Women in Health Development: Case Studies of Seleced Ethnic Groups in Rural Asia-Pacific 9789814345781

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WOMEN IN HEALTH DEVELOPMENT

The ln.stilut.e of Southeast A11ian Stud ies tiSEASJ was established as an autonomous organization in 1968. It i' a regional research cent re for scholars and other specialists concerned with modern Southeast .1\. O~t..-na . \\omitc to health programme s u~tainabil it~. In Vanuatu, it wa' perceived that tht' parallt'l imol•ement of relc,ant government development agencit'\ and the local kader'>hip could enhance tht' participation of women in health aeti' lliC'>. The training programme attempted 10 balance ski lls in problem formulation and the implementation or relevant programmes. The projects were carried out in the rural milieu of the ''omen \\ it h inherent problem!. emanating from re~ource cotNraint ~. the attitude of the community, the time allocation of women, 'ill age wnrtict~. the re\catcher•,' dilemma, the communit y work pace, and cata~trophc!>. At the end of the project period (thirt y-six month!>), the project'> were at diffen:nt ~tage~ of completion. For some, more time wa~ allocated to the imparting or !) kill'> in health problem definition, consem.u!> building, and planning. The o th er~

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Preface

embarked on easily demonstrable- tasks to show the women that with communal deliberation and action, they could meet their health needs. The approaches varied to suit the local conditions. Chapter VIII , the concluding chapter, extricates the integrative themes from the case studies and offers suggestions to address the issues of sustainability and self-reliance. The themes involve the assessment of the major areas in the involvement of women in the programme planning and implementation, such as ways by which the physical and external resources of the community could be drawn out, the data needs for the delineation of health problems, entry points, the local documentation perspective, the positive and negative factors in objective attainment, sustainability, and self-reliance. Towards the end, guide-lines for the implementation of participatory research in heaJth development were suggested. Finally, unresolved problems in participatory research were raised, such as the concept of participation, the selection of the participatory medium, the community's role, and incentives. While the challenges of participatory research in health development are immense, these should serve as a trail-blazer to researchers who wish to undertake truly significant work in health. The operational processes in this report do provide information sufficient to conclude that women can have dual tasks - the responsibility for the health care of their fami lies and contribution towards the formulation and solution of health problems at the macro community level. It is too early to determine the long-term implications of the project but in the long run, it is hoped that the active involvement of the women in the development of health in their communities will be considered at the policy level.

ACKNOWLEDGEMENTS

This report is the c ulmination of three years of collaborative work on "Women in Community Development in Asia and the Pacific" which was made possible by a grant provided by the International Development Research Centre (IDRC), Canada. The interest and conlinuous support of Dr Dae Woo H an, of the IDRC, throughout the cour e of the study are greatly appreciated. Professor Paul C hen of the Univer ity of Malaya was a project co-ordinator at the initial stage and a isted in the development of the proposal and the identification of the Pa cific country co-ordinators. When he left, Dr Niik Plange took over as regional co-ordinator for the Pacific. The collaborating researchers for this project were Dr Wong Mee Lian for Malaysia, Dr Orapin Singhadej for Thailand, Professor Thelma Corcega for the Philippines, Dr Jo hn Sairere for Papua New Guinea, Ms Cerna Bolabola for Fiji, and Ms H ilda Lini for Vanuatu. They a em bled and inte rpreted the project information for health development into case tudies. Special thanks a re due to Dr Somsak Boon· yawiroj of IDRC Social Science Di visio n who provided materials o n participatory research that provided insights into the philosophical foundati ons of the concept. T he helpful comments of Dr Antonio de J esus o f the International Institute of Rural Reconstruction during the post-project work shop also deserve special mentio n. I am thankful also to the Institute of Southea~ t Asian Studie~. particularly tO Professor K.S. Sandhu, for providing the excellent research fad lities a nd a ssistance in the project administration.

Development is increasingly seen as an awakening at the "bouom". i.e., a catalytic process offreeing the creative forces of the impoverished and e:rploited of any given society and enabling those forces 10 come to grips with the problems of underdevelopment - Hall '

I PARTICIPA10RY RESEARCH IN THE HEALTH SETTING Trinidad S. Osteria

In July 1987 the Institute of Southeast Asian Studies, with funds provided by the International Development Research Center (IDRC), embarked on a multicountry participatory research involving women in health development. The overall objective of this operations research was to plan, implement, and evaluate a programme of participatory research in health involving rural women in a var iety of settings in Asia and the Pacific. The specific objectives were as follows: I.

2. 3.

4.

To involve community women in the identification and examination of health problems, the formulation of possible solutions, and the implementation of selected strategies; To evaluate the process of participatory research and programming in community health involving these women in a variety of settings; To undertake a comparative analysis of both the programme process and outcome in the different settings in order to extricate factors relevant to the success and failure of the community health programme planned and implemented through the participatory approach; and To evolve a set of recommendations for the development of a selfsustaining/reliant community health programme implemented through the participatory approach.

Six countries participated in this project. All six communities had to meet the following basic criteria: 1. 2. 3.

rural agrarian community, tribal/ethnic in nature; socio-economically depressed; with access to some form of health care;

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Women in Health Development

4.

wi th an existing women's group or a ~tron g likelihood of developing women's groups; and with an interest in community development.

5.

The six areas selected for the st udy are listed in Table I. It should be pointed out that although the project focused on women, since they have the traditional responsibility o f the maintenance o f health o f the whole fami ly, it did not exclude the men . In many o f t he societ ies under consideration, men play an important and dominant role. In the communities being studied. it is the women who actually provide health care for member_s who fa ll ill, but men are responsible for the mobilization o f resources. e.g., construction of water systems, latrines, clinics, and the provision of transport for the ill. Invariably, women are the central figu re fo r fa mily health , but men play peripheral roles. In comparing communities on a cross-national basi . effons were made to draw out the cultural variations in the proceource~. maintenance o f local lllit1at1vc. and 1h1.· c 1abli hmelll of linkages between the communi!} and outside ag~:nm:~. Conununit~ participation require~ a significant amount of ta!>l-.. del.'cllllaliLalion. a de, ol ution o f finan cial resource~. and red uigning the structure o f the participatory programme, it will be u ~efult o e~tablish the coordinating and interacting links among the community. the agenl'y, and the

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Women in Health Development

various organizations working at different levels and aspects of planning, implementation, evaluation, and monitoring.

Review of Related Literature In participatory research three elements seemed to pervade in its operation: an awareness of the community problem drawn out through popular participation, the utilization of methods that are culturally appropriate, and the indigenous ways in which action is taken to validate solutions. Participatory research has been in existence for more than a decade. Its development can be traced to adult education in countries in Africa, Asia, and Latin America. T he basic philosophy is that if the community could identify its learning resources, then planning would naturally emerge from within. The literature on participatory research runs the broad gamut of land control, education, and health. In Ujung Pandan in Indonesia a community learning system was experimented wherein resource assessment and problem formulation were undertaken with the full participation of the community. 4 The initial task was the formation of a committee which would oversee the project. Group discussions centred on the resources available in the community and how other resources could be identified. The plan was presented to the provincial authorities, the regional resource personnel, the mayor, and the Jakarta Office of Educational Research and Development, together with an itemized classified list of resources which was to serve as the basis for a research design to study unused and underused learning materials. Within the Indonesian context, community participation in education programmes means co-operation between villagers and government officials. Joint participation between these two groups was continuous throughout the development process, in the planning, evaluation, and decision-making stages as well as in the initial research. The participatory research led to the pooling of ideas and information of both external and internal development agents, at the same time helping to create better understanding of and respect for each other as villagers and technical personnel. T he project also acted as a strong motivational tool among the villagers themselves as their opinions were sought and considered, which developed in them a sense of social responsibility for what was going on and a commitment to be actively engaged in community development and education. 5 T he Integrated Rural Development Project in St Lucia, West Indies, was built on three mutually exclusive concepts - development, integration, and participation. 6 The project aimed to provide communities with the ability to identify social phenomena, needs, problems, and projects. The workshops exposed community members to these skills and assisted them in planning

Participarory Research in the Healrh Seuing

7

adequate and manageable solutions to their problems, while at the same time imparting planning and evaluation skills. Three distinct phases of implementation were outlined: I. 2. 3.

A community orientation phase wherein the project was presented to the community at meetings; A participation investigation research phase during which formal surveys were carried out by community members and external researchers; and A search-for-solutions phase which led to the establishment of subcommittees with specific tasks.

In southern Thailand in 1985 an adult education research programme was launched based on the premise that villagers could achieve concrete economic benefits through participation in non-formal educational activities. 7 This was achieved initially through a series of workshops that enabled the community to define and prioritize its problems, assess local and governmental resources, and plan to act upon an issue. A community survey was followed by workshops where many insights were presented by participants on the survey results. Priorities of project focus and target groups were discussed and decided openly by the village leadership. Resource inventory and plans for resource utilization were carried out to address village needs. Projects identified included income generation, health and sanitation, educational services, infrastructure, and co-operatives. Belamide's8 study on the role of political education among the farmers in the Philippines revolved around community meetings to discuss broad political and economic forces at work on the villagers' lives and create an awareness of powerful economic structures based in distant cities and countries that affect them. In South Korea participatory research was used to develop the operating processes for a co-operative store.9 This was undertaken through regular meetings which perceived the significance of women as an important subclass in development. In involving them, important ideas were elicited on water and sewerage design, grain storage, and food preparation and selling. The Kanita project in Malaysia utilized the systematic approach in participatory research which evoked community participation from the early stage of problem formulation until evaluation. 10 A number of action projects were carried out, such as the communal health care drive, the setting up of a pre-school centre, a proposed bore-hole water system project, and a freshwater aquatic project. The focus was the development of community skills in leadership and decision making. In India several illustrations of participatory research were made, which included holding a camp where tribal women assembled for a day to analyse their problems and take collective action in common interests. Cadre building

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Women in Health Development

of activists in urban and rural unions of workers and rural labourers utilized a participatory approach to education and evaluation of field projects. •• In the Philippines the role of non-government organizations in participatory action programmes has been elucidated in a model called Community Implementation and Planning System (CIPS). 12 It is an empowering process where the people decide, plan, and implement their programme called participatory action research. The community members decide that they want to go through the process of procuring information to assist them in making a decision to improve the cond itions in the community. From the information, activities are planned and corresponding resources mobilized in terms of time, persons, and funds to implement the plan. The community is trained in research, planning, project implementation, and consultation facilitation. The system is viewed as cyclical and interactive where the community conducts the research, planning, and programme implementation. The process starts again as soon as it perceives the need for planning, research, and another project implementation. The method was initiated in a number of villages, which showed that given training and credit facility, the community members could effectively do their own research and subsequently implement the plan. Past organizational experience, coupled with high political awareness, makes CIPS adaptation easy.

