linguistic Minority Communities - SEAMEO

Communicating Life-saving
Health Information to Ethnolinguistic
Minority Communities
by Anne Thomas
NTFP, Ratanakiri
Cambodia

‣ Context
‣ Ratanakiri Case study:
• Cholera Epidemic
• Lessons Learned
‣ Ratanakiri NGO Health Education
• Clean Water
• TBA training
• TB training
• Community health volunteers
• Mobile teams: nutrition, malaria, HIV/AIDS
• Literacy Health Education
‣ Lao Case Study: Health knowledge research
‣ Summary- Ratanakiri, Lao Best Practices
‣ Conclusion

Context: Ratanakiri Province
‣ Ethnic Languages: 6
‣ Geography: Remote
‣ Education: Pre-literate,
newly literate
‣ Khmer Language: Very limited
‣ Beliefs: Animistic-
‣ Sickness caused by spirit world
‣ Water source: rivers, streams
Protection system
during epidemic

Ratanakiri Province-
240 villages
85,000 ethnic minorities
•Kavet-Brao-Krung
•Tampuan, Kachok
•Jarai

Case study: Cholera Epidemic
Ratanakiri

Unboiled
drinking
water,
especially
for rice wine
ceremonies
Animals under house,
no water or sanitation
facilities, contaminated
rivers, streams, wells

AWD/Cholera outbreak April-Aug 2010
Ratanakiri, Cambodia
LAO PDR
Mekong
River
Sesan
River
- Population
(2008) :150,466
- Ethnic
minorities:85%
- Population at risk
with malaria: 90%
- Districts:09
-- Villages:240
Pop. density:14/km 2
- HC : 11
- HP : 18
- RH : 01
- PHDO: 01
Source: Ratanakiri PHDBriefing (adapted)
Districts with
Cholera
outbreaks
April-Aug 2010

Krung
Ethnicity:
Kam Village
AWD/Cholera death
followed by funeral with
buffalo sacrifice
Rice wine ceremony
Unboiled water,
contaminated food

2 days later-
Every household
stricken- 90
persons total
3 deaths before
health officials
arrived
Community long house
transformed into
emergency treatment
centre

AWD/Cholera Epidemic
Ratanakiri: April- Aug 2010
1984 cases, 38 deaths
‣ Hardest hit province in the country
‣ AWD/Cholera epidemic spread faster,
lasted longer, and highest death rate in
ethnic minority communities
‣ Few medically un-attended deaths- if can
get to health facility promptly-
100% survival
(Source: Ratanakiri Provincial Health Dept Briefing)

• Some staff: Villagers want videos, not low tech
dramas‟
Challenges
‣Ethnic minorities:
High rates of
Transmission/death
‣Contaminated Water
‣Some NGOs:
•Decision makers on vacation
•Local staff: „Responsibility of health sector, not
education, com‟ty development sector‟
• „No money‟,„Not in workplan‟, „Not our mandate‟

‣ Government health staff
don‟t know ethnic
languages
‣ Avoid the word „cholera‟
‣ Communities :
• Few literates
• Limited or no Khmer
• Materials designed for
townspeople not
effective for minorities
Challenges cont‟d
‣„Taboo‟- closed villages

Opportunities
‣ Provincial Governor: „State of Disaster‟ –
mobilize all GOs, NGOs, IOs for health
education
‣ Provincial Health Dept: allow use of term
„cholera‟ for local health education
‣ Packet of cholera education materials already
approved/field tested/successful (1999)
‣ Education clearly makes a difference- especially
boiling water, good food hygiene

Opportunities cont‟d
‣ Local NGO can mobilize bilingual/bicultural
youth volunteers
‣ 50 Ethnic minority secondary students
return to villages from dormitories
‣ All NGOs have ethnic minority staff
‣ Some NGOs have excellent:
• Mobile health education teams
• Effective Video „spots‟, puppet shows
addressing cholera in local languages
• Flexible workplans- rapid response to allocate
staff, funds

Emergency mobile education teams
Bilingual staff & volunteers trained and equipped:
NGO staff, Youth, Students on Vacation, Gov‟t Health staff
Brao
volunteer-
Evening river
crossing with
illustrated
cholera
education kit

AWD/Cholera Picture story

AWD/Cholera Picture Story
‣Symptoms
‣Transmission: Contaminated
‣Water & Food
‣Good hygiene, attitude & behaviour
change essential:
Wash hands, boil water
‣Prompt referral saves
lives

Training + Providing Picture Story Kits:
‣50 indigenous students dormitory-
5 languages, 20 villages
‣Local NGO- youth volunteers-5 languages
‣District and commune Health Posts: 29
‣Provide kit: drama, song, pictures

