The results of the four case studies in Ghana, Mexico and Bangladesh will be discussed in terms of two major categories.
The first category involves the Effectiveness of the Training Activities and will include:
1. PHC tasks and services performed by traditional practitioners;
2. attitudes of practitioners;
3. community acceptance of these services;
4. extent of collaboration between healers and health agency staff;
5. changes in health behaviours of community members where TPs have served, and
6. changes in health conditions in these communities.
The second category pertains to Administrative Issues related to planning, implementation and evaluation of training activities for traditional practitioners, including the training of trainers.
A. EFFECTIVENESS OF TRAINING
Six criteria were used to judge the effectiveness of training programmes and the impact of these programmes on the communities. Results of interviews in the four projects are discussed under each of the following six criteria.
1. What PHC skills that traditional practitioners were taught, are they now performing in their communities?
Responses from interviews conducted at the four project sites are summarized, when applicable, according to services performed by TPs in maternal and child health, nutrition, personal hygiene, sanitation and health education.
a. Maternal and child health services - The majority of women surveyed from all four projects consulted TBAs for services for pregnancy and child health problems. TBA services included the following:
• pre and post natal checkups;
• diagnosing women for high risk pregnancies, such as anaemia, pre-eclampsia, dangerous fetal positions and referring to the hospital;
• measuring height and weight for monitoring growth of children;
• maintaining a clean environment for delivery;
• disinfecting instruments to prevent tetanus;
• delivering babies and cutting and tying the cord properly;
• performing artificial respiration on infants;
• advising mothers how to prepare and use ORS and treat diarrhoea;
• referring children for DPT, polio, and BCG immunizations and mothers for tetanus injections;
• maintaining cleanliness to prevent infections;
• counselling women about childbirth, sexuality and family planning.
b. Nutrition services - The following nutrition services were primarily performed by TBAs:
• assessing nutritional status of mother and child;
• advising mothers on how to get a balanced diet, and using supplemental foods during pregnancy, breast feeding, and how to wean infants;
• recommending alternative foods when taboos interfere with a balanced diet;
• supplying iron tablets and vitamin E capsules.
c. Personal hygiene services
• washing hands and cutting nails when treating patients and attending labours;
• cutting and binding the cord in a hygienic and sterile manner.
d. Sanitation services - These services were primarily performed by herbalists, spiritual traditional practitioners, and bone setters:
• cleaning, drying, and preserving herbs in a hygienic manner;
• classifying herbal plants accurately for treating patients;
• keeping flies away from herbal medicines;
• storing herbs in clean containers to make them immediately available for treatments;
• advising patients to use clean water and latrines.
e. Health education services - Traditional practitioners from all four projects participated in community meetings. In the Cuetzalan and Savar Projects, 100 percent of those surveyed took part in these meetings. In the Dormaa Project, 95 percent participated. TBAs in the Manda Project answered “no” to participating in meetings, however, 8 of the 15 community members indicated that TBAs did assist them in obtaining resources for getting safe water and slab latrines within the community.
Traditional Practitioners attended community meetings for the following purposes:
• to help plan, organize and conduct activities related to promoting health, schools, cooperatives, and political affairs;
• to promote the building and use of latrines, improved nutrition, digging of wells for safe water, reduction of accidents, reduction of mosquito breeding, preparation and use of ORS, and keeping animals in pens;
• to help dispel superstitious beliefs about foods and ghosts that are believed to cause certain diseases.
In addition to participating in community meetings, two-thirds of all TPs interviewed reported that they met with each other in small groups to conduct the following activities:
• to refresh their own minds about what they have learned during training;
• to share with each other their knowledge about treatment methods;
• to educate other non-trained traditional practitioners in what they know;
• to improve collaboration between the TBAs and other traditional practitioners.
2. How have the attitudes of traditional practitioners changed since training?
a. As A Total Group - When TPs were asked how the training had helped them in their practice, many responded that their own feelings had changed, e.g., feeling more competent in their work and having more popularity and status in the community. Some of their comments were as follows:
• “More people know about me now and I am getting more clients”;
• “More people come from the outside to visit me”;
• “We have more popularity and respect”;
• “I have achieved more status - more people come and that is a sign of great respect in our culture”.
• “(The training)... has opened my mind wide and increased my confidence greatly. Many people have gotten to know me”;
• “The training has taught me how to keep myself clean and to wash, clean and dry medicines properly”;
• “I believe we have reduced the number of deaths because we refer patients to the hospital on time”.
b. TPs in the Dormaa Project - The TPs expressed that being associated with the training project has not only accorded them more respect from their communities, but improved their ability to identify serious cases, refer them to the hospital, i.e., regarding knowing when to treat certain cases and when to refer to the hospital, and to treat patients with their own herbal remedies. They responded that their judgement had improved. They felt more self-reliant, better coordinated as a group, and more united with their communities. Many TPs had been encouraged to keep records in their practices, and were doing so.
(1) Maternal and child health - All ten of the trained TBAs interviewed indicated that all pregnant women in their villages consulted them when they went into labour. They referred the women to the hospital only when it was necessary. They said that they had learned to identify high risk pregnancies by examining mothers for complications and then referring such patients to the hospital for delivery. Of the ten, three were currently offering prenatal care for mothers to detect complications at an early stage. They said they were able to make referrals after learning to diagnose high risk pregnancies and anaemia. Three felt that learning to detect where the baby’s head was located was one of the most helpful things about the training.
TBAs also responded that they now gave advice to women on family planning and how to prepare ORS and administer it to children with diarrhoea. Three TBAs had begun keeping records and had started monitoring growth using arm and leg beads for measurement.
(2) Nutrition - Sixteen of the twenty-three TPs reported learning about the importance of a balanced diet for all of their clients. They said when food taboos interfered with nutrition, they were able to recommend substitute foods in order to help patients maintain an adequate diet. Nine of the twenty three TPs observed gradual improvement in their young clients by measuring and recording changes in height and weight with the use of strings of beads.
(3) Sanitation - All of the thirteen TPs who commonly used herbal medications in their practices (herbalists, spiritual traditional practitioners, and bone setters) reported learning how to clean, dry and preserve herbs with sanitary and hygienic methods was the most helpful part of the training sessions. Additionally, these TPs and herbalists said they had begun to classify herbal medications to prevent mix-ups during treatment, and were now keeping the herbs in stock so they would be available when needed.
Six TPs mentioned learning that germs were invisible and how important it was to keep flies and faeces away from medications because this could spread disease within the community.
The TPs said they were also instructed in the practice of personal hygiene when treating patients and, as a result, nine of the ten TBAs interviewed emphasized the importance of washing their hands before attending labour and of cutting the umbilical cord with a new blade to prevent infection. Six TBA’s mentioned the importance of using pure oil to cover the navel of the newborn and also of covering their mouths when coughing as an important way to prevent the spread of infection. Four TBAs indicated that they were careful to sterilize the binding cord used to prevent bleeding before tying it.
(4) Health education - All twenty-three of the TPs interviewed indicated that they participated in community meetings and activities to plan development activities such as sanitation, construction of toilets, improvement of schools, discussion of political issues, and proper care of children in the community. After the training, nine of the twenty-three TPs said they began to give talks on nutrition, water, sanitation, and how to reduce mosquito breeding in their communities. Three TBAs began teaching mothers how to prepare ORS for their children.
All twenty-three of the TPs interviewed reported that they were now conducting meetings and activities with other practitioners in their areas. They met in order to train other TPs on what they had learned in the project, to refresh their own minds on project content, to plan other activities, to improve their work, and to exchange advice and experience on the subject of herbal medicine. One herbalist reported learning what specialties each traditional practitioner practices. For example, seven of the eleven herbalist and spiritual traditional practitioners mentioned that they cooperated with TBAs and other TPs in the area of herbal medicine. They educated one another with advice and experience in using herbal medications and exchanged supplies of medicine.
Health agency staff members noted that TPs acted as local health inspectors in some communities and promoted clean villages and good water. It is a requirement that in order to be invited to participate in the training a traditional practitioner must serve on the Health Council. The TPs interviewed said they began to organize their communities to take action about certain health problems, such as clearing weeds to prevent mosquitoes, digging wells, and keeping goats and sheep in pens. A community health worker reported that TPs were invaluable in mobilizing the community when the health centre came to immunize the children, and that they advised mothers about growth monitoring during that time.
c. TPs in the Cuetzalan Project - Many of the herbalists described how they had learned to dry and store herbs in a sanitary way and to preserve them in alcohol or in a petroleum base so they could have them available when treatments are needed. TBAs reported they were able to diagnose high risk pregnancies and refer them to the hospital. They were more aware of the importance of washing hands, cleaning newborn babies and cutting the umbilical cord properly. They also began sending children to the hospital for immunizations.
