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Annex B: Outline of format for situation study report

Rural Water Supply and Sanitation

Distribution:
Reporter:
Date:

A. GENERAL

1. Village/Ward/V.P/Ilaka:
2. Distance from the nearest road point:
3. Distance from the Headquarter:
4. Existing Water Sources by type, condition and use.
5. Knowledge and awareness regarding the request for water supplies.
6. Experience and traditions in the community or collective activities.
7. Comments: adequacy, areas for schemes, settlement patterns etc.
8. Houses by type, livestock and poultry shade, open space/yard in around the house.
9. Common Property - land, forest, water.
10. Government and Non-governmental Organization activities
11. Schools/by type, number and facilities and teachers' relations, with attitude towards villagers

B. SOCIAL

1. Population and Households by Ward, Caste/Ethnicity and Size.

2. Village economy, and major sources of livelihood of the people.

3. Socio-cultural and political affairs and management (Com. Leaders) Village Councils possible contacts.

4. Existing social system - Chowkidar/Katuwal, Bista, System, Guruwa, Tax system (informal) to pay for water (irrigation), barbers, village smith, and other artisans.

5. Role and Status of women, cultural inhabitation - movement, participation work and village gatherings.

6. Remark on village solidarity, cohesiveness, beneficiaries' active involvement.

C. WATER SOURCES AND USE

1. Existing Water Sources by number, type, distance, Ownership (private/ public), Ward or households and use (drinking, household use, bathing, washing, livestock).

2. Water surroundings - Cleanliness, drainage, maintenance, platform etc.

D. SANITATION PRACTICES

1. Defecation practices Children, Women, Men. Places, Washing of hands, wearing shoes.

2. Village Sanitation - Streets, drainage, garbage disposal system.

????Outline of Health Behaviour Report

18. Use of qualitative research methodologies for women's reproductive health data in India

Building social science research for women's health in India
Workshops and consultant visits
The protocol: Investigating women's reproductive health in India
Discussion
References

By Margaret E. Bentley, Joel G. Gittelsohn, Moni Nag, Pertti J. Pelto, and Joan Russ

Margaret Bentley and Joel Gittelsohn are affiliated with the Johns Hopkins University, School of Hygiene and Public Health, Department of

International Health in Baltimore, Maryland. Moni Nag is affiliated with the Population Council in New York City. Pertti Pelto and Joan Russ are affiliated with the University of Connecticut, Department of Anthropology in Storrs, Connecticut.

This paper reflects a strong effort to build national capacities in research at the nonprofessional level. The paper describes the difficulties and successes of an ongoing effort to develop a useful system of data collection on women's reproductive health where no similar data have previously been obtained. The careful documentation and thoughtful analysis of project process and progress as recorded here in themselves provide a rationale for utilization of qualitative research. The issues of "how professional" and "how much education" were raised frequently during the conference in reference to RAP training and its application. This paper throws light on these issues as well as providing a strong case study of RAP application and training. - Eds.

EFFORTS TO ADDRESS the needs of women in the developing world have focused mainly on their roles as mothers and childcare givers [1]. This is reflected by the type of health statistics on women that are available - most of which report on maternal mortality related to childbearing. In India, for example, a population-based study in Ananthapur District of Andhra Pradesh found 830 maternal deaths per 100,000 live births (J. C. Bhatia, personal communication, 1985). The study also found an underreporting of maternal deaths.

While evidence from maternal mortality statistics alone indicates a distressing situation for Indian women, it is clear that the prevalence of illnesses during and after pregnancy and their impact on women's health have not been adequately assessed. For example, estimates of maternal morbidity have been primarily based upon maternal mortality. A study in one small Indian village found that for every maternal death, 16 women suffered from illnesses during pregnancy, childbirth, or within six weeks of delivery [2].

Studies that have examined morbidity of women apart from those related to pregnancy and childbirth are rare. A recent study [3] of 650 rural Indian women found that 92% of all women had one or more gynecological or sexually transmitted diseases, with an average of 3.6 diseases per woman. However, only 8% of the women studied had ever undergone gynecological examination and treatment in the past. Women appeared unwilling to seek medical treatment for their gynecological problems, or did not recognize them as health problems at all.

