Participatory communication to strengthen the role of grandmothers in child health: an alternative paradigm for health education and health communication
Published
in: Journal of International Communication, 7:2, pages 76-97, 2001
Douangchan Sihalathavong,
M.D., Maternal and Child Health
Institute, Vientiane
Abstract:
In
health education and communication (HE/C) strategies in community health
programs in developing countries the dominant approach involves the use of
directive communication methods to promote expert-defined changes in
individuals' health-related knowledge and practices. Another facet of most maternal and child health (MCH) programs is
their focus on women of reproductive age and the systematic exclusion of older
women, or grandmothers (GM), who, in many societies, play a leading role in
family health promotion. This approach
is supported by most governments and international development organizations
involved in the health sector. While
there has been relatively limited criticism of this approach to HE/C, there is
an extensive body of literature from adult education, development communication,
feminist pedagogy, medical anthropology and community organizing for health
which identifies the limitations of this predominant approach and suggests the
need to adopt alternative concepts and methods. Key facets of an alternative paradigm include: promoting changes
in community health-related norms; working with individuals within the family
context, and using participatory, empowering approaches in HE/C.
This
article reviews the literatures that support an alternative approach to HE/C.
Second,
it presents a case study based on an innovative community project in Laos in
which a participatory HE/C strategy was used to promote changes in community
norms related to child health by strengthening the role of grandmothers. Based on adult education concepts of transformative and constructivist learning, a simple, culturally-adapted methodology
was used involving stories, songs and group discussion which elicited
collective critical thinking and problem-solving. The outcomes of this participatory HEIHC experience include, on
the one hand, improved health-related knowledge and empowerment of GMs and, on
the other hand, increased confidence in GMs' child health promotion abilities
on the part of family members, community leaders and health workers. The positive outcomes of the project are
believed to be largely attributed to its conceptual and methodological
underpinnings, which have generally been overlooked in HE/C programs.
Introduction:
Most
health education/communication (HE/C) strategies in maternal and child health
(MCH) programs in developing countries are based on a standard approach, or
paradigm, which embodies three key parameters.
First, the goal of most programs is to bring about changes in individual
health-related behavior (WHO l997, Stetson & Davis l999, NGO Networks for
Health 1999). Secondly, the vast majority of these programs focus on women of
reproductive age (Santow l995, Leslie 1987).
Thirdly, the educational or communication methods used in most
programs
are based on a top-down, one-way communication process ( Aubel 2001, Stetson
& Davis Op Cit.) which Freire (1970) referred to as a "banking
approach.'
Programs
which are based on this predominant paradigm are most often referred to
as
health communication (HC) (AED 1995,
Graeff et al. 1993), however, other terms which are also used to refer to the
linear, information-dissemination approach include information, education and education (IEC), social marketing (Novelli l990, Manoff 1985) and most recently behavior change communication. The widely used HC approach was initially
propagated in the l970’s by North American development organizations, namely
USAID, and was subsequently embraced by many international organizations
involved in health and development. In
turn, it was adopted by many Ministries of Health (MOH) in developing countries
that have been recipients of technical support grounded in this paradigm. In most of the international organizations,
the HC approach is widely used without serious critical analysis of the
conceptual basis for it, nor serious consideration of alternative
parameters.
Over
the past 20 years, understanding of health-related behavior and of
communication and learning processes has considerably evolved in various fields
of research and practice namely, medical anthropology (Dressler & Oths
1999), development communication (Servaes et al. 1996, White et al. l994,
Melkote 1991), adult education (Mezirow 1991, Galbraith, 1991), community
organizing for health (Minkler 1998), community psychology (Heller et al.1984),
and cross-cultural psychology (Segall et al.1999). However, most HEIHC programs in developing country settings have
not systematically integrated alternative emerging concepts and modified their
approaches accordingly.
The
collective body of research and conceptual work referred to above, clearly
elucidates the limitations of the three parameters prevailing in most HEIHC
programs and suggests alternative concepts for MCH programs. First, rather than focusing on individual
behavior change, it may be more effective for public health programs to focus
on promoting changes in social norms which in turn influence individual
behavior (Clark & McLeroy 1995).
Second, rather than focusing only on women of reproductive age, it is
argued that health programs should take into consideration the wider family
context and seek to involve other influential actors within the household in
health promoting activities (Berman et al. 1994, Santow, Op Cit.). Third, rather than basing programs on the
top-down, one-way model of communication and teaching, programs and research on
participatory communication (Riaño 1994) and adult learning (Brookfield 1991,
Mezirow Op Cit.) clearly suggest that it is more effective to use a
participatory, two-way approach, particularly if the aim is not only to provide
information but also to strengthen critical problem-solving abilities.
The
purpose of this article is first, to review the literature which supports these
three alternative parameters for HE/C programs. Given the wide gap that exists between what is known about
learning and behavior change in families and communities and the simplistic and
dated concepts upon which most HE/C programs are developed, this review is
rather extensive. It deals with all
three parameters, however, the focus in on the third one dealing with recent
conceptual insights into teaching and learning processes and corresponding
methodological tools.
The
second purpose of this article is to present a case study on an innovative
participatory community HE/C project carried out in Laos which illustrates the
alternative paradigm. The infant and
child mortality rates in Laos are among the highest in Southeast Asia and
diarrhea disease and acute respiratory infections (ARI) are primary
contributors to these deaths (NSC 1995). The Maternal and Child Health
Institute (MCHI) in Laos, which is part of the MOH, decided to develop a
community HE/C strategy in order to improve household practices related to
management of these two priority illnesses.
Past HE/C strategies developed in the country both by governmental and
non-governmental organizations to address these and other MCH problems, had
focused almost exclusively on women of reproductive age. In addition, almost all earlier programs had
adopted strategies based on the predominant linear, message-driven HC paradigm
intended to promote changes in individual knowledge and practices.
A
qualitative community study, carried out in several provinces in 1996, revealed
the protagonist role that GMs play in home management of diarrhea disease, ARI
and other childhood illnesses (MCHI/WHO l996).
Based on those findings, the MCHI decided to develop a health education
strategy involving GMs. In spite of the
important role played by GMs in MCH in Laotian families and communities, no
previous HE/C programs had ever explicitly involved GMs. The first author, as a WHO consultant,
assisted the MCHI to develop a pilot HE/C project which aimed to strengthen
GMs’ practices related to home treatment of the two illnesses. In the innovative strategy, problem-posing
stories dealing with typical childhood illness episodes were used to elicit
critical thinking and problem solving amongst groups of GMs. The methodology used in the project and the
outcomes of the community HE/C activities are described in the second part of
this paper.
Literature
review
The
literature review deals with the rationale first, for promoting changes in
social norms, second, for focusing on key family actors rather than only on
women of reproductive age, and third, for using participatory, transformative
and empowering learning methods.
Changing community norms as a precursor to individual
behavior change: The roots of
the prevailing focus on individual behavior change in HE/C programs can be
traced to concepts from biomedicine (Laura & Heaney 1990), social
psychology (RUHBC 1989), behavioral psychology (Eider, 1987), and mass
communication (Shannon & Weaver 1949).
Criticism of the individual behavior change orientation in MCH programs
has to date been relatively limited and has come primarily from academics in
the North (Bunton et al.1991, Laura & Heaney 1990, Lorig & Lauren 1985,
McLeroy et al., 1988). The reductionist
focus on individual behavior change blatantly ignores insights from
anthropology (Dressler & Oths Op Cit.) regarding the influence of social
structure and collective socio-cultural values on individual beliefs and
behavior. In so-called
"traditional” societies, it is clear that collective, group values have a
preeminent impact on individual thinking and behavior (Dressler & Oths
ibid, Kayongo-Male & Onyango 1984).
