Question

Case Study #1: A Successful Bottom-Up Approach

Ban Vinai, a 400-acre refugee camp perched in the remote, hilly region of northeast Thailand, has been home to more than 48,000 residents since the Vietnam War. Residing in the overcrowded, dilapidated camp hovels are primarily the Hmong, an ethnically unique hilltribe people originating in the mountains of Laos. Before the war, the Hmong generally cloistered themselves off from Laotian society, preferring a solitary, exclusionary lifestyle of subsistence farming and distinctive cultural and religious tradition. In the late 1960s when the Vietnam War crept into Laos, however, the United States recruited thousands of Hmong fighters, who felt that their land and independence were threatened by communism. Displaced by the bombings of the North Vietnamese and Lao regime, the Hmong were forcibly relocated to state-run collective farms, or they voluntarily migrated to Thailand. Ban Vinai, one of the biggest Thai camps, was riddled with disease as a result of open sewage and high population density. In 1985, the International Rescue Committee appointed ethnographer Dwight Conquergood as the coordinator for an environmental health program in Ban Vinai. Instead of commuting to the camp daily, like the other expatriate researchers, Conquergood insisted on living in a thatched hut like the other Ban Vinai residents. Drawing on inspiration from Pedagogy of the Oppressed by Paulo Freire, an influential Brazilian philosopher, as well as Where There Is No Doctor: A Village Health Care Handbook, Conquergood was interested to see if theories of Third World performance art and village theater could be applied in Ban Vinai to raise awareness about health issues. One day, he noticed a Hmong woman humming folk songs on a bench. “Her face was decorated with little blue moons and golden suns, which he recognized as stickers the camp clinic placed on medication bottles to inform illiterate patients whether the pills should be taken morning or night. The fact that Conquergood considered this a delightful example of creative costume design rather than an act of medical noncompliance suggests some of the reasons why the program he designed turned out to be the most (indeed, possibly the only) completely successful attempt at health care delivery Ban Vinai had ever seen.” The first dilemma Conquergood encountered was a failed attempt by the medical staff to vaccinate all the camp dogs after a rabies outbreak. In an effort to discover why so few Ban Vinai inhabitants brought their dogs to the clinic to be inoculated, he said that he found that Hmong expressed much distrust toward local hospitals, which were primarily run by overly zealous foreigners from Christian charitable foundations. The hospital volunteers disrespected their traditional beliefs, cutting spirit-strings from their wrists because they were thought to harbor germs, removing neck-rings that Hmong believed protected the souls of small children, and denouncing Hmong confidence in shamans and herbalists. With these beliefs and perceptions in mind, Conquergood designed a “Rabies Parade.” It was “a procession led by three important characters from Hmong folktales—a tiger, a chicken, and a dab—dressed in homemade costumes. The cast, like its audience, was one hundred % Hmong. As the parade snaked through the camp, the tiger danced and played the qeej, the dab sang and banged a drum, and the chicken … explained the etiology of rabies through a bullhorn.” All three figures were strategically chosen to appeal to Hmong’s cultural ideologies. The tiger, a guileful creature in Hmong mythology, drew attention and inspired awe. The commotion of the singing and drumming of the dab, a supernatural spirit, drew people out of their huts and into the streets. The chicken implored the parents to vaccinate their dogs to protect their children. The adults, aware of the chicken’s divine status in Hmong folklore, listened attentively. “The next morning, the vaccination stations were so besieged by dogs—dogs carried in their owners’ arms, dogs dragged on rope leashes, dogs rolled in on two-wheeled pushcarts—that the health workers could hardly inoculate them fast enough.” Equally successful was Conquergood’s “Garbage Theme” month. “Drawing on the evil ogre character from Hmong folklore (poj ntxoog), we created an ugly Garbage Troll in soiled ragged clothes and a mask plastered with bits of garbage and dirt. The Garbage Troll would lumber into the centre of the playing space and begin dramatizing the behavior to be discouraged—peeling eggs and other food and throwing the waste on the ground, picking up dirty food from the ground and putting it into his mouth, and so forth.” Then “Mother Clean,” an eight-foot dancing puppet on a bamboo frame would sing a song with the following lyrics: “When you lived in the mountains, the wind and the rain cleaned the garbage. Now with so many people in Ban Vinai, we all must be careful to clean up the garbage.” Conquergood’s detailed investigation of the local cultural landscape, as well as his integration of Hmong practices and beliefs into the program’s architecture, resulted in widespread conscientization of the public about the perils of pollution and poor sanitation. The resulting behavioral change suggests that development organizations must engineer programs that are culturally sensitive, as well as locally endorsed and conducted, if improvements are to be made.

Case Study #2: An Unsuccessful Bottom-Up Approach

Grassroots development is seen by many as the means by which underserved communities can “have a voice, invested interest, and ownership in the development of their land, economy, education, rights, and values.” The Foundation for Sustainable Development claims that “[t]hrough listening to [community members’] needs, empowering their belief in change, and working beside them to implement practical solutions, real progress can be made that does not result in donor reliance and further disempowerment. Cultivating a thorough understanding of the complex realities ‘on the ground’ is the key to empowerment and collective action.” Sometimes, however, as seen in the following case study, even those involved in development work “on the ground” can be ineffective if the right questions are not asked. Before a strong stance on HIV education was adopted by governmental leadership in Thailand in the early 1990s, HIV/AIDS severely threatened national health infrastructure and general stability. Even after the implementation of a pervasive public information campaign and condom distribution plan, the country still battles to keep its prevalence rate low. It was in this environment that Peace Corps volunteers tried to do condom demonstrations for villagers in an effort to contribute to the national goals of HIV-transmission reduction.

