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Differences among villages

As shown in Table 1, there were marked differences among the three Posyandu consistent with the prior ratings of their performance. The participation of mothers in the weighing procedure in each of the villages is given in Table 2.

In Lemoh village, the close contact and cooperation among the three components and their activity (Puskesmas leader, village leader, and PKK leader) significantly improved the quality of services, and that village was evaluated as the best in North Sulawesi province in 1989. The Lurah in this village understood well the concept of growth and health, and he knew how to read and interpret the growth chart in terms of weight gain for its age. If the child was growing well, the Lurah recommended regular maintenance visits to the Posyandu. If the child was not adequately gaining weight, he advised bringing the child to the Puskesmas for medical help or having a consultation with the Puskesmas staff or kadre. It is not surprising, therefore, that the mothers in Lemoh village understood the concept of monthly weighing better than the mothers in the other two villages. Nobody in Lemoh village went to the Dukun (supernatural tradition healer) to ask for help to cure an illness.

"Focus group discussions" with key persons in Lemoh village (sub-village leaders, PKK, teachers, religious leaders, school principals, heads of hamlets), showed that they recognized the importance of the Posyandu for the benefit of the community. They claimed there, that the health status of the people had improved, the children were growing better, and the infant mortality had been sharply reduced - indeed they had not heard of even a single infant death in the past year. The factors accounting for this situation were the people's understanding in this village that good health is desirable, that mothers should bring their children to the Posyandu regularly, and effective improvements in environmental sanitation.

In Walian and Sukur villages, husbands did not pay much attention to the growth charts because they considered this to be more women's business. But, in Lemoh village, husbands were always keen to see the results of weighing. They understood the growth chart, and the implications of gaining weight or not gaining. They stated that the way to follow the development of their children was to watch the growth chart. They were happy if their children gained weight, and unhappy if they did not.

In all villages, the child had priority for food distribution in the family and parents gave more food to the child to enhance weight gain. The mothers in all the villages studied hoped that the kadres could demonstrate in a practical way how to make nutritious foods for infants, not only by explaining food models. Most mothers found it difficult to practice the kadre's advice in their homes.

Management of growth monitoring

In 1982, when growth monitoring was introduced, a general meeting was held in each village hall to identify persons who had the capability of becoming a kadre (village volunteer). The Lurah invited PKK members to discuss the issue of volunteerism, and asked whether they would be willing to be nominated as kadres. Only women should be selected, because they were most responsible for the welfare of children.

The selection criteria were:

• residence in the villages,
• preferably married,
• literate, and
• acceptance by the community.

Nearly 50% of the trained kadres were no longer active, because of moving outside the village, family problems such as pregnancy, child feeding, etc. New kadres were then selected to replace them, and also to fulfill the needs for more kadres in new Posyandus.

Three-day training sessions for approximately 30 participants were held in each village to provide knowledge and skill, and foster a belief in the usefulness of growth monitoring to secure commitment by the community. Most training consisted of "learning by doing," practice on weighing, plotting cards, interpretation of the care, recording the information, counselling, referring system, and other activities related to the Posyandu. Each participant was provided with a growth monitoring manual. The trainers were personnel from Puskesmas, the Department of Agriculture, Family Planning, PKK and the local government.

The competition to test knowledge and skills is organized by the PKK every year. By doing this, kadres are motivated to perform activities more efficiently. They prepare themselves by reading manuals more often and discussing their experience. Another way to improve the kadres' performance is to learn by doing, particularly for untrained kadres during the Posyandu session. The Puskesmas personnel continue to teach the kadres competency in weighing, interpreting the card, and in nutrition counselling.

Lemoh village was ranked the best in the North Sulawesi Province in 1989. This village had the best Posyandu in terms of services, the reporting system, and nutritional and health status of children. Key persons were responsible for motivating mothers and facilitating the location of Posyandu; the community was responsible for funding the food supplements; and the Puskesmas was responsible for providing immunization, supervision, and for motivating community participation.