Women's reproductive health, therefore, remains largely unexplored in India and elsewhere throughout the developing world. Epidemiological studies are needed to identify the most serious of women's health problems in India, to determine their relative prevalence, and to identify the factors affecting prevalence. Along with clinical and epidemiological data on women's reproductive health, descriptive ethnographic studies are needed to establish how women perceive their own health and morbidity and how these [actors influence their decisions to utilize health care services and how they use them. At present, there is a dearth of anthropological data on women's health available to guide programme decisions and resources.

In India, the social sciences have made some contributions to research in community health [4], but relatively few of these efforts have addressed the needs of applied health programmes. The holistic perspective and research methodologies of medical anthropology have much to offer applied health programmes [5, 6]. Qualitative research, particularly "rapid" anthropological methodologies, are especially appropriate for describing the system of factors that influence women's health. These methods are ideal for exploratory research, for hypothesis generation, and for programme planning, monitoring, and evaluation. To incorporate the social sciences appropriately into applied work in women's health requires a strategy that balances a strong focus on useful short-term applications with selective strengthening of institutional capacity.

Building social science research for women's health in India

A recent initiative by Ford Foundation/India has addressed the gap of knowledge regarding qualitative data for women's reproductive health in India. A grant by the Ford Foundation to Johns Hopkins University, Department of International Health, will implement multiple activities to increase the social science research capacity for women's health in India. The title of the project is, "Building Social Science Research for Women's Reproductive Health in India."

The project involves training in qualitative data collection methods and analysis for a number of organizations that are involved in service delivery and research activities for women's health. Most of the participant groups are Ford Foundation grantees. Participant organizations, which form the basis of an informal "women's reproductive health network," can be divided into two main categories: 1) non-governmental, "action" organizations that provide direct health services to women and who wish to complement these activities with the collection of primary data on women's health and health-seeking behaviour; and 2) applied health research groups, including private organizations and selected investigators/departments within academic institutions. Although the research experience of these two categories of participants is very different, it was considered desirable to include the latter category in the network because of their potential for training and capacity-building activities in the future.

A number of the groups are already involved in clinical or epidemiological research on women's health, although most of the NGO action groups view service delivery and social change as the emphasis of their work. These groups are primarily interested in collecting qualitative data on women's health to design more effective and culturally appropriate programme strategies. However, one of the objectives of the project is to produce a set of comparative data that describes how Indian women define their own health and health care options. To this end, a "working protocol" has been developed that can be adapted to guide the research of each individual group (unpublished document, The Johns Hopkins University, Ford Foundation, September 1990).

Workshops and consultant visits

The principal training strategy for participants in the network consists of twice-yearly workshops, in which the organizations share materials and techniques, develop research skills and research programmes, and obtain qualitative data management and analysis skills. Two workshops have been completed. The first, held in February 1990, was a two-week workshop that focused on training in qualitative research methodologies. Activities included two fieldwork days, where qualitative data were collected using a variety of techniques, such as key informant interviewing, focus group interviews, and direct observation. A major emphasis of the workshop was on writing expanded, detailed notes based on the brief notes collected during the fieldwork experience. The second workshop, held in October 1990, emphasized qualitative data analysis. For this second workshop, each group brought along data that they had collected since the last workshop. Most of the data had previously been entered into WordPerfect files by each group. These data formed the basis of training in qualitative data analysis, including both manual and microcomputer analysis using a text retrieval software programme.

A third "writing" workshop was planned for spring 1991 to transform the data into a set of papers that will be published as a monograph. To present these papers and the project, a session on "Listening to Indian Women Talk about their Health " was proposed for the National Council for International Health (NCIH) conference in dune 1991.

The workshops have the following five objectives:

1. To familiarize participants with the concepts, methodologies and issues involved in qualitative research in women's reproductive health.

2. To assist participant organizations with the implementation of the qualitative aspects of projects in women's reproductive health.

3. To teach techniques in the methodological documentation of knowledge acquired through qualitative research, the proper maintenance of collected data, and effective modes of analysis of the data for dissemination to health agencies and other users.

4. To provide a forum for discussion of key concerns and issues relating to the conduct of research into women's reproductive health.

5. To contribute toward the long-term development of social science research in health by disseminating the research work done in India and elsewhere.

The workshops promote the appropriate use of microcomputer methods into participant organization activities, for research design and implementation, and for data management and analysis. Depending on the resources and capacity of each group, their use of microcomputers for data management and analysis varies.

