Mixed Messages

A group of volunteers, including myself, has just completed a Behavior Change seminar facilitated by Bonnie Kittle in Thiès.

Peace Corps volunteers work to promote certain behaviors among their host country nationals. A health volunteer wants mothers with children under the age of 5 to wash their hands with soap and running water at the 5 critical moments every day. An agg volunteer wants rice cultivators to weed their fields a certain number of times per month. A CED volunteer wants entrepreneurs to reinvest a certain percentage of their monthly profits back into their business. We want them to preform behaviors--hand washing, for example--that are scientifically proven to reduce a specific problem, such as high child mortality.

The current Peace Corps approach to promoting various behaviors is flawed. It recognizes that some people aren't doing the beneficial behaviors, but assumes that lack of knowledge is the biggest barrier to behavior change. As a result, Peace Corps promotes activities primarily designed to increase knowledge. For example, health volunteers are encouraged to hold mosquito net care and repair demonstrations. The problem is, there are many other different barriers to behavior change that aren't taken into consideration.

The Designing for Behavior Change framework helps us answer the question why: why are some people preforming the behavior, while others are not? Thanks to the Barrier Analysis, we can accurately determine which barriers are most significant by interviewing members of our priority group. We can then implement activities designed to directly address those barriers. The DBC framework proves that there's no need to guess or assume anything. Activities shouldn't be generic and universally applicable. They must be tailored to the specific target group, their environment, their culture...

The activities we partake in and the messages we promote are only the tip of the iceberg. A successful outcome is contingent on what's under the surface. 

I thought it might be fun to take a look at some ads and public health messages. To keep it interesting, I've selected two conflicting messages. What are some of the determinants and bridges at play? 

Getting young people to stop smoking

Positive consequences: increase the perception that doing the behavior will result in positive things
Action efficacy: increasing the perception that the action effectively deals with the problem (high mortality rates correlated with smoking)  

Culture: decrease the perception that smoking is associated with young culture 

Getting young people to smoke
Social norms: increase the perception that the influencing group approves of the behavior
Perceived positive consequences: increase the perception that smoking makes you attractive and intrinsically yourself

 Make sure that young people never start smoking
Social norms: increase the perception that the influencing group disapproves of the behavior
Perceived negative consequences: increase the perception that smoking gives you bad breath
Perceived positive consequences: decrease the perception that smoking makes you attractive

Getting young people to stop smoking
Perceived Severity: increase the perception that smoking kills
Perceived susceptibility: increase the perception that young people are susceptible

Getting smokers to continue smoking
Social norms: increase the perception that the influential group approves of the behavior
Perceived negative consequences: reduce the perception that smoking is bad for your teeth
Perceived severity: decrease the perception that smoking is detrimental to your health 

These advertisements and public health messages are all effective in their own ways. Their creators know their target audience well. All its concerns are minimized in the cigarette ads, or maximized in the public health messages. Each plays on different universal motivators to its advantage: attractiveness, health, long life, success. It's interesting to see that two conflicting behaviors can be promoted with such different motivations. This information is powerful, and isn't always used in a beneficial way.

Books and Backpacks

To be clear, I'm not particularly proud of these little projects. I'm not here to hand out free stuff, and I don't even want to be associated with free stuff. I don't want to encourage the mistaken notion that all foreigners have plenty of money to hand out. I don't plan on doing projects like these again. But I did do them, so here are a few pictures. 

After hours spent sorting books from Books for Africa 

These will benefit several schools, including Dassilami primary school

Top students receive backpacks with school supplies

Universal Bed Net Distribution

November was bed net month. It all started with a formation organized by Karang's ICP and an agent for USAID targeting local health relays and ASCs. The formation was intended to familiarize participants with the three steps of bed net distribution: the "recensement", the actual distribution, and the follow-up.

The formation in and of itself wasn't very interesting to me; all the information was clearly delineated in an instruction manual, and the process itself was straight-forward. In addition, most everything was in Wolof, which I don't speak.

Instead of listening, I spent the two day doing what I love best: people watching. When you don't understand a language, you start focusing on body language and intonation instead. Despite--of thanks to--linguistic limitations, there's a wealth of information to be gleaned in this way. It's easier to sense tensions between two men respectfully greeting each other, for example. I also like to analyze how people choose to occupy space in relation to one another. In the Senegalese context, people tend to disaggregate by gender. Whereas Americans like to spread out as much as possible, the Senegalese sit very close together and frequently integrate touch as part of various interactions. The familiarity can also be attributed to their shared social circles, which encompass wide geographic areas and an impressive array of people. Their auditory memory for names is truly incredible.

About a week later, it was time to start "recensement" work. In small groups, health relays visited each compound within a designated geographical area, taking careful note of the number of adults, children under 5 years of age, sleeping spaces, and available bet nets. Each head of household was given a coupon listing his address, nearest health post, a number, and the bed net distribution date.

I was involved in the recensement in Dassilami Soce, Boutilimite, Saroudia, and a neighborhood in Karang. To be honest, it was hard and hot work walking all day under the sun.