The kadres in Lemoh village received free services at Puskesmas. In the other Puskesmas, only a few of the kadres received such services. (The usual charge was Rp 500, or US$ 0.35 per person per visit.) To sustain the motivation of kadres, this kind of reward needs to be provided for all kadres in all villages. Another reward might include field visits to another district, to observe activities similar to their own. Trips like this give kadres an opportunity to exchange experiences and return home with a greater pride in their work. Also, visits from government personnel and from other high-ranking organizations help to build confidence in both kadres and supervisors.

The PKK in Lemoh village had generated income by fund raising, e.g., selling foods to families in the villages, exhibitions, traditional music shows, etc. This gave them adequate funds to maintain their activities such as providing food supplements at the Posyandu, or to provide uniforms for kadres.

In Walian and Airmadidi villages, children aged 0-12 months regularly visited the Posyandu. After one year of age, they did not visit the Posyandu every month because they had completed their vaccinations. Mothers only brought their children to Posyandu for vaccination, not for growth monitoring. On the other hand, in Lemoh village, the mothers brought their children regularly up to the age of three years, even though vaccinations had been completed at the age of one year. They understood the benefits of weighing as well as vaccination. They believed that weighing was important for promoting better child growth and intellectual capacity; children became more active, appeared better, and were rarely sick.

In all three villages, attendance of children above three years of age was significantly less. According to the mothers, the scale was not suitable for them; the children did not like it and they ran away when their mother tried to bring them to the Posyandu. Although growth cards were amply available at the Posyandu, there were also private growth cards produced by food companies (Sun, Promina, Nestle) containing commercial infant food advertisements. These were found in Walian and Airmadidi villages. In Lemoh, all private growth cards were replaced by the original card produced by the Ministry of Health. The growth pattern of children using private growth cards was worse than that of other children. By the age of six months, most of their growth curves started going down, crossing the undernutrition line by the age of nine to 11 months.

Commercial infant foods are too expensive for most village families to buy in adequate amounts. Most infants who eat these refined foods refused to eat locally available foods, probably because the commercial foods were more palatable. Childhood experience strongly affects the development of food habits [2]. Therefore, children may develop a preference for refined foods which, in the long run, may cause problems with diversification in their food selection.

In all, Posyandus mothers are expected to pass in succession to each of five tables:

table 1: registration
table 2: weighing
table 3: recording weights and plotting cards
table 4: interpreting and counselling
table 5: immunization

These activities are scheduled at each Posyandu's session in 911 villages, every month. The announcement to remind mothers to bring their children to Posyandu is also made by the Lurah over a loudspeaker on each attendance day.

In general, weighing was done hastily without making sure of a stable point. There were almost always errors of several hundred grams. There was also not enough care taken in balancing the weight of the children; this resulted in an overestimate of children's weights by 200 to 600 grams. The most difficult tasks for kadres were interpreting growth lines and nutrition counselling. These tasks were almost always done by the most senior kadre (Table 1). In Walian, we observed that this task was taken over by Puskesmas personnel (health workers).

In all villages, growth cards were taken by the mothers and retained in their homes. In Walian, kadres frequently complained of lost cards, and several looked very dusty. The mothers had little incentive to pay attention to the cards except as a record of immunization. We observed during home visits that lost cards were used as a reason for not coming to the Posyandu. In Lemoh the cards were rarely lost.

During home visits we did observe growth cards of the children. In Lemoh, 74.0% mothers brought their children more than four times to Posyandu compared to 62.0% in Sukur (the good Posyandu), and 48.3% in Walian (the fair Posyandu).

In general, 95.2% of the children were brought to Posyandu by their mothers, and only 4.8% by others such as grandmothers or relatives. These opportunities should be used effectively by kadres to give nutrition and health counselling, because the mothers who were responsible for taking care of the children were the ones who attended the sessions.

