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The Niger programme planning experience

In November 1989, the Ministry of Health in Niger was involved in the initial stages of developing a child health project in the Department of Zinder in the eastern part of the country. This project is being implemented by the Ministry in collaboration with CARE International, a non-governmental organization. Health education is one of the main components of the project. Salient characteristics of the planning exercise in Zinder were:

1. Health education programme managers and health service providers were involved in all steps of the data collection and programme planning process.

2. A process learning approach to programme planning was employed that combined bottom-up and top-down planning.

3. The first step in the planning process was the collection of qualitative information from several of the villages in the catchment area using informal data collection methods.

4. Based on this data, proposals for the health education content and for the communications strategy were formulated, and subsequently, the planning team then returned to the villages to get feedback from the community on those proposals.

5. Based on the community feedback, the educational strategy was revised and finalized.

A team composed of technicians from both the Ministry of Health and the Ministry of Planning participated in phases one through three. The Ministry of Health participants included the two regional health education directors, a senior male nurse and three female nurses. Participants from the Ministry of Planning included two sociologists and one rural development technician. The finalization of the strategy in Phase IV was exclusively the responsibility of the health sector staff.

Phase I: Data collection

Initial data collection for health programmes is often limited to clinical and/or epidemiological information that satisfies the concerns of health technicians and health planners. A prerequisite for the development of any health education programme is information relative to the different aspects of the problem of concern. Programme planners should have information on the community's perspective on the problem of concern and on their present approach to dealing with it. Quantitative survey data on knowledge, attitudes and practices (KAP), frequently used for this purpose, need to be supplemented with qualitative data, if in-depth insights into community beliefs and practices are to be obtained [3, 19].

Step 1: Clarification of Ministry of Health programme priorities and concerns

A first step in planning for formative research is to assure that those responsible for data collection fully understand programme priorities and concerns. In Zinder, prior to discussing what type of information to collect from the community, the planning team reviewed the Ministry of Health's guidelines for the prevention and management of diarrhoea and dehydration at home and in health centres. The Ministry guidelines reflect the clinical concerns of health professionals and are similar to those found in other countries.

Step 2: Definition of the specific objectives for community data collection

It was decided that information on the social, cultural and economic/ resource factors related to diarrhoeal disease management should be collected. A simple conceptual model was developed to help the Zinder team members visualize the three categories of data to be collected. The model was inspired by Foster's [20] work on the introduction of innovations into traditional societies, by Green's work [21] on the key assessment variables to consider in the development of health behaviour change programmes and by the literature on the health-seeking process [22]. Given the Ministry's concerns relative to diarrhoeal disease and the conceptual model or "map" of the problem, the planning team assisted in defining the specific objectives for each of the categories of data collection.

Step 3: Social influence analysis

In the social influence analysis [8] the planning team was asked to identify those persons having either knowledge or resources that influence how the child with diarrhoea is cared for. In traditional societies, mothers usually have the main responsibility for the care of children; however, other individuals in the family and community do influence what is done when a bout of diarrhoea or other child health problem presents itself. In this analysis, the team identified the following influential persons:

1. mothers of young children
2. older women, including grandmothers
3. fathers of young children
4. bokas (traditional healers)
5. marabouts (religious leaders)

It was agreed that information should be collected from all of these groups in order to have a holistic understanding of the perception and management of diarrhoea in the community setting.

Step 4: Choice of data collection methods and preparation of data collection instruments

The team discussed the characteristics, advantages and disadvantages of quantitative and qualitative data collection methods. The past experience of the team members was exclusively with quantitative data collection and they were initially skeptical about the appropriateness of qualitative data collection. They reluctantly agreed that qualitative information should be collected. Semistructured group and individual interviews were to be conducted to collect information on: knowledge and practices related to diarrhoeal disease; the roles played during diarrhoeal episodes by different individuals in the family and in the community; communication networks; and resources related to diarrhoea management. Interview guides were developed for each type of interview to be conducted based on the previously defined specific objectives.