“In the old days volunteers used bananas in the demonstration but switched to wooden replicas when they discovered that some participants went home and actually put condoms on bananas thinking it had some sort of power to keep them safe.”

HIV/AIDS education and prevention is a large part of the work carried out by Peace Corps volunteers working in health sectors of Africa, the Caribbean, Eastern Europe, and Central Asia. While encouraging condom use “is a critical element in a comprehensive, effective and sustainable approach to HIV prevention and treatment,” how the educational material is communicated to its target audience must be adapted to local cultural circumstances to avoid ineffectiveness in health programs. A document published by the United Nations Population Fund, UNAIDS, and the World Health Organization states that:

• “Condoms must be readily available universally, either free or at low cost, and promoted in ways that help overcome social and personal obstacles to their use.”
• “HIV prevention education and condom promotion must overcome the challenges of complex gender and cultural factors.”

Recognition of and respect for such cultural factors and social obstacles can be achieved through “cultural competence.” Achieving this competence “implies having the capacity to function effectively as an individual and an organization within the context of cultural beliefs, behaviors, and needs presented by consumers and their communities.” This includes involving the community in pinpointing issues and generating solutions, collaborating with other local agencies to determine best practices, and evaluating receptivity to and outcomes of community-based endeavors. In addition to a more meticulous examination of the culturally acceptable methodologies of knowledge dissemination, a “cultural broker”—a liaison between outsiders and insiders who understands “the health values, beliefs, and practices within their cultural group or community”—might have been helpful in the Peace Corps volunteers’ situation as well.

As a brief counterexample of how community health education about sexually transmitted diseases can be done effectively, we look to a case study from the Asaro Valley of the Eastern Highlands Province of Papua New Guinea. In their preliminary investigation, researchers found that while the national prevalence of some STDs is high—with 25% of both men and women having Chlamydia and 45% of women suffering from trichomonal vaginitis—knowledge about how STDs are transmitted is low. Before they started their health education workshops, researchers sought the guidance of a professional health educator from the country’s Division of Health. The native specialist shared the teaching techniques to which she thought Papua New Guineans would best respond. These included lectures, visual aids, group discussions, one-on-one health education, interviews, and demonstrations. These techniques were then tested and evaluated in various community settings to determine which were most well-received.

In the beginning, teaching aids included “cardboard models and puppets, line drawings of basic reproductive anatomy and drawings of people engaging in various activities or showing signs and symptoms of disease.” Also, educators utilized both bananas models for condom demonstrations. When villagers voiced discontent about the explicit nature of the materials, researchers adapted by asking village representatives to preview the materials before they were used in the workshops. This action expressed to the villagers that the researchers were flexible in their methods, accommodating to cultural beliefs about sexuality, and sensitive to participants’ discomfort. “[E]nthusiastic support from the leaders” also helped augment the researchers’ credibility. Researchers found that the majority of women had never seen nor used a condom. Hence, it was “important to demonstrate their use, and also to get the participants to handle them and, if possible, practice putting them on the models.” Contrary to the changes that were necessary in Peace Corps condom demonstration protocol, “bananas worked better than wooden male models, because the women were less embarrassed about handling them.”

The lesson that can be learned about the difference between the one group's approach in Thailand and the approach of researchers in Papua New Guinea is simple: merely working “on-the-ground” is not enough to create a successful bottom-up approach. It takes cultural competence, intensive assessment of community values, adjustment to cultural preferences, and space for open dialogue and feedback to implement an efficacious health education campaign.

Questions:

What are three aspects of the case that consider new information or that offered deeper context.

What are two aspects of the case that can apply in practice healthcare field now or in the future.

What is one aspect of the case that found confusing, created question for further consideration, or which would to learning more.

Answer 1

CASE STUDY 2

1.3 aspects

• Cultivating a thourough understanding of the complex realities 'on the ground' key to empowerment and collective action.
• Even those involved in developement work 'on the ground' can be ineffective if right questions are not asked.
• Recognition of and respect for cultural factors and social obstacles can be achieved through cultural competence.Achieving this competence implies having the capacity to function effectively as an individual and an organization within context of cultural biliefs ,behaviours and needs presented by consumers and communities.

2.2 aspects

• "Cultural brokers " a liasion between outsiders and insiders who understands the health values ,beliefs and practices within their cultural group or community. They act like bridge between common people and health care workers which can be implenented in health field.
• Demonstration protocols should be laid which can be used in health care field to demonstrate regarding many health problems to common people.And also lectures ,visual aids group discussions ,one -on-one health education and interviews can also be included for more and easy awareness of the people.

3.1 aspect

• To create a successful bottom up approach is 'cultural competence' itself is enough?
• Is there any thing to concentrate on psychological aspects of the people?so that they can come out of the general myths they have regarding condoms and STDs.