Two spiritual TPs indicated they would like to strengthen the Traditional Practitioners Association and to obtain sponsorship from other organizations. All seventeen of the TPs stated that they participated in community activities either at village assemblies, schools, or cooperatives following the training sessions.
d. TBAs in the Manda Project - Health agency staff and community members were asked what services the TBAs performed. Five of the eleven TBAs felt that learning about the benefits of vaccinations for BCG, polio, and DPT was one of the most helpful aspects of the training sessions. They also learned how to perform pre-and post-natal checkups and care for mothers during pregnancy.
These staff members also made specific reference to TBAs being effective at encouraging community members to obtain family planning methods and immunizations. The Senior Trainer said that the TBAs essentially, “were doing the government agencies’ work”. The Assistant Trainer of TBAs mentioned “it was more helpful to use TBAs to educate the community because they are highly accepted by the community”, and the TBA Forum Organizer stated the main strength of using TBAs in PHC services is “that communities now received better services at lower cost.”
(1) Nutrition - All eleven of the TBAs interviewed learned ways to dispel superstitious beliefs that people had about food and advised people how to achieve better nutrition and practice good food habits. Also, all eleven TBAs learned to advise mothers to supplement their babies’ diets with additional foods between the ages of four to five months.
Four of the community members interviewed indicated that trained TBAs advised them specifically on what supplemental foods to wean their children on at the age of four to five months, and five people said the TBAs advised them on how to get a balanced diet for themselves and their children. Thirteen of the community members said the TBAs were very conscientious about advising clients to protect against vitamin A & D deficiencies and to take iron tablets during pregnancy.
(2) Personal hygiene and sanitation - All eleven TBAs reported they learned how to prepare themselves and their patients hygienically before attending to any clients as well as how to maintain a clean environment for a hygienic delivery. They also learned to disinfect instruments in order to prevent tetanus. The TBAs said they were also taught to instruct mothers to wash their breasts before nursing their babies and to use only safe water for drinking and sanitary purposes.
All fifteen community members interviewed reported that trained TBAs taught them about proper personal and family hygiene. Three men said they were advised by a TBA on how to build a latrine for their community.
(3) Health education - Six TBAs indicated that one of the more helpful things they learned in the training sessions was how to dispel superstitions about ghosts (a prevalent cultural belief is that ghosts cause certain diseases). Five of the eleven TBAslearned the importance of keeping babies warm in the winter and cool during the hot season.
e. TBAs in the Savar Project - All four of the Health Agency Staff members indicated they felt the training programme was successful. They based this upon feedback they got from field representatives who reported how well the TBAs were functioning. The Assistant Project Officer stated that the TBAs were performing, “with full ability, responsibility and dedication.”
Four health agency staff members said that the TBAs were most effective in advising communities about health issues and conducting health education sessions. They also indicated that the TBAs were invaluable in performing checkups, conducting normal labours, attending to pre- and post-natal care, identifying high risk mothers and making referrals to the local clinics when complications arose.
All of the 26 community members interviewed said they had received some type of service from their local trained TBA. These services included:
• measuring height and weight;
• assessing nutritional status;
• examining to determine the position of the fetus;
• advising on eating supplemental foods during pregnancy;
• giving out pictoral cards to pregnant women as a visual aid to help them monitor their pregnancy;
• supplying iron tablets and vitamin E capsules;
• advising on pregnancy precautions, breast feeding, immunizations for themselves and their babies, and on family planning methods;
• identifying delivery dates, edema, and anaemia;
• attending labour.
In addition they said the TBAs organized monthly community meetings to educate pregnant mothers and other community members about nutrition, the birth process, when and how to use ORS for diarrhoea, and other subjects.
(1) Maternal and child health - All of the TBAs interviewed reported learning how to determine the position of the fetus, and to correctly perform physical exams of mothers in order to identify high risk conditions such as anaemia and pre-eclampsia. Five of those interviewed advised pregnant women to not do heavy work and to rest after lunch. The TBAs also said they were instructed in the correct method of tying and cutting the umbilical cord and seven mentioned this as being particularly helpful. Five mentioned they learned the importance of checking for a complete placenta after its delivery. Three said they learned to weigh children after birth and eight reported being instructed about immunizations for both mother and child. In addition, eight indicated that the instruction on artificial respiration was one of the most helpful sections of information during the training.
Eight of the TBAs also reported that they were beginning to help families select family planning methods. And three TBAs indicated that they were discouraging breast feeding mothers from taking birth control pills.
(2) Nutrition - Seven of the ten TBAs reported learning the importance of a balanced diet for all their clients. They advised pregnant women to eat supplemental foods and to take more frequent, smaller meals, as well as to reduce salt intake. All indicated that they supplied Vitamin A capsules and iron tablets to their clients. All ten TBAs learned the importance of having mothers immediately feed colostrum to their newborns in order for the children to get the most nutritional benefit from breast milk. Three reported learning to advise mothers to feed their children additional nutritious foods after the age of five months in order to supplement their diets.
(3) Personal hygiene and sanitation - Eight of the ten TBAs interviewed reported that they learned the importance of hand washing, nail cutting and the removal of rings before examinations and deliveries, and seven mentioned learning to boil the blade and cord used in cutting the umbilical cord following delivery. Three remarked about learning to clean the child and mother in a hygienic manner after birth and the importance of maintaining hygiene during labour.
Nine of the community members interviewed indicated that formerly TBAs used bamboo and unclean blades to cut the umbilical cord following birth, but after training they were using clean blades and hygienic methods.
(4) Health education - TBAs indicated that they were conducting home visits in order to advise pregnant and nursing mothers to eat the right foods and rest. Eight of the ten TBAs reported using pictoral (health record) cards to help keep track of progress during pregnancy and to determine any indications of complications.
All ten of the TBAs interviewed reported that they participated in community meetings and activities. These meetings were used to bring women in the community together to discuss health, hygiene, prenatal care, and the importance of immunizations for mother and child. These monthly meetings were also used by the TBAs to record the weights of the babies in their communities.
In addition to participating in monthly community meetings, all ten of the TBAs indicated that they also conducted meetings with other TBAs. These meetings were used to discuss problems with their practices, to conduct follow-up training, and to share knowledge and experiences. They also held discussions regarding income generation and practised their literacy lessons.
3. How satisfied are community members with the traditional practitioners services?
a. As A Total Group - In all four projects, 100 percent of community members who had visited TPs were very satisfied with the services they received from TPs. They responded that healers were friendly and accepting, careful and confident. When asked if they had any dislikes about any of the TPs' services, they all replied "nothing."
Community members responses indicated that they had more trust in the abilities of TPs after they had been trained.
b. Dormaa Project Community Members - Seventeen members of village communities were interviewed to determine their satisfaction with their local TPs. They were first asked what health problems their families faced. Their responses included: hernia, fever, piles, malaria, measles, coughing, yaws, abdominal pains, asthma, diarrhoea, jaundice and headache. All of the seventeen interviewed had obtained treatment from TPs, though not necessarily for all of the above conditions. Most of the treatment from TPs consisted of herbal medications. All were very satisfied with the services they obtained. All of the clients interviewed felt that the TPs were friendly in manner and most mentioned that they were "accepting" as well. One client described the TPs as being "very cordial".
Responses of community members indicated they had more confidence and trust in the abilities of their TPs after they were trained. Some community members said they preferred to go to trained TPs rather than to untrained ones for treatment.
c. Cuetzalan Project Community Members - Only two of the community members that were interviewed had been clients of TPs in the past year. These clients were both females, ages 22 and 36, and they were asked their opinion of the attitudes of and services offered by their local TPs. Both women were satisfied with the competence of their TPs and liked the services provided, commenting that the TPs were careful, confident, and very friendly. The services were for a birth, a diarrhoea case, and a treatment for "susto" and "mal de ojo".
These latter two conditions were traditional illnesses that are commonly treated by local TPs. "Susto" is thought to be caused by fright and is more frequent with children. The child wakes up afraid, with headache, tremors and tightness, and often gets pale, thirsty, lazy, and lacks appetite. When this happens a curandero (TP) is called to determine the cause of susto and to provide treatment.
"Mal de ojo" (bad eye) is another common traditional illness that is thought to be caused by the "evil eye" of a person who looks at another and captures their soul. When this happens the person gets weak, loses appetite and gets sick. The cure is provided by a curandero who treats the person with herbs and prayers.