Training Student volunteers
The drama that
saves lives
The song that
saves lives

Mobile teams- Drama in Villages
& Hamlets
Teams busy night & day at height of outbreak

Local Village Volunteers
‣Mobile Team trained
health volunteers each
community
‣Most community
members and volunteers
illiterate-
‣Illustrated handbook &
picture story ensures
correct information
‣Each volunteer
equipped with set of
illustrated materials

Village volunteers
taught to use
picture kit + give
short messages for
greeting on trail-
‣„Remember to boil your water
‣„Remember to wash your hands‟
‣„Cholera can be prevented‟
‣„Cholera can be treated- don‟t delay‟

Best
Practices
‣Bilingual ethnic actors
‣Interactive Question-
Answer, Soap as prizes
‣Humor effectiveengaging
audience
‣Audience of 200-300
common- for 2-3 hours

‣Consult with village
leaders to decide best
place for drama
‣Beware of breaking
taboos!!!!!
‣Flexible: under tree
outside if inside is „taboo‟
‣Partner w/government
to perform drama at
clinics, provincial
hospital
‣Coordinate w/NGO to
perform to crowd before
Puppet Show

10 verses!
Song easy to
learn and
remember
‣traditional
chant
‣ethnic
languages
The song that saves lives-
Symptoms, transmission, prevention, treatment-

AWD/Cholera-Kavet Ethnic Group

Patient‟s
house
Rice Wine
Ceremony-
Drinking
unboiled
contaminated
water

Peer Education – Literacy Teacher arrives
Remember the song:
„Hurry to Health Centre, don‟t delay
Cholera comes from contaminated
water, it spreads like wildfire
This water is contaminated-
Boil your drinking water
Patient needs re-hydration NOW
Hurry, don‟t delay!!‟

Patient‟s husband:
“Yes, I understand now
I learned the cholera song in
literacy teacher training
I remember the drama too
I remember now
But I did not know this was
cholera
I thought it was ordinary
diarrhea”
(3 months into epidemic)

Another life
saved through
peer
education in
local language

Mobile AWD/Cholera
ResultsTeams
‣ Attitude and Behaviour change!
‣ Villagers washed hands, improved water &
food hygiene, boiled water
‣ Prompt referral of patients- deaths
prevented
‣ Health Education by NGOs + treatment by
gov‟t medics helped contain epidemic

Lessons Learned
‣ Villagers open to learning+ attitude & behaviour
change during crises- Important to seize this
opportunity
‣ Drama:
• Low tech- 5 minutes to collect props - all
available locally
• Interactive- engages audiences
‣ Cross-cultural extension workers understand
local language and taboos
‣ Adjust story as needed
‣ Teamwork- Health Education + Gov‟t medics
providing treatment was key to success

Lessons learned
‣ Health education team must be invited by the
village leaders
‣ Village leaders must
agree to content of drama
location
‣ Bicultural team helps ensure
does not go
against their taboos
(heavy penalty if blamed
for bringing bad luck)
‣ Be flexiblehappy
ending OK
‣Message must emphasize
“quick referral for
treatment–don‟t delay”

NGO Projects:
Clean Water & Sanitation: ICC
„We see a huge difference
using local language vs. using
Khmereven
if they say “yes yes we
understand Khmer‟‟
Filter or well construction is
successful only when
instructions are given in
local language

Water & Sanitation- ICC
‣„It is crucial to use the local language in water
& sanitation education, even if people say „yes
yes we understand‟‟ ‟
‣BUT really they understand only about 30%
‣Must train ethnic staff of each language group
to be effective

Traditional Birth Attendant (TBA)
Training: ICC
‣ TBAs trained in 45 villages
‣ Use local language, interactive
training
methods for illiterates
‣ Ethnic minority midwives 2
districts competent as trainers
‣ Reduction in dangerous
practices & death
‣ Only 1-2 maternal deaths in 45
target villages in recent years

TB Peer Education-
V-ORT
‣ Patients trained as
peer educators
during 2 month
hospital stay
‣ Patients draw own
pictures
or select line drawings to color
‣Patients practice teaching peers before being
discharged
‣Receive‟Peer Educator‟ bag plus pictures

TB Peer Education, cont‟d
‣Over 450 patients
trained as peer
educators since 2006
‣Illiterate, from
remote ethnic villages
‣Project covers all 6
health centres treating
TB in province

