Contents - Previous - Next

Preliminary analysis of free listing and pile sort data

Table 2 represents the health disorders frequently mentioned by women through free listing; leucorrhoea, various menstrual disorders, fever weakness and aches/pains in body comprised the commonly cited morbidities. When informants were asked to clarify excessive menstruation and scanty menstruation, the response usually was in terms of days, i.e., 'excessive' and 'scanty' referred to menstrual periods over seven days and under three days, respectively. Occasionally, women compared their present cycle to that before marriage or birth of children. Similarly, leucorrhoea (excessive white discharge) or 'safed paani' as a health disorder meant discharge that was abnormal compared to their previous experience (usually the time period before and after deliveries) and was invariably accompanied by other symptoms like backache. Thus, whenever possible, women were asked to clarify the terms they used to represent illness/symptoms.

Table 2. Free Lists of Women's Illnesses (N-60): The First Fifteen illnesses

The pile sorts data in Table 3 reveal that certain illnesses were commonly grouped together, e.g., fever-headache (82%); fever-body ache (70%), scanty menstruation-stomach ache (53%), leucorrhoea-backache (42%).

The data showed the close association between fever and headache, weakness and excessive menstruation, with body ache appearing close by. These symptoms, backache-leucorrhoea formed one cluster; pain in hands and legs formed another. Scanty menstruation and stomach ache were less closely associated, while problems in the natal period stood separate. From the explanations provided by women, it appears that the grouping of symptoms was based on self experience or experience of a family member. When women were asked to explain the reasons for piling selected cards together, the reasoning process sometimes led to changing of the piles, in which case the final pile was chosen for analysis.

According to Weller and Romney [2], the results of pile sort methods, using samples between 30-40, generally reach reliabilities above 90 percent. In this case, the sample size was even more: 60. It is proposed to explore further the pile sort methodology using a greater number of cards (e.g., 25); 'multiple sort' using different criteria (e.g., age groups involved, severity etc.) each time end 'tried sort.'

Discussion

Table 3. Pile Sort Data: A Similarity Matrix of Women's Illnesses

Key

In the context of women's morbidity, what did RAP achieve for the present project?

• RAP helped create a heightened awareness of, and an increased sensitivity to, the emic point of view, which NGOs operating in field conditions for several years are familiar with, but take for granted. Familiarity of the BCC personnel with the language, social organization and economic structure of the communities enabled them to cover the ground quickly as far as general ethnographic information was concerned, leaving them with more time to explore unknown territories - i.e., reproductive health problems. In contrast, in an inter-country dietary management of diarrhoea (DMD) project in Peru and Nigeria [4], difficulty was experienced in collecting adequate core data specifically for project needs in the time available, due to the necessity of obtaining general cultural information.

• Through emphasis on detailed documentation, RAP methodology trained the project personnel in regular documentation procedures and in recording their experiences. In contrast to academic or research personnel, whose strength lies in proper documentation, the experience of NGOs suggests that their focus on delivering services tends to result in neglect of proper recording of their experiences, i.e., impact evaluation gets precedence over process evaluation. The present project team believes that RAP has helped create a balance between the two.

• Documentation of the emic perspective is expected to contribute towards a realistic formulation of educational messages in the project's health and nutrition activities for women and adolescent girls. For example, an educational-cum-iron supplementation programme to reduce prevalence of anaemia in adolescent girls is under way, in which RAP methods lead to involvement of girls and their mothers right from the beginning, when they talk about their beliefs/practices pertaining to growth, development and health problems (anaemia) in adolescence.

Beyond the project, hard data from ethnographic research may help to make convincing recommendations to local government authorities to improve their health and nutrition programmes, particularly programme-related training of functionaries and education of beneficiaries.

Examples in the literature where anthropological and social marketing techniques have been employed to involve intended beneficiaries in improving their nutrition-related practices are the World Bank funded Indonesia Nutrition Development Project [5] and the DMD Project in Peru and Nigeria [6].

• Ethnographic research contributed towards intervention programmes. Like most NGOs, a primary concern of the Council is provision of need-based services to deprived communities. In this context, RAP served as the initial link in the chain of qualitative and quantitative data collection on women's health and provision of services. Services, in turn, made the data collection easier and more credible, especially in urban slums where the community was more exposed to data collectors and less often to service providers.