Step 5: Training of interviewers

All members of the planning team were to participate as interviewers in the village data collection exercise. As suggested above, some of the team members had experience collecting quantitative data, but it was the first time that any of them would be involved in qualitative data collection and, therefore, training was of critical importance.

Training for qualitative data collection should address knowledge, attitudes and skills with special attention given to the attitudinal component. In qualitative research, the reliability of information collected depends to a great extent upon the interviewer's ability to establish rapport with community members, and this in turn depends to a great extent upon the attitudes he/she has towards interviewees.

The planning team members participated in a three-day training session. The first part dealt with the socio-cultural factors associated with community health-related practices, the differences between the community's and health personnel's perspective on community health problems, and the importance of community data collection as a precursor to the development of health education programmes. Through a series of case studies and small group exercises, the team members examined their own attitudes towards rural communities. The importance of exclusively listening and not advising interviewees about what they should do to solve specific problems was given particular attention. The latter portion of the training addressed the practical aspects of data collection in the villages: the specific data collection objectives; the steps in conducting semi-structured interviews; verbal and non-verbal behaviour; the use of the data collection instruments; group facilitation skills; and note-taking.

Step 6: Collection and analysis of village data

All of the team members were involved in the data collection and simultaneous data analysis. The team spent three days in each of two villages inhabited almost exclusively by Hausa people. Upon arrival in each village, a meeting was held with the chief to inform him of the team's objectives and to ask for his assistance in identifying the individuals and groups to be interviewed, according to the criteria defined ahead of time by the team. In each village, small group interviews were conducted with mothers, grandmothers, fathers, Bokas and Marabouts. Individual interviews were carried out with mothers concerning the availability of the resources necessary for the management of diarrhoeal disease and with men and women concerning village communication networks.

Each day the team conducted the interviews, analyzed and summarized the information collected, identified information that was either unclear or incomplete, and planned how to gather the missing information during subsequent interviews. The female nurses on the team were especially adept at establishing good rapport with the mothers and grandmothers and encouraging them to express themselves freely. Female nurses also had the best understanding of the linguistic and health-related concepts of the women.

Step 7: Summarization of findings

When the team returned to the regional capital, they prepared a summary of the findings for each category of information collected. A few examples of the findings are included here.

• Knowledge and practices related to diarrhoeal disease management and prevention at home:

Six different types of diarrhoea were identified. For each type the interviewees identified distinctive causes, symptoms, and modes of prevention. The types of diarrhoea identified by the population do not correspond to biomedical classifications, except in the case of diarrhoea accompanied by blood, i.e. dysentery. Likewise, most of the causes and modes of prevention described by the communities interviewed are not scientifically explicable.

• Persons who directly or indirectly influence the management of diarrhoeal disease:

The community data collection suggests that the management of diarrhoea is influenced most by family members, family friends and relatives. Of secondary importance are traditional healers. Health workers appear to have the least influence, and they are usually only consulted when the other two sources of advice have failed.

• Communication networks at the village level:

For men, many formal organizations that constitute communication links were identified at the community level. In addition, the times and places that they meet informally were identified. For women, it was found that few formal organizations exist, but numerous occasions for informal contact and communication among women were identified, including weddings, birthdays and market days.

Phase II: Formulation of recommendations for the health education strategy

Based upon the conclusions of the data collection, the team members formulated recommendations both for the diarrhoeal disease educational "content" and for the "process" to be used in communicating that content to different community groups.

Step 8: Formulation of recommendations for health education content

Identification of the educational content was based upon the simultaneous consideration of community beliefs and practices related to the prevention and treatment of diarrhoeal disease, and of the national CDD programme priorities. In addition a number of key principles related to the promotion of behaviour and social change, were discussed and they were also taken into consideration in defining the educational content. Examples of the recommendations developed are included here:

• The community's beliefs related to the types, symptoms, and causes of different diarrhoeas and to alternative modes of prevention should be accepted and emphasis should be given to promoting appropriate interventions during diarrhoea.