In most cases, MCH health education programs have not seriously taken
this into account.
An alternative goal in MCH programs is to promote changes in community
norms, collectively defined values and practices, which indirectly can lead to
changes in individual beliefs and practices.
This option is supported by the conclusions of a major review of health
education interventions (Clark and McLeroy Op Cit.) "To have enduring
effects, interventions must have an impact on social norms" (Ibid., p.
277). In the health education project
in Laos, the objective was to promote changes in community norms related to
prevention and management of diarrhea disease and respiratory infections, as a
precursor to individual behavior change.
Focusing on grandmothers, the learning institution:
Most
MCH programs based on the individual behavior change paradigm narrowly focus on
women of reproductive age based on the assumption that if their knowledge
and attitudes are changed they will automatically modify their own
practices. Implicit in this orientation
is the assumption that younger women can autonomously decide what behaviors to
adopt. It assumes that women are
somehow independent of the socio-culturally-defined values and practices, which
are dictated in the larger household and community contexts of which they are a
part (Berman et al. Op Cit., Mosley 1984).
While the reductionist focus on women, and their children, simplifies
the parameters which program planners have to deal with, it gives a superficial
picture of the mufti-dimensional intrahousehold processes related to family
health. This perspective camouflages
various household level actors, such as older women, men and older siblings who
influence, either directly or indirectly, decisions regarding health and
illness-related situations. The role
conferred on older women in most traditional societies to define and transmit
socio-cultural norms from one generation to the next (Mead 1970) is blatantly
disregarded in HE/C programs which focus exclusively on younger women.
Anthropologist,
Margaret Mead (ibid.) was one of the first to discuss the critical role which
grandparents play in transmitting socio-cultural values and practices from one
generation to the next. While
discussion of the role of older women, or 'grandmothers,' in the mainstream
public health literature has been generally ignored, their role in child and
family health has been observed and documented in different cultural contexts
in Africa (Kayongo-Male & Onyango, Op Cit.), Asia (Jernigan & Jernigan
1992), Latin America (Finerman 1989, McKee 1987) and the Pacific (Kataounga
1998, Biuwaimai 1997). In a discussion
of development communication, Fuglesang (1982), points out the significant role
played by grandmothers, referring to them as a "learning institution' in
the family and community.
In
Laos, the role played by GMs in household level decision-making related both to
health promotion and illness management was first documented in the 1996
qualitative community study carried out by the MCHI (MCHI/WHO 1996). The failure of earlier studies on different
MCH issues to document the role of GMs can probably be attributed to both
instrument and interviewer biases. The
l996 study results clearly delineated several categories of responsibility
related to MCH which Laotian society confers on GMs, namely, teaching the
younger generation, supervising others involved in child care and directly
giving both advice and care to children.
As stated above, the results of that study were the impetus for
developing the HE/C project that aimed to strengthen the role already played by
GMs in MCH.
From directive health communication for behavior
change to empowerment learning
In the
prevailing health communication (HC) approach used in community health programs
around the world, the focus is on the dissemination of messages to 'persuade' or 'convince" people to adopt
expert-proposed changes in their behavior (Braun et al. l994, Graeff et al. Op
Cit., WHO Op Cit.). The language used
in such programs (audiences, target groups,
message delivery, sender & receiver, persuasion) clearly implies a
top-down, one-way mode of communication and a passive role for community
members who “participate” in such a process (Thomas 1994).
While
there has been some criticism of the health communication behavior change
approach within the community health field, the most incisive criticism of the
model has been articulated by academics and practitioners from the field of
development communication. Since the
l980’s, development communication experts, many of whom are from the South,
have strongly questioned the predominant communication paradigm adopted not
only in the field of health, but in other development fields as well. They have criticized the
positivist-instrumentalist approach inherent in the conventional communication
paradigm based on modernization theory in which the mass media play a dominant
role in the transmission of expert-defined solutions to problems faced by local
communities (Melkote Op Cit).
Diaz-Bordenave
(1994) dismisses the relevance of communication strategies based on behaviorist
and knowledge-transmission pedagogies in the context of so-called development
programs. Riaño (1994) denounces the
diffusionist, one-way communication mode employed in most development programs
in which community members are expected to participate as "active
listeners' and in turn “embrace the development messages” which are
disseminated to them. Kaplun (1983)
states that in Latin America there is widespread criticism of the 'transmission
model of communication' in which either the communicator or media play a
manipulative role as the "architect of human behavior. Melkote (Op Cit. ) asserts that the one-way
communication model, and a focus on the use of mass media, contributes to an unhealthy
dependency relationship between communities and development programs. While there has been considerable criticism,
on both ethical and pragmatic grounds, of the predominant linear and top-down
approach to communication embraced in most development programs, these concerns
been given relatively limited attention in international health forums and
programs supported by development organizations in the North.
The
participatory learning approach used in the work in Laos was informed primarily
by concepts and methods from adult education (Freire Op Cit., Mezirow Op Cit.),
but also from development communication (Melkote Op Cit., Servaes et al. Op
Cit., White et al. Op Cit.) and
feminist pedagogy (Belenky et al. 1986, Riaño Op Cit.).
Transformative learning
The
limited success of past HE/C programs, based on linear, individual
behavior-change models, can be attributed in part, we believe, to the failure
to take into account insights from the extensive research and practice in adult
education regarding communication and learning processes. Since the early 1990's the dominant models
in adult education have dealt with transformative
learning, or learning which leads to changes in learners' beliefs or ways
of seeing the world. In the
transformative learning paradigm, the learning process involves the construction of knowledge rather than
the internalization of pre-defined knowledge, or messages.
In
behaviorist, information-processing theories of learning, based on a positivist
framework, "Learning is a process of accumulating information” (Cranton
l994, p. 9). From this perspective it
is assumed that prescribed health knowledge or messages will be internalized by
learners and that, in turn, this new knowledge will trigger changes in their
behavior. In contrast, in the
constructivist framework, 'knowledge is constructed by the individual and there
is no objective reality" (ibid., p.9).
For example, a woman whose child has diarrhea "constructs" her
own approach to dealing with the illness which may draw on information and
strategies learned from her mother, from television, from neighbors, from
health workers and from her own past experience. In the behaviorist view it would be assumed that this woman would
immediately put into action a standardized health message dictating what she
should do irrespective of her socio-cultural beliefs, resources and advice
received from others.
Transformative
learning potentially takes place when "learners" actively and
critically analyze both their own experience and alternative solutions
presented to them in order to construct' their own strategies to deal with
everyday problems, Transformative learning models are supported by the work of
Freire (Op Cit.), Kolb (Op Cit.) and Mezirow (Op Cit.).
The
cornerstone of Kolb's (ibid.) experiential
learning theory is the systematic analysis of experience. He posits that optimal learning can only
take place when an individual actively reflects on an experience that he/she
has lived through, or one which relates to his/her life experience. Kolb's experiential learning cycle, widely
used in non-formal adult education programs, is a valuable methodological tool
for structuring participatory and transformative learning. Unfortunately, it has been used to only a
limited extent in community HE/C programs.
