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Designing manuals to promote optimal ignorance and active application

The strategy used to promote both optimal ignorance and active application is to incorporate the early identification of possible recommendations (in the case of diarrhoeal diseases control, approaches to promote oral rehydration therapy and feeding) into the data collection and analysis process. The first part of the manual guides the use of key informant interviews to collect basic information about local types of diarrhoea, perceived aetiologies of diarrhoea, prescribed interventions for different types, and associated symptoms. It instructs the data collector to use this basic information to sketch a summary of the classification system and to draft a preliminary outline of his/her understanding of the belief system. The preliminary information is then used to identify a list of "possible approaches" to promote appropriate case management practices. The manual emphasizes "non-judgmental brainstorming" to produce a listing of all possible approaches, including any that may not initially seem to be appropriate.

The manual then guides the user to assess and list the pros and cons of the different approaches and to identify questions that must be answered to further explore the possible approaches. Subsequent data collection with key informants then focuses on collecting additional information to explore the possible approaches in more detail. The additional information can then be used to select and possibly improve upon the best of the approaches.

The early identification of possible and culturally specific approaches to solving programme problems addresses two goals: it focuses data collection on topics and issues that are most relevant to the programme's objectives; and it assures the development of thoughtful and specific recommendations. This strategy can also facilitate the application of ethnographic data to developing more culturally appropriate survey instruments. After selecting the most appropriate of the possible approaches, it is necessary to determine how widely the beliefs and assumptions supporting those approaches are held. The ethnographic manual for CDD programmes guides the design of a structured questionnaire to determine whether the beliefs and practices identified by key informants are shared by other members of the community. The structured questionnaire can also check the appropriateness of the "optimal approach(es)" selected in the preceding sections of the manual.

Identifying "possible approaches"

The strategy of early identification and assessment of possible approaches to promoting programme recommendations was field-tested in the context of ethnographic studies of diarrhoeal diseases conducted in Baluchistan, Pakistan and South Sumatra, Indonesia. The Baluchistan study focused on identifying culturally appropriate ways of promoting oral rehydration salts (ORS) solution packets and sugar-salt solutions (SSS). In South Sumatra, the focus was broadened to seek ways to promote both the administration of extra fluids (including ORS and SSS) and continued feeding during diarrhoea.

Data collectors in Baluchistan identified 13 different types of diarrhoea that are most commonly distinguished on the basis of perceived aetiology. The 13 types include heat diarrhoea, constipation diarrhoea, indigestion diarrhoea, teething diarrhoea, fallen stomach vein diarrhoea, hot wind diarrhoea, cough and cold diarrhoea, bloody diarrhoea, spirit possession, worm diarrhoea, earache diarrhoea, measles diarrhoea and sunken fontanelle. The prescribed action or treatment for a particular episode is based on, and varies according to, the perceived local type. Most local types of diarrhoea are considered "hot" and are therefore treated with cooling remedies. There is a consensus that sugar is "cool" and salt "hot". Therefore, the mixing of salt and sugar in a diarrhoea remedy (as is the case in ORS and SSS) is particularly problematic in the context of the local belief system.

Key informants in Baluchistan expressed four basic assumptions about how the body works (folk physiology) and what happens during diarrhoea (folk pathophysiology) that are particularly relevant to understanding their management of diarrhoeal diseases. These basic assumptions are:

1. There are four humoral qualities - hot, cold, wet and dry - that are usually in balance in the body. Illness results from an increase or decrease in one or more of the humours in relation to the others.

2. The stomach is the centre of the body. Food is digested in the stomach and nutrients go from there to other parts of the body. The stomach is connected to other parts of the body by "veins" .

3. Children cannot digest food as well as adults. Diarrhoea results when a child is given food that he/she cannot digest.

4. Like any other container, the stomach gets "dirty". This can cause a blockage or it can cause excess heat. It is good to periodically "clean out" the stomach.

Table 1 lists some of the approaches to promoting oral rehydration therapy (ORT) in Baluchistan that derive from this preliminary understanding of the components and dynamics of the local belief system related to diarrhoea.

In this context it should be noted that intravenous (IV) fluids are very popular among the population studied. They are valued as especially strong medicine. Although generally considered "cold", IVs are described as being appropriate for both "hot" and "cold" illnesses because they do not go into the stomach, but go directly into the veins.

