Action through Participation

As a Research Administrator, my responsibilities include assisting faculty members make grant applications in Public Health research areas and coordinating capacity building workshops for early career researchers in grants writing and manuscript drafting. At one point in my career, it was but natural to pine for a deeper understanding of ‘field work’ to add value to the documents I would prepare. An opportunity to visit two ‘field sites’ to document successful best practices came through and I was happy to commit to them instantly. The first was to document record keeping by front line health workers in Eastern India. The second was to document health promotion in community settings in Western India. Both required engaging with health workers and community in equal measure. Both broadened my thinking and understanding beyond all the research papers and reports I had read.

One of the field site was a small dingy room without a window. About 30 women sat in the room, some mothers, some daughters, some newly weds and some with infants, all cheerful, oblivious to the dark interiors. A henna competition was on, to gauge whose henna bedecked palms were the best in terms of design and colour. Before prizes were announced, the women were asked to speak on what their dream was about their daughters. The henna competition had broken their inhibition and now they all spoke up. One woman said she wanted her daughter to be healthy, one said education and going to school was important, another spoke about financial independence. But they all spoke, and not about challenges they and their daughters face every day, not about the resource limited households they had to go back to, but about their dreams and aspirations for their next generation.

It was then that the Project Manager told the women about family planning methods, about how spacing between children was one way to keep both the mother and her children healthy, about discussing family planning options with their husbands and families and reaching out for resources and medical assistance in the nearby locality, in case they needed further advise.  What I was observing was a participatory action or engagement, where the community is an active lead for any intervention being planned for them. The Project Manager was part of a larger project involving community, private and public medical practitioners and health centers. He was not an MD or a PhD, but was highly skilled in community engagements. There was a level of comfort that he demonstrated especially while handling a taboo subject like family planning methods with women from a very conservative section of the society. Later on he told us that it was important for him to understand what the community wanted first, before he aligned it with what he wanted to tell them about his project.

Six months later, I had an opportunity of being involved with a group of researchers planning to conduct a study on immunization coverage in Eastern India through community intervention. The Intervention specialists, began with a question for the community. Once again the question was about their dreams and aspirations. As per their experience, for any community intervention to be sustainable, it was important to have the community participate in the study, not as a recipient, but equal in status as the researcher conducting the study. Most often, community interventions require social and behavior changes to have positive outcomes and this can be achieved when the community believes that there are substantial gains from the study which align perfectly with roadmaps to their dreams.

In one of our institutional projects on rain water harvesting and storage in several villages, it was seen that when the community participated as equals, there was substantial ownership. At the end of the project, when the research project team pulled out of the community, the residents took up a mechanism to pool in resources and maintain the structures built and the processes for water regulation, as a regular mechanism. The project was renamed as ‘Aapno Yojana’ meaning ‘our/my project’.

Additionally, cultural contexts are often overlooked while designing community interventions. In a country like India, where each region is different from the other, be it in language, religion, tradition, beliefs etc, one intervention will not be replicable in another setting. Participation from the community in devising intervention strategies not only provide ways to conduct the intervention, but also help drawing out indigenous solutions in resource sharing in resource limited countries.

Participatory Action Research can be valuable in sustainable community interventions. Some of the methods use a lot of listening and then devising an intervention plan along with the community. What is required is a strong monitoring and evaluation component to measure progress at every step. The cons include

  • Ethics- Both the researcher and the community have to believe that the intervention will benefit the community. While aligning the community’s goals with research objectives, there should not be a forcing on or manipulation to align research objectives leading to coercion.
  • Choosing community leaders- especially in projects where community is required to openly discuss topics that lead to behavior change, often a few representatives from the community are first addressed who then in turn become a relay team of informing others in the community regarding the intervention. Sometimes, these leaders can become quite dominating and forceful with their ideas and thoughts. In order to maintain balance, adequate monitoring and constant dialogue with the leading team and the community is required.
  • Not connecting with appropriate stakeholders- in addition to the community, the local health governance members have to be a part of the project. Once the project is completed, they would be required to continue to administer, monitor and guide the community.
  • No linkages with national/ state programmes/resource agencies- In order to be sustainable, the community intervention has to have linkages with ongoing national, state programmes. The project team should also be able to forge linkages with resource people who can be sought locally, like front line health workers, medical practitioners, hospitals, healthcare centers, diagnostic agencies and pharmacies. This would be valuable when the project is completed and the community still has people to reach out to.

