Baseline Surveys and Barriers to Change Analysis

Behavior change is a fundamental part of our work as Peace Corps volunteers. It’s also the most difficult. Try changing your own habits, let alone those of an entire Mandinka village. Behavior change is also the least glamorous aspect of the job. Infrastructure projects, for instance, yield tangible and concrete results. Behavior change is harder to measure, and it’s always a work in progress.


My aim is to replicate the baseline survey that Venchele designed and conducted between November 2012 and January 2013. I’m hoping that doing so will allow me compare and contrast the results, so as to ascertain any progresses or setbacks. The survey is intended to yield data on a wide array of subjects, including current mosquito net usage, basic WASH knowledge, and recognition of common child illness’ symptoms among community members.


Many of these areas of intervention are associated with indicators in our community health project framework. Peace Corps Senegal is expected to help 880 health service providers increase their capacity to implement malaria prevention and treatment activities by 2018. One of the tools we have to measure our progress is indicator HE170, defined as the “Number of individuals who slept under an Insecticide Treated Net the previous night”.


The resulting data will have to be interpreted carefully. If I see that the number of people who slept under a mosquito net decreased between 2012 and 2014, then I’ll have to find out why. Is it because I conducted the study during the dry season instead, when people do not perceive mosquitoes to be prevalent enough to warrant sleeping under a net every night? Or could it be that the village population is growing and that no additional nets were distributed? This is when a barrier analysis questionnaire comes in handy. Identifying the barriers to behavior change will enable me to design activities and identify resources to effectively remove or undermine those barriers.


Our tools are based on the health belief model, which tries to predict and explain people’s health behaviors. It speculates that an individual will engage in a health-related behavior if he or she thinks that a specific illness can be avoided, believes that the behavior will help him avoid that illness, AND is confident that he/she can successfully carry out the behavior.


For example, a person will likely to repair the holes in his mosquito net if he believes that malaria can be avoided, thinks that repairing the holes in the net will help him avoid malaria, and is confident that he/she can repair the holes in the net.


The health belief model is predicated on the understanding that behaviors/actions follow from perceptions rather than objective truths. Formative research is a crucial aspect of the work, because it can help us understand why individuals are not engaging in certain health-related behaviors. We have to get a sense of what our communities believe to be true. For example: if they don’t think that repairing their mosquito net will help protect them from malaria, then they won’t repair their nets even if you teach them how.

The health-belief model is comprised of a series of determinants, each associated with a list of possible questions designed to assess barriers to behavior change. The following chart is intended to serve as a guide:

http://wiseabouteyes.preventblindness.org/educators/lessons-for-teachers/lessons/eye/eye.html

Formative research is a crucial aspect of the work, because it can help us understand why individuals are not engaging in certain health-related behaviors. We have to get a sense of what our communities believe to be true. For example: if they don’t think that repairing their mosquito net will help protect them from malaria, then they won’t repair their nets even if you teach them how.


The health-belief model is comprised of a series of determinants, each associated with a list of possible questions designed to assess barriers to behavior change. The following chart is intended to serve as a guide:

Determinants	Sample Barrier Analysis Questions
Perceived self-efficacy/skills	Do you know how to repair your bed net? What would make it easier to repair your bed net?
Perceived social norms	Is it acceptable to repair a net? Who would like/not like it if you spent time, resources, and energy repairing a bed net?
Perceived positive consequences	What are the advantages and benefits of repairing your bed net / having a bed net without holes?
Perceived negative consequences	What are the disadvantages of repairing your bed net?
Access	How difficult is it for you to get the material you need to repair your bed net? How difficult is it to find someone who can repair your bed net?
Perceived cues for action/reminder	Is it easy to remember to repair your bed net when you notice a hole in it?
Perceived severity?	How serious is it to have a hole in your bed net?
Perceived action efficacy	If you sleep under a repaired net, how likely is it that you will get malaria?
Perceived divine will	Is it Gods will that you have holes in your net and get malaria?
Policy	Are there any laws or polices that make it more likely that you repair your net when there is a hole in it?
Culture	Are there any cultural rules and taboos against repairing your net?
Universal motivators	What is the one thing you want most in life?

Technical Training: WASH (Water, Sanitation, and Hygiene) Infrastructure

Clean water is defined as properly disinfected and stored waters that is free from E. coli bacteria. Living in Senegal has made me realize just how precious clean water is, especially when you have to carry gallons and gallons of it in a baignoire precariously balanced on your head.

There are many types of available water sources in Senegal; these primarily include forages, wells, pumps, boreholes, rainwater, and robinets. Each has its own advantages and disadvantages. For example, water pumps don’t require forage, they can be sourced to a shallow water shelf, and they are covered—which decreases risk of contamination. However, they can be expensive to built, expensive and complicated to maintain, and require NGO involvement for design/construction. Many volunteers build some kind of water source infrastructure during their service, and it’s up to them to figure out which type is best suited to their community.

Quick step back: it’s especially important to conduct surveys in the community to ascertain need before starting such a big infrastructure project. Many people in my community have asked me to install robinets in the village. While I have not yet conducted surveys, I’m not convinced that they really “need” robinets, or that it’s the best option for my community. Not only are they expensive to build and maintain over time, they also require community members to pay for each gallon of water used. I think it might be more of a status symbol.