Ethnographic data related to diarrhoeal diseases in South Sumatra, Indonesia reveals a very different belief system. Illnesses associated with loose stools are generally categorized into only three types: "regular" diarrhoea; diarrhoea with vomiting; and diarrhoea with blood.

There is much greater individual variation in the perceived causes of, and the recommended treatment for, diarrhoea than in the reported types of diarrhoea. Dirty or unboiled water, dirty food, and certain types of food are the most commonly identified causes of loose stools. Excess heat or fever, hot weather, spoiled breast milk, trauma, worms and a "fight" between hot and cold air are other aetiologies named. Several informants referred to kuman (tiny invisible animals that cause disease) as causing diarrhoea. A large variety of decoctions prepared from various leaves and plant products are used to treat diarrhoea. Individual informants generally recommend different treatments for different types of diarrhoea, but the study team could not identify any consistent pattern of treatment or any underlying principles (such as treating hot illnesses with cold remedies) to guide selection of a remedy.

Existing concepts of what happens in the body during illness are dynamic, with certain symptoms or illnesses frequently "leading to" other symptoms or illnesses. "Fever" and "air inside" play a role in the folk pathophysiology of many illnesses, including diarrhoea. Key informants frequently describe sequences of muscle ache caused by an injury leading to fever, which in turn leads to an illness such as diarrhoea, cough or seizures.

The possible approaches to promoting ORT derived from a preliminary understanding of the belief system in South Sumatra are listed in Table 2. The list reflects a recognition of, and concern about, weakness and thirst during diarrhoea that is similar to the concern with these symptoms expressed in Baluchistan (Table 1). The list of possible approaches for South Sumatra also reflects the fear of one illness "becoming" another, more severe illness, and the concept of "kuman" both of which are peculiar to the population in South Sumatra (Table 2).

Exploring possible approaches

In both the Baluchistan and the South Sumatra studies, the pros and cons of each approach were identified in the context of available information about the belief system. As an illustration, the pros and cons of the approach "ORT prevents and treats weakness" in the Baluchistan context are summarized in Table 3. In assessing an approach, data collectors also identify unanswered questions related to each of the possible approaches. For example, in the initial assessment of "ORT prevents and treats weakness," it was considered potentially helpful that mothers in Baluchistan are concerned about weakness and that they actually have home remedies that are intended to treat weakness. Preliminary data collection, however, did not provide any information about how mothers define "weakness", about the association of weakness with different types of diarrhoea, or about the amounts of existing remedies that are given to treat weakness. Therefore, data collectors focused subsequent data collection on answering these questions, and questions related to each of the other possible approaches listed in Table 1.

At this juncture it is instructive to note that the "ORT prevents and treats weakness approach" was considered in both field sites. In Baluchistan, further data collection revealed that only a limited number of diarrhoea types are associated with weakness. Therefore, the approach might not encourage the use of ORT for all diarrhoeal episodes. Existing home remedies for treating weakness contain large concentrations of sugar because sugar is perceived as giving strength and energy. Furthermore, certain commercial preparations composed of glucose (without salt) are considered superior to ORT for preventing and treating weakness because they are only needed in small amounts (a few teaspoons three or four times a day). For these reasons, "ORT prevents and treats weakness" is not considered an optimal approach for promoting ORT use during diarrhoea.

In contrast, additional data collected in South Sumatra suggest that promoting ORT as a means of preventing weakness may be effective in that setting. South Sumatran mothers perceive weakness as a potential consequence of all types of diarrhoea (including diarrhoea due to teething and other developmental processes). Furthermore, mothers perceive weakness as the direct result of loss of water and food from the body through the stool. At present, mothers do not know of any way to treat the weakness except to stop the diarrhoea. This failure to recognize fluid and electrolyte replacement (and not necessarily stopping the diarrhoea) as the key to treating diarrhoea-induced weakness is common among all cultures. However, the existing recognition of water and nutrient losses as the cause of weakness may facilitate the linkage between ORT and preventing weakness.