In case of community interventions where participatory action cannot be utilized, appropriate ways to conduct research dissemination should be explored. Often research dissemination is done at a higher level, involving government functionaries, policy makers, research groups. The people who would benefit most, the community is not informed regarding the research results. Importantly, changes are being driven by some funding agencies who advise for strong dissemination components at proposal stage itself. Medical research involving drug and patient trial results are often not shared due to ethical factors. However, there are many public health research projects where dissemination mechanisms are not explored adequately. As a result, public health research is still conducted in silo and shut down in large cumbersome reports that are not accessible for wider reading.

A few interesting examples of participatory community interventions using different methods are-

  • The Maternal and Perinatal Death Surveillance and Response[1] project initiated by the Ministry of Health and Family Welfare in Bangladesh, which helped make substantial improvements in maternal death indicator. During open discussions with the community on maternal death at childbirth, the project team realized that excessive bleeding during delivery and delay in seeking appropriate medical care, delay in accessing appropriate transport to the nearest hospital, caused an increase in maternal deaths. Interventions were created to address these issues followed by policy level changes that led to better indicators.
  • Community Photovoice project[2], where community members took photos or wrote and spoke stories regarding barriers and promoters of eye care in rural India. Their voice identified a few key barriers such as alcoholism, unregulated blood sugar and hypertension. These can now be adequately addressed by strengthening the healthcare fabric within the locality.
  • Participatory Women’s group addressing maternal and child health[3]– front line health workers used participatory methods to prioritize neonatal and maternal health issues amongst a women’s group that in turn spread the information amongst women through implementation projects that they themselves assessed.
  • Developing smoke free homes in Kerala[4]– Pilot studies suggested that Community participatory action helped substantially reduce second hand smoking in homes. Interestingly, the study showed that husbands, who did not stop smoking on request of their wives, did so when the community together aimed at a ‘smoke free home’ drive.

It is also important for Public Health researchers to obtain information regarding various successful participatory action research methods that have been tried and tested.  A compilation of literature on various approaches to participatory action research is required. This would help researchers understand the implications of community participation and then to design intervention plans that have potential to be scaled up. Perhaps all the major funding agencies working with communities could come forward to collate information on their successful community intervention projects, at one place. Or perhaps scientific publication houses could bring out commissioned papers in this direction.

At a time when Public Health research funding is slumping across the world, it would benefit to test out different methods of participatory action that have scalability and sustainability while being minimally resource intensive. In developing countries where population numbers are high, people are the true strength and the only resource. Bringing them together, learning from them and linking them to the local resources available should be the primary objective of the researcher involved in designing community interventions. Participatory Action Research can help bridge the gap between people and the Sustainable Development Goals we have set for ourselves to a great degree. As researchers, we have to merely facilitate this connection.

 

[1] Biswas, A., Rahman, F., Eriksson, C. and Dalal, K. (2014) Community Notification of Maternal, Neonatal

Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6,

2218-2226. http://dx.doi.org/10.4236/health.2014.616257

[2] Rani PK. et. al. (2017) Envisioning eye care from a rural perspective: A photovoice project from India. Int.Q.Community Health Educ. doi: 10.1177/0272684X17736153

[3] Tripathy, P. et. al. (2016) Effect of participatory women’s groups facilitated by ASHAs on birth outcomes in rural eastern India: a cluster-randomised controlled trial. The Lancet Global Health, Vol 4, No.2, e119-128. DOI: http://dx.doi.org/10.1016/S2214-109X(15)00287-9

[4] Nichter M. et.al. (2015) Developing a smoke free homes initiative in Kerala, India. BMC Public Health. 15:480. doi:  10.1186/s12889-015-1815-1

Advertisements

Gender Views

We received a wedding invitation last week from our professional network. The invitation card mentioned the name of the groom (whom we know) and the bride to be. Her name is ‘Trophy’. Now I know, one can only imagine how she would have gone through school and college with that name, and also of the innumerable puns (intended) that would have surrounded her at all ages. However, I was thinking of the day she was born. She must have made her parents so happy and I can practically visualize the pride and delight her parents would have felt in holding her and showing her off….you know…like a prized possession (almost like Lion King!)