While focused on qualitative methodologies, there is an emphasis on the integration of qualitative with quantitative research methods. Workshops emphasize hands-on experience, either in the field conducting research, managing and analyzing actual data, and/or preparing written documents. Workshops include the use of resource persons from local universities, and research institutions and social marketing agencies.

Workshop topics will be identified throughout the course of the project, with the topic of the next workshop being decided by workshop participants and faculty during the previous workshop. For example, during the recent workshop on data analysis, one of the participant groups suggested that the "manuscript writing" workshop be the next focus for the network.

The workshops are complemented by frequent visits by a team of medical anthropologists (including Indian and non-Indian anthropologists), all with South Asian experience, to each research site. During the visits, assistance is given to develop, implement, and manage the qualitative research programmes on women's health for individual participant organizations in the field. These intensive "working visits" are a critical component to the strategy, since they allow individualized planning and technical assistance for each group's research. Moreover, the visits are important for the team of medical anthropologists because they provide an understanding of the main activities, field conditions, and resource constraints that face each group attempting to integrate research into its programmes.

To facilitate communication among these groups in the interim periods between workshops, a quarterly "network newsletter" will be produced and distributed by one of the organizations. The newsletter will include "reports from the field," issues in fieldwork, data collection, and analysis, and letters to the editor.

Groups that have attended both of the first two workshops included participants from the Society for Education, Welfare Action (SEWA-Rural, Jhagadia, Gujarat); Streehitikarini (Bombay); Baroda Citizens Council; (Baroda, Gujarat); The Child in Need Institute (CINI, Calcutta, Bengal); Operations Research Group (ORG, Baroda, Gujarat), the Centre for Health Education, Training and Nutrition (CHETNA, Ahmedabad, Gujarat); and the Society for Action and Research in Community Health (SEARCH, Gadgiroli, Maharashta). In addition, three academic institutions are involved in the network, including the TATA Institute for Social Sciences (Bombay), Departments of Health Services Studies and Medical and Psychiatric Social Work; Christian Medical College (Vellore), Departments of Community Health and Biostatistics; and the Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), and the Department of Community Health.

The protocol: Investigating women's reproductive health in India

The protocol, which is considered a "working document," contains guidelines and procedures for carrying out community-based qualitative research in women's reproductive health in India. The manual is intended for use by health professionals and social scientists with interest in qualitative research methods. Although the protocol was developed for use by the groups in the informal network, it can be adapted by other groups within India and to other settings. It is designed to be carried out as a series of specific tasks and is not intended to be a thorough investigation of all cultural-behavioural aspects of women's reproductive health in a community region. The Table of Contents for the protocol is shown in Appendix I.

The main purpose of the protocol is to create a body of knowledge about how women define their health problems and what they do about them. The information can be used to facilitate programme development in women's health and to inform national and programme managers and policy makers. The results of the ethnographic study are intended to assist the NGO groups to: 1) develop effective home care recommendations and health messages; 2) select appropriate forms of popular terminology and language use for health care workers to communicate effectively with women; 3) improve household morbidity, mortality and treatment surveys by suggesting ways of adapting questions and terminology to take account of community perceptions and practices; and 4) to identify the main constraints to improving the condition of women's reproductive health and suggest locally appropriate strategies to deal with these constraints. It is anticipated that the study results will be of use to the wider public health community in India.

When the protocol is used in connection with programme planning, the objectives are:

1. To develop recommendations for appropriate communication with women, and effective health care advice through description of the cultural explanatory model(s), specifically:

• Identification of the local belief systems and terminology by which women label and interpret various forms of women's health problems. Of particular importance is documentation of terms and symptoms by which women recognize illness.

• Identification of the specific signs and symptoms that women attend to in evaluating reproductive health problems. This information will permit selection of the appropriate language for discussing their condition.

• Identification of the specific signs and symptoms and combinations of symptoms, with the associated beliefs concerning their seriousness, which lead women to seek treatment from health centers and/or other medical practitioners. This information will permit the selection of appropriate language for encouraging women to seek health care when they develop signs suggesting serious illness.

• Identification of other related beliefs and knowledge among women regarding the use of home remedies and medications, and other aspects of home management of women's health problems. This information will be useful for identifying women's expectations about appropriate home care. It will also permit identification of "superfluous" home care advice; that is, information that does not have to be conveyed in health workers' discussions with women.