In addition to the two community members, two of the health agency staff reported that based upon their contact with patients in the hospital the community members were satisfied with the services offered by the TPs, particularly because the TPs understood the traditional diseases and knew how to treat them.
d. Manda Project Community Members - Fifteen members of four villages were interviewed to determine their satisfaction with the services of their local TBAs. All fifteen had received some type of service from a TBA, and all indicated they were very satisfied with the services provided. When asked about the manner in which the TBAs attended to health problems, eleven mentioned that TBAs were "friendly". Other descriptions included: "very patient, sensitive and accepting," "very good," and "tried very hard to understand." When asked if there were any problems with the services provided, all those interviewed indicated that there were "no dislikes" and two women stated: "They were available to us anytime to solve our problems - we liked them very much."
e. Savar Project Community Members - Twenty-six community members were interviewed to determine their satisfaction with the services provided by their local TBAs. All were very satisfied with their services. Nine of the women agreed that the trained TBAs had greatly reduced the deaths in this community. When asked about the manner of the TBAs, all of those interviewed remarked that the TBAs were friendly and three women commented that they were pleased with their visits. Community members were asked if there was anything they disliked about the services of the TBAs and all respondents replied "nothing."
4. How has collaboration improved between traditional practitioners and health agency staff?
Collaboration was defined as how traditional practitioners and the Western practitioners related to and worked with each other. This was expressed by how well they respected and communicated with each other and made referrals. The overall findings from responses from both TPs and health agency staff indicated that generally there was good collaboration and very positive relationships were established, although this varied with individuals from place to place.
a. Dormaa Project - Eleven official health agency staff representatives were interviewed about their relationship with and their views about TPs. Most felt that TPs, well trained, could be even more effective than health agency staff in providing health education and preventive work in their local communities. Some also stated that TPs were now more familiar with common rural diseases, and were able to recognize when a patient should be referred to the nearest clinic. Those interviewed commented that trained TPs made many more referrals to the hospital for conditions of breach delivery, primipara, anaemia, retained placenta, hypertension, fits, oedema, delayed first stage, second stage delivery, and previous Caesarean Section.
The senior nurse midwife at the Dormaa Hospital mentioned that she reciprocated by referring some maternity cases to a TBA, usually when no problems were expected or when the patient lived far away from the clinic. The staff agency members also recognized the TPs as a valuable resource in rural communities where there was no clinic, or in cases when patients were unable to get to a clinic.
Effective communication between TPs and staff was encouraged by the use of coloured referral cards. Blue was for a normal referral and pink for emergencies. Seven of the community members interviewed mentioned that they noticed when TP's began to use these referral cards in their community and took the cards with them when they went to the clinic. All of them felt that this had improved the relationships between the TPs and the hospital staff and made for better care in their communities.
One problem with these referrals was that many of the TPs were not able to read or write, and thus it was difficult for them to fill out the referral slips. However, in some communities there were persons who could read and write and helped bridge this communication gap between TPs and staff. In other communities, traditional practitioners were allowed to accompany their patients to the clinic for treatment, and this enabled them to communicate with the health agency staff about the health problem verbally. Most hospital staff members felt that their relationship with the TPs was very friendly, and that they worked together for the good of the communities they served. One nurse in charge of a community clinic invited TBAs to come to the well baby clinic and help monitor growth rates and weight of local children. The senior nurse midwife at Dormaa Hospital remarked that the TPs were extremely inquisitive and eager to learn from the staff.
The majority of TPs interviewed described their relations with health agency staff as being very friendly and reported that the establishment of a mutual referral system improved communication and collaboration. When TPs were asked about which conditions they referred to the hospital, their responses included: tetanus cases, infections, meningitis, anaemia, cuts that required suturing, broken bones, polio, paralysis, neck problems, malaria, difficult labours, and bleeding during pregnancy. Fifteen of the twenty-three TPs interviewed reported that they received reciprocal referrals from clinic doctors and nurses in cases such as osteomyelitis, madness, spiritual conditions, miscarriages, vomiting and bleeding during pregnancy, difficulty breathing, boils, bedsores, abscesses in the throat, dislocations and fractures.
Two of the twenty-three TPs interviewed had reservations about their relationship to the hospital staff. They felt that the staff did not entirely trust them yet and that some looked down upon TPs' methods as inferior to Western practices.
b. Cuetzalan Project - Eight official health agency staff representatives were interviewed about their relationship with TPs. The opinions of these staff members about the quality and extent of collaboration between them and the TPs were varied. Some felt that the collaboration was very good and others said it was not good at all. In one community, staff members said they collaborated more with herbalists than with TBAs simply because the herbalists referred patients to the hospital more often. The hospital director indicated that it was more common for nurses than other hospital staff to have closer relationships with TPs, because, unlike physicians, many of the nurses were native to the area and understood the concepts of traditional medicine.
All of the health agency staff interviewed felt the TPs training programme was effective. When asked about the main strengths of using TPs to provide primary health care services, three of the staff noted that TPs are usually community leaders who are well respected and able to speak directly to the local population. The same staff indicated that community members do not identify with medical health workers in the same manner as they do with the TPs. Also, one doctor indicated that TPs were able to understand primary health care and its purpose. Two nurses indicated that TPs worked to prevent illness, improve the environment, and raise the consciousness of their communities.
When staff members were asked how the TPs could be most helpful to their communities, one suggested that they work together with Western practitioners. It was felt that this collaboration not only exposed the TPs to Western practices, but also exposed staff members to alternative cures for certain diseases such as mal de ojo, susto, and moiera. "Moiera" is a traditional illness that is caused when a child's fontanelle is sunken due to dehydration from diarrhoea. For example, TPs "make a spiritual cleansing to make safe the individual, family, and the community."
Two other staff members added that the participation of communities in health education and promotion efforts was very important, and if TPs were able to increase the number of participants in these programmes, it would be a useful way to integrate the TPs into the health system. Two other staff members interviewed noted that TPs were effective because they were able to recognize certain diseases and make many referrals to clinics including: second and third degree malnutrition, tuberculosis, high risk pregnancies, surgical patients, tubal ligations, irregular bleeding in the vagina (cancer), and fractures.
Three of the eight staff respondents indicated that some staff members had trouble accepting the new roles of the TPs. TBAs seem to be accepted without reservation, however, spiritual TPs and bone setters were not as confidently accepted in all cases.
TPs described collaboration from their perspective in a variety of ways. Thirteen of the seventeen TPs interviewed described their relationships with health agency staff as being very good. Six of the TBAs reported receiving referrals from doctors "when a child was not properly placed and needs turning." Six of the TBAs mentioned "nurses can help explain when we do not understand the doctors." The two bone setters indicated that they referred patients to the hospital when it was necessary. The priest TPs reported that they did not collaborate much with doctors and nurses, but would like to improve relations. Most of the TPs received help and referrals from health staff. Eight of those interviewed reported receiving referrals. The spiritual TPs had treated some cases that were referred by doctors "when Western treatment did not seem to help."
c. Manda Project - Five official health agency staff representatives were interviewed about their relationships with the trained TBAs. They reported that health agency staff generally accepted the new roles of the trained TBAs. (Health agency staff here included both staff of the NGO Project and the doctors and nurses in the government clinics and hospitals where the TBAs make referrals.)
All of the TBAsinterviewed described relations with health agency staff members as being good. TBAs reported making referrals of patients for family planning, immunizations, and in cases of high risk pregnancy. Six TBAs also indicated doctors and nurses sometimes refer normal patients to trained TBAs. Five of the TBAs said they receive support and assistance from the hospital/clinic staff at any time.
d. Savar Project - Three of the four staff members interviewed indicated that collaboration between TBAs and staff had not always been good, but more recently had become very effective. The TBA Supervisor stated, "The clinic staff benefit because when our TBAs refer cases and advise mothers about family planning and immunizations, more people go to the clinic/hospital and their statistics go up." The Project Coordinator stated that the degree of collaboration can also depend on the geographical area in which they work.
Ten TBAs were asked about their relationship with health agency staff and they reported that collaboration was for the most part good. However, three of the TBAs indicated that they were accepted by some doctors and nurses, but not by others. Five of those interviewed reported that doctors and nurses accepted their referrals "courteously." These TBAs indicated that they personally took patients to the clinic and received good cooperation when staff members were able to identify them as trained TBAs from their badges and special sharees (dresses).
All ten of the TBAs interviewed indicated that they made referrals to their local clinics or hospitals. The conditions for which they made referrals included: tetanus injections, haemorrhoids, retained placenta, incomplete delivery, and prolonged labour.
5. How have community members behaviours changed after traditional practitioners provided new services?
a. As A Total Group - Health agency staff and TPs reported they had observed certain health behaviours of community members after the trained TPs began working in the communities. These behaviours are summarized under their major content areas.