According to Venchele’s base line surveys, clean water access is an important issue in Dassilami Soce. A full 40% of individuals do not have access to clean water, which may explain the high rates of diarrhea and skin infections in village, especially among children. I’m still not sure exactly why these water sources are unclean, because the sources of contamination are unspecified. I have no doubt that well covers would help protect the water from contamination. During VV, Venchele mentioned that acid rain was a probably contaminant during the rainy season, which also coincides with increased rates of diarrhea and skin infections. In Saroudia and Boutilimite, I was told that some of the wells do not yield good or “sweet” water. This water is used only for washing laundry, not for drinking or cooking. I’m still not sure if this means it doesn't taste good, or if it’s salty, or if it’s otherwise contaminated.

My nearest well in village.

So just because these are many possible options available to the Senegalese people does not necessarily mean that it’s good quality and healthful water.

And even when it is good water, it often needs to be treated for turbidity, parasites, and/or bacteria. Common methods include prefiltering, chlorinating, or boiling. I can tell you straight off the bat that my villagers do none of the above with their drinking water.

Once it’s been treated, it needs to be safely stored in a container with a tight-fitting lid. Even well stored and treated water is only considered safe for a small length of time: for instance, boiled water is considered safe for 24h. After that, it has to be treated again.

Latrine projects are also a popular project among Peace Corps volunteers. I have friends who have only one latrine in their village—namely, their own personal latrine. Their villagers go into the bush to relieve themselves.

A typical village latrine: what I'm working with

The case de sante's latrine: what we might build in village....

...with its next door douche

There are many different types of latrines, but Peace Corps promotes a few in particular. The simple latrine has a square or circular pit, with a hole for defecation and some kind of shelter. The VIP-ventilated improved pit is a simple latrine with a vent pipe and fly screen to minimize pest and odor. Double vault/pit compost latrines have two pits built side by side. When the first pit is full, another shelter and hole is built over the second pit. The waste in the first pit is slowly composed over the next 2 years, and can be used as fertilizer in the fields. The offset privy’s pit is built at an angle from the actual latrine shelter and defecation hole. A pipe with pour flush allows waste to travel from the defecation hole to the pit. It allows for easier waste removal, and minimizes pests/odors.

Choosing a good location is pretty crucial. When building a latrine, you have to make sure it’s at least 2m above the wet seasons water table, at least 15m away from the nearest water source, and at least 6m away from the nearest house/compound. If you build the latrines in the middle of a public space, people may not want to use it. If you build it under trees, it might start to stink.

Here’s how one would go about building latrines:

·      Contact the nearest post de santé and its Hygiene and Sanitation Committee to tell them about your project and include them as needed

·      Consider asking an NGO or other organization for assistance

·      Identify the best kind of latrine for your village

·      Determine the kind of community participation involved. Many NGO’s and programs require community members to contribute some funds or manual labor. You can also write a grant, and get funded through Peace Corps

·      Insist that each family receiving a latrine go through training for maintenance and hygienic use of latrines. This should be a non-negotiable condition to receiving a latrine. For instance, people should know to cover their latrine holes to avoid flies, which can propagate many serious illnesses

·      Hire manual labor and amass necessary material. Lists are always good. Disperse material carefully

·      Plan during rainy season, build during hot season. If you try building latrines—or many water source infrastructures for that reason--during rainy season, you run the risk of having the hole you’re digging collapse

Bottom line: WASH infrastructure will probably take up plenty of my time over the next 2 years. There’s a lot to be done…

Technical Training: framework, RME tools, and Malaria

I’m back at the Thies training center for an intensive two-week technical training. So far, the sessions have been jam-packed with information, resources, and practical tools. Between classes and catching up with friends, I’ve had very little time to digest and sort through it. I’d like to take some time now to break it down.

Here we go

1) Community health project framework

The tech team provided us with a review of the project framework we were introduced to during PST1. This framework is intended on helping us fulfill Peace Corps’ 3 main health sector goals by providing concrete numerical objectives paired with carefully defined indicators. We are told to “start with the end in mind” when planning projects; that is, we must always design projects that will directly fulfill the objectives and overall goals.

The three main goals of community health:

Goal 1-Communities will improve their ability to prevent and treat malaria

Goal 2-Communities will adopt behaviors and practices that contribute to overall maternal and infant health

Goal 3-Community members will adopt water and sanitation hygiene practices and behaviors resulting in improved health

An example of an objective for the 1^st goal:

-By the end of 2018, 97, 840 community members will increase their access to malaria prevention goods and services and will adopt appropriate malaria prevention and treatment seeking behaviors.

Each objective is

·      accompanied by a list of projects that will enable volunteers to collectively move towards fulfilling that objective. For example: trainings, workshops, and distribution of insecticide-treated bed nets…

·      accompanied by a number of output indicators, which enable volunteers to measure the scope of their impact. For example, a volunteer might record the number of insecticide-treated bed nets purchased by or delivered to her community.