• Mothers should be encouraged to give large quantities of liquid to children with diarrhoea to avoid "rama" (the Hausa notion of thinness and weakness that result from diarrhoea).

• Fathers should be encouraged to assist with the care of the diarrhoeal child and to provide the necessary nutritional and financial resources.

Step 9: Identification of target groups

Based upon the findings, it was decided that health education activities should be directed not only at mothers but also at other persons who influence mothers and who can provide community support for change. Primary and secondary target groups for the strategy were identified:

Primary target groups

- mothers of young children
- cloistered mothers of young children
- older women, including grandmothers
- fathers of young children

Secondary target groups:

- traditional birth attendants
- community health workers
- religious leaders (Marabouts)
- traditional healers (Bokas)
- village chiefs
- teachers

In some of the Hausa villages in the area, all or some of the women are cloistered. They are forbidden from going out of the courtyards of their homes. The social situation of cloistered women is quite different from that of other women and the team decided that they constitute a separate target group for whom special activities must be envisaged.

Step 10: Formulation of recommendations for health education activities

The choice of educational activities was based on several considerations, including: definition of health communication; characteristics, advantages and disadvantages of mass and interpersonal communication channels; knowledge of certain aspects of the behaviour change process; and the characteristics of the target communities.

The team agreed to avoid one-way information transfer from health workers to the community, and defined communication as a two-way sharing and problem-solving process. The prevalence of informal communication networks in the target community fed into analysis of the potential uses of interpersonal and mass communications. Based upon this analysis, it was decided that the educational strategy would emphasize the use of interpersonal communications activities. These were envisioned for both the community and health centre levels.

Leaders from each of the target community groups would be trained to serve as informal educators with their respective groups. Health workers would receive training in interpersonal communication to reinforce their skills in interacting with mothers and families.

Phase III: Test of proposed health education strategy with the community

In Phase II of the planning process, the recommendations for the health content and activities were based upon initial data collection from the community, but it was believed important to discuss those proposals with community members before proceeding to implement them. Therefore, it was decided that the team should return to the same communities where the initial information had been collected, to present the proposals for the strategy developed in steps 8-10 to the different target groups, and to elicit their feedback.

Step 11: Development of participative group health education sessions

The planning group team was divided into two sub-groups and each was asked to prepare either a role play or a story that would stimulate community groups to discuss both existent practices and new options related to the prevention and management of diarrhoeal disease. The sessions were to be based first on Freire's use of a "code" that reflects back to the community a part of their own reality, and second, elicits their collective analysis of that reality 123-25 ] . The role play and the story that were developed incorporated elements from both the communities' beliefs and practices and from the CDD programme priorities. Both were open-ended stories, and for each a set of questions was prepared for the facilitator to use following the presentation to get the participants to discuss their own beliefs and practices relative to those depicted in the story.

The story was prepared for the women and the role play was given to the men. Both dealt with a typical bout of diarrhoea and emphasized the roles typically played by the women and men, respectively. When the team members had sufficiently practiced their presentations they were ready to present them in the villages.

Step 12: Return to two villages to discuss the strategy with the community and to test health education activities

There were two objectives for the second visit to the selected villages: first, to discuss the proposed strategy with the village leaders and to elicit their feedback on it; and second, to experiment with non-directive, participative health education techniques. Upon arrival in each of the villages, a formal meeting was held with the community leaders to discuss overall diarrhoeal disease strategy and to elicit their suggestions for working with the different target groups. Following those discussions, groups of mothers, fathers and grandmothers were invited to discuss and watch the story or role play. In each case, following the role play or story the prepared open-ended questions were used by one of the team members to engage the participants in a discussion of what they had seen and heard. In all cases, the villagers showed great interest in the stories and said that similar situations had existed in their village. As for the subsequent group discussions, most of the participants gave their opinions about the stories they had heard and shared their beliefs about the appropriate practices to use in such a situation. As the participants talked, the facilitator reinforced certain beneficial existent practices, such as continuing to give the child food and drink, and encouraged the modification of other practices, such as the need to increase the amount of liquids and food given.