In both the Baluchistan and the South Sumatra study sites, additional key informant interviews helped to answer questions identified in the process of assessing possible approaches. Terminating data collection following additional key informant interviews, however, would risk basing final recommendations on beliefs and practices that are peculiar to a small and non-representative portion of the population. For that reason, data collectors in both sites proceeded to develop and administer a structured interview to larger and more representative segments of the respective populations. Neither set of data collectors followed a rigorous procedure in developing and pretesting the structured interview (as might be followed in designing a formal survey instrument). The development of the structured interviews, however, serves as a model for using a combination of qualitative data from a small number of key informants and quantitative information from a representative sample of respondents to develop final recommendations.

Conclusion

The paper has argued that requiring data collectors to identify possible approaches to addressing programme problems early in the course of the study can focus the data collection on topics and issues of maximal relevance to programmes, and can facilitate the application and use of ethnographic information. The comparison of similar studies conducted in Pakistan and Indonesia demonstrates that, although the same themes may recur in different settings, the meaning of those themes cannot be determined without additional cultural information.

Acknowledgements

The field work reported in this paper was supported by the Diarrhoeal Diseases Control Programme of the World Health Organization. The authors gratefully acknowledge Ms. Hamida Baluch and the directors and staff of the Baluchistan Integrated Area Development Programme. They also thank the village, regency and national staff of the Indonesian Diarrhoeal Diseases Control Programme.

Endnote

1. Correspondence: Elizabeth Herman M.D., M.P.H., Department of International Health, Division of Disease Control, The Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore Maryland 21209.

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. Bentley M, Pelto G. Straus W. Adegebola O. de la Pena E, Oni G. Brown K, Huffman S. Rapid ethnographic assessment: application in a diarrhea management program. Soc Sci Med 1988; 27: 107-16.

3. Nichter M. From Aralu to ORS: Sinhalese perceptions of digestion, diarrhea, and dehydration. Soc Sci Med 1988; 27: 39-52.

4. Coreil J, Genece E. Adoption of oral rehydration therapy among Haitian mothers. Soc Sci Meld 1988; 27: 87-96.

5. Kendall C, Foote D, Martorell R. Ethnomedicine and oral rehydration therapy: a case study of ethnomedical investigation and program planning. Soc Sci Med 19: 253-60.

6. Green E. Traditional healers, mothers and childhood diarrhea! disease in Swaziland: the interface of anthropology and health education. Soc Sci Med 1985; 20: 277-85.

7. Scrimshaw SCM, Hurtado E. Anthropological involvement in the Central American diarrhea! disease control project. Soc Sci Med 1988; 27: 97-105.

8. Chambers R. Shortcut methods of gathering social information for rural development projects. In: Cernea M, ed. Putting people first: sociological variables in rural development. New York: Oxford University Press/for the World Bank, 1985; 403.

12. Adaptation of RAP to monitoring settlement trends in areas covered by successful disease control programmes: Onchocerciasis

Background
The land settlement review
The Burkina Faso case study
Conclusions
Acknowledgements
References

By Della E. McMillan, Jean-Batiste Nana and Kimseyinga Savadogo

Della McMillan is affiliated with the Institute for Development Anthropology and the World Bank; Jean Batiste Nana is an anthropologist and Director of Research for CEARD (Cabinet d'Etudes d'Appuis et de Recherche pour le Développement); and Kimseyinga Savadogo is a sociologist and chair of the Department of Economics, University of Ouagadougou, Burkina Faso.

This paper represents an unusual adaptation of RAP: Determination of the impact of a programme for the control of onchocerciasis on land settlement patterns in Burkina Faso, West Africa. It describes the rapid assessment procedures using both qualitative and quantitative approaches to be cost-effective in depicting differences among the villages, recent trends since the last census and valuable background information on the settlers. Among its limitations were lack of information about settlers who immigrated into an area, mined the soil and left, and the impossibility of obtaining accurate information on income trends. - Eds.

ONCHOCERCIASIS HAS LONG been considered to be an important factor in the under-population of large areas of agriculturally valuable river basin land in West Africa. It was anticipated, therefore, that the Onchocerciasis Control Programme (OCP), which was initiated in 1974, could make a substantial contribution to the area's economic development (Figure l). Seventeen years into the programme, however, there is increasing concern about the long-term environmental sustainability of the extensive crop and livestock production systems being created by this resettlement process.