·      accompanied by a number of outcome indicators; the data yielded will bring PCVs that much closer to reaching the objective. For example, a volunteer might record the number of people who slept under an insecticide-treated bed nets last night.

I think the project framework is exciting for several reasons.

1) The indicators used are standard indicators, which means that NGOs and governments the world over are using the same indicators to measure progress. They give Peace Corps and its work credibility as an international actor in improving community health.

2) The framework—its goals, objectives, and indicators—hold Peace Corps Senegal and its volunteers accountable for the work they do. We want to know whether we are effective, whether we are actually making a SMART (Specific, Measurable, Attainable, Reachable, and Time-bound) difference.

3) It can serve as a guide and tool for volunteers designing new projects.

Projects are designed as follows:

Inputs-->Activities-->Outputs-->Outcomes-->Impacts

Concrete example: by teaching mothers how to cook nutritious meals for their children, we will be working towards achieving objective 2.2: “By the end of 2018, 1440 women will adopt at least one infant and young child feeding practices resulting in improved nutritional status”.

A well-fed pair in village 

Say we want to teach mothers how to make cereamine, a nutritionally dense porridge, for their infants and young children.

·      Inputs include time, people, materials

ex: counterpart, chairs, mats, ingredients for nutritious meal cooking demonstration, mothers and their infants

·      Activities

ex: training on how to make cereamine, a nutritionally dense porridge

·      Outputs

ex: number of women receiving the training on how to make the porridge

·      Outcomes

ex: number of women who can demonstrate the ability to make the porridge

It’s good to note the difference between outputs and outcomes; just because 20 women attended the training, doesn’t necessarily mean that they will be making the porridge on a regular basis. I, for one, used to conflate the two.

2) Recording, Monitoring, and Evaluation Tools

           

We had a couple of great session on the importance of taking thorough surveys before initiating any project in order to assess community need, strengths, and weaknesses. For instance, you don’t want to put a great amount of time and resources into teaching your village women how to make cereamine if there’s no malnutrition in your area.

Designing and conducting a survey:

·      Think about your objectives

-what kind of information do you want to gather

-remember data must be relevant to the project framework

-quantitative or qualitative data?

-practice/behavior is best assessed through observation and qualitative data collection

·      Choose your demographic characteristic

-employment status, gender, ethnic/language group, age, sex…?

·      Plan, plan, plan

-how (interviews, observation)?

-who (sample type, work partners)?

             Set a deadline and a schedule!

·      Write out your survey questions and translate your survey questions

-get help from a language instructor as needed

-test out your questions on someone first, to make sure they are culturally appropriate and to make sure they make sense

·      Record your data

-medium (excel sheet, pre-drawn sheets)?

·      Control for quality

-are participants’ answers influenced by [your counterpart’s presence, for example]?

-do your participants understand the questions?

-is the order of the questions influencing answers?

-will people be more responsive to indirect questions?

-observe and use your judgment

·      Construct an action plan based on answers

-what does my community know/not know?

-where can I make an impact?

Once I get back to village, I’d like to start designing and conducting a series of surveys. I’m not sure where to start, though. Malaria or WASH?

3) Malaria

Fun facts:

-Severe malaria can sometimes cause an infected person’s eyes to turn yellow.

-Many people get malaria at the end of the rainy season—in November or October—because they stop sleeping under their nets: “no more rains, no more mosquitoes”. Wrong.

-People who don’t sleep under their nets every night have many reasons for not doing so. One of those reasons: “nets don’t fit the room well, or the shape isn’t good” (according to a survey by Networks).

-Pregnant women are more vulnerable to Malaria, due to changes in their immune system. Apparently, the placenta is also a prime hiding spot for parasites, since it’s so rich in nutrients and oxygen. This is all bad new for both the woman and her fetus.

We had a particularly interesting session with a 5^th (!) year volunteer in the south, who has been working on applied malaria projects. He is deeply involved in bridging the gap between Senegalese health services and his sick community members. The bottom line: the burden of illness is unequal in Senegal; opportunities for seeking out and acquiring health services are not equal either.

“Invisible cases” often slip through the system. Sometimes, people are too far away from their nearest health structure, and don’t seek out treatment at all. They may get better on their own, or not. Sometimes, their lack of confidence in the health system discourages them from going: they doubt that the medication will be available, or they have poor rapport with health care providers. In my own experience, I notice that my ICP tends to take on a very patronizing and dismissive attitude when interacting with his patients.

“Lost cases” are also frequent. These are patients with malaria who do make it to a health structure, but whose diagnosis cannot be confirmed. Senegal is often subject to medical stock-outs or breaks. Sometimes, RDT (Rapid Diagnosis Tests) are unavailable. Instead, they are diagnosed with diarrhea or respiratory illnesses, which have overlapping symptoms with malaria.

So: can we actually know the frequency and burden of malaria?

As this gap between resources and people narrows, the recorded incidence of malaria may very well increase. This is tricky: it does not necessarily mean we’re not making progress in preventing new malaria cases; in fact, the actual prevalence of malaria cases may very well stay the same or even decrease.

Numbers are always stickier than we think.

More to come...

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