Though gender bias exists throughout the world as per scientific literature, I may be one of the fortunate few who is yet to document this from any practical experience. In fact, my family may be quite weird. I am an only child and all my uncles and aunts (5 of them) have only a single girl child. Maybe it’s a genetic predisposition, but we have been a very contended lot with a house full of women. Sometimes I do feel, we have sidelined the male population to a background in our family. We do include them in decision making processes, but just so they don’t feel left out (J).

It is however, extremely important to have different perspectives while making important decisions for the family like health choices, financial choices, education for children, marriage decisions, buying a home etc and a balanced view emerging from all family members irrespective of their sex is valuable. I also think children and adolescents make good decisions too and should not be undermined in the process. More than stressing on gender, I am of the view that each person is valuable and has a lot to contribute. The dynamics of power distribution will change when we start valuing each person, instead of attaching adage of male female, girls boys etc.

The fact is that my family may be part of a very small microcosm. I have women colleagues who have felt domination every day of their lives, I have male colleagues who are constantly overruled by their mothers while making family decisions with their wives for their children. Power has and will always lead human kind through all ages.

There are three delays in obtaining timely healthcare, type 1 delays are those made at the family level, where the decision that the ailing person in the family needs urgent healthcare in a timely manner can lead to survival or death of the person. Type 2 delays are often transportation or means to get to the closest healthcare and can depend on decisions, economic conditions etc of the family or surrounding community, terrain and accessibility in remote areas and the type 3 delays are adequate and timely healthcare provided to the patient in a healthcare facility. All three delays together or individually can lead to survival or death. Gender plays an important role in all these delays and is particularly crucial at the type 1 delay stage. There is a lot of research evidence that type 1 delay causes extensive bleeding at child birth in mothers who deliver at home, especially in low and middle income countries and together with type 2 delay causes the largest portion of maternal death. Same is true for neonatal deaths.

What are the barriers? Gender is only one of them; social, traditions, customs, faith, economics, illiteracy, ignorance make up the rest. What are the solutions? Education of every child, awareness of family and community, more participatory mechanisms to include women, men, community in government health schemes are a few answers, together with greater outreach of front-line health workers into urban and rural communities.  Often in Maternal and Children Health programmes, the men are sidelined, however, they should know the programmes and their views are as important as the women and mothers. Community empowerment and education of all will lead to better understanding of men and women in general and build stronger families. As part of a public health research organization, the best we can do is to include a equal gender lens in all our studies. To be inclusive and create projects that benefit everyone and don’t exclude men and/or boys. Health should be gender free, it is for and by all.

 

 

Organizational Leadership

“Leadership consists of nothing but taking responsibility for everything that goes wrong and giving your subordinates credit for everything that goes well”-Dwight D. Eisenhower

Last week Prof David Peters from Johns Hopkins University (JHU) was in our institute, addressing our faculty members for a short while. As an established public health practitioner, overseeing his division of 140 plus researchers and academicians with research network and collaborations across most countries in the world, he took up an impromptu session on career building with our faculty members at a mere notice of 5 minutes.

Through an informal discussion, Dr Peters examined the current level of research engagement in each faculty, where they wished to see themselves in five years and the opportunities and support they would need to do so including self work. He also helped acknowledge the challenges in our systems and ways to deal with them. These are not aspects that our faculty is unaware of, and given that solutions in the context of JHU may be quite different from our own indigenous solutions, there is always a scope for deeper introspection. However, the leadership quality he demonstrated was impressive. For the two hours, he held everyone’s attention. The engagement was participatory and there was an element of mentorship without being patronizing. Nor did he express his mastery over any particular area. He was more facilitative than overbearing.

The next day, the new Director of our institute (another seasoned public health practitioner) sat down with all faculty members and helped them devise a personal research plan, based on each person’s training and expertise, interests and where they wished to reach in some year’s time. There was an accountability plan as well along with it, each faculty was asked to write milestones, deliverables albeit self assessed and self proposed. I have worked in many organizations, however, this was the first time I came across a true leadership driven activity where a career plan was being devised for individual member with an accountability framework. I certainly hope that a supporting and enabling environment is provided to fulfill these individual goals. Our institute is small with a small team of faculty, hence face to face meetings, individual plans may work. In bigger groups, especially where there are 140 researchers involved, a lot is derived by setting an example that trickles down from top to bottom. More like stewardship that has been explained in a number of journal articles.