Working with health relay Khady Coly in Karang 

I then spent a week and a half labeling bed nets for distribution in Karang. The Senegalese government now requires that every net distributed be labeled with the head of household's name, the number on the coupon given to him, his village or neighborhood, and the date of labeling. This policy makes it hard for people to sell nets given to them for free (courtesy of USAID). This work was pretty tedious and rather thankless.

There were many bed nets...

...and plenty of work to go around 

And, finally, D-day:

Matching nets to coupons 

Villagers crowding the health hut entrance in Dassilami 

Any program with multiple steps practically invites error. Both the ICP and the USAID agent visited each team once a day in the field. However, quality control during "recensement" and the follow-up was difficult. That errors had been committed became apparent on distribution day: some people complained that the relays had missed their house, and others claimed that they had received too few nets. Whether or not this was true, additional labeled nets were located and handed over.

Unfortunately, the follow-up was even worst. Relays are required to visit each household to make sure that nets are hung, that people are in fact sleeping under them, and that the women know how to wash them properly. By this time, both my ASC and I were a little burned out. I didn't protest too much as he dragged me from house to house as quickly as he could. Worst still, practically no one in my village had take the time to hang their free nets.

I was so unsatisfied with my work that I did the follow-up all over again, far more carefully. I finally got most of my villagers to hang their nets. However, are they actually sleeping under their nets? Everyone claims that they do when asked, but I'm not convinced. Most villagers believe that there aren't any mosquitoes during cold season, and that their risk of contracting malaria now is very slim. In reality, many have tested positive for malaria recently. Going forward, I'm going to have to convince them that sleeping under the nets every day, all year round is crucial.

Now, everyone should have a mosquito net. The real work begins now. 

Envy and Inspiration

My work partner and I have big dreams for the health hut in Dassilami Soce.

Here's what it looks like so far:

This is an ongoing project that I inherited from my ancienne and colleges. We still need to paint it, install solar panels, and build a maternity ward. Those major projects are all in the works, since the plans are already submitted and Pharmaciens Sans Frontières has pledged to provide funding.

Ultimately, we aim to make the health hut an autonomous entity, run entirely by the villagers themselves. Medication and consultations costs should be minimal, matrones and ASC should receive a yearly compensation (monetary or otherwise) from the village, a committee should be formed to properly manage the health hut, and the health hut should be able to run its own recurring (such as "pesées"). We're still working on all of these criteria, and we definitely have our work cut out for us. 

Even once the major projects listed above are completed, I have a feeling that the life-giving breath of the health hut will still be missing. I've been visiting other health structures to see what they were doing right, how they were doing it, and if it's replicable in my village.  So far, I've been to two highly functioning health huts: the first is in a village called Pacala, which is way out in the sandy bush. I'm hoping to go back soon, but here are some pictures of the community nutrition room they have there: 

The ASC and health relays do a monthly baby growth monitoring here

Listed members of various village groups and associations 

How the community represents the village major landmarks and resources 

Demographic data for different age groups over time

These chart papers show how organized and motivated the health team is. Not only do they hold monthly activities of all kinds, they also track their progress over time to make sure that their work is having the desired effect. This data is proudly displayed on the walls of the health structures. 

It's clear that such sustained efforts and excellent results are due in part to strong community support. I was lucky to meet with several village leaders, who all said that all villagers are invested in improving overall community health. Every year, each head of household donates some amount of grain or equivalent sum of money to the health hut team and committee. This contribution helps motivate and encourage the health workers, who have only a small mandate as volunteers. The health hut and its activities are entirely self-sustained; in french, we'd call this "une case de santé autonomisée". This is a goal I'm working towards in Dassilami Soce. 

The second health hut is on an island named Djinack Bara, where my work partner Ben has worked in several different capacities.

One of the health hut patient room 

The ASC's roles and responsibilities 

Notice how clean and livable that patient room looks. The health post in Dassilami still needs a faire amount of work, but even now cleanliness is an issue. The ASC doesn't have basic cleaning materials, and doesn't have enough money to purchase them. The consulting room is rarely wiped down, and biological waste piles up until it is finally disposed of (improperly). 

The neatly hanging mosquito nets are another nice touch. Sometimes patients in Dassilami Soce have to stay overnight, but we've only just acquired new mosquito nets. They're not hung yet. 

I was also very impressed by the signed roles and responsibilities form. It's tacked on the wall next to the front door for all to see. The transparency appeals to me. The patrons know what the ASC's responsibilities are, and can set their expectations accordingly.  At Dassilami Soce, we've been having some trouble determining once and for all which treatment practices and medications are allowed at the health hut level. Villagers don't have a clear understanding of the ASC's areas of intervention and limitations. 

I'd love for the community of Dassilami Soce to show the same level of commitment in supporting its health team. They're only so much you (NGO, health worker, etc) can give a community--there has to be an equivalent amount of investment on its part as well. When people are valued and recognized for their work, they tend to go the extra mile.