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My Public Health Project

February 19, 2011

I decided to post the project description that I wrote for a scholarship application and my personal notes from the first week of training.  I expect they will be insightful to you.

D and I with our Session 1 trainer's guide

Project Description

The organization’s activities fall under three broad categories: health, education, and community development.  My role is to expand the health programs to help the organization further achieve their mission of “reversing the cycles of poverty, disease and death in Mozambique”.  Currently, the health programs consist of a nutrition program and clinic for the children of HIV+ mothers.  The clinic supports nearly 800 children and their caretakers on the program by providing full-cream powdered milk, sugar, oil, crushed peanuts, corn meal, and/or beans, as appropriate, every 2 weeks.  Each child’s growth is monitored, and the child and caretakers’ health is checked.  The clinic treats most health problems presented, providing the prescribed medications, and also refers patients to the hospital when necessary.  The program recently expanded into a larger building with more children enrolling every day.  The program is ready to add to its component of direct patient care, an education component for caretakers, and an equine therapy component for mentally challenged children on the nutrition program.  Counseling and education are given on an individual basis by the nurses, which is often time-consuming and too late to help.  Therefore, I will be spearheading the education arm of the nutrition program with the goals of preventing acute presentations in the clinic and improving the health of the community.  The objectives are:  1. Teach health and hygiene to at least 360 caretakers of the children of HIV+ mothers over 8 weeks, 2. Train a clinic assistant to teach the curriculum continually and to new audiences in the future within 9 weeks, and 3. Write new health lessons, and test and modify them within 9 weeks, and submit them to the creators of the hygiene curriculum for expansion of their own curriculum and training.

I will be teaching the health and hygiene curriculum to the HIV+ mothers or other caretakers of the nearly 800 children enrolled in the nutrition program.  The hygiene portion of the curriculum was written by another small American NGO called Grace-Connection (now Hydrating Humanity), and has been used in Kenya.  It employs a participatory teaching style that generates discussion by asking a series of questions and showing pictorial posters.  The curriculum includes seven lessons: Introduction to Germs, Disease Pathways, Blocking Disease Pathways, Water Collection, Water Purification Methods, Water Storage & Use, and Good/Bad Hygiene.  I will be writing the health lessons to add to the curriculum.  These lessons will be relevant to the issues seen among patients of the clinic and their families.  Topics include “Home Treatment of Diarrhea”, “Infant to Childhood Feeding Timeline”, “ARV and Other Prescribed Drug Adherence”, “Family Planning”, and “Prevention of Anemia”.  These lessons will follow the same format as the hygiene curriculum as much as possible, and will subsequently be submitted to Grace-Connection for use in their programs.  I will teach the combined curriculum over 8 weeks, in 2 week blocks.  Every day that the clinic is open (Tuesday through Friday) for 2 weeks, lessons 1, 2, and 3 will be taught in the morning, as the caretakers wait to be seen in the clinic by the nurses.  In these 2 weeks, most of the caretakers will come to the clinic once, and some twice.  Another set of lessons will be taught for the next 2 week block, and so on.  In this way, the number of caretakers who participate in all lessons of the curriculum over the 8 weeks is maximized.  The number of participants present for each morning and afternoon session will be recorded. Caretakers will also receive a “punch card” on which I will mark in which lessons they participated.  It is my hope to be able to offer a small award to the participants who participated in all lessons of the curriculum over the 8 weeks.

In order for the education arm of the nutrition program to be sustained, a new facilitator will be trained.  One of the clinic assistants who can translate the lessons from English to Shona will be ideal for this training.  The relationship will be mutually beneficial, as she will offer cultural insights as I impart new knowledge and skills, with the aim to empower her.  For the first few days of each block, I will facilitate the lessons and the clinic assistant will translate.  When she is ready, she will facilitate the lessons and I will provide guidance and feedback as needed.  By the end of the 8 weeks, the clinic assistant will have facilitated each lesson several times. The clinic assistant, being a local national, will offer great insight into the effectiveness of the curriculum’s suggested dialogue, including the health lessons which will be written according to international standards like the Integrated Management of Childhood Illness guidelines.  We will discuss each lesson in detail and make necessary changes to make the lessons more relevant and culturally acceptable for our audience.  By the end of the 8 weeks, the entire curriculum will be printed, posters colored, each page in a plastic page protector, and compiled into binders.  All necessary supplies for demonstrations and activities will be gathered.  These materials will be left in the charge of the new facilitator.  All digital documents will be stored with one of the nurses of the clinic, who will also oversee the education arm of the nutrition program after my departure.  The clinic gets about 25 newly enrolled children per month, depending on the season, and I foresee the new facilitator being commissioned to teach other audiences in local churches and villages in addition to these new children’s caretakers.