Other uses of RAP

In India, several NGOs are doing commendable work to improve the health status of needy urban and rural communities [7]. Thus, the anthropological approach may be applied meaningfully to promote:

• Street Hitkarini's female education programmes;
• Demystification of medicine through education as attempted by the Child-in-Need Institute;
• Attitudinal changes towards health as attempted by AWARE;
• The 'reach out to women' efforts of the rural health project;
• Experimentation of varied health communication techniques by the Comprehensive Health and Development Project at Pachod.

These examples highlight various possible applications of RAP methodologies for public health interventions by NGOs in India.

Difficulties faced in the present project in the application of RAP

• The high turnover of the Lady Medical Officer (LMO). Finding and retaining an adequately trained LMO for the project has been a difficult task. As a result, the uniformity and continuity of the qualitative research and provision of curative medical care are adversely affected.

• The organizational priority of the Council to provide services as well as the need to conduct ethnographic research often necessitated revision of time schedules to synchronize both.

• Certain difficulties were inherent in the RAP methods themselves and these were highlighted earlier.

Recommendations

1. RAP needs to be applied in different settings in India: NGOs, government organizations, universities, and elsewhere. Bentley et al. [4] have also suggested that these methods should be further developed and tested under varying geographical and cultural conditions to establish their strengths and weaknesses.

2. Limited experience thus far suggests that RAP is best applied along with quantitative, epidemiological research, as each complements the other. In fact, the inter-disciplinary approach - for example, as recommended by Brown and Bentley [8] for improved nutritional therapy of diarrhoea should be more vigorously followed in public health programmes.

3. For developing countries in general, and for NGOs in particular, there is a need to develop, implement and evaluate intervention-linked RAP. Spradley [3] recommends that ethnographic research begin with informant-expressed needs. Social scientists can no longer ignore the uses to which research findings are put.

4. Finally, there is a dire need to build up a body of persons trained in ethnographic methodologies in the fields of medicine, nutrition, and allied disciplines. This training may be imparted either through modified university curricula or special training programmes.

Acknowledgements

The present project is supported by a grant from the Ford Foundation (8800778). Thanks are also due to the Foundation for training the project personnel in ethnographic methodologies through periodic workshops. The project team members Vandana Agarwal, Mona Shah and K. Latha Menon are sincerely thanked for their valuable comments and suggestions during the preparation of this paper.

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. Weller SC, Romney AK. Systematic data collection. Qualitative research methods Series 10. California: Sage Publications Inc., 1988.

3. Spradley JP. The ethnographic interview. Florida: Holt, Rinchart and Winston Inc., 1979.

4. Bentley ME, Pelto GH, Strauss WL, Adegebola O. de la Pena E, Oni G. Brown K, Huffman S. Rapid ethnographic assessment: applications in a diarrhoea management program. Soc. Sc. Med.; 1988; 27(i): 107-16.

5. Manoff International Corporation. Nutrition communication and behavioural change component, household evaluation (vol. IV). Indonesian nutrition development programme. Washington, DC: Manoff international Corporation, 1983.

6. Brown KH, Bentley ME. Report from Peru: Dietary management of diarrhoea. Mothers and children Bulletin on Infant Feeding and Maternal Nutrition; 1989; 7(3): 1-5.

7. The Ford Foundation. Anubhav: Experiences in community health. New Delhi: The Ford Foundation, 1988.

8. Brown KH, Bentley ME. Improved nutritional therapy of diarrhoea: A guide for planners and decision makers involved in CDD programs. Washington, DC: PRITECH, 1988.