It’s not always about salary increments and benefits. Sometimes employees stay back in an organization because of self and career development plans that override benefits. Leadership involves looking outside oneself, creating an atmosphere for team members to rise and also be accountable for their actions, while mentoring them throughout. Most importantly, a leader understands the practical realities of their team members, resources, limitations and designs future plans accordingly.

  • How important is it for organization leaders to have social interactions with their colleagues?

“Sometimes you have to take a break from being the kind of boss that’s always trying to teach people things. Sometimes you just have to be the boss of dancing”.-Michael Scott, The Office

The answer to some extent lies in a mutual attitude. From my personal experience, Directors of institutes who had a regular faculty and staff meeting with their colleagues over a cup of tea had greater commitment from employees to solve organizational issues in a collective way. Not just issues, but volunteering in organizational activities also rose.

  • How important is it to reiterate organization values amongst the employees?

“Ten soldiers wisely led will beat a hundred without a head”.- Euripedes

There is no harm in reiterating organizational values like quality, accountability and trust at employee meetings. However, the leadership should also demonstrate these values amply before harping about them. Sometimes honesty goes a long way, real life stories also help where the leadership may explain that they set out to achieve something and were unable to, however they learnt something more important in that process. Being a leader doesn’t mean 100% success rate, it just means that one is able to cope with life in a much better way.

  • People management vs time management

“The best executive is the one who has sense enough to pick good men to do what he wants done, and self-restraint to keep from meddling with them while they do it.” –Theodore Roosevelt

The answer is in making an impact. Organizational leaders are hard pressed for time between internal, external engagements, overseeing all the activities within organization, making decisions and also traveling around the world. Yes there is a need for balance in everything, however, making an impact in everything one does, adding value to meetings, however small these are, would be one way to leave a lasting impression. While delegation is a part of management, even more important is to know who can accomplish what in the given time.

  • Being able to take risks

“You miss 100% of the shots you don’t take”. –Michael Scott, The Office

In spite of having a deep understanding of whether a team can accomplish a task, the leader is still open to taking risks and challenging the norms. Yes there is a line between taking an intelligent risk and stupidity, but the leader has a sixth sense in terms of understanding that their team would rise above their own comfort zones to achieve a certain goal. Sometimes trust and confidence go a long way. For the first time, our new Director is moving the academic section from paper copies of books to kindle/tab versions. This is not a new aspect in India. Most Indian Institutes of Technology’s have moved to e-books a long time ago. But someone had to come to our institute of 10 years and make that move.

Leaders are perhaps not born, but made through their experiences, ambitions and will to work hard. Mostly importantly leaders are made through their undying faith in others and their undying faith in their own strengths.

Mother’s day- How do we save our mothers?

We have recently celebrated the woman who has helped us cope with life not only during our childhood, but also adulthood. We showed our appreciation to the superwoman, who shields us from everything that could cause us pain, and sometimes, to our embarrassment and sometimes joy, tries to guard us even when we are supposed to have found our own footing in the big world outside home. She is universally revered across cultures, religions, countries or the n number of divisions we have made to segregate ourselves.

But something isn’t right. Why are our mothers dying and why haven’t we been able to curtail this, even in 2017?  Maternal death is a serious issue especially in developing countries. Although we have brought down global maternal mortality by 47% since the 90s, as per the World Health Organization (WHO), about 830 women die due to pregnancy/delivery related problems around the world each day. These are mostly preventable. 99% of these deaths occur in the developing countries.  The odds of a 15 year old dying due to pregnancy/delivery related issue in developed countries is 1 in 4,990. In the developing nations, it is 1 in 180. Sadly most of these deaths occur due to reasons that are within our control.

Severe blood loss during pregnancy and post delivery is the main reason, followed closely by infections. In most cases of severe hemorrhage, injections of Oxytocin are enough to slow down blood loss. The many reasons for maternal death are health inequities, aka, basic services are not available to those who cannot pay for care. Distance to the nearest health care facility, availability of medicines in the facility, inadequate services are also key reasons adding up to the issue. A UNICEF led project in 6 states in India based on verbal autopsy of family members and community members of mothers who had lost their lives during child delivery, showed that cost for transport to the nearest health facility, literacy level of the mother, community awareness were leading cause of maternal deaths.