Mezirow
(Op Cit.), the most prominent constructivist theorist, defines the objective of
adult education as perspective transformation. In his view, the aim of an educational
strategy is to strengthen learners' critical thinking and problem-solving
skills to enable them to decide whether and how new information and experiences
can be integrated into their prior learning in order to "construct"
their own strategy or solution to real-life problems. According to Mezirow, transformative learning can come about
through a process of dialogue and critical reflection with others and can lead
to changes in people’s beliefs and attitudes.
Freire's
(Op Cit.) perspective on adult learning resonates that of both Kolb and Mezirow
as regards his conviction that meaningful learning must be based on the
learners' reality. However, while Kolb
and Mezirow are concerned primarily with individual learning, Freire was
primarily interested in collective or group learning processes. Freire strongly criticized the prevalent banking- approach to education, wherein
pre-packaged solutions are communicated to learners on the grounds that it is
both manipulative and ineffective in helping them deal with real problems at
the family and community levels. He
proposed a problem-posing approach in
which learners are involved in dialogue and analysis of their own reality which
can potentially bring about "creative transformation' in individual and
collecting thinking. Both Mezirow and
Freire view knowledge “as a construction that human beings make rather than an
objective truth that they discover” (Merriam 1993, pp. 52-53).
Despite
the relevance of constructivist principles to HE/C efforts to promote the
integration of popular and biomedical models of health at the community level,
most programs have totally ignored the concepts and methods embodied in the
constructivist model of transformative learning.
While
North American educationalists, such as Mezirow and Kolb, have focused more on
individual learning, Jarvis (1987b), a British adult educator, like Freire,
deals with the social nature of learning.
Jarvis states, "Learning is not just a psychological process that
happens in splendid isolation from the world in which the learner lives, but is
intimately related to that world and affected by if (ibid. p. 11). His work on learning processes within social
contexts is particularly relevant to more traditional societies, such as Laos,
where individuals are significantly influenced by group values and learning. The impact of group values and learning on
individual attitudes and practices has generally not been explicitly dealt with
in HE/C programs.
Role of
the facilitator in transformative learning
In HE/C
programs in developing countries the primary focus has been on the technical
content of communication and education activities and relatively limited
attention has been given to the quality of inter-personal communication
relationships between health educators/facilitators and community members. The critical role of the facilitator, or
"educator,” in educational activities has been emphasized, however, by
adult educators (Robertson 1996, Brookfield 1991), health educators (Van Ryn
& Heaney 1997, Wallerstein & Sanchez-Merki 1994), rural development
technicians (Chambers 1998) and participatory development communicators (White
1999, Bessette & Rajasunderam1996).
Both
Brookfield (Op Cit.) and Robertson (Op Cit.) emphasize the need for adult
educators to be facilitators of learning rather
than disseminators of knowledge in
order for them "to help learners to construct their own knowledge"
(Robertson ibid., p. 42). Robertson
identifies prerequisite skills for fostering transformative learning: the
ability to establish trusting, helping relationships; and the ability to engage
in sensitive and authentic dialogue.
Research in health education has shown that the attitudes and skills of
facilitators in helping relationships have an impact on the extent to which
community members embrace health promoting behaviors proposed to them (Van Ryn
& Heaney, Op Cit.). Insights into the role of the facilitator in
interpersonal, health promoting activities are found in the literatures on
social influence (Raven 1965), empowerment (Israel et al. 1994) and
transformative learning (Mezirow & Associates1990). Concepts from each of these fields converge
on the importance of the facilitative and helping role required of “teachers”
in order to promote openness to new ideas, self-confidence and learning on the
part of “learners.”
Van Ryn
and Heaney (Op Cit.) recently reviewed current knowledge regarding factors that
contribute to the effectiveness of "helping relationships" in health
education. They discuss three types of
interpersonal power exercised in interpersonal relationships. The first two, information power and expert power, appear to be the most
frequently used in HE/C. According to
these authors, research has shown that the third type of power, referent power, based on respect and
acceptance of clients, is more likely to facilitate health-promoting behaviors
than the other two types.
A
critical issue discussed in the literature on community empowerment, and
analogous to concepts presented by Van Ryn and Heaney regarding prerequisites
for establishing effective helping relations, is the need for power to be
shared between facilitators and community members (Israel et al., ibid.). While there is increasing discussion of empowerment approaches in international
health programs, often the power-sharing dimension is neither explicitly
discussed nor put into practice. For
many health professionals, accustomed to using an approach based on top-down
expert and informational power, it appears to be particularly difficult for
them to embrace the role of co-learner
which Freire viewed as essential in facilitating learning in others.
Based
on these concepts dealing with the role of the teacher-facilitator, three key
practice principles have been identified which should be adopted by
facilitators who aim to promote transformative learning on health amongst
community groups. First, facilitators
should show respect, unconditional
positive regard and acceptance of learners. Second, they should use a participatory approach to foster
dialogue and learning. These two
principles are essential for establishing a comfortable, open and motivating
communication relationship (VanRyn & Healey Op Cit.). The third principle deals with the need for
facilitators to challenge existing beliefs and values through the use of critical questioning strategies to
stimulate reflection rather than to merely assess recall of priority
information (Brookfield Op Cit). While
information acquisition is one aspect of learning, the central component of
transformative learning involves rexamination of existing beliefs and schemas
alongside new, alternative elements.
Brookfield explains the significance of this critical dimension of the
facilitator’s role in promoting learning.
"Skilled critical questioning is one of the most effective means
through which ingrained assumptions can be externalized” (Ibid., p. 92). In the development communication literature,
these ideas are resonated in White's (Op Cit.) concept of the catalyst communicator. She asserts that in participatory education/
communication activities the primary role of the facilitator-communicator is to
create an environment for dialogue, learning and transformation.
Participatory development communication
Many of
the issues addressed in the development communication (DC) literature are
extremely relevant to HE/C programs.
However, relatively limited attention is given to DC in the
international health literature and programs, perhaps due to the fact that the
conceptualization of communication differs considerably between the two fields.
In programs which adopt a HC approach the focus tends to be on the technical
information to be disseminated whereas in the DC orientation considerable
importance is also given to the type of communication relationships developed
both between communities and technical experts and within communities
themselves.
Development
communication experts (Diaz-Bordenave Op Cit.., Servaes et al. Op
Cit., Bessette & Rajasunderam Op Cit.) argue that communication strategies
should be based on horizontal communication relationships which promote two-way
knowledge-sharing and power-sharing
which can lead to empowerment and social change. Thomas asserts that such relationships must be based on
“dialogue, reciprocity and understanding based on mutual respect” (Op Cit. p.
49). Servaes and colleagues (Op Cit.)
assert that an approach based on dialogical
communication is often rejected by development workers who are accustomed
to using communication strategies based on exercising power over others. White addresses the empowering dimension of
participatory communication that elicits "consciousness-raising through
critical reflection about their own condition, which will lead to a significant
voice in social action” (Op Cit. p.48).
Diaz-Bordenave (Op Cit.) states that participatory DC has far-reaching
implications insofar as it can contribute to the development of more
participatory societies where people are empowered to transform their reality.
Gender perspective on communication and learning
Several
concepts from feminist pedagogy are particularly relevant to community HE/C and
specifically to working with grandmothers in MCH programs. Belenky and colleagues (Op Cit.) assert that
in community programs teachers of adults should play a "facilitative"
role. They metaphorically refer to
teachers as midwives. "Midwife-teachers are the opposite
of banker-teachers. While the bankers
deposit knowledge in the learner's head the midwives draw it out' (Ibid. pp.