To develop more sustainable agricultural systems requires assistance. The use of the term "assistance" refers to the provision of basic services and infrastructure to settlers operating on their own initiative [1]. At the local level, settlers are provided with essential support in the form of infrastructure (roads, bridges, wells, etc.) and social and economic services (crop and livestock extension, health facilities, credit, schools, non-formal education, etc.). This support can be used to guide settlers into carefully selected areas or to provide assistance to spontaneous settlers or hosts already occupying a site. Specific interventions depend on the broader ecological, economic, sociopolitical, and institutional context for development in a given area.

Especially important in determining what types of assistance are appropriate is whether or not an intervention is started early or late in the resettlement process. By the time an area has experienced haphazard spontaneous new lands settlement, development planners have fewer planning options, and these available to them tend to be more costly, both in economic and social terms.

Yet solid information on which to base area planning is often lacking. Existing data are often out of date or inappropriate. New data using conventional methodologies may take several years to gather, input, and analyze.

Figure 1.The Onchocerciasis control programme and case study sites in Burkina Faso, Ghana, Mali and Togo

1. AVV planned settlements at Mogtedo, Bombore, Linoghin and Rapadama
2. Kompienga
3. Niangoloko
4. Solenzo
5. Damonogo settlements
6. Overseas National Onchocerciasis Secretariat (NOS) Project Area
7. Red Volta Valley
8. Tono Irrigation Area
9. Dioila
10. Finkolo
11. Manantali
12. Selingue
13. Tienfala
14. Yanfolila
15. Project FED-Agbassa
16. Mo Plain

Source: McMillan, D., J.B. Nana and K. Savadogo 1990 [9]

This paper proposes a rapid assessment approach as one method for policy makers to monitor intraregional and interregional immigration trends in the OCP river basins. Instead of completing a detailed census form on each household, the rapid assessment procedure obtains secondary information through interviews with village and neighbourhood leaders. The utility of this approach is demonstrated in a study of settlement-related development at four river basin sites in Burkina Faso.

The central argument of this paper is that the rapid assessment approach gave researchers a quick, cost-effective means of describing policy relevant aspects of the new land settlement taking place. These trends could not be shown from the existing base of census data. Moreover, this information allowed researchers to place some of the local level issues of areas affected by control into a wider regional context. This had an important impact on the policy recommendations that could be developed from the research.

Background

Onchocerciasis is a disease transmitted to humans by the female black fly Simulium damnosum [1]. The fly carries the larvae of a parasitic worm, Onchocerca volvulus, which invades the epidermic tissues of the skin eventually reaching the anterior chambers of the eye. Clinical indication of the disease appears only after repeated bites from infected flies. Effects include skin discoloration, itching, subcutaneous nodules and, in the later stages, eye lesions that may result in blindness. The fly can breed only in fast flowing streams or rivers. As a result, the greatest incidence of the disease occurs among people who live in river valleys - hence the common name for Onchocerciasis is river blindness.

Since 1974, the Onchocerciasis Control Programme (OCP) has concentrated on controlling the disease by preventing the propagation of the black fly. The programme originally covered 764,000 km² in seven countries - Benin, Burkina Faso, Côte d'Ivoire, Ghana, Mali, Niger, and Togo. In 1986, the OCP area was expanded to cover 1.3 million km², including additional parts of Benin, Ghana, Mali, and Togo, and parts of Guinea, Guinea-Bissau, Senegal, and Sierra Leone (Figure 1).

Onchocerciasis is considered to be an important factor in the under population or abandonment of large areas of agriculturally valuable riverain lands in the West African savanna. It was anticipated, therefore, that successful control of the disease could make a substantial contribution to development. Control would provide new economic opportunities for settlers from the drier, more populated regions. It would also provide a vast area of underpopulated river basin land where infrastructural development and extension services could be planned and directed in a way that would reduce environmental degradation and foster sustainable, economic growth.

This economic impact was expected to be greatest in the impoverished landlocked Sahelian countries.

Seventeen years into the programme, onchocerciasis is no longer considered a public health threat in the original seven country control zone [1-3], and many of the river basins are also being reoccupied [4-6]. Most settlement is spontaneous, with little or no access to basic infrastructure, social or economic services [6-10].