Session Debriefing and Reflection

I. Block 1: Intro. to Germs, Discovering Disease Pathways, and Blocking Disease Pathways

Day 1:  Most of the questions in the pre-test were answered fairly accurately and thoroughly by one grandmother present.  It is good that she knows, but there is the potential for this to have made it difficult or uncomfortable for those who didn’t know the answers, to say so, and to later learn on their own through the lesson.  It could also cause the evaluation to be inaccurate.  This dynamic seemed to make the crowd feel that they didn’t need the lessons, and therefore made it difficult to explore the ideas together through discussion.  In addition, it was planned to teach Lessons 1 and 2 in the morning, and then teach Lesson 3 to those who stayed to be seen at the clinic.  However, all caretakers were seen in the clinic by the time I began teaching Lesson 3.  Therefore, the audience didn’t have the background of Lessons 1 and 2, so I taught an abbreviated version of both, and then continued with Lesson 3.  Unfortunately, those who attended in the morning didn’t learn the ways to block the pathways of disease!  Lesson 3 requires participants to explain a picture on the poster handed to them, and tell the audience how that action blocks the pathways of germs.  The women didn’t understand the diagram with string showing the pathways, nor did they seem to understand the concept of presentation.  Many of them gave up and left during this process.  Though there were probably about 20 women to begin with, I handed out only 8 attendance cards.

Tomorrow, we will teach all three lessons in the morning.  The problem of the pre-test is unavoidable and it will only be administered for the first 4 days of the first block.

Day2:  Today, the pre-test went better – some good answers and ideas were presented, but they were not comprehensive.  I do wonder if the women who arrive in the morning are the “wealthier” women who can afford to pay for a bus to the clinic, and those who arrive in the afternoons are those who walked for long distances.  This has many implications about their education level and aptitude for learning.  I was able to complete all three lessons in 2 hours today, but I forgot to ask the women to make their own song about a healthy practice to share.  During the presentation time in Lesson 3, it was difficult to get the caretakers to speak loudly, and to hold up the picture for all to see.  However, they presented many good ideas about why that action is healthy.  I have been allowing them to present from where they sit or stand, but D suggested that next time, we should allow them to stand next to us, facing the audience.  On the one hand, I don’t want to stand in front of the audience, myself, as an instructor; I would like my role to be more of a facilitator.  However, this is difficult to do on the small porch of the clinic, to sit where all can hear D and I speak, and to show the diagram where everyone can see.  Because of these activities, it becomes more of a presentation/professor style of teaching, than the desired discussion/participatory style.  Another problem we are having is that the diagram is set up on a sheet hung over the rafters, but the wind is so strong that even with bricks holding the end of the sheet, it is flying out.  Perhaps we can try putting the diagram on the wall, though that isn’t the best place for viewing it.

D and I decided that since the crowd in the afternoon is different than that in the morning, we will try teaching Lessons 1-3 again this afternoon.  We agreed that today’s morning session went much better than yesterday, for many non-descript reasons.  D also expressed that she would prefer that I continue facilitating this week, and she will begin next week.  I agree with this plan.

In the afternoon, there were only a few people waiting to be seen, and D and I decided not to teach in the afternoons because the caretakers are more eager to get home after being seen, anyway.

Day 3:  Today’s session went very well!  There was a particular mother among the participants who was very engaged, thinking hard about the pretest questions, and answering when she could.  She seemed well educated and eager to learn.  In fact, when she didn’t know the answer to one of the pretest questions, she demanded that she needed to know the answer!  I told the participants that they would learn the accurate answers for all of these questions, and I would tell them the answer to this one, but they have to remember it when we get to the lesson in the coming weeks.  This particular woman stood up when she spoke, and she spoke loudly, clearly, and succinctly.  We will consider her for assistance and training under D when she is teaching the curriculum without me.  I told D that she should keep her eye out for someone to assist her and to be trained.

In Lesson 3, when the participants are to present posters to each other to explain the healthy practice, I described the task differently today, and it worked much better.  There was more order, and they presented to each other, rather than to me and D.  They all listened to each other well.