(1) Maternal and child health behaviours:
•mothers changed from consulting untrained TBAs to trained ones;
• more pregnant women consulted TBAs for pre and postnatal care and labour; (hospital staff in Dormaa estimated up to 70% of women were delivered by TBAs)
• more mothers were taking iron pills during pregnancy;
• mothers went to clinics for immunizations and brought their children to be immunized;
• mothers prepared and fed ORS to children with diarrhoea;
• more mothers were practising family planning and breast feeding.
(2) Nutrition behaviours:
• more people were choosing to eat foods to obtain a more balanced diet
• more children were eating vegetables and eggs
• more mothers were feeding children supplemental foods for weaning
• some families were beginning to raise chickens for food.
(3) Sanitation behaviours:
•some villages had organized to build latrines and were using them;
• mothers taught their children to defecate in pans instead of around the homes;
• mothers were bathing their children more frequently
• some villages were digging wells to obtain safe drinking water
• clients of traditional practitioners were keeping their homes cleaner
• more mothers were boiling water for drinking;
• more individuals practised personal hygiene, such as washing hands, cleaning dishes, cutting nails, wearing shoes.
(4) Environmental health behaviours:
•some villages had cleared brush and weeds from around their houses to eliminate mosquito breeding places;
• some villages had cleared wastes and trash to reduce the spread of diseases;
• some families were keeping their sheep and goats in pens to prevent the spread of diseases.
(5) Health education behaviours:
•community members sought traditional practitioners' advice on personal hygiene, nutrition, and family planning;
• people were dropping common superstitious beliefs about eating certain foods;
• community members assisted traditional practitioners with their farming to reward the traditional practitioners for their services.
b. Health Behaviours in the Dormaa Project Community
(1) Maternal and child health - All 10 of the trained TBAs who were interviewed mentioned that following training, all pregnant women in their villages consulted them when they went into labour and nearly all chose to remain in the villages to deliver their children. They referred mothers to the hospital only when necessary, in cases of high risk pregnancies or previous Caesarean Section.
According to the hospital staff, up to 70% of pregnant women now delivered their babies in the community because it was less expensive than the hospital and it also alleviated the need for the difficult and sometimes lengthy trip to the hospital. After the training programme, the community seemed to have more faith in the abilities of the TBAs. According to one hospital nurse, "The pillar of primary health care lies in the hands of traditional practitioners".
When asked what they had learned from the TPs to prevent illness and to keep their families healthy, eight community members mentioned the importance of visiting clinics for services such as immunizations. And the Nurse-in-Charge at one community clinic reported that TBAs in her area were teaching mothers how to prepare ORS for their children, and that this was very helpful for early treatment of dehydration.
(2) Nutrition - According to the Project Coordinator, "people are now much more conscious of trying to eat a balanced diet, they now understand that filling the belly alone does not make good nutrition." This belief was borne out when eight community members identified the importance of a balanced diet as one of the important things they learned from the TPs since the training took place.
(3) Sanitation - Five of the twenty-three TPs interviewed reported that they had organized people in village communities to build latrines since the training, and these communities were now more conscious of using them instead of defecating around the village. Additionally, one TP noted that children were now being taught to defecate in pans or to use the latrines built by the community. One mother reported that she learned from a TP about the importance of bathing her children every day. One village chief stated that he helped his community organize itself to dig wells for the village drinking water supply, and two others reported that communities were now more careful to drink only protected or safe water.
Two villagers reported learning the importance of hygienic practices such as cutting their children's fingernails in order not to spread any germs that might be collected under uncut ones, and not spreading their clothes on the ground to dry.
(4) Environment - Eight of the seventeen community members interviewed reported that under the direction of trained TPs, they were clearing brush and weeds from around the outside of the villages in order to minimize mosquito breeding areas. These eight community members also indicated that the TPs had started to emphasize the importance of keeping the village and surrounding areas clear of any waste materials and trash where insects or scavengers might feed and thus become transmitters of disease. The importance of confining sheep and goats to pens in certain sections of the village was also emphasized by these TPs to prevent the spread of disease.
(5) Health education - Seven traditional practitioners reported that when the TPs spoke to the community or visited homes to talk about health, personal hygiene, nutrition, and family planning, their advice was now much more accepted by family members, and sometimes the community even solicited their advice on these matters. These TPs also reported that since the training, the community has helped them more on their farms as payment for treatment.
Seven villagers reported that following the training, TPs made periodic visits to their community to educate them about the importance of a balanced diet, environmental sanitation, and personal sanitation practices. A bone-setter exercised his role as health educator by advising people to be careful to reduce fractures.
One traditional practitioner spoke about the importance of the counselling role with patients. These changes seemed to show a broader role for the TP not only as someone to go to when ill, but as an educator and health promoter - someone from whom to seek advice about not becoming ill in the beginning.
c. Health Behaviours in the Cuetzalan Project Communities
(1) Maternal and child health - Six TPs reported their clients lacked trust in the TBAs that had not participated in the training project and therefore went to the ones that were trained.
(2) Nutrition - Seven TPs said they had observed that children in their communities had received better nutrition following the training, that is, the children were eating more vegetables and eggs compared to the period prior to the training.
(3) Sanitation - Thirteen TBAs responded to the question about the observation of changes in community behaviours following their training. Seven of these noticed that the homes of their clients were cleaner and that mothers in their communities began to pay more attention to the cleanliness of their children. In addition, these same TBAs noted an increase in the practice of boiling drinking water before consumption. One TBA interviewed in a small group stated that in one community where she spoke to people about the importance of sanitation, the community built 50 latrines in 2 1/2 years.
(4) Health Education - The Chief of the Department of Traditional Medicine in the Project reported that she noticed after the TPs were trained and began working in the communities, the families tended to follow the TPs suggestions for health promotion. She said that TPs were spiritual leaders and if they recommended hygiene, nutrition and immunization, community members tended to follow these recommendations.
d. Health Behaviours in the Manda Project Communities - Six of the eleven TBAs reported that since the training they noticed more interest in the use of family planning methods. These same six TBAs also indicated there was an increase in mothers feeding colostrum immediately to their newborns. Pregnant women began to obtain tetanus shots and mothers received post and antenatal checkups. They also reported a decrease in the number of maternal deaths since the implementation of the training and five TBAs reported that mothers brought their babies to get medication for worms.
According to one health agency staff member:
"Family values are changing in rural areas, families now want no more than two children. They take their children to TBAs to get immunized and they consult trained TBAs for advice with family planning methods."
And two other staff members similarly indicated that children are being inoculated in the communities for childhood diseases and mothers for tetanus because of the TBAs efforts to educate people about immunizations. These statements were borne out by fourteen of the fifteen community members who were interviewed and who reported that TBAs had advised them on the importance of getting tetanus injections and other immunizations.
(1) Nutrition - All eleven TBAs interviewed noticed a change in the behaviour of community members with regard to food habits. Some people were more conscious of eating a balanced diet and others began to feed their children supplemental foods in addition to breast milk at the age of four to five months. Eight reported that mothers had learned to feed their babies colostrum immediately after birth to begin the breast feeding cycle. Some families began to raise chickens for food in order to round out their diets. Additionally, five TBAs reported an increase in the number of mothers taking iron pills during their pregnancies.
(2) Sanitation - Six of the eleven TPs interviewed reported noticing changed behaviour in their communities regarding the use of safe water for drinking, cleaning dishes, and washing hands. Five TPs noted community members were cleaning their homes on a more regular basis.
One community member reported that trained TBAs educated the community about personal and environmental hygiene such as food, water, and sanitation.
One staff member noted that communities were becoming very conscious of using safe water for their needs. And two other staff members noted there were slab latrines being built in some communities and people were using them to improve environmental sanitation. The Assistant TBA Trainer reported that community members began to keep the areas around their homes cleared for the same reason.
(3) Health education - The TBA Programme Officer remarked that due to efforts in community education by trained TBAs, common food superstitions were being abolished, such as not eating eggs or fish during pregnancy, eating small amounts during pregnancy to have a small baby, and eating only dried foods after delivery.
e. Health Behaviours in the Savar Project Communities - A farmer and small businessman, said: "I am more confident about the TBAs - now we send mothers to the TBA instead of the hospital." Three of the four health agency staff members reported that since the training of the TBAs, they have noticed that the community members have started to change their superstitions regarding food practices and other health related topics. "They can now accept looking at pictures of a birth, while before this was not accepted because of the inhibitions associated with sexuality in their Muslim culture. Their TBA training has made them much more accepting and at ease about discussing childbirth, sexuality, and family planning with women."
(1) Maternal and child health - When asked about what new things the TBAs had taught them to do in order to prevent illness, five of the community members indicated they now got immunizations, accept family planning methods, and if pregnant, do not work too hard and rested after work. Twelve of the 26 community members interviewed reported learning that they could identify anaemia by looking at the lower eyelid.