217-218). Other key precepts of
feminist pedagogy which influenced development of the HE/C strategy used with
GMs in Laos include: the importance of acknowledging and validating women's
roles, the value of subjective knowledge and experience; the need to challenge
the sexist and ageist stereotypes about women; and the need to empower women in
their family and community roles.
Riano's (Op Cit.) gender perspective on women's participation in
communication and learning activities at the community level provides
additional support for involving GMs in community HE/C strategies. She maintains that in virtually all
societies men are accorded dominate status in public communication forums which
tends to mask the critical communication function assumed by women related to
their socially-defined roles in reproduction, production and community management
activities. In traditional societies in
Southeast Asia, as in Africa and Latin America, older women do play an
important role as "informal communicators' in each of these spheres. Riano's work supports the notion that
efforts to increase GMs' access to communication information and tools can
strengthen their role and status as communicators in their respective
communities. She also draws attention
to the critical communication function played by women's groups which
constitute "informal networks of exchange and collective strategies of
survival” (Op Cit., p. 39). She argues that communication strategies
should work with these networks as a way of strengthening the capacity and role
of women in the community. The research
in health education which has shown that strategies which work through social
networks can be effective in promoting changes in health-related norms (Israel
& Rounds Op Cit.) lends further support to the relevance of working with GM
networks.
Systems approach to community capacity-building
In
addition to the conceptual tenets summarized above, the GM project was also
informed by several other concepts. The
overall approach was grounded in an ecological
framework for health promotion
(Green et al. 1996, McLeroy et al. Op Cit.) in the community setting, involving
multiple categories of community members.
Principles from community organizing (Minkler Op Cit., Ross 1955)
were applied in the identification and collaboration with existing community
leaders and structures. An assets approach (Kretzmann
&MacKnight 1993) was adopted, as contrasted with the prevailing deficits
approach, in which the aim is to acknowledge and strengthen existing community
resources, namely GMs. Lastly, the
health education methodology reported on here embodies a community empowerment approach (Wallerstein & Bernstein 1994,
Rappaport, J. 1984) wherein community members and health workers are involved
in a participatory process of dialogue and negotiation as a means of increasing
community capacity and commitment to collectively solve problems on their own
and/or in collaboration with development workers.
Case
study: Participatory health education/communication strategy with
grandmothers
The
objective of the community project in Laos was to strengthen GMs' knowledge and
practices related to home management of diarrhea and respiratory
infections. The community HE/C
activities were carried out in a poor, rural, agrarian area, in 10 villages
which are between 40 and 50 kilometers from the capital city, Vientiane. In each village, five community sessions
were conducted over a four-month period.
Participants in the community meetings were primarily GMs, but male
community leaders and female community representatives of the Lao Women's Union
also attended. In the community
sessions, simple songs and problern-posing stories describing typical illness
episodes and alternative treatment strategies were used to stimulate discussion
of “traditional”and “new” ways of dealing with childhood illnesses promoted by
the MCHI. The community sessions were
facilitated by a team of five women doctors, all MCHI staff.
Based
on the conceptual precepts discussed above, four critical facets of the HE/C
methodology are described: working through existing mediating social structures;
the familiar comfortable setting; the participatory, culturally-adapted
educational materials; and group facilitation to encourage and challenge
participants. The rationale for each of
these aspects is presented along with an explanation of how each was
operationalized.
· Working through existing mediating social structures
The
HE/C activities were carried out with existing networks of grandmothers,
traditional community leaders and women's association leaders, all mediating
social structures (Note l.)[i]
in the Laotian village context. While
grandmothers were the focus of the intervention, both community and women's
group leaders were also involved. The
rationale for involving all three of these groups was that each of them play a
role in defining and communicating community norms related to child health
practices.
·
Familiar,
comfortable setting
According
to experts in adult education, "adult learning and knowing are profoundly
structured by the context in which they occur” (Merriam Op Cit. p. 74). In many HE/C programs, however, the context,
or setting, in which learning activities take place is given limited
consideration. In the Laotian project
the setting for the learning activities was carefully chosen and arranged to
ensure that GMs felt comfortable both going there and being there.
Most
Laotians are Buddhists and in the Buddhist areas where the project was carded
out, virtually all villages have a pagoda where 4the monks reside and carry out
their religious activities. In Buddhist
areas, a task specifically assigned to older women is to care for the monks,
including their meals and clothing. The
HE/C sessions were held in the pagodas where GMs frequently go and feel
comfortable, During the sessions they sat together on the mats, as they frequently
do with the monks. They were assembled
in a circle, along with the session facilitators to facilitate sharing and
interaction. The GMs sat in the inner
circle while the community leaders sat just behind them.
·
Participatory, culturally-adapted educational materials
The
educational materials developed for use with the GMs were simple, low-cost and
intended to stimulate participatory teaming.
The songs and stories were developed by health workers, school teachers
and Lao women's union representatives in a participatory materials development
workshop. The songs and stories all
incorporate both traditional socio-culturally defined roles, values and
practices related to diarrhea and respiratory infections with MCHI-recommended
health information.
Songs
A
series of 13 simple songs were developed, many of them based on traditional
Laotian tunes. Singing is a common past
time in Laos, however, songs had previously been used to only a very limited
extent as a tool for HE/C. In the pilot
project, the purpose of the songs was two-fold: first, to acknowledge the
importance of GMs’ role in household child health matters; and second, to
convey key information recommended by the MCHI regarding home practices related
to the two childhood illnesses. A third
function of the songs, which were used both at the beginning and end of the
community sessions, was to make the GMs feel comfortable in the community
sessions.
The
Grandmother Song (below), illustrates how the songs were used to acknowledge
GMs' role and at the same time provide health information. The incorporation of popular terms used for
different types of diarrhea in the community's taxonomy of diarrheal disease,
illustrates how elements of the socio-culturally accepted beliefs and practices
were incorporated into the songs.
THE
GRANDMOTHER SONG
[Grandmothers'
role in home treatment of diarrhea]
Chorus
Grandmother! Grandmother! Grandmother!
You are
the one who supervises.
You are
the one who is kind.
You are
the one who advises
Everyone
how to be healthy.
At the
same time you supervise and protect (repeat) so that children will not get
diarrhea like *thong su and *thong sia.
When
you find that a child has *thok chuak or *thok thong
Give
lots of liquid and encourage them to eat (repeat)
Repeat
chorus
* These
terms are part of the community’s taxonomy of different types of diarrhea.
From a
learning perspective, it has been known for many years people are more
motivated to engage in a learning activity if the teaching content reflects
their own reality (Jarvis, 1987a).
Unfortunately, this principle is often overlooked in the development of
health education materials.
stories
The
specific purpose of the stories was to stimulate critical thinking regarding
household management of childhood illness episodes and to promote changes, or perspective transformation (Mezirow & Assoc. Op Cit.), in GMs' ideas and
practices related to child health. Each
story described an illness episode which incorporated both existing roles,
beliefs and practices of community members and “new” advice promoted by the
MCHI. The transformative learning
process was stimulated both by the story content and by the accompanying
questions.
There
has been some use of stories in HE/C programs in the past in different
countries (Labonte 1999, Begbie 1985, Hilton 1981), however, in most cases they
have been used to instruct people what they should do when faced with certain
health-related problems. In the
conventional health education story line (Hilton, Ibid.), a problematic health-related
situation is presented and the story characters either do what health workers
prescribe and live healthfully ever after, or they refuse to follow health
workers' advice and suffer the consequences of either illness or death. Such stories are typically accompanied by
recall questions to assess participants' ability to repeat the correct
solutions, or “messages” related to the depicted problems in keeping with the
"banking-approach" (Freire, Op Cit.)
