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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

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