Personally I find the lack of awareness and non adherence to hygienic practices during childbirth and subsequent death of mothers due to infections, is most unsettling. Sepsis is a major problem, both in maternal as well as neonatal death. These defy all norms for extent of negligence. Additionally, through our incessant use of antibiotics we have successfully created microbes which are now resistant to most drugs, hence can easily compromise an infected mother and her newborn.

The WHO has recently adopted a resolution on sepsis that urges member nations to be more cognizant regarding causes, prevention and treatment of sepsis and tighten policies and regulations of activities leading to Antimicrobial resistance (AMR), to develop AMR stewardship activities and strengthen hygienic practices, clean childbirth practices and improvement in sanitation and nutrition.

Some of the basic things that we could do at our levels would be to create awareness amongst everyone we come in contact with. Every time we visit a clinic or a hospital, we could inquire about guidelines followed in infection management, waste management and AMR. We could also remind the health practitioners about hand hygiene and seek their advice in ways to prevent infections at our homes.

Every family needs a mother and every mother deserves a good healthy life, especially one that can be met by a few prevention steps

 

.

Intergenerational transmission of poverty and escaping the poverty trap

Image result for intergenerational poverty india

Last weekend I watched a delightful movie on something quite close to my heart. ‘Nil Battey Sannata’ depicted a mother and daughter’s journey through life. There were several moments which I could totally identify with. It was superb acting by a very able cast and although the subject was very down to earth, of a mother’s trials to provide a good future for her daughter, the cinema did do justice to balance all emotions very well. The teenage daughter had already resigned to the fact that her mother wouldn’t be able to put her through an expensive higher education, and had gone ahead and explored options of choosing a career as a nanny, something within her realms and ability.

A few days ago I was involved in a project dealing with intergenerational transmission of poverty and some of the dialogues in the movie brought back thoughts from work. The mother depicted in the movie was a daily wage earner, working in the informal sector. In India and many other lower and middle income countries, there is a huge section of population working in the informal sector and most survive on day to day earnings. Some don’t have enough to meet their daily needs and most do not have anything to save for the future. And this brings in another worry of a huge population of elderly people resulting from the same informal sector, without any sort of retirement savings.

I strongly feel that every human has a right to dream a rosy future and somewhere when one is consumed with thoughts solely of how they/their family can survive the next day, life is not completely justified. There is some information from research and mostly from the field of economics that intergenerational poverty is transmitted from parent to children especially in those living below the poverty line (BPL). Somewhere, there is a little mismatch, since the huge middle class strata of India, which extends from those just above the poverty line to those doing very well, often times demonstrate examples of children capable of attaining their dreams through hard work and education loans and scholarships and being able to climb from one strata to that higher. This is somehow extremely difficult for the poorest of the poor (BPL), even though many of the schools have very similar opportunities for growth. Additional aspects such as health and nutrition have been implied to add to lower school attendance in children and the reasons for being unable to escape the poverty trap become complex with multiple compounding factors.

What has been seen to work to some extent is conditional cash transfers (CCT). And more evidence from research is needed in this area. Pilot projects where cash transfers were made to the BPL families, tagged with compulsory school attendance, or availing government immunization/health programmes were seen to effect family nutrition and quality of life in a positive manner. School attendance also improved due to better nutrition and health. This would probably be a mechanism to escape the poverty trap. However, much more needs to be done in a proper structured manner. Also the process for CCT needs to be efficient without involving too many intermediaries that can raise avenues for corruption or bureaucracy or both (one stop mobile money transfer has worked well in Kenya). Community cooperatives also work to some extent, however, a strong community engagement, community participatory action methods are needed to be explored.

I am often frustrated that researchers do not come together to build sustainable projects. Grants are mostly driven with motivation for a few publications, or a PhD degree or obtaining a faculty position. Sustainable projects can be made possible only by a multidisciplinary team and until researchers stop working in silos where an economist only works with another economist and a qualitative researcher only with their own folks, it will be very difficult to achieve anything meaningful on the ground. One can generate multiple models of why things are not working, but ground level realities require tangible practical solutions and most importantly, ones which are sustainable in minimum resource settings.

Picture acknowledgement- Asian Development Bank