The
structure and use of the stories in the GM project was quite different. The development of the Stores drew on the
work of Kolb's experiential learning model,
on Freire's work with problem-posing
codes and on Brookfield's (1991) use of critical
incidents to stimulate critical reflection and problem solving. A key tenet of adult education, articulated
by each of these authors, is that in order for learning to be meaningful it
must be based on people's experience.
In the problem-posing methodology developed by Freire, story or picture
“codes” are used to depict existing community situations, and they serve as a
stimulus for group discussion of problems, causes and solutions. Brookfield's use of critical incidents is
similar insofar as they are descriptions of either real or constructed
problematic situations, based on people's reality. In Brookfield's approach the critical incidents are used to
elicit critical thinking which he
defines as, “reflecting on the assumptions underlying our and others' ideas and
actions, and contemplating alternative ways of thinking and living” (ibid., p.
x). In the work of both educationalists the codes, or incidents, portray
problematic situations but do not suggest any solutions.
The
stories developed for the project in Laos differ somewhat, however, from both
Freire's problem-posing stories and Brookfield's critical incidents. Based on a methodology developed by the
first author (Aubel, 1995) two types of information were incorporated into the
stories used with the GMs. Like
Freire's codes and Brookfield's critical incidents, the stories reflect many
aspects of community life, including typical settings and activities, as well
as health-related roles, values and beliefs.
The second type of information, not included in the Freire’s and
Brookfield’s pedagogical tools, is priority health information which MOH
programs wish to promote. In each story
an illness episode is described in which one of the characters, articulates
more "traditional" ideas regarding treatment, whereas another
character articulates the "newer' treatment ideas. They are all stories-without-an-ending. The juxtaposition of the community's
'popular model" of health/illness alongside the "biomedical model' of
health/illness serves as a catalyst for discussion of both.
In
order to ensure the systematic discussion and critical analysis of the story
content, and to stimulate transformative learning, for each story a set of
questions were developed based on Kolb's (Op Cit.) 4-stage experiential teaming
cycle. Kolb delineated four stages in
the learning process: 1) a concrete experience (in this case the story of an
illness episode); 2) observation and reflection on that experience (i.e.
discussion regarding both the popular and biomedical models); 3) generalization
or formulation of conclusions; and 4) discussion of possibilities of
experimenting with the conclusions formulated in stage three. A facilitator uses the questions to guide
the group discussion.
In each
story the protagonist is a GM, reflecting the leading role they play in health
matters in real life. In all cases
they are portrayed as competent and respected women, corresponding to an
important concept from feminist pedagogy (Belenky et al. Op Cit.).
·
Group
facilitation to encourage and challenge participants
The
fourth critical dimension of the community HE/C methodology relates to the role
of the facilitators during the group education sessions. Their role was to support and encourage the
GMs. At the same time they were
expected to challenge them to critically analyze both their past beliefs and
practices and the new, alternative concepts related to child health. The facilitators used critical questioning
strategies based on, but not limited to, the pre-defined questions
corresponding to the four levels of the experiential learning cycle.
The
initial orientation of the facilitation team members included a simplified
discussion of key concepts related to: the different types of power and
empowerment; co-learning; transformative learning; and strategies for
developing an effective helping relationship.
Based on the three key transformative learning practice principles
(discussed above), there was discussion of techniques that facilitators were
expected to use to show respect and acceptance of the GMs and to encourage them
to participate. These techniques
include: the use of supportive, empathetic statements; non-verbal cues which
signal acceptance such as smiling, head nodding and eye contact; avoiding
statements which imply blame or criticism; and active listening to reflect back
on clients' ideas and build on their strengths.
In
order to prepare team members to use a participatory communication and learning
approach the were introduced and practiced to other techniques as well: using
open-ended questions to stimulate critical thinking; active listening to seek
clarification regarding GMs' ideas; sharing common life experiences and
feelings in order to establish rapport with the GMs; showing acceptance of GMs'
ideas and feelings; ensuring that all participants have an opportunity to voice
their opinions and impeding participants from dominating the discussion; and
asking GM participants to periodically summarize the discussion.
At the
end of each session, the facilitator elicited questions from the GMs either on
the content of the story or the discussion itself. This allowed the MCHI team members to share their own opinions,
without imposing them. In the last step
in the group discussion the facilitator asked for feedback from the GMs,
community leaders and women's group representatives on both the story content
and discussion.
GM
involvement in the health education activities
The
number of grandmothers who participated in the health education sessions far
exceeded the project team's expectations and most GMs participated enthusiastically
in the sessions. They had never before
been involved in organized health education activities and at first many were
shy and afraid to participate. As the
health workers established rapport with them, their confidence grew, they
learned to clap and sing and became increasingly candid in sharing their own
experiences and ideas. Many insisted
that they wanted to learn the "new ideas” about child health.
In all
villages the GMs were both enthusiastic and emotional about the songs. Many stated, "It is true what the songs
say, GMs have an important role to play in child health.” They were
consistently moved by the "Grandmother Song," which praised them for
their role in child health. Each time
it was sung tears were seen in some GMs' eyes.
They said, "This song means you love us and respect us."
In all
of the villages confident, intelligent and articulate "GM leaders"
emerged who encouraged the others to consider the 'new ideas." The
following declaration by a 70 year-old grandmother is a poignant example:
"Before I came to this session today, I had the
same ideas as GM Chancy (in the story).
My mother taught me that a child with diarrhea should not drink or eat
too much. The teacher in the story is
from the younger generation and she has been to school. She is telling us the new ideas about how to
care for sick children. She didn't say
we should give up all of our old ideas but we must listen to her advice. She is trying to help us. I know that the next time one of my little
ones has diarrhea I will do as the teacher has advised and encourage him/her to
eat and to drink. (Raising her hand and pointing to the others in the circle)
And the rest of you are you ready to change?"
In all
cases, solutions discussed by the GMs were based on a combination of
traditional and 'new' practices.
Outcomes of the pilot project
In order to assess
the effectiveness of the community level HE/C activities and to document the
implementation process, both quantitative and qualitative data collection
activities were carried out. Pre and
post individual quantitative interviews were conducted with GMs on 11 key
aspects of home management of diarrhea and respiratory infections in order to
assess possible chances in their knowledge.
Interviews were carried out with 175 GMs , between 45 and 75 years of
age. This data revealed that in all cases GMs' knowledge
increased, and in many cases significantly.
Team members were very surprised by these results given their
assumptions about older people's inability to learn and the relatively limited
intensity of the HEIHC activities.
Qualitative
data collection consisted of process documentation (Korten 1989) by team
members during all village activities.
This involved recording comments by and observations of GMs, CLs and
MCHI staff members during all village visits.
This data provides insights into the impact which the community health
education strategy had on GMs' knowledge and practices related to diarrhea and
respiratory infections, on family members, on community leaders and on health
workers themselves.
Impact
on GMs:
Based
on triangulated qualitative data, collected from several categories of
community actors, it appears that by the end of the four-month project some of
the GMs were not only putting some of the new ideas into practice but also
recommending them to others. Some GMs
reported trying out new approaches related to encouraging sick children to eat,
drink and continue breastfeeding. In
all communities, CLs stated that some of the GMs were trying the new advice,
and that they were encouraging them to do so.