(2) Nutrition - Seventeen community members reported that under the direction of the trained TBAs, they have learned the importance of maintaining a balanced and nutritious diet. They now tended to eat smaller meals on a more frequent basis and concentrated on nutritious foods. One client of the TBAs reported, "I did not know vegetables could provide vitamins or that we should eat a variety of foods to get a balance."
Two women noted that it was important to feed babies colostrum immediately after birth and to add other foods with breast feeding after the age of five months. Nine women said that measuring the height and nutrition status of children was important. Also, five TBAs said that their clients were now giving ORS to their children for diarrhoea after being educated in how to do it.
(3) Personal hygiene and sanitation - Five of the ten trained TBAs reported that their clients now practised general cleanliness. Thirteen of the twenty-six community members interviewed specifically indicated that they are following the good hygiene practices advocated by the trained TBAs. These practices included hand-washing before meals and after using the toilet, cutting fingernails, wearing shoes, and bathing their children every day.
(4) Health education - Nine women from communities indicated that their TBAs made monthly visits to the village to hold discussions about various topics. These visits were used as educational forums to inform community members about issues such as the importance of good nutrition and personal hygiene, the benefits of family planning, and the warning signs of possible pregnancy complications.
Eight of the community members reported that their TBAs gave them a pictoral card (health record card) to use during pregnancy to keep track of progress and to mark off milestones such as tetanus immunization. They also used these cards as educational tools to help pregnant women recognize some warning signs of possible complications with their pregnancy, and also as guides to show what constitutes a balanced diet.
6. How have health conditions improved in communities where trained traditional practitioners have worked?
a. Summary of Advantages to the Community, Traditional Practitioners, and Health Agencies.
The data indicate that trained TPs play an important role in promoting primary health care services in communities, identifying critical cases early, and referring them to clinics and hospitals.
(1) Advantages to the community:
•increased treatment for certain Western diseases;
• referrals increase immunization coverage for tetanus and childhood diseases;
• hygienic use of herbal medicines and convenience of these medicines being preserved and stored;
• increased village sanitation - use of latrines and disposal of trash;
• faster referral of serious cases to hospital;
• more deliveries are performed safely in villages;
• improved nutrition among children and adults;
• increased availability of safe water;
• people practice more personal hygiene;
• mosquito breeding is reduced;
• saves money and time for community members.
(2) Advantages to the traditional practitioners:
• more status and acceptance by the community
• increase in private practice
• more united among their own groups
• enhanced leadership in the community;
• better able to mobilize communities for health promotion, i.e. for immunizations, to obtain better nutrition, better sanitation and safe water;
• better reputation in the area
• greater confidence in own skills
• less fear to practise openly.
(3) Advantages to the health agencies:
•decrease in work load in hospital maternity wards;
• decrease in maternal and infant mortality, and in anaemia and tetanus cases through prompt referrals;
• traditional practitioners can mobilize communities quickly for staff programmes in nutrition and immunizations;
• costs to hospital are reduced.
b. Improved Conditions in the Dormaa Project - In the Dormaa Project the Ministry of Health Department of Statistical Records had data recorded from the last three years which documented the changes in still births and maternal and neonatal deaths in regions where the trained TBAs had worked. These data are shown in Table 1.
Maternal Services in Dormaa District Hospital
* Mothers delivered by trained TBAs
Source: Statistical Records, Ministry of Health Dormaa District
As noted in Table 1, the increase in the number of deliveries by trained TBA's has increased from 11% in 1990 to 31% in 1992. This is related to a corresponding decrease in the number of still births (from 7.4% to 2.10%), maternal deaths (from 0.20% to 0.09%), and neonatal deaths (from 2.20% to 0.60%) over the two year period.
The statistical records also recorded data for status of malnutrition in children 0-6 years in 5 communities served by trained TBAs. Table 2 indicates that over the 13 month period for which data was recorded, normal nutrition status in children increased from 46% to 62.3%; the percentage of mildly malnourished decreased from 32.4% to 26.7%; and the severely malnourished children decreased from 21.4% to 16.1%.
Change in Malnutrition Status of Children 0-6 Years in five communities served by trained TBA's (As measured by weight/age)
A = normal nutritional status
B = mildly malnourished
C&D = moderately to severely malnourished
Source: Statistical records of the Ministry of Health, PHC Nutrition Project
c. Improved Health Conditions in the Cuetzalan Project - An attempt was made to obtain data that would indicate changes in rates of maternal and infant mortality, malnutrition, or other health conditions as a result of trained healers working in communities. Such data were not available. The medical director of the Cuetzalan hospital indicated that their statistical records were not in a condition that they could compare health statistics in regions where trained healers were working with regions where they were not.
However, health agency staff members did report their observations about health improvements. When asked about the benefits of the training programme to the community and hospital, they reported that delivery complications had decreased over one year, that deaths from childbirth had diminished, as well as the number of patients they had seen at the hospital with advanced conditions of disease.
d. Improved Health Conditions in the Manda Project - An attempt was made to obtain statistical data which would show improvements in maternal, perinatal or neonatal mortality rates in areas where the trained TBAs were working. The Medical Director of the Manda District Hospital, where such data was kept, was interviewed, and he said that they had not been able to collect reliable data on registration of births and deaths. It was therefore not possible to draw any conclusions regarding changes in maternal and infant morbidity or mortality since these data were not available for those areas where TBAs were working.
e. Improved Health Conditions in the Savar Project - The Medical Director of the Hospital in Savar Thana was interviewed to find out what records they kept to determine morbidity and mortality rates of mothers and infants. He indicated that they had no reliable data available to make these determinations. It was therefore not possible to document any changes in health conditions as a result of trained TBAs working in the communities.
B. ADMINISTRATIVE ISSUES
In order to successfully design and implement the training and utilization of traditional practitioner programmes, government policies should be established to address major issues and to regulate the activities of TPs.
Such policies could include the scope and nature of tasks for which TPs should be trained; the content of the training and selection of participants; the extent of accountability for performance; rewards given for service; the types of records and reporting procedures required; and systems for monitoring performance.
In the context of developing policies for the training and utilization of TPs in community primary health care programmes, it is important to emphasize that in the four training projects studied, none of the TBAs, herbalists and other TPs were employed by the sponsoring government or non-government agency. Thus there was no formal employment contract between the agency and the individual practitioners. Generally, TPs function as private practitioners and they depend upon their clients for remuneration.
Because of the nature of this relationship, health agencies should consider that any regulations governing their performance should be used as guidelines only. The conventional meaning of supervision of an employee by a nurse, doctor, or other agency staff member does not apply in cases where TPs have been trained to perform primary health care services for which they have made a voluntary commitment to work.
For this reason the words 'supervisor' or 'supervision' have not been used in this report, even though the documents and staff comments from the case studies have described 'supervision' activities that they carried out with TPs. In this report, instead of using the word 'supervision', it has seemed more accurate to use terms such as 'support' or 'guidance', since these more accurately reflect the true nature of the professional relationship which exists between the agencies and TPs.
There was one exception to this voluntary work situation in the Cuetzalan project where the hospital paid a fixed daily fee to the TBAs and the other TPs who practised on a rotating part time basis in consulting rooms set aside for their practice of traditional medicine within the hospital facilities.
a. GHANA - The Ghana Ministry of Health has within the last few years established a Minister of Traditional Medicine. As of 1992 the MOH was in process of establishing an official government policy on the use of traditional practitioners for the country as a whole. The following is an excerpt taken from the government's policy statement:33
"Hence government policy is to enable Ghanaians to use whatever form of health care they desire. M.O.H. collaborates with TBAs and the Centre for Scientific Research into plant medicine. M.O.H. is therefore, training TBAs to improve quality and scope of their practice. Through this, the TBAs will be able to manage diarrhoea and motivate couples to accept Family Planning services."
"Among traditional practitioners M.O.H. acknowledges that there are some who have treatment for diabetes, fractures, etc. all of which are valuable resources which should be used. However, there are "quacks" but M.O.H. lacks the expertise and competence to identify such people. It is only the communities who know the good ones. Hence M.O.H. is advocating the setting up of Regional Traditional Practitioners Association for accreditation of members."
b. MEXICO - The Government of Mexico has a very strong policy toward the support and promotion of traditional medicine which is spelled out in detail in a 44 page document34. This document begins with a statement of basic principles:
"The right of indigenous people that live in the Mexican Republic to conserve, practice, develop and transmit our traditional medicine and to defend the medical beliefs, concepts and practices inherited from our ancestors, practised and renovated by present day indigenous traditional practitioners.