Table 1 summarizes the characteristics of Posyandus in each village. Conditions surrounding weight sessions, registration (table 1), weighing (table 2), recording (table 3), counselling (table 4), and immunization (table 5), were different in each Posyandu. In Lemoh, the kadres performed the tasks better than kadres in Sukur; and kadres in Sukur performed the tasks better than those in Walian. In Walian, there was no kadre to record weights or plot curves in table 3. The kadre's position was taken over by a Puskesmas worker and he did all the plotting, recording and immunizations. According to the schema, immunization should be carried out in the last table (table 5), but in this Posyandu it was in table 3. There was no nutrition counselling given at Posyandu in Walian, but a speech was given at the beginning of the weighing session to remind mothers to come to Posyandu the next month, to motivate them to come regularly, and to recommend family planning.

In Lemoh and Sukur, nutrition counselling was given by kadres in table 4. For a child whose weight was increasing, the kadre advised the mother to continue feeding the child the same food in greater quantity to allow for growth. If a child had lost weight, the kadre determined whether the child was sick. If so, she recommended that the mother bring her child to the Puskesmas (Community Health Centre). The mother was advised to give more foods and more diversified vegetables. For children under one year, the emphasis was on breast-feeding, and more nutritious infant foods such as "nasi tim," composed of soft steamed rice mixed with vegetables, beans, tofu, tempeh, chicken liver, or meat. The PKK (family welfare movement) plays an important role in more effective functioning of Posyandus, as observed in Lemoh village.

Table 1. Characteristics of Posyandus

Table 2. Frequency of Visits in the Last Six Months

FREQUENCY OF MOTHERS' VISITS

The PKK in Lemoh raised more money from their communities for food supplements, uniforms, etc., and they had better physical facilities provided by the hamlets. This is to some extent due to the more active participation of the village leader (Lurah) and more cooperation by the physician head of Puskesmas. Out of these studies emerged a set of practical evaluations and recommendations for improving the growth monitoring programme.

Acknowledgements

The authors wish to express their gratitude to Mr. P.S. Widodo, Mr. M.E. Pascoal, Miss A. B. Montol, and Mr. R. Rachman who conducted data collection in the field.

Endnotes

1. Scrimshaw NS, Husaini MA, Scrimshaw MW. A comparative exploration of the determinants of infant mortality in Lombok (NTB) and D.I. Yogyakarta. Report to the Ministry of Health R.I., 1990; available from the UNU Food and Nutrition Programme office, Charles St. Sta, P. O. Box 500, Boston, MA 02114-0500.

2. Government of Indonesia - UNICEF. Situational analysis of children and women in Indonesia. December 1988, revised April 1989; available from the UNICEF office, Jakarta

References

1 Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care. Anthropological Approaches to Improving Programme Effectiveness. Los Angeles: UCLA Latin American Center, 1987.

2. Surbakti S. Husaini MA, Husaini YK. The pattern of feeding and the nutritional status of infants and children in Indonesia. In: HKA Visser and Bindels JG, eds. Child nutrition in South East Asia. Dordrecht: Kluwer Academic Publisher, 1989.

9. Applying RAP in Cape Verde, Africa and in poor areas of Rio de Janeiro, Brazil

The Cape Verde experience
RAPing in the periphery of Rio de Janeiro: Application of anthropological procedures to the assessment of programmes of nutrition and primary health care
Endnotes
References

By Clarice Novaes da Mota, Ph.D.

Clarice Novaes da Mota is an Adjunct Professor at the Instituto de Filosofia e Ciencias Sociais, Universidade Federal de Rio de Janeiro (UFRJ), Brazil and also a visiting scholar at the Department of Anthropology, University of California, Berkeley.

These descriptions of RAP in Cape Verde and Brazil were abstracted from a more comprehensive paper on the author's experiences with the methodology that was presented at the conference. A second abstract has been placed in the section on training in this volume for the sake of organization. This experiential analysis of the application of RAP to determine the impact of a programme for training traditional birth attendants in Cape Verde demonstrates the flexibility and practicality of the methodological approach when there are both time and language constraints. - Eds.

MY MOST MEANINGFUL experience with the application of RAP was in a Portuguese-speaking African country, and not in Brazil. Apparently a contradiction, this fact illuminates the possibility of applying RAP even when it should be more difficult or awkward to proceed with a rather quick evaluation when the context is almost totally unknown to the investigator.