Community Participatjon in Health In the health field community participation has been utilized at different levels in the Asian region. The Kwun Toong project in H ong Kong was aimed at enhancing the people's capability of self-help by being partners with the professionals in building up a health community. The community health development component consisted of: I.

2.

3.

Taking every opportunity possible to educate people who come to use the health services on self-help and mutual aid by poster displays, slide and sound presentation on the management and prevention of endemic problems, tips on healthy living, health counselling, special health maintenance programmes, and health campaigns; Encouraging their active participation in community health promotion through growth monitoring, becoming health advocates in promoting breast-feeding and good child-rearing practices, and visits to the elderly and disabled; Experimenting on the use of appropriate health manpower and technology such as nurse-physicians' assistants, part-time community health workers, and nursing aides; and

Participatory Research in the Health Se{{ing

4.

9

Development of a family-focused. needs-orientated database and a multidisciplinary team in health-care management. "

In the village of Ban Mogchamphae in Thailand, the first drug cooperative was organized by which each family in the village was to contribute 2 baht per mo nth for a one-year period to maintain the supplies. A monitoring committee. consisting of members elected by the villagers, wa~ formed to audit the co-operative' financial ope rat ion . and a vi llage volu nteer was assigned to operate the outfit. The fea~ ibil ity of the project led t he go,·ern me nt t0 e.\pand its scope of operation to cover thirty-two vi llages all over the country. ' ~ A module for an intervent ion programme for the urban poor was developed in M alay ia through communal discussion o r the problems and the involvement of the resident s in the formulation of solutions. Particularly focused was the const ruction of health centres in squatter communities a nd the participation of women in income-generating activities. 15 In the Philippines 16 six barangays in the southern pan of the islands participated in the experiment, training and utili1ing volunteer mothers to provide basic services in the communit y. Each mother was re ponsible for a catchment area of about ten hou ehold s. They proved to be active providers of promotive health services although their activities were limited to environmental sanitation, herbal gardening. and food production . With longer training and adequate supervision, mot her~ stand a good chance of becoming adequate providers of health ervices in communit ie . In ru ral communities in T hailand's upper northeast region, a participatory action re earch wa ad opted to d etermine effecti ve method for promoting commu nit y partic ipation in the modificat ion of food habits. T he overall acti vities included problem identification, solution formu latio n, implementation. monit ori ng. and evaluation. Target audiences were idemified and communicatio n medta involved interpersonal communication and promo tion of the existing local communication systems. Res ult ~ of the project showed that the food habib of the target groups were improved 5igniflcantly thro ugh a ctive participation of local residents and authorities in conjunction with the use of appropriate effective communicatio n media. '' The l ndone!>ian programme on health was communit y based and wa!> o ne a sp ect of village improve ment which included agriculture. comm unications, nutrition education, and income-generating activit ies. Community health workers were responsible to a village health ..:onunittee . A hcctlth in~ urancc scheme was established b) whid1 the' illagc cornm Jt tce colkued and admini ~ ­ tered surplu!> fund !> to promote activi tie!> that •vuu lcl gent•ratc inconlt' fur the communit y. 'b Another stud y in the Philippine!> organized communit y members into unit5 that would choo!>e and :.uppon health worker~ who would be responsib le

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Women in Health Development

for the health activities of each unjt, Evaluation focused on the educational process needed to improve ways"of meeting the programme objectives. 19 Rifkin, however, indicated that many planners assumed that communities were fairly homogeneous and that the acceptance of a plan of action by community leaders was an acceptance for the good of, and on behalf of, the community. T hey failed to define the communjty's diversity, power groups, and basic economic inequalities. As a result, certain activities brought programme values and actions into conflict. 20 Besides, the various health programmes viewed community participation in a wide spectrum, from mere participation in service delivery to involvement of the people in the planning of programmes that had been predetermined. The literature surveyed pointed to the increasing recognjtion of the people's potential for self-reliance, focusing on community-centred activities as an approach to development. In all these studies the people as providers of health care have been increasingly tapped on a participatory basis. This participation has been considered as an empowering process in which they, in partnership with those able to assist them, identify the problems and needs and increasingly assume the responsibility to plan, administer, monitor, and assess the communal actions decided. Beyond the health benefits that community participation approaches may provide, such strategies may also lead to the development of a self-sustaining and self-reliant health programme. Once the community becomes aware of its capability of resource mobilization for local initiative and self-help, the positive outcome of community health development increases. Self-reliance is the keynote of the people's health participation programme. In such situations, where greater responsibilities fall under the auspices of the people and utilization of local resources is optimized, the possibility for programme sustenance is increased. Therefore. a health project that has been developed by the recipients themselves within the social and cultural milieu in which they operate would be an effective demonstration of the capability of the people to address the health needs that they have identified through approaches that are within their means. Women's Participatio n in Health Development A significant development in the Third World in the past decade is the increasing involvement of women in the social and economic programmes. T his detracted from the social tradition that assigned the home as the central point of the woman's life. Earlier perceptions of women led to their role as recipients of development inputs, which has shifted towards their potential tasks as health service providers. A United Nations Development Programme (UNDP) report in 1980 indicated that

Participatory Research in the Health Selling

II

since it is invariably mothers who have the main responsibility for the health of their families, the effective implementation of the concepts of primary health care implies the participation of women at all levels of management and administration, a concept that is as yet far from being accepted or realized. 21

In all societies women are providers of health services within their domestic milieu. The diagnosis of illnesses, home management, provision of appropriate foods, and decision to solicit external assistance are all components of the health-care delivery of women. The health action project will operate on the assumption that it will be appropriate to the women in agricultural economies and it will not take scarce time resources away from their domestic tasks. Two basic reasons posited for the involvement of women in health programmes are: (1) successful health development cannot be pursued without their participation since they are the basic health providers; and (2) recognition of equality of the sexes implies that there should be improvements in their health conditions, their access to health resources, and participation in decision making at all levels. In many societies households and women are viewed in an interchangeable and intertwined fashion. What is important is to extricate the forces and interventions that can facilitate the development of women in their role as health planners and managers within their location in the broad spectrum of socioeconomic-political change and development within their community. Organization of the Report

This report is composed of eight chapters. The first chapter presents the philosophical foundation of participatory action research involving women as well as the methodological considerations in the multi-country research. Chapters II to VII deal with each country's experience in initiating and implementing participatory research in health from which specific issues related to replication and generalization of the project are extracted. The last chapter consolidates the case studies and readdresses the basic objectives of the study.

II THE BERAWANS OF SARAWAK, MALAYSIA Wong Mee Lion

Sarawak, part of East Malaysia. borders northeast Kalimantan. It has a population of 1.65 million. In the Fourth Division of the Baram District, the majority of the people are the Orang Ulu or Berawans. The Berawans in Long Jegan number 600, occupying 61 bilik (attached dwellings) in a longhouse and 2 single dwellings. Despite being Christian and receptive to modernization, they observe the strict rule of uxorilocalit y for residence. The common family grouping is the joint famil y with two or more nuclear families linked through maternal lines. The longhouse, which is the basic unit of social organization in the village, is under the ~harge of an appointed leader who in turn is under the charge of the headman of the whole village. The present leadership part y was elected by the residents in the longhouse. Land is owned on a communal basis. The method of farming is shifting cultivation. The nearest clini~ is accessible only by river, which takes about 2 Y1 hours. For sanitation each latrine, built in the iorm of a wooden shack, is constructed next to the kitchen. Water is supplied via the gravity feed system and piped to each individual bilik. Ea~h household is required to burn its own rubbish in the dug-out pit behind the bilik. Malmurition is a common health problem. This, in addition to frequent worm infestation, diarrhoea, and upper respiratory tra~t infection, predpitates even worse forms of malnutrition. Si1Ke embracing Christianity, the Berawans have discarded most of their traditional beliefs and illness is no more associated with the spiritual realm. Most of the mothers breast-feed their babies and weaning is introduced after seven or eight months, when the child is given porridge and soya sauce. Rice is the main staple food of the Berawans, supplemented by tapioca.

