A. REVIEW OF LITERATURE
A comprehensive review was conducted of readily available published literature, (books, periodicals, reports and papers), based on studies, reviews and projects where traditional practitioners were included in community settings.
This review was conducted utilizing the following published and unpublished sources:
1. The library computer systems of the University of California, Berkeley. This included the MELVYL and GLADYS systems, which link all University of California campus libraries as well as the MEDLINE System, which contains books and periodicals of the Schools of Public Health and Medicine.
2. The Combined Health Information Database (CHID) of the U.S. Public Health Service, Department of Health and Human Services, Communicable Disease Center, Atlanta, Georgia.
3. The World Health Organization’s Regional Offices in Africa, Southeast Asia, Western Pacific, the Americas, Eastern Mediterranean and Europe.
4. The International Health Policy Studies Program of the University of California School of Medicine, San Francisco, California.
5. The Network Secretariat, University of Luxembourg.
6. The School of Public Health, University of Sao Paulo, Brazil.
7. The Centro Internacional de Educacion y Desarollo Humano, Colombia.
8. The International Children’s Center (BIRD), Paris.
9. The Health Education Research Centre, Perugia, Italy.
10. Technologies for Primary Health Care (PRITECH), Arlington, Virginia.
11. The International Child Resource Institute (ICRI) computerized child resource information bank, (CRIB), containing records of information on child and family health from over one hundred countries.
12. The Hesperian Foundation, Palo Alto, California.
13. ICRI’s field representatives in 52 countries.
Those sources which conformed to the scope of this report were abstracted, reviewed and their references were researched to obtain further appropriate sources. These were in turn obtained, reviewed and abstracted where appropriate.
Several hundred articles, books, reports and papers were reviewed for this study, covering the years 1973 to 1990.
REVIEW OF UNPUBLISHED INFORMATION
ICRI contacted a wide range of organizations known or believed to have studied or worked with traditional practitioners to request unpublished information. These organizations were requested to supply any information they might have on studies or projects using traditional practitioners as community workers. We asked for any of the following information:
• Journal and newspaper articles
• Training materials
• Any other pertinent information about traditional practitioners as community health workers in various countries and regions.
B. FIELD EVALUATION OF ONGOING TRAINING PROGRAMMES
Using data collected from project documents along with field interviews and observations made during visits to the projects, this report presents qualitative descriptions of four case studies. Data are described and analyzed for each of the case studies, conclusions are drawn regarding the effectiveness of the projects and the lessons learned, and recommendations are made for further action.
The field work was conducted between September 1992 and August 1993. The Project Director was the principal investigator and, with the help of a counterpart who was assigned from each country, collected data during the field visits. Two weeks (10-12 working days) were allocated to collecting data at each site, with the exception of Bangladesh, where the two week period was divided between two NGO projects.
It was decided that in order to achieve the above objectives of the project, several sets of data must be collected:
1. Data to indicate how effective the training programmes were in imparting the desired knowledge and skills to the traditional practitioners.
2. Data to suggest what impact the traditional practitioner’s new services had upon the communities they served.
3. Data to recommend what types of training methods and materials are most appropriate in training traditional practitioners for PHC services.
Ideally, to measure the effectiveness of a training programme on its participants, and to determine the impact of trained traditional practitioners providing PHC services to a community, one would need to have measures of knowledge, attitudes and practices of the trainees before and after inception. In addition, a controlled experimental study should be established to eliminate other factors that might influence the relationships being studied.
This type of quantitative evaluation was not performed because the projects studied had not obtained such baseline data, nor had they established control and experimental groups from which to measure changes in peoples behaviour and health conditions as a result of the training programmes. Additionally, field conditions such as low literacy levels and limited project resources imposed constraints that made it impossible to collect quantifiable data.
In view of these circumstances, it was decided to obtain qualitative information such as beliefs, feelings, and observations from three groups of people who were vitally involved in the projects. Personal interviews were obtained from individuals of the following three groups:
1. Health agency staff members - the administrators, trainers and other related staff;
2. Traditional practitioners - the trainees and the providers of the PHC services;
3. Community members - the clients or recipients of the services.
The following four criteria were then established to measure the effectiveness of the training programmes:
1. What skills taught during training were traditional practitioners now utilizing in their communities?
2. How have the attitudes of traditional practitioners changed since training?
3. How satisfied were community members with the traditional practitioner’s services?
4. How has collaboration improved between traditional practitioners and health agency staff?
The following two criteria were established to determine the impact of the training programme on the communities:
5. How have the health behaviours of community members changed since traditional practitioners began providing these new services? (as perceived by interviewees in the three groups).
6. How have health conditions improved in the communities where trained traditional practitioners have worked? (as perceived by interviewees in the three groups and statistical data available from the health agency).