By far the major criticism of spontaneous settlement is that unassisted settlers tend to use wasteful agricultural practices, with little attention to sound management of soil, forest and water resources [11-22]. If immigration rates are low, extensive cultivation and livestock practices are generally sustainable, since reserve lands remain available. As population densities increase, it becomes difficult to allow for fallow periods sufficient to restore soil fertility. Increased pressure on a settlement area's natural resources is generally associated with rising levels of social conflict among settlers, hosts and pastoralists [1,9,23]. Predictable sources of conflict include livestock damage to settler crops as herd sizes increase, growing problems with potable water, pastoralist resentment at being denied access to former grazing areas and water sources, and a diminished supply of easily accessible fuel wood [1]. By the time these problems emerge, the levels of social conflict may be so high as to discourage the types of concerted community actions needed to develop sustainable land use systems.

Assistance is required to obtain the full economic benefits of river blindness control and for these to be sustained. This development concept is referred to in the literature as "assisted spontaneous settlement" [24-27]. "Assisted spontaneous settlement" occupies a middle ground between government-sponsored new lands settlement (e.g., where the government coordinates settler recruitment, transfer, and support services), and completely spontaneous settlement.

Timing is extremely important in determining what types of assistance are most likely to be successful. Area zoning to reserve certain lands for forests or grazing, for example, is more effectively conducted at an early stage of new land settlement. Zoning carried out once settlement has begun is more likely to impinge upon homesteads or fields that have been created in areas whose natural resource potential is best suited for other purposes. Forced relocation to clear these areas almost always creates ill will. In addition, by the time conflict has reached this level, the original forest, soil, and water resources will usually have been at least partially depleted. Efforts to restore an eroded natural resource base are generally far more expensive and complex than efforts to control soil and forest management before serious damage occurs. Thus, there is a critical need for a rapid, cost-effective tool that allows policy makers to monitor new land settlement trends.

The land settlement review

This paper proposes a rapid assessment approach as one method for policy makers to use in monitoring immigration trends. Instead of completing a detailed census form based on individual interviews, the rapid assessment procedure obtains secondary information on households through interviews with village and neighbourhood leaders. The interview form limits the information on each family classified as "immigrant" to one line of data indicating family size, area of origin, primary and secondary occupation, and year of immigration for the individual designated as recognized household head.

The utility of this particular type of rapid assessment approach is demonstrated by a study of settlement-related development in Burkina Faso. The procedure was designed to complement a set of sample questionnaires and research guidelines developed as part of an eleven country survey of new lands settlement in the OCP river basins.

The larger project is referred to as the Land Settlement Review, or LSR. The LSR was carried out by the Institute for Development Anthropology with funding from the United Nations Development Programme (UNDP); the World Bank was executing agency.

The Land Settlement Review was designed to assist governments, foreign donors, and non-governmental organizations (NGOs) with the design of low cost programmes to facilitate development in areas being settled. The specific objectives of the Review [1] were to:

1. describe and evaluate settlement experiences to date, including organized and spontaneous types of settlement in the OCP areas and, where relevant, selected experiences elsewhere;

2. draw conclusions from these experiences concerning the major factors that promote (or detract from) rational settlement-related development and to derive lessons regarding the most effective interventions that influence such factors; and

3. (based on 2 and 1) provide recommendations and guidelines on: (a) how to manage the effects of spontaneous settlement; (b) what types of land use planning or other activities are needed prior to and in conjunction with spontaneous settlement; and (c) how to plan and implement initiatives in the future to support viable, low-cost, sustainable settlements and settlement-related development in the OCP areas.

To carry out these tasks, the Land Settlement Review developed detailed case studies of settlement-related development in four OCP countries (Burkina Faso, Ghana, Togo and Mali). A less intensive comparative study based on interviews and existing materials was conducted in the seven other OCP countries, including Côte d'Ivoire, Guinea, Guinea-Bissau, Benin, Senegal, Niger, and Sierra Leone.

An average of four study sites in each of the four case study countries were chosen to represent a range of settlement and development interventions. Final decisions concerning research design and analysis were made by the four interdisciplinary teams that developed the case studies. Each team included a mixture of international and national consultants working in a single country, although each of the team leaders had comparable experience in other OCP and non-OCP zones. To enhance the possibility of comparability between sites, researchers were given a set of sample questionnaires and research guidelines designed to examine household immigration histories, patterns of production, consumption and investment, the nature and uses of returns on production, off-farm activities, and natural resource management.

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