The Berawans of Sarowak, Malaysia

13

Status of Women Women make up more than lwo-fifths of the population and they wield considerable influence in the community. They are the major health-care providers in the famil y. Though the women marry at an early age of seventeen years, their maternal role starts from childhood when they are trained to look after the younger siblings and per for m household chores. The easy access 10 educalion recently ha allowed for improvement. In the course of this, two women who completed their nine yea r~ of education were enrolled in an agricultural course offered by the Agricultural Department. At present, they teach the other women in the commun ity to cultivate plots of vegetables and cash crops such a s cocoa. Women o rgani7e themselves inlo groups, each with an elected leader. Two women grouf)~ were for med and they had their own plots of vegetable garden at the far two end-. of the longhouse vicinity. Each bilik was allowed to cultivate two plot~ of vegetables such as kangkung, long beans, bitter gourd, brinjals. four-anglr bean~. and fruit trees. These vegetables helped to supplement the people\ diet, whid1 mo re often than not lacked vitamins, iron, and protein. Seeds needed were o btained from the Agricuhural Department while land wa~ obtained with the approval of !he land committee. Traditionall), brideprice was paid in heirloom property such as gongs, ornament , ja r~. a nd bati l-. materials. At present. brideprice is mainly in the form of money or gold. accompanied by some heirloom property. If a man decides to divorce . he l o~e~ a ll his rights, including the land he has cultivated and his chi ldren. I I the di\orce is on a mutual basis or initiated by the wife, a cert.ain amount ol property will have to be given to the husband.

Community Mobilitation. nata Collection and Analysis Prior to thi!. project , ~ upport had already been establi!.hed with the communit y through the training a nd fielding of village healrh pro mo rers. Neverthe less, participatory re~ea rch, which involved the systemaric planning and implementation of a community-based self-help scheme, remained a relatively new experience for the Berawan women. T hus, steps were undenaken to prepare and organize them for th~:: planning process. A meeting was initiall y held with the village leader and e lders IO explain the purpose of the project and to request that a group of women be trained on methods of data collectio n and heahh care. Aided by the headman and elders, a group of eighteen mothers with at least four years of education was selected.

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Women in Health Development

Training for Dala Colleclion and Analysis Training for data collection was conducted in the bilik of the village headman by the researcher, research assistant, a nd three local health staff. It was aimed at creating awareness of health problems, promoting gro up cohesion, generating confidence. and disseminating info rmation on nutrition and health promotion. A team approach was adopted from the start. with the group divided into three smaller sub-groups, each under the g uidance of a facilitator. The training programme started with a game. in which the participants were asked to create plasticine models of community members with health problems. Many created models of their grandparents with emaciated loof feeding p rogramme, kindergarten, and the training programme. Care was taken to match the skills and experience of the participants and faci litators with the appropriate task force. For example, the community health nurse with twenty years of experience in nutritio n programmes led the task force in the children's feeding programme. The facilitator's role was to stimulate and focus, discuss, and encourage participants to explore and ide ntify way!> to best ru n the p rogrammes to meet their needs. With regard to the feedi ng programme, it was decided to involve mothers in the food preparation. Reci~ \\-ere drawn from locally available, nutritious, cheap, and culturally acceptable food~. Activities in the kindergarten included nutrition and personal hygiene education; basic sl..ilb such as counting and reading; growth monitoring; and physical examina tion for commo n health ailments. A d emonstration of the children's feeding programme, in which the participants and other volunteer!> prepared food from locally available and cheap sources fo r forty children, wa!> held to solicit com munity interest a nd support .

Organization of Committee and Activities Although this was a women's project, the village headman was placed at the helm owing to his influence and ability to mobiliLe the community. The head

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Women in Health Development

of the women's health committee. who was a former school teacher and the headman's daughter-in-law, was ·selected as the headmistress of the kindergarten. An advisory committee was formed to provide referral and background support. It comprised staff from the district government departments - agricultural, health, and community development agencies. A simple functional organization chart was drawn showing the roles and functions o f the various subcommittees in relation to the goal of the project, emphasizing the importance of a team approach.

Community Assembly The proposed plan was presented by the head of the women's health committee to the villagers for their consensus at a community assembly. Several community members doubted their capabilities in providing financial and material support to sustain the programme. A village elder suggested community subscription. This was rejected by some of the villagers initially, who felt that the government should fund the kindergarten. The researcher then explained to the community the constraints faced by the government in providing services to remote areas, stressing the need to harness locally available and abundant resources. They were also assured of full technical support and guidance from the health team. The headman appeared to be among the first to internalize the idea of self-reliance. He appealed to the villagers to stand on their own feet and work together. To show that help should come from within, he donated some money on the spot. The head of the women's health committee indicated their intention to sell cakes and handicrafts to finance the project, and start a vegetable garden for the feeding scheme. With this, the villagers subsequently expressed their willingness to subscribe to the project and provide labour for the feeding programme and the formation of the kindergarten.

Training Training was conducted locally to provide project workers with knowledge on child health and the skills to perform the specified tasks. Local \\Omen trainees provided information on simple preventive and promotive care ol children. The research team imparted skills on administration. record keeping, organization, and communications to ensure the capability ol the community for selfmanagement and eventual programme sustainability. Talks. demonstrations, foc used group discussions, role playing, individual assignments, and practice exercises were used. Other training methods included the use of regular com-

The Berawans of Sarawak, Malaysia

19

mittee meetings to improve communications skills. The participatory approach adopted in programme planning also assisted in building confidence and developing leadership. Specific training sessions on teaching and agricultural skills were organized with other relevant government agencies, such as the agricultural and community development agencies. The initial four-week training course was conducted in the evenings, just before the harvest season so as not to disrupt the community's usual socio-economic activities. Programme Implementation

The programme was implemented by the local workers, with the head of the women's health committee taking responsibility for the implementation of activities. She was given a copy of the functional organization chart and the activity schedule to assist her in co-ordinating the activities. Moral and technical support was a lso provided by the researcher's team which visited the area at fortnightly intervals during the initial implementation phase. The preparatory activities included conversion of an unused hut into a kindergarten and construction of furniture by the men, registration of pre-school children, preparation of educational materials, and organization of the kitchen and duty roster for the children's feeding programme. The kindergarten and feeding programme was implemented in January 1989, after three months of detailed and careful planning. All the twenty-eight children aged 4-6 years were enrolled. Activities were aimed at developing the social, mental, and physical well-being of the children, which included nutrition and personal hygiene education, singing, counting and reading, as well as growth monitoring and screening for illnesses. The mothers were trained to prepare meals for the children under the supervision of a food supervisor. Rice, vegetables, fruits, and firewood were brought by the mothers. Dry rations were provided by the food committee. Funds for the project came from local self-financing activities such as the sale of kueh (cakes) to the nearby school, sale of handicrafts, and regular subscriptions by parents. A salary was paid to the kindergarten teacher to ensure her fu ll commitment and to strengthen her accountability to the community. Programme Monitoring and Supervision

A monitoring mechanism was established at the local and central J~vels to assess the progress of the activities towards set targets, identify problems, and find quick practical solutions. At the local level, the kindergarten teacher proved capable of maintaining a record of child attendances, growth charts, and a register of common illnesses and children at risk. Other committee

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Women in Health Development

members maintained records of utilization of funds and feeding programme activities. Monitoring at the intermediate level was provided by the researcher, local community health nurse, and field agricultural officer who made frequent visits d uring the first few months following implementation. Some problem s encountered d uring the early implementation phase included shorta ge of food supply arising from the drought; attrition from the kindergarten owing to inability to pay and loss of interest; and fi nally, non-acceptance of the kindergarten teacher by some mothers who indicated their preference for a more qualified teacher. Prompt action was taken to develop new recipes from dried peas, which could be stored. A sliding-scale payment was introduced. whereb~ mothers from the lower socio-economic groups would pay only a minima l fee and compensate for this by taking more turns in prepa ring meals. A dialogue session was held with the mothers to assure them of the kindergarten teacher's capability. She was also given formal training by the community development agency and on-the-job training by the supervisors. As the ultimate goal is for the programme to be self-sustaining, subsequent supervisory visits focused on the problem-solving process and capability building of the women. After the first two months, weekly and fortnightly visits were reduced to three monthly visits.

Evaluation The evaluation was carried out in October 1989. about ten months after the implementation of the project. It was based on the quantitative and qualitative assessment of the project effects. Apart from this, the development process that had led to the outcomes was also evaluated as it would contribute to a better understanding of the participatory process in community-development projects. The indicators used included those relating to performance of activities; health and environmental status; health and health-related practices; project acceptability; and capability building among the women. Information was procured from the household survey and participant observations. Data were also obtained from monitoring records. As this project had evolved out of local planning and implementation efforts, it was decided to involve the community in the evaluation exercise so that they could assess for themselves the progress of the project and modify it to suit their needs and match their capabilities. A training session was thus held to ensure that the researcher and the local women would have a common understanding of the participatory evaluation approach. It was stressed to them that the aims of the evaluation were not only to look at the resultant project benefits and inform mothers about them, but more so it was to identify problems and seek solutions to overcome them in order that the project might be sustained.

The Berowans of Sarowak, Malaysia

21

Ewluation of Objectives The objectives formulated during the planning phase in 1988 formed the basis for the evaluation of the project's progress and activities. It should be noted that the objectives were focused on performance targets rather than impact o n health status as the latter may not be tangible within a short period of ten mo nths. In addition the change in health status may be confounded by other variables such as social. environmental, and climat ic changes. Thus, in the absence of a control group, it would be difficult to ascertain whether the improvement in health status is due to the project per se or other factors. In contrast, the performance of the programme activities, being directly affected by the degree of community participation, would give a direct a ssessment of the development of the community participatory process.