Community Health Volunteers-
NTFP
Role play: importance
of immunizations

Community Health Volunteers cont’d

Health Education (HU)
‣ Mobile teams- specific topics
Overnight in villages- Nutrition,
malaria
‣ Video „spots‟ 6 languagesvarious
topics (inc. cholera)
‣ Community drama e.g. HIV/AIDStrain
community members to form
a mobile team-
• Find out local beliefs in each area,
adapt drama
• E.g. belief in Ratanakiri:
• ‘that person looks healthy, can’t be
sick with HIV/AIDS’

Integrate Health Ed into Bilingual
Literacy -ICC, NTFP
Cambodia NFE Department:
Literacy lessons: 5 topics
Bilingual NFE Curriculum-
2 x health lessons
Kavet Teacher training:
HIV/AIDS song

NFE Lesson Re-hydration lesson (Brao language)

Literacy
Curriculum-
Unicef “Facts for
Life”
Re-hydration
lesson
Discuss picture in
local language
before starting
literacy lesson

Ari Vitikainen photo
Lao PDR

Lao PDR:
Case Study
„ Field Research:
Gender and Ethnic
Issues that Affect the
Knowledge and Use of
Reproductive Health
Services‟
Ari Vitikainen photo
UNFPA
2006
Method: Local ethnic minorities trained to
gather information using local languages

Ethnic groups in the study
6 ethnic villages:
Bokeo Province: Akha,
Lahu Na
Oudomsay:
Hmong, Khmu
Salavan:
Ta Oy, Katang

Methodology
‣ Local ethnic male/female researchers trained to
conduct interviews in local language
‣ Interviews conducted in local languages
A „First!‟

North: Bokeo Province
Akha
Lahu Na
(Museu)

North: Oudomsay Province
Khmu
Hmong

Southern Laos
(Salavan) :
Katang
Ta‟oy

1. Key Finding:
Information Flow
„Immunizations‟
‣ Health official arrives, calls for village meeting
‣ Heads of household attend (males)
‣ Health official speaks national language (Lao)
‣ Village headman translates
‣ Men told to convey
message to their wives
‣ Outcome:
• few women hear
• very few children immunized

2. Key Finding: Population understands about
HIV/AIDS: 1 in 6 villages
Remote Hmong village
(almost no Lao
speakers):
‣ Old and young, men
and women- children-
Everyone!!
‣ High level of accurate
information &
knowledge

‣ Everyone in Hmong
village has clear
information –
understanding
about HIV/Aids!
‣ They don‟t speak
Lao
‣ Why? How?

‣ Hmong language
HIV/AIDS Radio
Drama
‣ Written by Hmong radio
broadcasters
‣ National radio
‣ People listened daily to radio
„soap opera‟
‣ Expansion: additional languages ‣UNESCO Cultural
in Laos, Cambodia
Section, Bangkok

Summary
Best Practices- Cambodia, Lao
‣ Recruit and Train ethnic
minority staff, students,
volunteers, community
members
‣ Local languages to
communicate:
drama teams, radio, videos
‣ Interactive, „popular ‣ Involve Education Sector
education‟ (not literacybased)
‣ Tailor activities: content,
‣ Strong Partnerships Gov‟t, message, method
IOs, NGOs

Summary- Best Practices
‣ Not- „One size fits all‟
‣ Design materials w/gov‟t, NGO, IO partners
‣ Find and follow up-to-date health guidelines
‣ Involve local population in design and
implementation
‣ Field-test materials
‣ Involve local community members: village
health volunteers, youth, students, peer
educators..
‣ Use innovative, low-tech and participatory
approaches (drama, songs, peer education)
‣ Share methods/materials between countriescross-border
ethnic groups

Conclusion
‣Do-Able
‣Creative methods
‣Low tech
‣By local peoples
‣Local languages
‣Knowledge, Attitude
AND Behaviour Change
‣Seize opportunities
provided by crises
‣Illustrated picture stories for
illiterate health workers:
Message clear, correct
‣Integrate health messages
into education sector
‣Strong partnerships key

Future opportunities?
‣ Opportunity: Hmong and Khmu TV: 30
min. 2x daily
‣ Cross-border sharing of informational
materials: videos, pictures, songs..
‣ Cross-border sharing & exchange of
information between target populations +
NGOs- „Don‟t re-invent the wheel‟
‣ Announce cholera promptly

References
‣ Thomas, Anne E, Louangkhot, Ny. Gender and Ethnic
Factors Impacting Reproductive Health Information and
Practice in 6 Ethnic Villages, (Volumes 1, 2) UNFPA
Lao 2007.
‣ „From Bullets to Blackboards‟ www.riseinstitute.org
‣ Dr. Hoy Vannara, Ratanakiri PHD, AWD/Cholera
Briefings, PHD Office, Provincial Office. July, Aug 2010