill in the left hand column completely before moving on to the further explanations of each problem. Respondents may limit their responses to an initial question if they realize an extensive subsequent question will be asked. If possible, these discussions should be tape recorded, so that the written notes can be checked for correct pronunciation and transcription or terms.

Data Analysis

Microcomputer Application (optional)

These data can also be analyzed using the Free List feature in ANTHROPAC.

Once there are a considerable number of terms, they can be systematically analyzed by tabulating responses. Form 3.2 provides an example of a data analysis sheet that can assist in this task.

1. Tabulate Problems of Women on Form 3.2. Be sure to use the terms that the women actually used in their own language. Do not combine terms, unless you are absolutely certain the two are virtually identical in meaning. It is always best to be cautious in this regard, by keeping the terms separate if there is any doubt about their different meanings.

2. Count and record the number of informants who mentioned each term.

3. Rank order items, based on the frequency of response, from most frequently to least frequently mentioned (see Form 3.2 for example). You may wish to include a percentage column, in order to compare the free list tabulations.

4. Sort the women's problems into broad categories such as "health related," "status related," etc. If a large number of terms have been elicited, the categories may be further subdivided. Tabulate solutions to different classes of women's problems in a new table.

5. Prepare tables which show the full list of terms and the number of respondents who volunteered each term. Re-examine the list of terms that were eliminated and check to see which informants offered them. Although few informants may have mentioned a given term, the list might yield some clues for follow up. For example, it may be the case that some terms are known only by older women or some only by the more well-educated. Even if these terms are not used later in the pile-sorting exercise in Unit 5, they could be examined further during the course of the study. The community health practitioners might benefit from knowing more about them when communicating with patients' families.

DATA COLLECTION FORM 3.1
Free Listing of Women's General Problems (sample)

A. What are the problems that women have in (name of community/area)? (COMPLETE BEFORE MOVING ON TO QUESTION C)

Interpretation Suggestions

1. Examine the distribution of responses. Items that are mentioned by all of the informants are probably very common, and/or are centrally important to that domain. Items that are mentioned by only one or two people are likely to be less widely known and used in the community.

2. A common finding is that the list of health-related problems or illnesses is quite a bit more broad than you would have expected originally.

3. How commonly are health problems and illnesses mentioned during this exercise? Do women seem to focus on health issues as major problems, or are they more concerned with social issues (e.g., alcoholism, wife beating, etc.)?

DATA ANALYSIS FORM 3.2
Free Listing Tabulation of General Women's Health Problems (sample)

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