Performan« of Activities A very high femal e participatory rate of 93.6 per cent was observed in the cooking sessions. Mothers did not turn up in five out of the seventy-nine sessio ns because some of them in the sa me d uty group had delivered around the same time . The dut y gro ups were reshu ffled and the participation rate went up again. The kindergarten attendance rate, which ranged from 45 to 75 per cent with a median of 61.6 per cent , a lmost met the set target of 75 per cent. The lowest attendan~·e rate was recorded in August when many children had coughs and cold~. Five children dropped out from the kindergarten, giving an attrition rate o f 18 per cent. However, two joined the kindergarten when the mothers saw it ~ benefits. Wha t was also noteworthy was that the political rival of the headman allowed his son to rejoin the kindergarten when he saw the progress of the ot her children. A to tal of twent y-one (56.8 per cent) of the set target of thirt y-seven health ta lks we re given. Reasons fo r not giving the talks were that the mo thers were no t interested in the tal ks o r they we re too busy. Payment of fees, though delayed, wa:. maintained satis facto rily. T he income-generati ng activities were rated as fair by both the researcher and the women themselves. Six sessions have been organized l>O far, when mothers participated in making cakes for sale to the school. What was noteworthy was that there was no acute shortage of fund!.. Subscri ptions fro m the parents had managed to sustain the kindergarten acti vit ies.

Food Supplies and Agricultural Development There was a sign ificant increase in agricultural food production (Table 2). Prior to the project, only twenty-eight (49. 1 per cent) out of the total of fifty-

22

Women in Health Development

TABLE 2 H ouseholds Involved in Vegetable Farming

Crops Grown

1988 (Pre-intervention)

1989 (Post -intervention)

No. (OJo)

No. (OJo)

Paddy Maize Fruits Vegetables

57 32 28 37

(100.0) (56.1) (49.1) (64.9)

Total Number of Households

57 (100.0)

52 (89.6) 48 (82.7) 54 (93.1) 51 (87.9)

p• (Significance level)

iblings. It was ob~erved that the majority of the children who attended the nearb~ s..:hool wore shoes now. Prior to this proje\.'t , it was common to see children walk ing barefooted to school.

24

Women in Health D evelopment

The percentage of children who washed their hands before meals also increased from 9.5 per cent to 85.2 per cent. The children were also observed to be much cleaner. An impact was also seen on the child-feeding practices of the mothers. The prevalence of breast-feeding increased from 69.9 per cent to 90.9 per cent. Only 9.1 per cent of infants were solely bottle-fed compared to 30.1 per cent prior to the implementation of the project. The majority of mothers (83.4 per cent) had introduced solid foods at 4-6 months rather than at 8 months. Fruits such as bananas and papayas, vegetables, and occasionally fish rather than rice and soya sauce were introduced as weaning foods. However, it should be noted that the change in child-feeding practices may not be due to the kindergarten project alone but rather to the collective efforts of the earlier primary health-care project and the latter project. Impact on Nutritional and Health Status

Assessment of the improvement in the nutritional status was made by comparing the weight for height of the children before and after participating in the nutrition programme (Table 5). The same twenty-two children were compared. It was not possible to compare those children who had dropped out or joined later. Prior to the project, two (9.1 per cent) children were severely malnourished with a per cent weight for height of less than or equal to 75. Ten months after the feeding programme, none of the children were severely malnourished. The number of malnourished children with per cent of weight for height of 76-79 also decreased from 54.5 per cent to 31.8 per cent. The absence of a control group and the small number make interpretation difficult. It is likely that the feeding programme had contributed to the decrease in acute malnutrition to a certain extent. The incidence of acute respiratory infections (ARI) and diarrhoea was determined using a two-week recall. The incidence of ARI in children under five years of age decreased from 37.8 per cent to 12.5 per cent. The reduction in the incidence rate of skin diseases, from 42.3 per cent to 32 per cent, was not significant however. The figures for diarrhoea were too small to make any interpretation. Although the decrease in ARI incidence cannot be solely attributed to the project, its contribution cannot be discounted. Assessment of Women's Capability The capability of the women was assessed by the researcher herself through interviews, participant observations over the two years, and an analysis of their record keeping. Mothers of the kindergarten children were also asked to

The Berawans of Sarawak, Malaysia

25

TABLE S Nutritional Status of Kindergarten Children

OJo Expected Weight for H eight*

January 1989 (Pre-intervention)

October 1989 (Post -intervention)

No. (%)

No. (%)

>90 80- 90 76-79 70-75 and, water, and labo ur. A levy of F$7 per household was also agreed o n. wit h 1he SSV having the responsibilit y for the collection of the contribution. The ho usehold contribution was to be used for the purchase of the chimney, the most expensive compo nent of the stove technology, and the required gravel and sand. Labour was to be cont ributed .

36

Women in Health Development

Within three weeks, the SSV in Matainananu and Naivoco sent their financial contribution. All purchased materials (cement and wire mesh) were sent by the Fiji Centre to Matainananu, from where the vilJa~..:rs from Naivoco collected their materials. A two-day stove-making workshop was later held at Matainananu for all members of the SSV in Bureiwai. Six women from Matainananu and five from Naivoco attended the stove-making workshop. Three women from the other two villages also attended as observers. The workshop covered issues relating to kitchen standards in the villages, the situation of depleting firewood supply, the inefficiency of open-fire cooking, and the effects of smoke on the women's health. Discussion papers on the issues were distributed to the women during the training session. The women, a nd some men, were taught skills in stove-making. A sample stove was cast on the first day and installed in the kitchen of the woman leader of the tikina SSV on the second day. Two wooden moulds were left behind in the two participating villages for the women to make their stoves at their own time. The people of Naivoco later manually transported their materials uphill to their village. The stove-making technology was taught to the village members. By December 1987, all the households in Matainananu and Naivoco had acquired smokeless wood-burning stoves although three kitchens in Matainananu and one in Naivoco did not use their stoves while better kitchens were being built. The research team later interviewed some women from Delaiyadua and Nadogoloa to find out the reasons for their non-panicipation in the stove project. The women in Delaiyadua revealed that they had informed their men at the village meeting (Bose Vakoro) but the latter felt that the stoves were not immediately needed. The women of Nadogoloa indicated that they had discussed the stove project with their men, who preferred another model (from another organization) rather than the one that was promoted by the Fiji Centre. Subsequently, the women of both these villages requested the Fiji Centre to assist them in acquiring the same stove design that was in use in Matainananu and Naivoco. The team asked the women users of the smokeless stove in Matainana nu and Naivoco for their opinion on the technology. All the stove users praised the technology since it requires less firewood, removes smoke from their kitchen, and the pots are cleaner after cooking as compared to their cooking over open fire. A number of families in l'vlatainananu have rebuilt their kitchens after they acquired the smokeless stove. The women users are still encouraging other women in their villages and in the other two villages to acquire the stove as it is more convenient. The acquisition of the smokeless stoves facilitated the discussion for the formulation of a participatory health-

The Bureiwais in Ra Province, Fiji

37

development project. The women felt that documentation was important to assess problems and pitfaiJs as the project progressed.

Selection of Village Recorders

In the informal meeting with the tikina SSV held during a visit in November 1987, the women were asked to nominate a Village Recorder (VR) for each village. The four women VRs nominated were briefed on their role and activities. They were provided with basic writing materials. As a prelirrunary task, they were to record major activities in their villages, e.g., meetings, fundraising events, communal work, and other traditional functions in which the community took part. All the women VRs were less than twenty-five years of age and unmarried at the time of their nomination. In a subsequent visit in early 1988, it was found that all these young women VRs had left their villages: two got married and were residing in two other villages in Bureiwai while the other two VRs had left to seek work in the city. The various village SSV were again asked to make new nominations for the VRs and to take into account the background of the women they nominated. The new VRs were all married women in their respective villages and three of them were under thirty-five years of age. All of them were literate in the vernacular, some with basic spoken English. Although one was pregnant, she mentioned that this would not affect her work. Another married woman replaced her when she delivered. It was decided that the major thrust of the programme would be competence building in the analysis of health problems and formulation of programme.

Training Worksho p fo r Village Recorders and Village Researchers

For a more detailed survey to assess the socio-economic and food situation in the communities studied, the Fiji Centre recruited four young women as research assistants (RAs) for a period of three weeks to assist the VRs. A one-week training workshop was held to teach the RAs basic skills in administering the prepared questionnaire and to record the responses accurately. The four VRs were trained for two days about their duties and responsibilities in the research project. They were provided with a written guide-line, in the vernacular, that outlined their 'job description'. Later, they were given a VR's kit, consisting of a large 300-page hard-cover book, two small notebooks, a ruler, two pens, a pencil, an eraser, and all the stationery contained in a plastic satchel.