The Cape Verde experience

RAP's pre-determined but flexible research structure proved to be extremely helpful in the planning and conduct of a rapid evaluation of Cape Verde, Africa. RAP allowed the researcher-evaluator to use a small sample to provide reliable and valid data. Cape Verde was a challenge: it was a new place for this researcher and the main language spoken was a mixture of African dialects and old Portuguese, with which I was unfamiliar. The study period was only three weeks during which the training of traditional birth attendants (TBAs), a programme organized by the Health Ministry and partially sponsored by UNICEF was to be evaluated.

The setting

The Republic of Cape Verde is situated in West Africa and is composed of an archipelago of nine inhabited islands some 400 miles from West Africa. The islands are geographically divided into two groups - the northern (Barlavento) and the southern (Sotavento). We stayed in the Sotavento island of Santiago, where the national capital - the city of Praia - is located and where half of the nation's population lives.

The research

The evaluation, done in February 1989, had two foci: to determine the impact of the TBA training programme on the target population and also to evaluate a training plan, determine the number of TBAs trained and review training materials. The evaluation would review pre/post tests of TBAs, access knowledge gained, evaluate the supervisory system and, from the qualitative point of view, explain the fundamental sociological factors that permitted such activities to occur.

There was very little documentation on TBA activities. The UNICEF Plan of Operations 1986-1990 stated the objectives of the TBA programme as being two-fold: (1) to increase the coverage of trained TBAs to 100% for Santiago, and (2) to train 30% of all TBAs in the rest of the country by 1990.

Therefore, a selected number of TBAs was to be interviewed to determine knowledge and practices. An initial activity was to define the sample to include interviews with: (1) health personnel, mainly the ones responsible for the training, and (2) the women who had given birth attended by a trained TBA, and an untrained TBA, and at any hospital.

The work was divided into three main areas: the capital city of Praia, the interior around the village of Achada, and the other side of the island, a beach area known as Tarrafal. I was helped by two people in Praia: a male nurse, who trained the TBAs, and a female social worker. The latter proved to be more helpful because she did not have the drawback of being identified as a trainer. With her, the women relaxed and did not feel that they had to put in a good word for the training programme. In the interior, another male nurse accompanied my visits with local TBAs. A total of nine recycled TBAs on the island of Santiago, where 82 women had been retrained.

Using local interpreters, in-depth interviews were done based on guides for "health providers." The UNICEF medical doctor asked questions on medical aspects of the TBAs and health agents. I learned with her what to ask, and I suspect that she learned with me what to ask in other areas.

A difficult task was to interview the clients in hospitals and clinics, as there was no time left to go to their homes. I opted to interview them in waiting room situations and using the "exit interview." I was also able to do a focus group at the hospital in Praia with 12 women present and one nurse as the translator. In fact, all the rules for a focus group were broken at that meeting; it was actually a very formal gathering that ended up in an informal chat in two languages. I, the facilitator, missed a lot of what was going on because of the language barrier. But, the session did provide insight into the clients' perspective of health services, mainly associated with hospital births, that had not been acquired in other interviews. In this situation the clients appeared to feel "important" and that their opinions of services really mattered, thus they spoke freely of complaints, suggestions and problems that had not been clear before.

Main research results

It was found that most women still prefer home births with the assistance of a TBA over going to the hospital, even though Cape Verde's Health Ministry is working to give good, reliable assistance. The ministry's efforts to train birth attendants throughout the nation were apparent. It was recommended that a more rigorous programme of supervisory training of TBAs be carried on through development of adequate training criteria and goals. It was recommended that the older TBAs be encouraged to retire, because they are not able to adapt and use modern techniques, materials and procedures. They were seen to be embedded in their "old ways" and did not see any strong reason to change.

The RAP guides were useful. They were helpful in organizing the work and the translated versions allowed my helpers to suggest terminology and actual questions that were culturally relevant but heretofore missing. The flexibility of RAP methods gave reason to believe that rapid assessment is indeed possible, even under duress.

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