"The right of all Mexicans to protection of their health in accordance with the 4th Art. of the Political Constitution of the United States of Mexico and to free access to services that provide traditional medicine.
"That the recognition of traditional medicine by the indigenous communities should constitute the basis for institutional recognition.
"The need to reaffirm the existence of a valid system of health care in the country which has the following essential elements: academic medicine, traditional medicine and domestic or home medicine. In consequence, this implies the need to establish laws and national programmes to protect and develop all these useful manners of healing.
"That traditional medicine forms part of the historic inheritance of the indigenous people as do 'their languages, cultures, practices, customs, resources and specific forms of social organization', and that, along with these, it should be protected and promoted in its development by law, in accordance with the 4th Art. of the Constitution.
"The right of indigenous traditional practitioners to form organizations that contribute to the consolidation and development of their knowledge base and practice.
"The right of the traditional practitioners to participate in the development of policies and programmes destined to improve the health status and living conditions of the indigenous communities."
The document continues with a description of objectives, and a plan for recognition and support, organization, assessment and training, creation and development of projects, follow-up and evaluation, legalization, and communication and diffusion. Because of this official government support, as of August, 1992, fifty two independent Organizations of Traditional Practitioners had been established throughout the country.
c. BANGLADESH - The Ministry of Health of the People's Republic of Bangladesh has established a policy for the selection, training, and use of traditional birth attendants. This policy is practised by the government training centres for TBAs as well as all NGOs and other organizations who desire to train TBAs. The VERC and the CCDB have followed these regulations in selecting and training TBAs in these two case studies.
2. Involvement of Community Members in Project Planning and Implementation
Issues related to planning and implementing projects for training TPs in primary health care will be discussed primarily in terms of the extent that community members were involved in the planning and implementing stages. All four projects studied had clearly written project plans which incorporated the involvement of local communities in their design and implementation.
Duties and roles in community involvement varied, i.e., TBAs became more involved with women's groups and meetings, whereas male herbalists and spiritual healers participated in general community meetings.
a. GHANA - Dormaa Traditional Practitioners Project - The Dormaa Project grew out of an anthropological study of traditional healing practices and was a pilot project based upon traditional beliefs of healing and how the practices of TPs could be strengthened. From the very beginning, staff realized that community members must be involved in the planning and implementing of the project. For example, the stated aim of the project was to promote cooperation and collaboration between all practitioners engaged in providing basic health care. This aim was spelled out more clearly in two of the three project objectives: "to establish and maintain relationships... between health care workers in the district, including TPs"; and, "To encourage a dialogue and cooperation among TPs and bio-medical workers..."
The process for recruiting and selecting TPs began in the communities where staff visited the Chiefs and elders to obtain their recommendations for TPs that were respected and trusted by the community. After review by the staff, the elders were again consulted to obtain their confirmation on candidates for training.
When the staff were developing training programmes for TBAs and for other TPs, they went to the communities to survey the TPs to find out what things they wanted to learn. Using these inputs as a base, project staff then integrated basic elements of primary health care into the training content.
In the Dormaa Project, 22 of 23 healers reported participating in community activities. There were no differences reported in the types of community work done by different types of healers. All were very interested in community development, sanitation and communal labour.
In addition, eight of the eleven health agency staff commented specifically on how effective healers and TBAs were in communities for providing health education, disease prevention, hygiene, nutrition, sanitation and community organization.
b. MEXICO - Cuetzalan Traditional Practitioners Project - The planning of the Cuetzalan Project was based upon providing primary health care services according to the needs of the indigenous communities. The development of objectives and training involved the participation of surrounding communities. Project planners also had a close working relationship with Mexico's National Council of Traditional Practitioners.
To recruit and select TPs, the project enlisted the Community Health Promoters to conduct a census of all TPs in their areas. These TPs were then invited to an orientation workshop. TPs were selected to participate in one of two training programmes, one for TBAs and the other for herbalists, bonesetters, and spiritual TPs. Each group was consulted as to what subjects they desired to learn.
The scheduling of training sessions in Cuetzalan on weekends was chosen to accommodate the needs of TPs, who generally came into town to market on Saturdays or Sundays.
All seventeen healers indicated they participated in village assemblies. Two of the male spiritual healers also participated in schools and cooperatives. Two of the five farmers interviewed specifically indicated they worked with their communities to improve the road and suggested working with healers to improve the water system and the school.
c. BANGLADESH - Manda TBA Traditional Practitioners Project - The Manda Project, sponsored by CCDB was based in an NGO which has, since 1992, reoriented its entire development approach towards people participating in planning programmes according to community needs and visions. The aim of this approach was to empower people with knowledge and skills to build sustainable levels of development. This approach was followed in the TBA training project. Although CCDB followed the official government guidelines for selecting and training TBAs, with government's permission, they modified the procedure for recruiting TBAs by asking the leaders of the villages to prepare a list of names of eligible TBAs. After each eligible TBA was interviewed by a staff member, the formal and informal community leaders were then consulted before a final selection was made.
In Bangladesh, only female TBAs were trained as TPs. Their response regarding participation in community meetings was varied. In Manda, none of the eleven TBAs said they participated in community meetings. However, eight of the fifteen community women said TBAs helped them to obtain resources for safe water and slab latrines.
d. BANGLADESH - Savar TBA Traditional Practitioners Project - The SAVAR Project, sponsored by VERC, also involved community members in selecting TBAs by forming a committee consisting of representatives from the donor agency, the Upazila Health and Family Planning authority and the VERC. It then made a final selection of candidates using government criteria.
The objectives and curriculum for training TBAs in the SAVAR Project differed significantly from the other four projects in three ways:
(1) The scope for providing MCH services was broadened to cover MCH care for mothers and children over a 320 day period from conception until two months after birth;
(2) TBAs were taught how to create income-generating activities for their own families and how to organize and show women in their communities how to do the same;
(3) TBAs were provided literacy materials to improve their reading and writing skills and to promote these skills among women in their own communities. These additional activities were based upon the needs of women in the project area.
All ten TBAs indicated they participated in community meetings. They reported getting together with groups of women to discuss health, hygiene, prenatal care and to monitor growth of babies.
3. Training Content
The content of the training programmes in each of the four projects was a result of the policies of the Government's Ministry of Health, the health problems within the country, and the priorities of the sponsoring government or nongovernment organization.
The Ghana Project, begun as an outgrowth of an anthropological study on traditional healers, was designed from suggestions from TPs in the district and interests of the Presbyterian Health Services and the Ministry of Health. The training was designed to cover all types of healers in the district - TBAs, herbalists, bonesetters, and spiritualists.
The Mexico Project was a direct result of a strong policy of the Government of Mexico to provide a dual system of health services to indigenous population groups. The content of this training project was similar to the Ghana Project in that it covered all the major types of TPs that practised in the region. These included TBAs (parteras), herbalists, bonesetters and spiritualists (curanderos).
Both projects in Bangladesh focused only on training TBAs, however the scope of the Savar TBA Project, which prepared the TBAs to provide pre and post natal care to mothers for almost an 11 month period, was much broader than that of the Manda TBA Project. The Ministry of Health in Bangladesh had placed a high priority on the training of TBAs due to the high incidence of maternal and child mortality and high birth rates in the country.
4. Training Methods and Materials
The discussion of issues related to methods and materials of training TPs will focus on two areas: (A) scheduling of training; and (B) appropriateness of training methods and materials.
5. Scheduling of training The four projects varied in the way they scheduled training activities over time.
a. GHANA - Dormaa Traditional Practitioners Project - The Dormaa Project, for example, held separate training courses for TBAs and other TPs because the course content was different. Sessions were held in half-day workshops twice a week for five months. This pattern was established to accommodate the needs of local TPs as each session was held in a village in the target area on days when TPs did not have to work on their farms. This periodic scheduling offered several advantages:
• It enabled the TPs to assimilate the information more easily than if the training had been presented in a large continuous block of time;
• It avoided the costs of housing and feeding TPs at a residential site for days at a time;
• It enabled the TPs to try out things they had learned in between sessions and return to discuss them.
b. MEXICO - Cuetzalan Traditional Practitioners Project - The Cuetzalan Project adopted a similar periodic schedule for training. Half-day training sessions were held for the TBAs on the first and third Saturday of every month. And the other TPs came on different Sundays of the month. The herbalists and spiritualists came on the first Sunday and the bone setters on the second Sunday. This schedule accommodated the TPs as many of them already had other reasons to come to town on the weekends. This periodic monthly scheduling had similar advantages to those in the Dormaa Project, except in Cuetzalan the TPs came to the hospital for training, whereas in Dormaa, the staff went to the villages to conduct sessions.
c. BANGLADESH - Manda TBA Traditional Practitioners Project - In Bangladesh, both the MANDA and the SAVAR Projects established a residential training system for the TBAs. The MANDA Project conducted a basic course of 11 days with a four-day refresher course which followed after six months. This was then followed six months later by a second four-day refresher course. The staff reported that this training pattern was satisfactory for three reasons:
• The residential conditions enabled the women to get away from family duties and distractions;
• The environment of the women living together allowed them to form close friendships, bond together, and feel more confident and united in their work as trained TBAs;
• The alternating between periods of training and work offered the women a chance to learn, practice, and then come together to discuss their learning, their problems and how to overcome them.
d. BANGLADESH - Savar TBA Traditional Practitioners Project - Staff in the SAVAR Project had a slightly different pattern of periodic training. They held a basic residential training for 10 days after which they returned to their communities to practice for four to six months. They then returned for a five day refresher course to review their learning and the difficulties they experienced in the field.