38

Women in Health Development

The VRs were to document all the activities in the community from June 1988 until the end of the project. Records of all village activities, meetings, and ceremonies were kept, as well as of all activities and meetings of the village SSV, especiaJly focused on discussions about women's projects. Records were also kept of any visit by any member of the community to the health centre, to market, or for any trip outside the village for other purposes. The format for recording was also explained so that a daily diary of events was kept. The VRs made reports in the vernacular on the research and follow-on project. The VR's record book was checked by the Fiji Centre team on any trip to the community. The VRs were paid an honorarium by the Fiji Centre on a six-monthly basis. The Village Research

The.J:our women RAs spent a week carrying out a detailed household survey in the four viJlages of Bureiwai. lt was arranged that each RA stay with the VR, as she was acquainted with the place and could serve as liaison in the village. On their return to the Fiji Centre, the RAs spent their last week aggregating the data they had collected for problem documentation. This was followed by workshops to carry out the various phases of the participatory research. Worksho p No. 1: Orientation fo r Women in Health Develo pment

This one-day training workshop was held at Matainananu. A week prior to the workshop, a radio message was sent to the women leaders of the tikina SSV notifying the group about the planned training and asking each of the village branches to send to the Fiji Centre three women participants, including the YR. The three women from each of the four village branches subsequently acted as trainers for their village SSV and became the core group for the project committee of the SSV at the village level. T he major aim of the workshop was to acquaint the women on the process of health-problem identification and solution development within their group and the community. Major discussions centred on the role of the VRs in their respective communities. It was found out that the VR from Delaiyadua was not in a position to undertake the task owing to the state of her health. The village SSV nominated a new VR, who was the original VR of Matainananu but subsequently married and settled in Delaiyadua. Other women were satisfied with the VRs that they sent to the Fiji Centre for training. Twelve participants and three observers attended the training. Each village group was given training

The Bureiwais in Ra Province, Fiji

39

materials, including pens. writing paper, sheets of newsprint, and short discussion papers that were all written in the vernacular. The first paper discussed covered the general goals of the Fiji Government Development Plan Nine (DP9) for 1986 to 1990. The government's desire to balance the distribution of resources and development projects was explained to the women. The women, however, indicated that the problem in ensuring equitable distribution of resources is 'lack of unity' within the village SSV. A number of them raised the issue of non-cooperation with the women's movement, and non-attendance of meetings. However, they all agreed that all the women in the village would carry out the activities that had been decided during the meetings even if they did not participate in the decision process. The second discussion paper dealt with the government's plan for education and health-related projects. The third paper stated the government's objectives and strategies for the 'Women in Development' programme. DP9 is the first government plan to mention women as a special group to be addressed. A Ministry of Women was set up after the military coup in J une 1987. The participants were reminded that the government recognizes the role of women in the family, village, community, and national development processes. The fourth document detailed the government's objectives and strategies for the health sector. The paper emphasized the importance of primary health care and preventive medical care. The fifth handout discussed the role of women in family and community health. The women were reminded that whatever work they carry o ut in the home is primarily geared towards the health of the famil y even though it may appear mundane. The basic health of the famil y depends on them. The afternoon session was spent training the women to acquire skills relating to simple data gat hering in the villages. The first topic covered was the concept of needs and how to carry out an assessment. A vernacular discussion paper on needs identification was distributed and read. This was followed by a series of illustrations and explanations. The object was to show the women how to assess the 'situation is' in relation to the 'situation should be'. The difference(s) they find is the need. The focus was o n what they could do to the 'situation is' to achieve the 'situation sho uld be'. Illustrations were made using the local experience of ownership of lavatory facilities, the prevailing water supply situation in Naivoco, the method of cooking over open fire with a smoky kitchen, and the fact that they wanted a smoke-free kitchen. The second paper for the afternoon was on problem solving and identifying various solutions when they arrived at the 'situation should be' level. The women appeared to have many ideas on how to solve the local problems

40

Women in Health Developmenr

that were discussed. Some of them said that they had never attended such a methodology workshop focusing on discussion of problems a nd solutions that village women could present. Past training programmes that they had attended did not cover such methodology. A short vernacular discussion paper on motivation was also distributed. The paper outlined reasons why people change their behaviour in relation to health, education, and housing. Three other papers were distributed to the women for discussion, namely on solutions to problems, prioritization of solutions, resource planning for these solutions, and what solution to adopt for a project. For the various papers the women became more involved when it came to the discussion stage with their own village groups. They were then able to discuss real problems relating to their daily life in their villages. At the end of the day's training programme, the trainees were reminded that they would be the core group for the operations research in their various villages. The women from each of the four villages would, on their return, report to their women leaders and request for a group meeting. At the meeting, the women would act as trainers and outline the process of project identification that they had learned. Four one-day village workshops would be convened in the first four weeks to discuss the topics covered in the training workshop (as the papers were with them). From their village meeting-cum-training, they should be able to identify a small project that would contribute towards fami ly and community health. They were advised to choose a simple project. Having b uilt up the basic skills in project identification and resource planning with a small project, they would have the confidence to work with bigger projects in future. The women were also asked to carry out a simple survey to detail the problems in their villages in relation to the project that they would eventually choose. A resource plan would have to be made to determine the locally available resources that would be needed for the project. The VRs were advised to keep records of all the discussions that took place in the women's meetings and other village meetings to see if the women's decisions were renected. Some interesting observations were made at these village workshops. Younger women and those married to men with lower social status in the village made less contributions to the discussions in the village workshops. A number of women could not participate freely in the discussions because a workshop was held at the horne of a male relative with whom these women observed a taboo relationship. Two of the women turned down an offer to write on the wallpaper because of this relationship. The women then decided that the second training workshop be held at the Fiji Centre. That would give them an opportunity to travel to the city

The Bureiwais in Ra Province, Fiji

41

where they could attend to their other businesses as well as collect the information that they required.

Workshop No. 2: Project Identification and Resource Planning This one-day workshop was held at the Fiji Centre attended by the same twelve women who participated in the first training workshop in Matainananu. The workshop aimed to evaluate the tasks carried out by the YRs in the previous month as well as to re-assess the methodology adopted by the women in t heir choice of project. This workshop included reports by the village trainers on the various problems encountered. T he VRs reported that they could cope with the documentation of village activities on a weekly basis except meetings. At the meetings, they could not record effectively because there was no order and only a few women dominated the discussions. Three of the YRs said that as the women's village meetings were held at inconvenient times most of the women did not turn up. The village report~ fro m the trainers were quite interesting as they focused on the various discussions by the women after the first workshop and the problem s that the women's organizations in their villages faced. The VR from Delaiyadua said that the three trainers had reported back to their women's meeting the proceedings of the workshop and had tried to explain the processes in p roject identification. The women then held two discussions on their work, the health situatio n in the village, and the problem that they wished to address through a project. The VR indicated that the village organization had problems as a sizeable number of it s women did not attend its meetings, but were willing to support any project that was decided. The women from Delai yadua expressed the need to have better laundry facilities as well as the smokeless wood stO\'eS as they had seen the ones in use in Naivoco and Matainananu . The VR from Nai voco reported that they had had four meetings since the first workshop and the turnout from the women was very encouraging. After the trainer~· di~cu ~sion of the proceedings of the first work shop, the village women all agreed that the priority was to get piped water for the village, b ut they mentioned that the Bose Vakuro had repeatedly approached the government for thai. Lack of toilet faci lities was also considered a problem as few households owned a pit or toilet. They wanted every household to have a toilet. The third concern was to raise poultry as an income-generating activity for their group to help them finance future women's projects. From Nadogoloa village, the VR mentioned that the women's group had held o nly two meet ings after the first wor kshop because of the poor attendance by the village women. A problem the women's group faced was the

42

Women in Heaflh Devefopmenl

lack of unity amongst them and poor attendance in meetings. H owever, the women who were present wished to address kitchen standards and the use of smokeless stoves as they had seen the kitchens in Matainananu. They also wanted to improve their laundry facilities at the communal taps as they did not have enough taps and wished to have a more comfortable work area for laundry. The VR from Matainananu indicated that they had not held any meeting since the last workshop as there were too many social, religious, and political activities in the village. They attempted to call two meetings but the turnout was so low (five women at the better turnout) that they had put off any other planned meeting. Like the two other villages, there was no unity amongst the women of the village and organizing a meeting was a difficult task. She also bl ''ailed the fact that the men of the village were not too supportive of any attempt to carry out any all-women project. From the casual discussions with various women in the village, a major concern was the pollution caused by animals, which constitutes a health threat to the water supply which they share with Nadogoloa and Delaiyadua. Animals (goats and cattle) roam around the village reservoir area. The other problems they identified were the heavy work-load of the village women, leaving them very little time for rest, and the problem of washing from communal taps. The women wished to have better laundry facilities around these taps. The team from Matainananu planned to hold three meetings at which they would discuss with the women the project identification processes that were covered in the first workshop. The second activity was an attempt to categorize the women's concerns and projects into commonalities. Because of the nature of the issues they raised, the concerns were categorized into human relations, women's work, and community concerns. T he women were asked to write on the blackboard the specific concerns, which are listed in Table 7. The resultant d iscussion from the reports revolved around problems, strategies, and projects. The women from Matainananu were advised by the facilitator that the pollution of their water supply by the animals could be dealt with in the village. The women's group could present their case to the Bose Vakoro and the Bose ni Tikina (village groups), and write or verbally complain about this problem to the medical doctor in charge of Bureiwai. In Bureiwai, men control animals and the income derived from their sale. Any negative health implications of this lucrative income-generating activity should be their concern. The women were concerned with the need for clean water to ensure optimum family health. It was vital for the women of Matainananu, Delaiyadua, and Nadogoloa to unite and present a statement of concern, verbal or written, to the various councils and authorities in their community.