11. Beyond data collection: Facilitating the application and use of ethnographic information to guide health programmes and further research

Designing manuals to promote optimal ignorance and active application
Identifying "possible approaches"
Exploring possible approaches
Conclusion
Acknowledgements
Endnote
References

By Elizabeth Herman, Margaret Bentley, Farhat Sultana, Maryanah Hamzah, Siti Huzaifah, Siti Masreah, Gretel Pelto, and Pertti Pelto

Elizabeth Herman and Margaret Bentley are affiliated with the Department of International Health at the Johns Hopkins University, School of Public Health and Hygiene in Baltimore, Maryland. Farhat Sultana and Pertti Pelto are affiliated with the University of Connecticut, Department of Applied Anthropology in Storrs, Connecticut. Maryanah Hamzah, Siti Huzaifah and Siti Masreah are affiliated with the University of Sriwijaya, Palembang, South Sumatra Indonesia. Gretel Pelto is affiliated with the University of Connecticut, Department of Nutritional Sciences in Storrs, Connecticut¹.

This paper describes the experience of the author and her collaborators in adapting the RAP methodology to diarrhoeal disease control programmes. The extensive information already available on beliefs and practices related to diarrheal disease guided the development of guidelines for rapid qualitative research on this topic. However, there was no similar background on using RAP derived information for specific programme recommendations or addressing management issues. Examples are given of the kind of information obtained by RAP that will determine the nature and success of intervention programmes for the control of diarrhoeal disease. In 1992, a set of guidelines for conducting RAPs on Diarrhoeal Disease Control programmes, authored by Herman and Bentley, will be published by The International Nutrition Foundation, Inc., Boston, MA. - Eds.

THE RAPID ASSESSMENT Procedures (RAP) methodology [1] was developed in response to a need for timely information relevant to primary health care and nutrition programmes. The past five years have witnessed the proliferation of manuals that apply the concepts and methods of RAP to a broad range of topics and interventions. These manuals have encouraged and facilitated the efficient collection of detailed information that is directly relevant to the needs of programmes. The challenge that now faces individuals and programmes attempting to adapt RAP is to go beyond the task of data collection, and to assure the appropriate interpretation, application and use of the information collected.

This paper describes the authors' experience in adapting RAP methodology to address the needs of diarrhoeal diseases control (CDD) programmes. This task was greatly facilitated by the availability of a wealth of information on beliefs and practices related to diarrhoeal diseases from a variety of settings [2-6]. These previous ethnographic studies helped to define the important topics and issues for inquiry, and to identify relevant themes (e.g. the association of teething and other developmental processes with diarrhoea) that recur across cultures.

Whereas the content of a manual for ethnographic data collection related to CDD programmes was guided by the results of preceding research, there was little precedent for developing a process that leads developing country anthropologists and other individuals using the manual to be more active in making specific programme recommendations. As documented by Scrimshaw and Hurtado [7] in their description of anthropological involvement in the Central American Diarrhoeal Disease Control Project, there is a tendency among applied anthropologists to make recommendations that are "...too sweepingly broad to be feasible". They emphasize that "...it is important for anthropologists to break their recommendations down into smaller, concrete, more manageable steps [2] and to spend the necessary time to see that the recommendations are integrated into program policies, messages and material" [3].

In developing a manual for CDD programmes, therefore, the authors faced the challenge of guiding the manual's users to develop specific recommendations that address common diarrhoea case management problems, e.g. low oral rehydration salts (ORS) use rates, the administration of inadequate volumes of fluids during diarrhoea, the misuse of antibiotics, and decreased nutrient intake in response to illness. Because of the number and variety of factors that affect these problems, the authors recognized the need to apply the principle of optimal ignorance:

"Optimal ignorance refers to the importance of knowing what facts are not worth knowing. It requires courage to implement. It is far, far easier to demand more and more information than it is to abstain from demanding it. Yet in information gathering there is often a monstrous overkill [8]."

In the context of a manual for CDD programmes, optimal ignorance implies focusing data collection on a limited number of the most "promising" possible solutions to commonly occurring problems in a given context.

This paper describes a manual developed to facilitate both "optimal ignorance" and active application of ethnographic data collected for diarrhoeal diseases control programmes. The purpose of the manual is to identify ways of promoting appropriate diarrhoea case management (particularly the administration of extra amounts of recommended fluids and continued feeding) in ways that are most consistent with existing beliefs and practices. The assumption underlying the manual is that, if prescribed behaviours are promoted in ways that "make sense" in the context of local beliefs, they are more likely to be adopted by the local population.

Contents - Previous - Next