Increased
sense of empowerment:
By both
validating GMs' roles and providing them with simple and practical new
information, their sense of importance and their confidence appears to have
increased both in the family and public spheres. One community leader stated, "Usually GMs only sit quietly
and speak softly with the Buddhist monks.
Now they can sing, clap their hands and share their ideas in public
places." Their participation in the group sessions appears to have
contributed to their greater sense of empowerment within the family related to
child health. Many GMs stated,
"Like the song says, our role in child health is important and we must
learn new things so that we can do a good job caring for the little ones."
In later sessions many GMs reported with satisfaction, "We have tried out
some of the new ideas, they have give n good results and our families now have
more confidence in us."
Family
members' perceptions of GMs
In Laos
members of the younger generation are expected to respect older family members,
however, their ability to learn new things is often questioned. GMs' demonstration of their ability to
improve their home care skills related to the two childhood illnesses appears
to have made some family members reassess their potential. A Lao Women's Union leader said, "This
approach has made the GMs feel more confident about taking care of our
children. This has made them feel
strong like a column in a house. Now
other family members have more respect for them and their advice."
Community
leaders' perceptions of GMs
At the
outset the community leaders were perplexed by the MCHI's plan to try to teach
the GMs, but as they observed the GMs' enthusiasm and learning they became
increasingly supportive of the initiative.
In all communities leaders stated that based on the results of this
experience they would be sure to include the GMs in future local health and
development activities, rather than to exclude them as they had usually
previously done.
Health
workers' perceptions of GMs
At the
outset, the MCH I team was rather skeptical about the ability of GMs to learn
and modify their practices. At the
conclusion of the project, they had all radically changed their perceptions
regarding GMs' potential. They said,
"In the past we never thought of working with GMs. The Laotian proverb says, 'You can't bend an
old piece of bamboo.’ But we have seen that the proverb is not true. The GMs were interested in learning and they
were able to learn new things.” MCHI
staff subsequently concluded that all future MCH programs should involve GMs.
One
year later
Unfortunately,
since the project was completed one year ago, unfortunately, there has not been
structured follow-up in the ten villages.
However, MCHI staff recently visited the villages and met with some of
the GMs. When asked what they
remembered about the group sessions, many related key elements of the stories
about childhood illnesses and emphasized what they had learned about
"giving fluids and encouraging sick children to eat," priority
messages in each of the sessions. GMs
interviewed were able to sing the four main songs used in the community
sessions. It is encouraging that some
of the learning that took place during the sessions appears to have been
retained in spite of the lack of follow-up over the past year.
Discussion and conclusions:
In
health education and health communication (HE/C) programs in developing
countries, there is considerable discussion of the need for programs to be
based on people's socio-cultural reality, to use participatory
approaches and to empower participants.
However, in many cases this fashionable rhetoric is not operationalized
in program strategies. The community
HE/C experience carried out with grandmothers in Laos, provides an example of
how these important concepts can be put into practice. It illustrates how local socio-cultural
roles, values and practices were used as the basis for development of simple,
culturally-adapted educational materials.
It illustrates how a participatory communication and learning approach
was used based on respect, dialogue and negotiation between the popular health
model and the biomedical model. It
illustrates how a participatory communication and learning approach contributed
to a increased sense of empowerment on the part of GMs, who had previously
usually been ignored in community health programs.
The response of grandmothers, other community members and health workers
to the participatory HE/C activities was very positive. GMs participated enthusiastically, their
knowledge of appropriate practices improved significantly and they made a
strong commitment to integrating “traditional” and "modern" ideas
into their health-related practices.
Many GMs defiantly rejected the widely-held Laotian proverb that
"You can't bend an old piece of bamboo" and most of them subsequently
demonstrated their ability to learn new things and to incorporate new ideas and
practices regarding child health into their toolkit of resources for promoting
family health. Community leaders were
very supportive of the strategy in so far as it acknowledged and strengthened
grandmothers' role in family and community health matters. They also modified their earlier assumptions
that GMs are unable to learn new things.
Health workers, accustomed to using a HE/C approach based on one-way
message-dissemination, learned how to facilitate group sessions based on
respect, genuine dialogue and critical thinking. The health workers involved in the project modified their
opinions regarding grandmothers' potential to learn new things about child
health and to play an active role in promoting “modern” concepts of home care.
We
believe that the very positive results of the project can be attributed, to a
great extent, to the project's conceptual grounding. The community HE/C project reported on here was based on a series
of theoretical and methodological perspectives which have not been
systematically integrated into community health practice from the fields of
medical anthropology, cross-cultural psychology, adult education, development
communication and feminist pedagogy.
Models and concepts that had a major influence on development of the
methodology include: transformative learning (Mezirow Op Cit.); participatory
development communication (Servaes et al., Op Cit., White Op Cit.); feminist
pedagogy (Belenky et al. Op Cit., Riano Op Cit.); relationship-based approach
(Tresolini & PFTF, 1994) assets-based approach (Kretmann & MacKnight Op
Cit.); and problem-posing methodology (Freire Op Cit.). The importance of these last three aspects
of the methodology is discussed below.
In the
methods used in HE/C in most international health programs, priority is clearly
given to the information, or message, content of these activities. Generally, the quality of the communication
relationships, between development facilitators and community members is
largely ignored. There is a nascent
awareness in development programs that insufficient attention has been given to
the attitudes and behaviors of development facilitators which appear to have a
determining influence on efforts to promote community involvement and
empowerment (Blackburn & Holland 1998).
In the GM project, priority attention was given to this dimension of the
HE/C activities. Principles of both a relationship-based approach (Tresolinii
& PFTF Op Cit.) and an assets-based
approach were applied and contributed to establishing a positive
psychological and affective climate for the learning activities which, in turn,
appear to have significantly contributed to the positive outcomes of the health
promoting activities.
Based
on the concept of a relationship-based approach, considerable effort was
invested in ensuring the development of close relationships between the health
worker-facilitators and the GMs, as well as in nurturing communication and
cohesiveness amongst the GMs. The
Laotian team members consistently showed respect for and interest in the GMs,
and interacted with them in a horizontal fashion, rather than as top-down
experts. Following an assets-based approach (Kretmann &
MacKnight Op Cit.) the simple songs and stories used in the community
activities acknowledged and praised GMs for their important role in family
health. Their traditional ideas and
practices were never criticized. The
combination of these two approaches constituted the foundation for building
rapport with the GMs, encouraging them to participate, to share their
experiences and ideas, and to increase their self-confidence in their own
ability to learn new things. This
experience highlights the importance of the affective, psychological dimension
of all communication and learning activities and supports Chambers' (Op Cit.)
call for greater efforts to bring about changes in development workers'
attitudes and behaviors to enable them to be effective agents of participatory
development. Community health programs
clearly need to focus more on these dimensions of communication relationships.
A third
critical facet of the community HE/C project was the Freirian problem-posing methodology (Freire Op Cit.) which was employed. The stories-without-an-ending elicited
active and critical thinking by GMs about typical child illness episodes. This method is in marked contrast with
frequently used HE/C methods based on rote learning and persuasion. The transformative learning methodology,
encouraged GMs to discuss typical problematic situations and to develop, or
construct, alternative solutions, in keeping with the constructivist paradigm
in adult education (Mezirow Op Cit.).
Whereas in predominant HC information-processing approaches learning is
viewed as a process of accumulating information, in the constructivist model
people construct their own solutions.