The Bureiwais in Ra Province. Fiji

43

TABLE 7

Categorization of Village Women's Concerns

Village

Human Relatio ns

Women's Work

Community Concerns

Delaiyadua

Lack of unity

Kitchen /stoves

Laundry

Water carrying

Toilet, poultry

Naivoco Nadogoloa

Lack of unity

Laundry

Kitchen/stoves

Mataina na n u

Lack of unity

Wor k-load, laundry

Pollution of water by a nima ls

Many of t he h uman relations problems could be addressed to the co m munity mem bers themselves. On t he completion o f t he table and the resultant discussion, the women adm itted t hat some issues were getting clearer to them. They were then requested to go back to their village for discussion to ascertain which of the projects listed their women's group wished to undertake, given their resources, the magnitude o f the activity, t heir capability, and the possible direct benefit. The women were reminded of t he importance of the last c riterion because it is well known in Fiji that the SSV carry out a lot of fund-raising activities to support projects t hat do not directly benefit them nor their own villages. T he trainers then reported to the villages the o utcome of their discussio ns. After taking into account the choices and limitations the women faced in their respective village!>, the trainers from Delaiyadua, Nadogoloa, and Matainananu reiterated their cho ice of improvement in the laundry facilitie!> a nd drainage systems. The wo men from these three villages agreed that their laundry work in the com munal tap a rea - taking turns in drawing water a nd rinsing their clothes under harsh a nd uncomfortable conditions - resulted in backache. They also agreed that the project would directly benefit the women. The trainers from Naivoco, however, decided to address the toilet situatio n for their project. A num ber of observations were made during these wo rksho ps. All the women acti vely contributed to the discussions and freely sto od up to write o n the blackboard when n e~.:es~ary, a~ compared to the village-based workshop carried o ut in Matainananu. The women had ideas about the problems that they faced and what their need!> were, but were not articulate in presenting

44

Women in Health Development

them for discussions. They tended to make short statements rather than elaborate explanatory ones. It appears that these village women needed to have furt her training to assist them to be more articulate in stating their problems and needs which could facilitate their discussions with government staff and other development workers. The attempt to get the women to briefly describe the problems to be addressed by their project was difficult. At the end of the workshop, the women were reminded that they should request for a meeting with their women's groups to report on the proceedings of the second workshop and the project they had selected. The trainers from Matainananu were reminded that they should call a series of village meetings as they had not formally met after the first workshop. The next workshop covered writing up a simple project proposal relating to the project chosen, a resource plan, and a time schedule of the project activities. The workshop was held in one of the other three villages. The women's projects commenced in March 1988, and as the projects were small, they were completed within two months. Monitoring activities took place before the final evaluation in the fourth month of implementation. Implementation and Monitoring

Since each team had an idea of the subsequent project to undertake, it was decided that the women would be made responsible for the implementation and management of the various projects, in their respective villages. In the succeeding two months, two visits were made to the communities to monitor the progress of the tasks. Work on the projects was slow, and some village teams complained of unavailability of needed materials and their heavy traditional commitments. All the teams attributed the slackening to the many village commitments and events. Even when a project was provided with the needed materials, it did not progress significantly. Four months after the projects were implemented, an assessment workshop was held. All the projects were unfinished. During this period, the village women's group in Matainananu split into two factions, along the line of the two yavusa. Consequently, the community projects had to be conducted in two different sites to cater to the two factions. The split in the group was a result of the pr~vailing traditional relationship between the two tribes and their perceived status. The village teams appeared to be revived only through constant visits by the Principal Researcher. A date was specified for the completion of all the projects, after which the village teams would visit all the women's projects as part of the research.

The Bureiwais in Ra Province, Fiji

45

hluation A workshop carried out in mjd-December 1989 centred on the evaluation of each project at the various stages of implementation. Factors assessed included the performance of the team, its relationship with the researcher, the activities of the various individuals and group; and the benefits to women in particular and the community in general. All members o f the community, especially the women, looked forward to the teams' inter-village visits. The communal laundries were appreciated by all members of each community as an additional faci lity. The women noticed that young men had begun to wash some of their clothes and that school-children enjoyed washing their school uniforms at the end of each school d ay. The women who used the facility had commented that they could now wash clothes without discomfort . The community toilet project was not completed at the time of the visit. Tho ugh ~ry household in Naivo co had acquired a toilet with seat , the construction of the shelter was not completed. The male vi llagers, the traditiona l house builders, had been engaged in the construction of a new road running by the village . They had assu red the village team that all the structures would be completed by March 1990. The women were pleased as that was the first time they had been involved in all phases of a project, from problem definition to implementation. At the time of the visit , so me young men were constructing seat s within one of the laundry structures.

Lessons and Issues This participato ry researc h task by women was the first to be carried o ut in any com munity in Fiji . The trategy adopted involved the provision of the necessary training to an existing women's group for a bouom-up approa~ h to identify, plan, manage, and assess project~ that would address a hea lth problem they were collecti vely concerned about. The research auempted to identify the processes that would enhance the collective definitio n of the problem , collective discussion, and collect ive action by the wo men's group and its community. From the outset of the research, a n existing women 's group was used rather than formi ng a new o ne. Though two newl y a ppointed ad hoc gro ups were set up - Soqosoqo Vakamarama Project Committee and Village Trainers - the existing group stated that the improvement of village health was o ne of its major objectives, bu t such health projects tended to o riginate from outside the village. The membership a nd leadership of the SSV were circumscribed,

46

Women in Health Development

and t he tendency of the group ~!J maintain the social and political status quo was well known. T he research was an attempt to identify the processes under which to provide basic knowledge and skills that would enable women to reassess their socio-economic situation, their role within the community, and decide on the strategies that they could adopt to improve the efficiency of services provided, thus improving the health situation of the community. Group training was a major activity throughout the four research phases. As the research dealt with a district (tikina) rather than one village, .a team of village trainers nominated by the women was ideal rather than group training for all the women. T he trainers provided opportunities to discuss issues that would increase their awareness of the role o f women in development. The issues were familiar to them when discussed in practical terms. The training became an 'eye and mind' opener for the women participants. The women were provided basic knowledge and skills for problem identification and finding solutions relative to their situations. At every point prior to collective discussion or action, some form of training was carried out by the outside change agent-cum-researcher/ facilitator, to imbue the women with the importance of detailed planning prior to implementation. T his was an effective way to monitor the progress of the activities and to get feedback from the groups involved. Part of the process was to keep records of meetings, decisions made, and events that took place in the villages, especially if such events had implications on the role of women in community health. VRs took notes for a six-month period, which was extended to twelve months. Records were sporadically kept. There was a high degree of record keeping in the early phase, very little to none in the middle of the project period, and some towards the end. Not all proceedings of meetings were recorded. The descriptive and lengthy records were a deterrent to efficient record keeping itself. The need to write brief statements has to be addressed in such participatory research projects in the future. Records of decisions made in meetings where the VR was in attendance were not kept. It was concluded that there was a need for the groups to formally keep records for their own reference. Discussions tended to be easily forgotten and short-lived until related activities took place. With such oral agreements the women would lose interest in the issues after a while. Fijian women tend to place confidence only on tangible activities. Thus the educational and training component of the research project had to be practical for the formation of a palpable project. Training is a very importan t component for the maximum involvement of the village women.

Tht Bureiwois in Ro Province, Fiji

47

The inactive status of the SSV at the time the project was initiated was attributed to the Jack of a programme or project. Leadership tended to be functional only when there are active projects. It is. therefore, essential that these women's groups sustain their projects to remain active. Vernacular discussion papers were provided to participants as the bases of all training activities. The availability of such papers increased the interaction between the participants and the researcher. The methodology ado pted where the participant read aloud for the benefit of others who might have hearing or sight problem appeared to be well received by the participants. From the experience o f the project. some issues need to be addressed: 1.

Continuity or sustainabilit y - The previous piece-meal approach to projects by the village women' groups was recognized. Each problem/ project ceased operation at the end of the implementation period and the sustainabilit y o f issue wa~ rarely taken into account. The situation was attributed to the lad of documentation ~ the women were not able to note down problems and i'sue~ that would serve as bases for the continuity of activities.

FIGURE I Schenw Showing

lh~ M~lhodology

Ent r) into the communit >

Followed in lhe Fiji Sludy

C'o mmurut y a!.~C \\Illl' nt

II nego t1at io n'

l rdm1ng to aggregatl'. G rou p meet ing for collect ive statement 4== = dl\l'U''· and p rc~en1 . , _ .:ont:ern~ of solutions

Gro up identif1.:at ion of next collect ive action 10 address: collective concerns

Tra ining fo r by

====~ trai n e r~

re~ea n:h cr

Group mccttng' t.:o lkl' ti\1.') for d r~• u~~ion o l p roblem~

l ratnlllg lUI lOiicl' II\C sta tement of ~oluuon~ of the group. In Bureiwai. older women tended to be leaders though there are younger women who can do better in the role. The leadership c ri si~ in each of the villages studied and in the tikina can be effectively addre~!>ed if a combi nation of training programmes for women leader!> on group and programme management can be arranged. Prevaili ng relationship~ between clans and tribes do affect the participation of women in programme~. A!> seen in Matainananu, the existing friction between the two tribes c reated the women's factions. Unless good relationship~ prevail between clam and tribe!>, leadership can be ea~ ily challenged or dcci!>iOn!> made ignored deliberatdy by women of other dan!>. The women will cn~ure that any committee involves member~ of the women in traditional leadership role . For them, the t a~k of making decisions and en~uring that re~pon~ ibilitie!> and ta~b are carried out will then be realized . Though the channel of communication in the leadership system is an open one and very informal, an alternate leadership pattern may not be conducive to women \ programme~ and projecb within the village committees, but prevailing leaders need improved training programmes for their role. The mobilization of members at clan level rather than tribe is more effective here. There is definitely a need to improve the quality of training as well as address issues in adult education programmes for women if the leadership q uality of village women's groups is to improve and be effective .

50

3.

Women in Health Development

The Need for Records in Programme Plans Traditionally, Fijians conduct their businesses orally and each activity is planned for until implementation. Planning for a number of activities that will take place in a sequence is a novelty to the administrative ethos of Fijians. The situation demands adequate documentation and some form of record keeping. The study groups in Bureiwai nominated VRs, but recording was sporadic. Decisions arrived at in meetings were often not recorded and events that affected women were rarely entered into record books. This points to the need for development agents to provide materials to improve documentation skills in such villages. The workshops for VRs, trainers, and project teams provided the opportunity for women to write and read. Many of them had never used paper and pen since they left school some 15-20 years ago. The provision of discussion papers in the vernacular was a training strategy appreciated by all participants.

4.