In Lesson 2, when talking about pathways of bacteria, the diagram is limited to transmission of bacteria from poop to the mouth.  However, it is important to describe how bacteria travels from one person to another to cause infection, for example in the case of conjunctivitis.  I am also sure to mention that kids touch everything, and then touch their mothers and siblings.  I emphasize the use of soap when washing hands, too.

Day 4:  The participants in attendance today were very noisy and difficult.  They talked amongst themselves, and all the babies were unhappy, crying continually.  The day started out with many participants, probably near 50, but as they were seen in the clinic, by the time I had finished the session, only 29 remained.  The attendance cards and headcount will therefore not be an accurate measurement of the number of participants in attendance.

During the pretest, one woman asked an old grandmother what methods of family planning were used before pills and injections.  The grandmother described frottage, which the men apparently reject nowadays.  After the discussion was translated to me, I explained that there are methods of family planning that don’t require the consent of the husband, and that we will be discussing such methods in the next 8 weeks in another lesson.  The methods I have in mind are the diaphragm and the female condom (which I believe are both available for free at the hospital), and the natural calendar method of counting the days and abstaining during the days of fertility.  The latter method may not work because it is most likely difficult or impossible for a woman to deny her husband sex, but on the other hand, they are very “crafty” people, and at least she can know when she is most likely to become pregnant, and avoid sex during just those days, rather than fearing pregnancy all the time.

In response to the pre-test question, “What causes diseases like diarrhea and infections?”, the same grandmother that described frottage explained that young people are the cause of the general illness of the population.  She said that “in the old days” there weren’t a lot of infections on the skin or of poop, but the youth are promiscuous and have brought all this illness to the people.  It is very sad and frustrating to hear such accusations!  There was always infectious disease among the human race!  It is true the HIV has been spread abroad because of promiscuity, but there are also many other factors.  I can see how this grandmother might think that it is the fault of the younger generation, but it was most likely in her generation that HIV/AIDS emerged!  The long civil war didn’t help the health of the population either.  To put the fault of the illness of the population on the youth, on the caretakers at the clinic, and/or on people living with HIV/AIDS, is inappropriate and damaging!  This grandmother is probably the caretaker of her grandchildren because her daughter died of AIDS.  I wonder what emotional damage she may have done to her daughter, blaming her for her own illness and that of her children, and what damage this grandmother does to those around her, blaming them for the illness of their children.  There are many, many cultural and traditional beliefs that do so much damage to the people, physically and emotionally!  What can we do?  Did this grandmother learn anything today?

There was a security gate installed at the clinic door, unexpectedly.  We pinned the diagram sheet to this door and it worked great!  The wind was not a problem!  Because conjunctivitis is a big problem, I added an explanation of this to the Diagram of Disease Pathways discussion in Lesson 2.  After the session today, I drew and colored new posters to present on this topic, as well as biting nails, and not concealing or changing dirty diapers.  I also made new healthy practices posters for Lesson 3, including cutting nails with clippers (not biting them, keeping them clean, and short so they don’t store bacteria), and washing clothes with detergent/soap and using bleach, especially when a family member is sick with any kind of infection.

After the presentation of the healthy practice of wearing sandals with the explanation that we should take them off before entering our homes so that the poop doesn’t get into the home, a woman removed her sandals before entering the clinic.  This made me very happy!  She was given information, and then put it into action!  Wow!

At the end of the session, I re-asked the pre-test questions that pertained to today’s lessons, gave a recap of information, and asked what they learned.  This seemed to be a better closing than other days, and I think it helped to reinforce the information.  I will continue to do this.

This is what happens when you hand the camera to someone who has never used one before...
D and I teaching, using a diagram (notice the scale for weighing the children in the foreground)

The caretakers sit on benches and bamboo mats on the concrete porch of the clinic.  I am there by the diagram made by pinning the posters in page protectors to a sheet hung on the security gate for the clinic’s door.  One of the caretakers is showing a pathway that bacteria takes from poop to the mouth to make us sick.  The photo is blurry because I asked one of the clinic assistants to take the photo, and she has probably never even touched a camera, and I didn’t explain the “push halfway down til you hear a beep”.  Average attendance each day is about 30 caretakers.  With this average, in total, we will have about 240 students in the first block, who will be expected to attend the next 3 blocks.  I hope to gain more throughout the weeks, and as I stated in the session reflections, each session starts with more caretakers than it ends with because the caretakers leave after they’ve been seen in the clinic (some stay), and the head count is taken at the end, when I hand out the attendance cards.

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