B. APPROPRIATENESS OF TRAINING METHODS AND MATERIALS
In order to determine the effectiveness of projects that are training TPs in primary health care, key questions must be answered. For example, what kind of training methods are being used? Are these methods appropriate to the education level of the participants? Do the methods fit the cultural backgrounds of the participants?
These questions are particularly relevant for the training of TPs because they come from cultures with long traditions of passing knowledge along orally and of learning skills through apprenticeships and hands-on methods.
Two criteria were used to determine the appropriateness of training:
1. Was the literacy level appropriate for the education level of TPs?
2. Did the training projects employ methods and materials that followed the principles of non-formal adult education?
1. Literacy Level of Material
The first criterion is extremely important for training TPs. Within the four projects studied, a total of 61 traditional practitioners were interviewed. Of this group, 42 or 69% were illiterate (could not read or write). The remaining 19 TPs had an average of only five years of school.
There was considerable variation in literacy rates between the four projects. In Dormaa, 70% of the TPs were illiterate and the others had an average education level of 5.6 years. In Cuetzalan, 53% of the TPs were illiterate and the others had an average education level of 3.6 years. In Bangladesh, the illiteracy rates were higher. In the SAVAR Project, all 10 TBAs were illiterate, while in the MANDA Project, 64 % were illiterate and the rest had an average education level of 5.8 years. The Bangladesh illiteracy rates tended to be higher because the TBAs were all women, and illiteracy is usually higher among women than among men in these countries.
The high percentage of illiteracy rates and the generally low levels of education among TPs indicates the importance of using training method that are educationally and culturally appropriate.
2. Participatory Methods
a. GHANA - Dormaa Traditional Practitioners Project - Dormaa Project staff reported that each training session focused on one topic, lasted from two to three hours and was held under a tree in a village. During these sessions they used the following methods:
• presented information on the topic;
• used AV aids (many were locally produced);
• encouraged TPs to exchange their ideas & experiences;
• related topic information to the TPs work;
• made field trips;
• told stories to illustrate ideas;
• used local songs & dances;
• TBAs were given 7 days of clinical practice in the hospital or clinic.
The training staff used three different TBA training manuals to present information in the curriculum. Two of these were prepared in Ghana and the third was published in London. There were no manuals available to teach the herbalists, spiritualists and bonesetters.
Staff prepared sets of 35 mm slides, which were produced locally, and used with small portable projectors. Flip charts and diagrams were prepared locally to illustrate different topics. Models showing the birth of an infant were also available.
The TPs responses to questions about the training were generally very favourable. Most had no complaints and said they understood the topics. They commented that the dialogue was good and they liked the visual aids.
The TPs made several suggestions for improving the training. Some wanted to learn about more diseases and protective measures against infections. They wanted to continue the use of dialogue and more visual aids such as slides and videos. Some
TBAs suggested they be allowed to accompany their maternity patients into the hospital delivery room to observe and learn from the nurse more about deliveries.
b. MEXICO - Cuetzalan Traditional Practitioners Project - The training methods used in the Cuetzalan Project were more or less similar for the three groups of TPs. The training was conducted in half-day workshops in classroom type settings at the hospital. Staff used a combination of didactic presentations followed by questions and answers. Emphasis was placed upon using small discussion groups where TPs could share with each other their techniques and methods of healing. There was a lot of "hands on" teaching with demonstrations, particularly with the TPs who were learning how to identify and preserve herbs for traditional medicines.
The staff made the best use of the few training materials that were available. There were a few manuals and visual aids available for training Health Promoters, but these were not generally suitable for indigenous TBAs. The manuals were written in Spanish and had many words and few pictures. The staff adapted what they could and created most of their own diagrams and posters.
For the other TPs, there were no manuals and few visual aids. Since a large part of their training covered the identification, preservation and use of herbs, the staff and participants created their own book on indigenous medicinal plants. This book was part of a larger project which the TPs took on as part of their training.
This project was the creation of a large botanic herbal garden on the outskirts of Cuetzalan. A large piece of land was donated to the local TPs association and the TPs as a group grew 315 different species of medicinal plants. They volunteered their time on a rotating basis to water and care for the plants and used the garden as a learning experience and as an income generating activity. The TPs learned how to identify and grow their own herbs and they sold the surplus for cash.
This project stimulated herbalists in the surrounding areas to grow their own community herbal gardens and to recover some income for their efforts. In one community an herbalist cultivated three hectares of ginger root as a cash crop as an alternative to growing coffee.
Health agency staff commented about how to improve the training programme. An administrator said he thought the training was too vertical - that it was too much of a top down approach coming from doctors and nurses down to the TPs. He thought there should be more interchange between hospital staff and the TPs. Another person wanted more meetings between TPs so they could exchange knowledge they had learned and have more opportunities to discuss how to apply these learning in practice. Another said the training staff lacked skills in how to teach adults and that they should teach TPs more methods of health education. Other comments were that the trainers needed more and better visual aids and they badly needed an up-to-date training manual.
The TPs who were interviewed also had comments on their training. Some had difficulty with the Spanish language. (Their native tongue was either Nahuatl or Totonee). They found some of the vocabulary difficult to understand. Only a few of the training staff understood Nahuatl and they frequently needed translators. TBAs wanted more observation and practical experience in the hospital. Other suggestions were to have more videos about the birth process and treatment procedures, and to learn additional items such as how to build latrines, how to control mosquitoes and disinfect water, how to teach others how to read, and additional information about how to use medicines to treat wounds, diarrhoea and dehydration, vomiting, and TB.
c. BANGLADESH - MANDA TBA Traditional Practitioners Project - The Manda Project trained TBAs in a residential site using a wide variety of training methods and materials and in informal learning settings. Many participative methods were used such as group discussions, demonstrations, and role plays. The staff prepared guidelines and daily lesson plans using a 128 page TBA training manual which was developed and printed in Bangladesh.
This project contained the greatest number and widest variety of training materials of the four projects studied. Among the visual aids were four model sets showing pelvis, fetus and infant; a large set of 35 mm colour slides filmed in Bangladesh; nine different sets of colour flip charts produced in Dhaka; a flannelgraph and a large flip chart on MCH/FP. The project presented each trainee with a 30-page colour picture book/flip chart to use in their work with mothers.
In addition to these visual aids, the training centre had a VCR, TV monitor, and a radio. The CCDB staff used the half hour health messages which the Bangladesh government radio station regularly broadcast for educational purposes as part of the training for the TBAs.
The MANDA Project staff offered some suggestions for improving the training programme. One was to have a well designed flip chart which they could give to each TBA for use in the communities. Another was to produce some good training videos that could illustrate the processes of examining a pregnant woman and the birth of a child.
The TBAs also requested some good videos that would show them how to deal with normal and abnormal procedures in birth. They also wanted more time during the training programme and to meet together as a group every month instead of every four months.
d. BANGLADESH - SAVAR TBA Traditional Practitioners Project - The training methods used to conduct the SAVAR project were similar to those used in the MANDA project. The curriculum followed the Bangladesh Government training manual and was presented using group discussions, role-plays, demonstrations, and brief lectures followed by questions and answers.
The materials used for training included a large coloured flip chart, a smaller flip chart, and a set of small flip charts for each TBA. Other materials included a model of a doll mother with placenta, a 35 mm slide set, and a UNICEF TBA kit. They also used a 35 mm slide set to teach income-generating activities.
An outstanding item which the project developed was a pictorial Home Based Maternal Record Card, used both for teaching and for use by the TBAs with mothers. This record card was unique in that it was almost completely pictorial and was designed to be understood by TBAs with little or no ability to read. It was still being field tested at the time of this study. When completed, it will serve as a home based record with which low literate TBAs can effectively chart the progress of a woman through pregnancy and delivery.