The Need for Articulation Skills The top-down approach used by development workers hinges on the assumption that communities are unable to carry out needs assessment for themselves. This research revealed that village women as individuals or groups are aware of their concerns and needs, but have never been given the opportunity to define them. The Fijian society, with its traditionally top-down approach in administration, its social norms determining decision making as the prerogative of those higher in the social hierarchy, evokes very little participation from the people. The women of Bureiwai are aware of their concerns and their needs, but did not have the opportunity to express them. Their concerns are stated in short phrases such that facilitators and researchers had to probe to elucidate on specific matters. The situation can be ameliorated by providing training workshops which address the concerns articulated by the women. The workshops can attempt to analyse the situation, and women can try to write paragraphs on project proposals. More written exercises should be prepared.

5.

Attitudes towards Development The Fijian vocabulary has no term for development but something synonymous to change, progress, and always means a forward (upward) move. The term veivakatorocaketaki is commonly used for development. The village sees development as increased income, non-traditional housing, vehicular transportation, or ownership of technology. Fijians tend to see development in the form of conspicuous 'hardware' within the environment. Urban lifestyle or easy Living is often mistaken for development. The women of Bureiwai had the notion that development always originated

The Bureiwais in Ra Province. Fiji

51

from outside their communities in the form of persons, ideas, resources, and projects. The women were never consulted on what they wanted to do nor what their concerns were about. The recent experience has shown that women can be trained to formulate, plan. and co-ordinate a development project. At one of the early training workshops for this research, discussion papers were used to create awareness amongst the women trainers on issues relating to government development plans, women in development, health, and rural and community development efforts. All the participant s had never read such papers and many were not aware of government plans and their implications on their lifestyle.

6.

Group Dynamics and Consultations The SSY had been in existence prior to the researcher's entry into the community, but wa~ not fully functioning a:- a service group for women. but a s a ~ upport iH' group to the traditional social systems. It was introduced into the village' and the districts, but was not living up to its objectives. Rather dormant, it functioned only when directed by the male members of the society. The group had no defined leadership nor any on-going projects or programmes. The researcher discussed with the women a need which would see t heir direct participation in a wood stove project. The project aimed at grou p rebuilding. The project was taken up by only two of the village SSY. The other two did not participate because the male members of their vi llages were not supportive . One of the participating groups, Matainananu, could not get all the households to join in because they were slow to respond to the household contribution of F$7. During the research, a series of training workshops for the village trainers and project team were conducted. All trainees were eventuall y to become facilitator~ in the follow-on group mel.'ting~ in between workshops to retrain other~ ~ well as to provide fcedbad from d ecision~ during their village SSV m eeting~. All the village teams reported litt le participation in the SSV sim:e not a ll women attended the meetings, forcing the trainers to elicit the women's views during informal group discussiom and meetings. On the surface solidarity exist ~. but in realit y, the variou~ dans and tribes within one village serve the interest ~ of the smaller groups rather than the village at large. A strategy that can be workable is for trainers to be selected by subclans (malaqali) or tribes rather than by the SSV. The basis of group solidarity in villages appears to rest with the dan rather than the inter-clans with a n overall clan headed by the chief.

52

Women in Health Development

Group dynamics is much higher within the clan rather than interclan, even though cross marriages take place. Marriages within the clan are considered incestuous. Future programmes should ensure that clan representation is the criterion for the maximum participation of women in the villages. 7.

Skilled People in Villages To ensure participation from the community, some skills would be needed. The project required skilled people within the village to estimate and mobilize resources needed for the project. A male member of the community was invited to join the women team of trainers to provide the required skill. All the skilled males were village technicians who had become skilled from apprenticeship with skilled people while working in \Jrban areas. The community considered them skilled in plumbing, carpentry, and house-building.

8.

Self-Reliance T hese communities have been traditionally self-reliant. Resources and technology were eventually brought in from outside these communities since they were deemed more efficient than those in these villages. Health programmes and trained personnel replaced the traditional health-care system, but were more focused toward curative medicine.

The project focused more on the creation of awareness of the development needs of the community and the building of skills in problem articulation, formulation of solutions, and development of plans. To sustain the project, the women should be aware of the health problems and participate in the formulation of solutions.

IV THE YAO OF LAMPHANG PROVI NCE. THAILAN D Orapin Singhadej

Lamphang Province is located in the nonhcrn pan o f Thailand. connected to Chiang Rai and Phayao Provinces in the nonh, Tak Province in the outh. and Phrae and Sukothai in the east. The villages ~elected for the ~tudy were Baan Kun H aeng and Baan Kew Tam in Pontago subdistrict of the Ngao district. The village are located on the mountains at the begin ning of hea' y flowing streams. Baan Kun Haeng is about 99 kilometre from the hean of Lamphang Province and about 16 kilometres from Ngao dist rict. The ncarc" comm unity centre is located in Pongtao, which is about 7 kilometres from the village. In residence is o ne public health worker from the Health and Famil y Planning P roject for Tribal People. Baan Kew Tam is located about 25 kilometre away from Baan Kun H aeng. The village head is often a ppointed by the government. Besides maintaining links with the government and caring for village visitors, the leader has the responsibility of resolving con flicts that may occur and is invited to weddings and other ceremonies. The Yao economy is based on agriculture. The Yaos are reputed to be industrious and productive farmers. Although their main subsistence crop is rice, they a lso produce tobacco, bean , pumpkin , melons, potatoes, cotton, and maize. Mo nogamy is the common norm among the Yaos although polygamy is ~ocia ll y acceptable in wealthy or powerful groups. Mates are usually chosen from their own tribes. There are three fo rrm of family: patrilocal, matrilocal , and nuclear. The Spirit Doctor i the religiou) leader of the Yaos. He performs ceremo nies in pregnancies, deliveries, engagements, weddings, funerals, and illnesses. The Yao~ believe that spirits inhabit the body but leave it in sickness, danger, or ~ h oc k. Aside from animism, Buddhism and Christianit y are practised.

54

Women in Health Development

Settlements are found high in the mountains and are governed to an extent by religious rules. No village is allowed to occupy an area directly above another village on the same mountain slope. Yao communities are usually very small, consisting of three to twelve houses generally sheltering about sixty individuals. These small hamlets are usually situated from 5 to 19 kilometres apart. Other structures in the village include huts for horses, buffaloes, pigs, or goats, and a hut with overhanging to serve as a granary. There may also be a fenced-in area for a small garden or vegetable patch. Houses are rectangular in shape and made of wood, bamboo, and fresh straws or leaves. They have dirt floors, with raised platforms for the beds. H ealing is usually left to the village shaman and the spirits. A pig may be sacrificed to a powerful spirit and a chicken to a lesser spirit. The social structure is basically founded on the nuclear family although it is inclined towards an extended family. All family members take their meals together. Women's Status

Although theoretically a patriarchal society in which the man exerts supreme power, the Yao woman holds a privileged position in the society and enjoys a great deal of freedom. A man can repudiate his wife only with her consent. The wife handles all financial matters, takes charge of the interior of the house, and usually holds the authority over the girls in the family, including in-laws. Men and women work together in the fields and in most cases, the women are allowed to share meals with their husbands when no guests are present. During engagement, the man has to pay the dowry for the bride. If a man behaves inappropriately, the woman can caU off the wedding and keep the dowry. After marriage the woman moves into her husband's home and worships his family spirit and ancestors. lf the husband dies or they get divorced, she cannot go back to her own fami ly. Divorce seldom occurs among the Yaos. The Participatory Project

In undertaking the task of mobilizing women for participatory research, the operational model is given in Figure 3 which outLines the steps involved, from the identification of the community entry point, formation of task forces and identification of women volunteers, health orientation, dialogue sessions on programme plans to implementation and evaluation.

FIGURE 3 teps in the Participator)· Actio n Research in Health Develo pment

COMMUNITY APPROACH Identification of organiz.ation~ concerned and leaders; Delineation of community struct ure. culture. ' 'alues, health status, etc.

FORMATION OF TASK FORCE

I

~ CREAT/0

VILLAGE LEADERS

--. Group p roce\~e\ for YWV and ' 1llagc headman

Selection of Yao women volunteers (YWV)

WORKSHOP 0 L._____.

-----..

OF AWARE.vt:S5

HEALTH

Awareness and stimulation of th e thinling proce~~:

~

~

n_ic_a_ti_o_n_ ___; _ u_, L_'J1_w_o_-_w_a y_ _c_o_m_m

Y\\'\'

Health personnel

~ Leader\ Welfare o fficiah

SECURI G OF YWV COMMITMENT Time lag between orientation and planning through periodical visi ts to collect information Food and nutrition Dialogues with YWV and Income-generating acti' itie> village leaders 10 1----- - - H ou>ehold dru g~ identify problems

Expression o f needs and ~ ~Mar let ing hand-embroided product> Supplementar} food preparation suggestion of act I\ 111 e~ Village drug lund

r;;::::::::

Implementation of plan>: Monitoring and evaluation

56

Women in Heallh Development

Preparation for the Research Basic information on the community was drawn from the available published and unpublished reports, informal dialogues, and meetings. T he conclusion drawn was that existing information was inadequate to assess the community in terms of health status, facilities, and knowledge so that appropriate interventions could be instituted . An anthropologist on Yao culture was briefed on the project and his perceptions were sought. The local beliefs and customs were shared with the research staff.