The group sessions were an occasion for the team members to assess community reactions to the proposed changes in practice and also to collect additional information on community attitudes and practices. In keeping with a process-learning or iterative approach to programme planning, the team members were encouraged to think of every encounter with a community group as an occasion for ongoing data collection, to continually improve their understanding of community values and opinions, and to revise their planning accordingly.

Step 13: Synthesis of the community feedback

When the team returned from the village visits, they informally evaluated the activities carried out in the villages. In regard to the discussion with the community leaders, several of the leaders expressed their satisfaction with the approach that the team used and said that it was the first time that Ministry of Health personnel had come to the village to listen and discuss problems with them before planning a programme. The leaders had made a number of suggestions for developing a strategy in their villages and their ideas were further discussed; many were incorporated into the strategy. As for the group education sessions, the consensus was that the participative educational techniques used were beneficial in terms of the interest shown on the part of the participants and in terms of the genuine dialogue generated among them. The group discussions following the educational activities had helped the team members to evaluate community reaction to some of the new ideas and practices they hoped to promote, had allowed them to understand better some of the community beliefs and practices, and had helped them to appreciate the importance of continuously seeking to understand the communities' perspective so as to improve the quality of communication with the people.

Phase IV: Finalize health education strategy

Step 14: Prepare final programme document

The last step in the programme planning process was to finalize the health education strategy based on all of the alternatives discussed by the team in the earlier steps, as well as on the feedback on the team's initial proposals received from the community.

Step 15: Finalize plans

A detailed description of the objectives of the strategy, its components, its implementation calendar and budget were finalized.

Conclusions

Many health education programmes are not adequately adapted to community socio-cultural realities. The programme planning exercise discussed here illustrates the use of a planning methodology that is believed to contribute to the development of more appropriate programmes. The team of data collectors from the Ministries of Health and of Planning was unfamiliar with, and initially skeptical of, the qualitative method proposed. However, as data collection proceeded, they were all ultimately convinced of the value of gathering in-depth qualitative data prior to developing health education strategies. The team for the preliminary data collection and for the development of the health education programme using the data collected included both health and rural development technicians, and the health sector members were both programme managers and service providers.

The programme development process was a learning experience for all of the team members in that it: demystified the data collection process; strengthened the participants' skills in community data collection; fostered sharing and team-work between health service providers and programme managers as well as between sectors. The planning team successfully dialogued with different community groups, re-examined their own understanding of community health problems, identified the shortcomings of past health education programme approaches, identified alternative strategies, and discussed those proposals with community members.

Four aspects of the planning process were particularly important in the Zinder programme development exercise: the initial collection of in-depth, qualitative data using informal data collection techniques; the involvement of a multi-disciplinary team in the data collection and programme planning processes; the contact between the planners and the client communities during the planning process; and the operationalization of programme planning as a problem-solving, learning process.

Acknowledgements

The authors carried out the work discussed in this paper with support from CARE International in the context of the Zinder Child Health Project. They wish to thank Jack Hazerjian, Cathryn McKaig and Susan Farnsworth of CARE International, Niger for their support during the duration of the field work.

References

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2. Pelto G. Cultural issues in maternal and child health and nutrition. Soc Sci Med 1987; 25: 553-59.

3. Foster G. Anthropological research perspectives on health problems in developing countries. Soc Sci Med 1984; 18: 847-54.

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

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6. Mills-Booth E, Green EC, Huntington D. Ethnographic Research: a bridge between traditional and modern health delivery systems. Communication for Child Survival: Field Note. Washington, DC: AID, Bureau for Science and Technology, 1985.

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8. Kendall C, Foote D, Martorell R. Ethnomedicine and oral rehydration therapy: a case study of ethnomedical investigation and program planning. Soc Sci Med 1984; 19: 253-60.

9. Aubel J, Mansour M. Qualitative community health research: a Tunisian example. Health Policy & Planning 1989; 4: 244-56.