To ascertain the impact of the trained traditional practitioner on health behaviours and conditions in the community, health agency staff, traditional practitioners and community members were all interviewed regarding their perceptions and observations. High agreement among them was taken as evidence that a condition existed. For example, if responses from health agency staff and from traditional practitioners agreed that collaboration had improved between the two groups, then this was assumed to be a true outcome of the training programme. If TBAs reported that they had advised mothers to get immunized for tetanus, and mothers reported separately that they had gone to the clinic to get such immunizations, then it was assumed that these mothers’ behaviours were a result of the TBAs advice, which was assumed to be the outcome of training.
These interview data were supplemented by information obtained from examining project plans for the recruitment and training of traditional practitioners, evaluation reports, and other project documents.
1. Selection of sites for case studies
Traditional practitioner training projects were selected from countries that represented three major geographic regions of the world: Africa, Latin America, and Asia. From these regions four projects were selected that met the following criteria:
• Projects should be ongoing and TPs should have been performing PHC tasks for at least six months.
• Projects should represent the training of different kinds of TPs and the performance of a variety of PHC tasks, i.e.:
• health education;
• maternal and child care, including family planning;
• growth monitoring and nutrition education;
• diarrhoeal disease control, oral rehydration therapy;
• hygiene, safe water, and sanitation promotion;
• promotion of immunizations against common diseases.
(It was the intent that the projects together should represent the full range of PHC activities listed above.)
• Projects should represent government and non-government sponsorship.
• The sponsoring agency must be willing to assign a local counterpart full-time for the two week period to work with the Project Director.
To identify appropriate sites, these criteria were sent to the WHO Representatives of the above three regions as well as to selected non-governmental organizations. They were asked to recommend projects that might fulfil the criteria and whose sponsoring organizations would be willing to take on a field evaluation. Recommendations were obtained from each of the regions, and ICRI negotiated directly with the local organizations to make the final selections and arrangements.
Four projects were finally selected from the three regions for the evaluation. They included:
(1) The Dormaa Healers Project, in the Dormaa-Ahenkro District of Ghana, jointly sponsored by the Ministry of Health and the Presbyterian Health Services.
(2) The Cuetzalan Traditional Practitioner Project, in the State of Puebla, Mexico, administered by the Instituto Nacional Indigenista, a Government Institute which promotes the establishment of health services to indigenous populations of Mexico.
(3) The Manda TBA Project, in the Rajshahi District of Bangladesh, sponsored by the Christian Commission for Development in Bangladesh, a non-governmental organization connected to the National Council of Churches.
(4) The Savar TBA Project, located in the Dhaka District of Bangladesh, sponsored by The Village Education Resource Center, a non-governmental organization which provides maternal and child health services to villages.
2. Collection of data
A variety of documents were collected from each project. These documents included:
• Descriptions of project needs, objectives, and methods and the agency’s official policy for using traditional practitioners;
• Training objectives, protocols, and methods;
• Evaluation and progress reports;
• Data on costs of training and support services;
• Training and health education materials that were developed by the project or secured from outside sources.
Interviews were held with three groups: (1) key project staff and health agency personnel; (2) trained traditional practitioners; and (3) community members who received services from the project. We intended to obtain a random sample of the latter two groups, but this was not possible due to constraints of time and availability of respondents.
Standardized questionnaires were designed to obtain information about peoples’ knowledge, attitudes, and behaviour regarding the tasks traditional practitioners were performing, community members’ satisfaction with these services, and the extent and quality of collaboration between traditional practitioner and health agency staff. These questionnaires are reproduced in Appendices 1, 2, & 3.
All interviews were administered jointly by the Project Director and a counterpart from the local culture who was assigned by the local project staff. This counterpart, fluent in English and the local language, established rapport with the interviewee and asked the questions in the local language. He/she then translated the answers for the Project Director who recorded them in English. This process seemed to be effective in establishing rapport and collecting the desired information, as all respondents seemed willing and eager to provide the information requested. It should be noted, however, that it is possible in the translation of answers between the local language and English some accuracy or meanings may have been altered.
Another advantage of enlisting the participation of a local staff counterpart for the two-week period was that it provided a good opportunity for the Project Director to strengthen the counterpart’s skills in interviewing and knowledge of participatory evaluation methods.
c. Training and educational materials
All available examples of training and educational materials were collected for evaluation of the effectiveness of the classes and workshops. Additionally, these materials were used to develop guidelines to assist other organizations in training traditional practitioners in PHC services.
3. Analysis of the data
The responses from the interviews were categorized separately for each of the three groups: health agency staff; traditional practitioners; and community members.
Their responses were analyzed in terms of the following categories:
• performance of traditional practitioner after training;
• attitudes of traditional practitioner after training;
• community satisfaction of services offered;
• collaboration between traditional practitioners and health agency staff;
• changes in health behaviours of community members;
• changes in health conditions of communities.