GMs were actively involved in constructing solutions to the child health
problems presented in the stories based on both their past knowledge and
experience, and the new information they had acquired. The advantages and impact of the
problem-posing and constructivist methodology were several; GMs
enthusiastically reflected on the open-ended, real-life problems depicted in
the stories which they were challenged to solve; in all cases the solutions
they constructed built on their values and reality; they were proud of the
solutions they developed on their own; and lastly, through the active, critical
thinking process they appear to have increased their sense of confidence and
empowerment as household health advisors.
This experience clearly illustrates how critical principles from adult
education can be applied in community HE/C programs. Most HE/C programs have blatantly overlooked the conceptual and
methodological insights from contemporary adult education literature which, we
believe, are extremely relevant to community health program efforts to promote
learning and health-related behavior change.
We argue that this blatant oversight needs to be addressed in future
HE/C programs.
The
results of this action research project strongly contradict the widely held
belief in MCH programs in developing countries that GMs cannot learn and will
refuse to change their ways. In an
attempt to modify MCH program planners' attitudes toward GMs in other cultural
contexts, it would be useful for similar action research projects to be carried
out to further explore the extent to which these older women are interested in
and able to incorporate simple, new ideas regarding child health into their
practice.
The
methodological approach used with GMs in Laos is believed to be applicable to
other socio-cultural contexts.
Currently a similar methodology is being used in Senegal in an NGO-MOH
project wherein GMs are involved in nutrition education activities. The preliminary findings are very promising
both in terms of evidence of learning and changes in GMs’ child health
practices, and in terms of the support being shown for GMs by other community
members and health workers.
In the
Laotian experience the extraordinary enthusiasm and capacity of the GM
participants disproved both the policy makers' underestimation of their role in
community health and the Laotian proverb's assumption that they cannot
bend. We suspect that experiences with
GMs in other societies would elicit similar enthusiasm and capacity. It is argued that in many societies the
incorporation of GMs into MCH promotion programs could be defended on two
grounds. First, because their
involvement may contribute to increased program effectiveness and second,
because there is an ethical imperative to acknowledge the experience and
commitment of these important, but often neglected, women.
Acknowledgements:
The
community health education/communication project reported on here was supported both by WHO and UNICEF in
Laos. The authors especially want to
thank Dr. Ponthep, Director of the MCHI in Vientiane, for his support for this
work.
Notes:
1.
A "mediating social structure" consists
either of "individuals," such as formal or informal community
leaders, or "institutions" which link individuals to the larger
institutions in public life, such as ministries etc. (Berger, P.L. and R. J.
Neuhaus 1977 “Mediating Structures and the Dilemmas of the Welfare State” in To
Empower People: The Role of Mediating Structures in Public Policy. Washington, D.C.: American Enterprise
Institute for Public Policy Research,
pp. 1-8.
References
AED
1995 A Toolbox for Building Health Communication Capacity. Washington: HealthCom, Communication for
Child Survival Project.
Aubel,
J. 2001 Communication for Empowerment.
New York: UNICEF and BASICS.
Aubel,
J. 1995 Learning through Dialogue:
Using stories in Adult Education.
Geneva: ILO & UNFPA.
Begbie,
G. H. 1985 Health Messages Through Folk Media.
Geneva: WHO.
Belenky,
M F., B. M Clinchy, N. Rape-Goldberger and J. M. Tarule 1986 Women's Ways of
Knowing: The Development of Self, Voice and Mind. New York: Basics Books.
Berman,
P., C. Kendall and K. Bhattacharyya 1994 “The Household Production of Health:
Integrating Social Science Perspectives on Micro-Level Health
Determinants” Social Science &
Medicine 38:2, pp. 205-215.
Bessette,
G. and C. V. Rajasunderam 1996 La Communication Participative pour le
Développement: Un Agenda Ouest-Africain. Ottawa: CRDI.
Biumaiwai,
T. M. 1997 Interview by author. Suva,
Fiji, Sept. 26,1997.
Blackburn
,J. and J. Holland (eds) 1998 Who Changes?
Institutionalizing Participation in Development. London: Intermediate Technology Pubs.
Boafo,
K. and N. George (eds) 1991 Communication Processes: Alternative Channels and
Strategies for Development Support.
Ottawa: IDRC.
Braun,
J., B. Burkhalter, A. Jimerson, N. Keith and B. Porter 1994 BASICS Strategy
Paper: BASICS Communition
Strategy. Arlington, VA: BASICS.
Brookfield,
S.D. 1986 Understanding and
Facilitating Adult Learning. San Francisco: Jossey-Bass.
Brookfield,
S. D. 1991 Developing Critical Thinkers: Challenging Adults to Explore
Afternative Ways of Thinking and Acting.
San Francisco: Jossey-Bass.
Bunton,
R., S. Murphy and P. Bennett 1991 “Theories of Behavioural Change and Their use
in Health Promotion: Some Neglected Areas” Health Education Research 6:2,
pp.152-i62.
Campbell,
C., R. Wood and M. Kelly 1999 Social Capital and Health. London: Health
Education Authority.
Chambers,
R. 1998 Foreward in J. Blackburn and J. Holland (eds) Who Changes? Institutionalizing Participation in
Development. London: Intermediate
Technology Pubs.,
pp.
2-7.
Clark,
N.M. and K.R. McLeroy 1995 “Creating Capacity Through Health Education: What We
Know and What We Don't” Health Education Quarterly 22:3, pp. 273-289.
Cranton,
P. 1994 Understanding and Promoting Transformative Learning: A Guide for
Educators of Adults. San Francisco:
Jossey-Bass.
Diaz-Bordenave,
J. D. 1994 “Participative Communication as a Part of Building the Participative
Society” in White and Nair (eds) Participatory Communication: Working for
Change and Development. New Delhi:
Sage, pp. 35-48.
Dressler,
W. W. and K. S. Oths 1997 “Cultural Determinants of Health Behavior” in D.S.
Gochman (ed) Handbook of Health Behavior Research 1: Personal and Social
Determinants. New York: Plenum Press,
pp. 359-378.
Elder,
J. 1987 “Applications of Behavior Modification to Health Promotion in the
Developing World” Social Science & Medicine 24:4, pp. 335-349.
Finerman,
R. 1989 “The Forgotten Healers: Women
as Family Healers in an Andean Indian Community” in C.S. McClain (ed) Women as
Healers: Cross-Cultural Perspectives.
New Brunswick: Rutgers University Press, pp. 24-41.
Freire,
P. 1970 Pedagogy of the Oppressed. New
York: Continuum.
Raven,
B. 1965 “Social Influence and Power” in
I. Steiner and M. Fishbein (eds) Current Studies in Social Psychology. New
York: Holt, Rinehart & Winston, pp. 371-382.
Fuglesang, A.1982 About Understanding: Ideas and Observations in
Cross-cultural Communication. Uppsala: Dag Hammarskjold Foundation.
Galbraith,
M. W. 1991 Facilitating Adult Learning: A Transactional Process. Malabar: Krieger Pub. Co.
Graeff,
J.A., J. P. Elder and E. M. Booth 1993 Communication for Health and
Behavior Change: A Developing Country Perspective. San Francisco: Jossey-Bass.
Green, L. W., L. Richard and L. Potvin 1996 “Ecological Foundations of
Health Promotion” American Journal of Health Promotion 10:4, pp. 270-281.
Heller,
K., R. H. Price, S. Reinharz, S. Riger, A.
Wandersman and T. A. D'Aunno l984 Psychology and community change. Homewood: Dorsey Press.