2. To describe the variable patterns and pathways of health careseeking used by women in relation to their health problems, and the various types of potentially modifiable constraints that may prevent or delay their seeking health care.

• Identification of economic, geographic, social, and cultural impediments that delay or prevent women from seeking appropriate health care for health problems.

• Assisting programme staff and health workers in understanding relevant cultural characteristics and conditions that are likely to strongly influence community responses to programme activities.

The specific objectives of the study are achieved through completion of three interrelated research activities:

1. Construction of an "explanatory model" or "cultural map" of women's reproductive illnesses from the perspective of the cultural belief system(s) in the specific study region.

2. Analysis of the signs and symptoms of illness, and other factors that women take into account in deciding to seek or not seek treatment.

3. Review of the health care resources utilized and not utilized by the population for treatment of women's reproductive health problems, and identification of the usual and preferred sequences of care-seeking and household management strategies.

The research methods include the following components:

• Qualitative, open-ended interviewing with key informants.

• Open-ended and structured interviewing, using free listing, sorting, and other materials with women respondents and key informants.

• Structured interviewing in clinics and other health care settings where women seek treatment for reproductive health problems.

• Structured interviewing of health-care providers, TBAs, and other traditional healers.

• Direct observation of patient-provider interactions in relation to women's reproductive health.

• Direct observation of women's behaviour related to their reproductive health (e.g., workload during pregnancy).

The research procedures, including the analysis of results, are organized into "units" that can be completed in sequence or individually. The investigation utilizes both qualitative and quantitative research techniques, but focuses primarily on qualitative data collection methods. Procedures for data collection and analysis are described, including a detailed section on the use of microcomputers in the field. The data are collected from interviews with key informants, a small community-based sample of women, a small clinic-based sample (including private practitioners), and among health care providers.

Discussion

The project described in this paper presents a model to build research capacity for the collection of qualitative, programmatic information on women's reproductive health. The project relies heavily on repeated and focused workshops, consultant visits for technical assistance, and the use of a standardized protocol/manual to guide the research. The advantages and disadvantages of this type of model and of manual-based programme research have been discussed elsewhere [6]. While it is clear that the long-term objective should be to strengthen in-country expertise in qualitative, applied health research methodologies, there is a need to transfer knowledge and skills to individuals and groups that have not previously used them. The strategy outlined here combines the use of intensive workshops, visits by technical consultants, and the creation of an informal network and network newsletter to achieve the goals of the project.

After less than one year, groups that had no previous experience conducting anthropological research have generated a substantial body of data on women's health. The data are in the process of being analyzed and written up, while at the same time additional fieldwork and skill-building is under way. An important feature of the project is that the activities, research topics, workshop agendas, etc. are decided by the groups themselves, although specific activities are facilitated by the project team. The rate of progress shown by the groups in their acquisition of knowledge and skills and in the production of data has been impressive. The challenge for the groups and the project will be to keep the momentum going, in a setting where the primary activity is to provide health services.

References

1. Winikoff B. Women's health: an alternative perspective for choosing interventions. Studies in Family Planning 1988; 19(4): 197-214.

2. Datta KK, Sharma RS, Razack PMA, et al. Morbidity pattern amongst rural pregnant women in Alway, Rajasthan - a cohort study. Health Pop Perspectives Issues Oct/ Dec 1980; 3(4): 282-292.

3. Bang RA, Bang AT, Baitule M, Choudhary Y. Sarmukaddam S. Tale O. High prevalence of gynecological diseases in rural Indian women. The Lancet 1989; 1(8629): 85-88.

4. Manchanda KS, Kumar V, Bhatnagar V. Understanding of diseases and treatment-seeking pattern of childhood illnesses in rural Haryana, India. Trop Geogr Med 1980; 32: 70-76.

5. Scrimshaw S. Hurtado E. Rapid assessment procedures for nutrition and primary health care: anthropological approaches to programme effectiveness. Los Angeles: UCLA Latin American Center, 1987.

6. Bentley M, Pelto G. Straus W. Adegebola O. de la Pena E, Oni G. Brown KH, Huffman S. Rapid ethnographic assessment: applications in a diarrhea management program. Soc Sci Med 1988; 27(1): 107-116.

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