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11. Justice J. Policies, plans and people: culture and health development in Nepal. Berkeley, CA: University of California, 1986.

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36. Use of rapid assessment procedures for nutrition programme planning, project reorientation, and training in Malawi

Characteristics of the areas to be studied: Malawi's rural areas and needs
The save the children plan: Use of RAP for information gathering as part of needs assessment for programme planning
Rapid assessment procedures for reorientation of the Ntchisi child survival and development project
Acknowledgements
References

By Gretchen Berggren and Beatrice Mtimuni

Gretchen Berggren is affiliated with the Harvard School of Public Health and Save the Children. Beatrice Mtimuni is also affiliated with the Harvard School of Public Health.

This paper describes three uses of RAP in Malawi, all related to improving nutrition. The first section stresses the often limited time frame available when RAP is used in planning, and describes how community level behaviors, knowledge and attitudes can be quickly explored with the resulting information feeding into the programme planning process. The second section describes RAP used in gathering data needed to explore potential new directions for a UNICEF-supported project focusing on soybean use to improve nutrition in rural families. RAP generated information suggests significant behavior change would not be simple and recognizes the need for better targeting and more regular interpersonal contact. An analysis of organizational resources needed to assure that such recommendations are feasible, would be a useful complement to RAP in this situation. The third section describes how RAP was used simultaneously to gather data on rural nutrition for a training course and to sensitize trainees on family nutritional issues. The value, and risks, of such an open ended exercise are described. - Eds.

NUTRITION AND AGRICULTURE projects linked to health interventions are a priority for Malawi, where malnutrition is recognized as a serious problem. This paper discusses how rapid assessment procedures were used to advise nutrition projects in four separate "impact areas" in rural Malawi. The first two are Mbalachanda (northern area) and Mkhota (centrally located), where Save the Children Federation USA (SCF) works; the third impact area is the Bolero impact area, north of Rumphi, where Save the Children/Malawi (SCM) hoped to work; the fourth is Ntchisi, where a pilot project of UNICEF and the Government of Malawi is located.

Despite efforts to curtail it, malnutrition in rural Malawian children remains a problem; it has been detected in all social classes. Nearly a quarter of children under five were reported as underweight for age in 1981; wasting (low weight for height) affects to 1% to 2% [1]. Children of farm workers (tenants or daily paid workers) who grow up on estates where cash crops are grown appear to be especially at risk. The largest portion of a family's time (including the mother's) is labour related to cash-cropping (such as tobacco raising). The mother needs to devote additional time to a traditional garden in an attempt to produce sufficient quantities of fresh vegetables and supplementary root crops for the family. During the planting season, many migrant farmers find neither seeds nor cuttings available to plant in the small garden plots made available by the estate owners.

The prevalence of nutritional stunting is not limited to certain rural areas. Malnourished children are detected through growth monitoring and promotion (GMP) activities at hospitals, rural outposts or in some cases by outreach teams.

The home-based "Road-to-Health" growth record, on which weight for age is graphed as recommended by UNICEF, is approved for use and is distributed to mothers who are asked to keep it and to bring it with the child whenever the child is referred for treatment. For several years, mothers have been counseled in the use of "likuni-phala," a weaning food distributed by the World Food Programme. It is a milled product of corn, beans and ground nuts. Because it has not been toasted or pre-cooked it requires 40 minutes of cooking in a separate pot. Compliance has been a problem.

The relationship between nutrition and infection is well recognized by Malawi doctors, who treat children with severe protein-calorie malnutrition in hospitals. Many of these children die.

The authors' task in working with community development organizations was to assess activities that were, or could have been, used to combat malnutrition, and to propose a nutrition intervention approach that would link local institutions, agriculture, health and women's project resources to activities at the grassroots level. In order to accomplish their tasks in the few weeks of time allotted, the authors turned to Rapid Assessment Procedure (RAP) methods [2]. These were: focus groups of mothers in a community setting, interviews with informants and randomly chosen home visits to mothers who could benefit from activities to prevent malnutrition.

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