Hilton,
D. 1981 Health Teaching for West Africa: Stories, Drama, Song. Brunswick: MAP International.
Israel,
B. A. and K.A. Rounds 1987 “Social Networks and Social Support: a Synthesis for
Health Educators” Advances in Health Education and Promotion, 2, pp. 311-351,
Israel,
B. A., B. Checkoway, A. Schultz and M. Zimmerman 1994 “Health Education and
Community Empowerment: Conceptualizing and Measuring Perceptions of Individual,
Organizational and Community Control” Health Education Quarterly, 21:2,
pp.149-170.
Jarvis,
P. 1987a “Meaningful and Meaningless
Experience: Towards an Analysis of Learning from Life” Adult Education
Quarterly 37:3, pp.164-172.
Jarvis,
P. 1987b Adult Learning in the Social Context.
London: Croom Helm.
Jernigan,
H. L. and M. B. Jernigan 1992 Aging in Chinese Society: A Holistic Approach to
the Experience of Aging in Taiwan and Singapore. New York: Haworth Pastoral Press.
Kaplun, M.
1983 Hacia una Communicacion Participativa.
Asociacion Latinoamericana de Educacion Radiofonica. Quito: Belen.
Katouanga, S. 1998 Interview by author.
Suva, Fiji. Sept. 26,1997.
Kayongo-Male and P. Onyango 1984 The Sociology of the African
Family. London: Longman.
Kolb,
D- A. 1984 Experiential Learning: Experience as a Source of Learning and
Development. Englewood Cliffs, New
Jersey: Prentice-Hall, Inc.
Korten,
D.C. 1989 “Social Science in the Service of Social Transformation” in
C.C.
Veneracion (ed) A Decade of Process Documentation Research: Reflections and
Synthesis. Manila: Institute of
Philippine Culture, Ateneo de Manila University, pp. 5-20.
Kretzmann,
J.P. and J. L. McKnight 1993 Building Communities from the Inside Out: A Path
Toward Finding and Mobilizing a Community's Assets. Evanston: Asset-Based Community Development Institute/Institute
for Policy Research, Northwestern University.
Labonte,
R., J. Feather and M. Hills 1999 “A Story/dialogue Method for Health Promotion
Knowledge Development and Evaluation” Health Education Research 14:1, pp.
39-50.
Laura,
R. S. and S. Heaney 1990 Philosophical Foundations of Health Education. New York: Routledge, Chapman & Hall.
Leslie,
J. 1987 Time Costs and Time Savings to Women of the Child Survival
Revolution. Washington: International
Center for Research on Women.
Lorig,
K. and J. Laurin 1985. “Some Notions About Assumptions Underlying Health
Education” Health Education Quarterly 12:3, pp. 231-43.
McKee,
L. 1987 “Ethnomedical Treatment of Children’s Diarrheal Illnesses in the
Highlands of Ecuador” SociaL Science & Medicine 25:10, pp. 1147-1155.
McLeroy
K. R., D. Bibeau, A. Steckler and K.
Glanz 1988 “An Ecological Perspective on Health Promotion Programs” Health
Education Quarterly 15:4, pp. 351-377.
MCH/WHO
1996 Learning From the Community: The Grandmothers' Role: Qualitative Study on
CDD and ARI. Vientiane: MCHI.
Manoff,
R. K. 1985 Social Marketing: New Imperative for Public Health. New York: Praeger Publishers.
Mead,
M. 1970 Culture and Commitment: A Study of the Generation Gap. New York: Natural History Press, Doubleday
& Co.
Melkote,
S. R. 1991 Communication for Development in the Third Word: Theory and
Practice. New Delhi: Sage.
Merrian,
S. B. 1993 An Update on Adult Learning Theory.
New Directions for Adult and Continuing Education No. 57. San Francisco:
Jossey-Bass.
Mezirow,
J. 1991 Transformative Dimensions of Adult Learning. San Francisco:
Jossey-Bass.
Mezirow,
J. and Associates 1990 Fostering Critical Reflection in Adulthood. San Francisco: Jossey-Bass.
Minkler,
M. 1998 Community Organizing and Community Building for Health (ed) New
Brunswick: Rutgers University Press.
Mosley,
W. H. 1984 “Child Survival: Research and Policy in Child Survival Strategies
for Research” Population & Development Review 1:10, Supplement 1, pp. 1
91-214.
NGO
Networks for Health. 1999. NETWORKS
Technical Approach to Behavior Change Programs. Washington, D.C: Networks
Project.
Novelli,
W. (1990) “Applying Social Marketing to Health Promotion and Disease
Prevention” in K. Glanz, F.M. Lewis and B.K. Rimer (eds) Health Behavior and
Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass Publishers, pp. 342-369.
NSC
1995 National Survey Census. Vientiane:
National Statistical Center.
Rappaport,
J. 1984 Studies in Empowerment: Introduction to the Issue. Prevention in Human Services, 3, pp. 1-7.
Riano,
P. 1994 Women in Grassroots Communication: Furthering Social Change. Thousand Oaks: Sage.
Robertson,
D. L. 1996 “Facilitating Transformative Learning: Attending to the Dynamics of
the Educational Helping Relationship.”
Adult Education Quarterly 47:1, pp. 41-53.
Ross,
M. 1955 Community Organization: Theory and Principles. New York: Harper & Row.
RUHBC
(Research Unit in Health and Behavioural Change) 1989 Changing the Public
Health. Chichester: John Wiley &
Sons.
Santow,
Gigi. 1995. “Social Roles and Physical
Health: The Case of Female Disadvantage In Poor Countries” Social Science &
Medicine 40:2, 147-161.
Segall,
M. H., P. R. Dasen, J. W. Berry and Y.H. Poortinga 1999 Human Behavior in
Global Perspective: An Introduction
to Cross-Cultural Psychology. Boston:
Allyn & Bacon.
Servaes,
J., T.L. Jacobson and S. A. White 1996 Participatory Communication for Social
Change. New Delhi: Sage.
Shannon,
C. and W. Weaver 1949 The Mathematical
Theory of Communication.
Urbana:
University of Illinois Press.
Stetson, V. and R. Davis 1999
Health Education in Primary Health Care Projects: A Critical Review of Various
Approaches. Washington, D.C.: CORE Group.
Thomas,
P. 1994 “Participatory Development Communication: Philosophical Premises” in
White, S.A., K.S. Nair and J. Ascroft (eds) Participatory Communication:
Working for Change and Development. New
Delhi: Sage, pp. 49-59.
Tresolini,
C. P. and Pew-Fetzer Task Force 1994 Health Professions Education and
Relationships-centered
Care. San Francisco: Pew Health Professions Commission.
Van Ryn
and Heaney 1997 “Developing Effective Helping Relationships in Health
Education
Practice” Health Education & Behavior 24:6, pp. 683-702.
Wallerstein,
N. and E. Bernstein 1994 “Introduction to Community Empowerment, Participatory
Education and Health” Health Education Quartedy 21:2, pp.141-148.
Wallerstein,
N. and V. Sanchez-Merki 1994 “Freirian Praxis in Health Education: Research
Results from an Adolescent Prevention Program” Health Education Research 9:1,
pp. 105-118.
White,
S.A. 1999 The Art of Facilitating Participation. New Delhi: Sage.
White,
S.A., K.S. Nair and J. Ascroft. 1994 Participatory Communication: Working for
Change
and Development. New Delhi: Sage.
WHO
1997 IEC Interventions for Reproductive Health: What do We Know and Where do We
Go? Family Planning & Population Unit, Division of Reproductive Health,
Geneva: WHO.