Initiation of Contact with the Community From the analysis of the situation of the community based on the aforementioned information, discussions were held with relevant government officials from the Public Welfare Section, the anthropologist from the Tribal Research Institute, and the National Family Planning Centre. Although there was a consensus that the health knowledge and status of the population were inadequate, there was a felt need to document such inadequacy as well as the knowledge gaps. Therefore, the research team undertook a survey of the two villages in February 1988, obtaining information on the vital rates (births and deaths), number of houses, total population, drinking water supply, environmental sanitation facilities, weight of newborn, immunization status, nutritional status, prenatal care, deliveries, lactation, and supplementation. Results revealed that in Kew Tam, there were 130 houses and Kun Haeng, 109 houses. Water supply was adequate for more than a third (35.4 per cent) of the households in Kew Tam and less than a fifth (18.3 per cent) in Kun Haeng. Most of the households have latrines. In Kew Tam, 6 per cent of the infants were underweight ( < 2500 gms), and the corresponding percentage in Kun Haeng was 21.4 per cent. T hat immunization was incomplete was revealed by 25 per cent of children who had their third OPT (Diphtheria, Pertussis, Tetanus) in Kew Tam and 38.5 per cent in Kun H aeng. Prenatal visits were likewise minimal. In Kew Tam, 30 per cent of infants were delivered by untrained Traditional Birth Attendants (TBAs), and in Kun Haeng, all four women who delivered were attended by a trained traditional midwife. T he analysis of the data pointed to the dire need for health education as an entry point to the formulation of relevant health programmes. It is through health awareness and consciousness building that women can be mobilized to deliberate on their health problems. Therefore, a training programme to acquaint women on socialization and leadership skills, as well as orientate them to the basic concepts of health using a culturally based (agricultural) approach, was planned.

The Yoos ()j

Ulmphon~

Pronnce. Tho1ltmd

~1

Preparation for lraining In mobilizing the communit y for the trammg, a number of people were approached to discuss the objectives of the training programme - t he government officials from the Public Welfare Section in Lamphang Province. the anthropologist who has intimate knowledge of the community. and the village headmen. The village headmen were informed of the objectives of the o;tudy and the mechanism of its implementation. Initially, the headmen doubted the capability of the women to act as health providers in selected programme~ as they perceived that they did not have the required skills. After several discussions and explanations, the headmen finall y agreed to assessing thi~ possibility. The researcher and the government officials from the Public Welfare Section went to one village during a Men's Initiation ceremony and obo;crved the women cooking. Inquiries were made if these women could volunteer for health-education training and eventually, share their knowledge with other' while doing their usual embroidery tasks. Likewise, in another village, the researcher orientated the women on the importance of training for health .

Selection of lhlinees The selection process was done in close co-ordination with the Ministry o f Public Welfare a nd the Health Promotion Officers. The latter contacted the village headmen who would be responsible for the identification o f trainees. The researcher emphasized that the staff were not to choose the participants. The villagers themselves should decide to whom the women would be eventually accountable. The criteria for selection of the trainees were the following: I.

2. 3.

Female, 15-44 years old, regardless of marital status; Ability to speak or understand either a northern dialect or cemral Thai language; and Ability to read and write simple words, e.g., name.

It was agreed that each woman would be assigned to a catchmem area of ten households. Twenty-nine women were recruited for traini ng. The trainees were relatively young. The majority were single, with less than half o f them illiterate. Not one had ever attended a training programme. Exposure to media (radio, newspapers, etc.) was limited. The majority of the married women were using injectable contraceptives and im ra-uterine devices (IUDs). Knowledge of family planning methods was high a nd the attitude was considered positive. More than half of these women did not know o f vaccines for children and for pregnancy. Nearly half were knowledgeable in food supplememation.

58

Women in Health Development

In the trainees recruitment, the government officials preferred older women who are generally involved in decision making and often consulted by the village officials. Furthermore, the issue of trainees selected by the village headman who may not be recognized by other families in the village may affect the eventual utilization of the services of the women. However, the researcher felt that young women are more amenable to new knowledge and are better suited to the task of information dissemination. The trainers were drawn from the National Family Planning Centre (NFPC) - four females and an audio-visual man. Two nurses from among the women were involved in the pretesting of the health-care concepts.

Curriculum Development

-

Initially planned for five days, the training workshop was aimed at developing skills for the Yao women in four areas, namely: (I) reading and writing enhancement; (2) income generation; (3) implementation of a nutrition programme; and (4) maternal and child health, family planning, and curative care. Given the busy schedule of the Yaos, the field staff requested for a reduction in the training period to three days. For this reason, activities for reading and writing and basic treatment were rescheduled for the next series of training. The deputy director of NFPC was made responsible for the field coordination, including the identification of resource persons. The module developed utilized the agricultural approach which was patterned after the Philippine International Institute for Rural Reconstruction (IIRR) experience inasmuch as the familiarity of the Yaos with agricultural processes could lead to better insights on the health concepts through parallel illustrations. Such an agricultural approach appealed to the group and led to better knowledge retention and concept acceptance. Family-planning concepts were initially presented. A nip chart was developed which included topics such as the anatomy/ physiology of the reproductive system, rationale for family planning, and mode of action of common contraceptive methods such as pills, IUDs, and condoms. One of the problems encountered was the understanding of English terms such as 'induce' and 'conception' which indicated that the text terms needed to be simplified and illustrations modified to reflect the local situations (e.g., hens should be smaller and darker in colour). The concept of ovulation could be viewed in terms of a hen laying eggs. A family-planning kit was used in the educational sessions, composed of a plastic/ resin attache case with fifteen leaflets (brochures), a pelvic model (female), frontal section, and contraceptive devices. In addition a cloth poster

with six to seven illustrations showing the poverty cyde (sick nes!>. competition for food , education, labour. etc.) and other family-plan ning methntt'C'OSI

lslond. Vonuotu

73

implementation plan . This was followed by a three-day training workshop with the aim of orientating members of the task force on the health situation. the possible causes of health problems, and their olutions. For the first visit to the villages, a letter wa ent by the researcher to each of the nine village chiefs to call a meeting with the women. The men and the chief were requested to be pre ent at the meeting. The meeting was opened with a prayer read by the chief and the church leader. The researcher chaired the meeting. She informed the people about the health stat us of the communit y and invited comments and views. It was evident that mo tly men and the chief spoke. The men aid that they were not aware of the existing health situation and as such were pleased that this project enabled them to pledge their assistance to whatever plan was decided. A prioritization of health problems was made. Based on the data consolidatio n, specific causes for existing problem were stated, such as lack of knowledge about food for malnutrition; the presence of coconut shell and empty tins holding water for malaria; smoking. breathing in dust, a nd lack of proper ventilatio n for chest infection; and worms, unsafe drinking water, and dirty hands for diarrhoea. The members o f the task force were asked to evaluate the first visit to the villagers and find out whether the project aims (problem discussion) had been achieved. They were a lso asked to analyse the health problems and come up with proposed solutions. Questionnaires were presented. The members of the task force also learned how to conduct interviews using questionnaires and identify resources available in the community. Dates were set for the subsequent visits to discuss possible solutions to the health situation and identify resources available in the community. The task force, by this time, had built up confidence and was divided into groups of two. The meetings were mainly with the women. The proposed solutions, as identified by the women, were nutrition education, home gardening, personal hygiene, village a nd sanitation programmes, improvement of pit latrines, and income-generating activities. Planning for the Health Strategy

Mechanism for Identification and Prioritization of Health Problems The research team assisted the tas k force in developing solutions to identified causes of illnesses. They also highlighted possible solut ions to the health situation based on the previo us discussions. The women identified health problems which were then analysed and trans formed into health programmes for planning purposes. In the problem analysis phase, the possible causes of illnesses were identified with the pro posed solutions by the community. Suggestions were sought from the women as to how eac h solutio n was to be achieved .

74

Women in Health Development

Priority Health Problems Five problems were identified by the task force as contributory to the overall health status in Ward I. These were: lack of water, lack of appropriate health education, inadequate nutrition education, insufficient family income, and understaffed health services.

Lack of Wate1: The piped water system serving Ward I was installed in the late 1960s and has been expensive to maintain. The system serves three wards, including Ward I. The service could not be maintained effectively since the communities could not afford the costs. The upgrading should consider equitable distribution. Another issue is purification or quality control. At present, there is no quality control of either piped water or other types of waterdistributing reservoirs. There is inadequate water for bathing, washing utensils, and hand washing. This has resulted in the prevalence of skin infection. Even drinking water is not readily available. Lack of Environmental Health Education. Respiratory infection, diarrhoea, parasitism, and malaria are related to inadequate environmental health facilities. The majority of the households in Ward I have uncovered pit latrines and poor waste disposal system, resulting in the spread of disease by flies. Head lice are common. A village settlement, which used to be bounded by a clean area, is now fringed with tall grasses and hedges, encouraging the breeding of rats and mosquitoes. There is a sanitarian located at each LGC responsible for village sanitarians at the area council level. To implement the Primary Health Care (PH C) P,rogramme at the ward level, Ward I has a village health spokesperson located in each of the nine villages, responsible to the village chief. There is no female health spokesperson, and no women's representation in any previous health planning committees. According to the Secretary of the North Area Council, female involvement has been deemed unfeasible due to lack of support from the chiefs and the communities. In food production there were the land ownership issue, soil infertility, and traditional methods of food production. The population lacks an understanding of food groups, their nutritive value and contribution to the body function. Traditionally, foods are consumed according to their availability during the harvest, such as root-crops, green vegetables, fruits, nuts, and berries. Protein foods, such as beef and pork, are consumed mainly during ceremonial feasts or on important occasions. The staple food, yam, is harvested once a year and the present poor harvest does not guarantee a full year's food supply. Education on soil preparation and food production techniques should

Thl'

i- Vanuotus m Word I. f'r>ntl'C'Ohop.

Finahz.atton of cu1dt· line\ for participatory

a~o.·h • e,•tm c n t

rc)carch in hcull h.

- sdf·~u"' l ainnbili t)'

Training for da1a ~ollcction, pro~e )\111~.

a nd

interpretat ion, prt~cnta t ion

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