A unique feature in the SAVAR TBA training programme were the weekly follow-up meetings held for small groups of TBAs in their work areas. These meetings were organized and conducted by staff Field Supervisors and had a dual purpose - continued training and follow-up support.
The TBAs who were interviewed gave some suggestions for improving the training programme. One said it would be very helpful to have some videos on how to examine a pregnant woman and identify the position of the fetus in utero. Several said that at the beginning they had difficulty understanding some of the content but after the reviews and discussion they had no trouble.
3. Training of Trainers
Training trainers is an important issue in programmes that train TPs. Trainers must possess knowledge in their specialty area, as well as effective skills in teaching adults with less ability to read or write and little or no experience with a classroom style of education. The trainer must also be able to communicate well and have a sensitivity to and understanding of cultural beliefs and practices of TPs. Most doctors, nurses, educators, and other health professionals therefore need some preparation to participate effectively in such training programmes.
Three of the four projects conducted special training workshops and activities for their trainers. The Dormaa Project staff organized a two day workshop to train their PHC and hospital staff. This workshop included an understanding of traditional healing and its medicines, adult teaching methods, communication skills, and interpersonal relations.
The Cuetzalan Project had no organized plan to train their staff. While the staff appeared to be technically competent, they had no preparation in non-formal adult education or health education methods. This may account for the fact that their training workshops were somewhat more formally presented and had fewer training and health education materials.
The Manda Project held a five day course on training content and methods, plus once or twice a year they held a 3/4 day workshop on a current topic. They also encouraged staff to attend continuing education and short courses on training TBAs.
The Savar Project sent their TBA trainers to a special one month training workshop before they began the programme, and the Coordinator of Training took a course that included curriculum design, preparation of materials, and logistics.
4. Follow-up Support
After training, TPsmust be given ongoing support in the field if they are expected to effectively carry out their new tasks and responsibilities. Regular guidance must be provided to help TPs solve problems, improve their practice, and facilitate good collaboration between them and Western health workers so that appropriate referrals of high-risk and complicated cases can be made. Such support could include periodic visits and meetings with TPs in the field to review skills and solve problems, continuing education programmes and/or follow-up workshops to upgrade skills and practice.
All four projects studied had excellent periodic follow-up support built into their programmes. Details of this support are summarized as follows:
The Dormaa Project staff made support visits to all trained TPs at least once per month and organized half day refresher courses every three months to review topics covered in the training. Two day workshops were periodically presented to trainers and project staff so they could review project activities and make improvements needed.
In the Cuetzalan Project, follow-up support was built into the monthly training sessions for all TPs. The TBAs met twice a month, and the others once a month. In addition, all TPs met together monthly in a general assembly to review their work and make plans for other activities. And TPs who worked in the hospital on a rotating basis received guidance from members of the hospital staff.
The Manda Project devised a system where trained TBAs met in groups of 15 in regular forums every four months. Project staff met with them to review progress, help solve problems, and give them up to date information.
In the Savar Project, Field Supervisor staff organized weekly half day meetings for all TBAs. They usually held these meetings at government clinics or local hospitals to improve the coordination and referrals between the TBAs and the government nurses and doctors.
An important part of a training project is the evaluation of results. Unless steps are taken to determine what specific knowledge and skills the participants have learned and how effectively they are performing services in the community, the organization will not be able to determine how successful the programme has been. It is also useful to identify any difficulties that have occurred and what follow-up actions or other changes may be needed to improve the programme.
No data could be found to indicate that formal evaluations were performed in the Dormaa and Cuetzalan Projects. Staff members did report that they held information evaluations during training sessions and workshops.
The Manda Project had carried out three evaluation studies within the last seven years. In 1986, the CCDB commissioned a survey of the knowledge, attitudes, and practices of TBAs. A major objective of this survey was to obtain information on which to develop a course curriculum and course contents for the TBAs based on the above experiences and traditional system.35 Two years later, in 1988, the Health Programme Coordinator of CCDB performed an evaluation of the ongoing training programme for TBAs. The 54 page evaluation report36 described a quasi experimental control study comparing trained TBAs to a group of untrained TBAs from adjacent areas. In this study, technical inputs from course curriculum, criteria of trainee selection, training methodology, and learning materials were reviewed. Pre- and post-programme comparisons of KAP changes showed statistically significant differences.
The most recent evaluation of the Manda Project was conducted in October-November, 1992 at the request of the Ministry of Foreign Affairs of the Dutch Government, which provided funds for CCDB's Rural Development Programme. A comprehensive evaluation of the TBAs training programme was undertaken at this time. Results of this comprehensive evaluation study were reported in a 67 page document.37 A unique feature of this evaluation was that it combined the expertise of a five member Dutch/Bangladesh team who used a participatory approach in obtaining information from trained and untrained TBAs.
In 1991 the Savar Project undertook a comprehensive evaluation after the first year of its TBA training programme. A five member team consisting of the Training Project Director, the Executive Director of VERC, a representative from the ODANGO project, one Upazila Family Planning officer, and the Assistant Coordinator of VERC's Research, Evaluation and Documentation unit conducted the evaluation using non VERC staff women to collect data from pregnant and delivered mothers and TBAs. Overall, the findings were positive and demonstrated that the trained TBAs were performing effectively. The study also pointed out some weaknesses and problem areas in the programme. Results of the study were described in Evaluation Report on VERC-MCH Project.38
6. Costs of Training
The costs of training traditional practitioners were described for each case study, where such data were available. A summary of these cost data is presented here.
In the Ghana Project the average direct cost for training an herbalist, spiritual healer or bone setter was approximately US$98. The average cost for training a TBA was about US$40. No administrative costs were included in these figures.
The average cost for training a TP in the Cuetzalan Project was approximately US$110. This applied only to the initial training period because data were not available to calculate the costs for the periodic follow-up training.
In the Manda Project the average cost of training a TBA was approximately US$30. These costs included selection, training and follow up. When administrative costs were included, it doubled the average cost to about US$60.
The average cost for training a TBA in the Savar Project was estimated at US$95. This included all direct expenses for the basic 10 day course plus the five day refresher course.
These cost figures should be considered as general guidelines only, as in some cases data were not available to accurately figure all costs. Also, while these figures include direct costs for basic training, in some cases additional follow-up training was also provided. These costs do not include expenses for providing continued support in the field, which in some cases was extensive.
In spite of the tenuous nature of these cost figures, they do give an indication of the range of costs for training TBAs and other TPs. Direct costs for training a TBA in the projects ranged from US$30 to $110. Similar costs for training other TPs ranged from US$98 to $110.
7. Project Difficulties
Project staff reported a number of difficulties they experienced in different stages of planning and implementation. These difficulties did not necessarily occur in all projects, but are reported here in summary:
1. A few hospital physicians did not respect or trust the TPs, which led to fewer referrals between some of the TPs and these physicians. One staff member said this tended to happen more often with new young doctors who had to serve their required residence in a rural hospital upon graduation from medical school.
2. One project reported that at the beginning some of the older TPs were suspicious of the new training project and hospital staff and were reluctant to share their ideas in the training sessions. It was reported that they felt they were being spied upon, but these feelings disappeared after they gained confidence in the training staff.
3. Another project reported that they had difficulty in scheduling training sessions at times when all TPs were available. These were sessions held in the community and many TPs spent time cultivating their own farms.
4. A problem common to all the projects was that the low level of literacy among TPs made it difficult and sometimes impossible for them to keep good health records of their clients. One solution was to have these TPs enlist the help of a literate villager to help record information. A related problem occurred in projects where some TPs spoke only an indigenous language and the staff had to use an interpreter to communicate information.
5. Several projects indicated lack of adequate training materials such as slides, flip charts, models, and videos. And several staff said they would like to have more skills on how to teach adults, as they believed they put too much emphasis upon lecture and information giving and not enough on participation methods.
6. Both staff and TPs emphasized that not enough rewards were given to TPs for all their additional time and effort providing primary care services to communities. All agreed that more rewards should be given, but most staff said their lack of organizational resources made it impossible for them to provide anything more.
7. TBAs and other TPs stated they wanted to provide better facilities in their own communities for treating their patients. TBAs requested a room which they could keep clean, where they could store their own birthing supplies and deliver babies in private. Due to limited space, herbalists and bone setters also requested more room for their patients since sometimes they had to keep them for up to several weeks for extended treatments and recuperation.
8. In one of the Christian homes sponsored projects, the training staff encountered resistance and conflicts over differences between Christian doctrines of spirituality and traditional views of spirituality. Some Christian leaders thought the spiritual TPs were practising Paganism and using other ceremonies that Christianity forbid, and thus did not want to recruit such TPs into the programme.