Posted by: lilyhamburger | January 9, 2010


HAPPY NEW YEAR! I celebrated the turning of the decade by making 150 ladoos (yummy sweets made from gram flour) on the kitchen floor, and then watching a little lunar eclipse on the roof while eating “chana” and “dhana” (dried chick peas and peanuts) as a full moon prayer service echoed in the distance. Before the adventures – culinary and otherwise – distract me, I want to tell you a little bit about the work I am doing here at ARCH. I’m teaching English to the staff, and hoping to start work on the website ASAP, but mostly I’m helping with a community health project. It’s like a dream come true for me. But I’m about to get serious, are you ready?

Before I arrived, community health staff here had started doing direct education sessions in the villages to teach people about basic hygiene and preventing common illnesses like scabies and diarrhea. But they were going out and giving a slideshow lecture that lasted over an hour, and villagers weren’t really inspired to change their behaviors. So they asked me to come up with ideas to actually get people to change and adopt behaviors like washing hands, bathing with soap and a clean towel, washing clothes, covering food and drinking water, etc. When this project idea was first outlined for me, my brother reacted as a brother only should: “YOU are teaching about hygiene?!” Yes.

As you can imagine, explaining the reasons behind these behaviors to people without any concept of germ theory and a completely different outlook on the world, not to mention personal hygiene, is difficult. It requires a lot of creativity about communicating new concepts to people with zero education and a very short-term view of actions and consequences (i.e. no concept of prevention, only “I am sick so I need medicine”). I could not come up with a way to teach villagers without input from people here who know more about their perspective than I do – experienced staff and people from the villages.

First, I made this up using some hints from similar projects I read about online:

Steps to creating an effective behavior change program:

1. identify ideal behaviors

2. identify current behaviors

3. identify constraints for each ideal behavior (beliefs and logistics)

4. identify possible solutions

5. develop communication strategy for introducing solutions

I talked these steps through with the ARCH community health higher-ups (spontaneously, one Sunday that I thought was a day off…there is NO advance planning in my work life it’s slightly insane). Here is what we came up with – mostly it’s a reorganization of what they have been working with already:

Common Illnesses Ideal Prevention Behaviors
A. Skin Infections

– scabies

– lice

– ringworm

– boils

– daily bath with soap and plenty of water

– separate, clean towel

– clean clothes daily

– closed bathroom

– head bath once per week

B. Gastro-intestinal

– Diarrhea

– Amoebiosis

– Worms

– Abdominal pain

– Acidity

– toilet

– safe drinking water = safe source and safe handling

– safe food = fresh and covered; clean kitchen

– hand washing (before and after certain activities)

– cutting finger nails

– hydration for diarrhea

C. Malaria and fever – no open stagnant water

– spray DDT

– gambuzi fish

– mosquito net

– chloroquine at monsoon

D. Respiratory

– Cough and cold

– Pneumonia

– ventilation of house

– avoid kitchen fumes

– separate handkerchiefs

– hand washing

– immediate treatment

E. Deficiency diseases

– Anemia

– Night blindness

– Goiters

– Child malnutrition

– nutritious diet rich in iron, iodized salt (yellow fruits and green vegetables)

– grow vegetables at home

– treat worms

– iron tablets for women

– identify anemia as illness

– vitamin A supplement

– breastfeeding from day 1 and supplementary food at 5-6 months

– infant immunization

– immediate treatment

F. Oral hygiene – brush teeth twice per day

– rinse mouth after meals

– eliminate bad habits such as tobacco and sweets

– treat problems

They picked out three villages to pilot this project in based on where the most competent field staff are. We drafted a plan for a program that involved teaching key messages for one health topic each month. I was then asked to plan a meeting to discuss the plan as well as communication strategies with supervisors from the villages. I brainstormed all the strategies I know about communication and motivating people. Guys I was thinking back to my 9th grade CAP classes (don’t put too much text on one slide) and all the way up to coaching Takoma Fire softball (positivity motivates!). It was so invigorating to feel like my education, my personality, and my professional experiences had all provided me with skills to contribute substantively to this effort. I have never felt that before.

At the meeting with the village supervisors, first we went through the ideal behaviors and barriers, which yielded a lot of insights from the village supervisors! I was so happy that they felt comfortable talking and had things to contribute because a lot of the time the health workers don’t. And I felt like ARCH staff was running the meeting but using my methodology and it was working. Don’t get me wrong, the language barrier was agonizing, but we learned a lot from each other I think and came up with some good strategies for the program. We listed activity ideas for teaching about health topics and engaging villagers in the messages instead of lecturing them. The revised program looks like this:

Community Health Awareness Program 2010

Timeline and Plan Outline

(Revised 28 December 2009)

This pilot program will be conducted in 3 villages over the next 6 months. After evaluation and revisions are complete in August 2010 the program will be repeated in other villages in ARCH project areas. The pilot villages and staff are as follows:

1. Malgar – Chandar Bhai (HW) and Sarad Bhai (coordinator)

2. Mamabhacha – Purvi Ben (HW) and Ramesh Bhai (coordinator)

3. Nagariya – Madhu Ben (HW) and Mayur Bhai (coordinator)

Program outline:

1) Meet with key persons in each village

a) The HW and coordinator will select influential villagers to attend an introductory meeting in the first month (Jan 2010).

b) All ARCH community health staff will attend, including all HWs from the area.

c) At this meeting, the Ideal Behaviors – Practical Solutions dialogue activity will be conducted, and all primary disease prevention messages will be summarized using posters and picture reading as an overview of what is to come.

d) HWs will practice conducting this meeting when the HW meeting is held at the beginning of the month. Then all HWs will be introduced to the communication methods.

2) Introductory meeting with each hamlet

a) In the second month (Feb 2010), HWs and coordinators will conduct an introduction to prevention and improving village health in each hamlet of the village (or those which are accessible).

b) ARCH community health supervisors will attend the first of these orientation meetings, and the subsequent meetings will be conducted by the HW and coordinator alone.

c) At this meeting, a foundation of dialogue and open communication will be established. Few messages will be delivered, but the concepts of prevention and improving health should be discussed. HWs and coordinators should clearly state their role so villagers do not get the wrong impression of why we are coming.

3) Topic-specific meetings each month

a) At the beginning of each month, one primary disease is introduced to each village with 2 to 3 key prevention messages.

b) This presentation is conducted by the HW in each village, and ARCH community health supervisors are present for the first meeting of the month.

c) Interactive activities are used to engage villagers and explain the key behavior change messages.

d) One activity each meeting will focus on germ theory and/or the concepts of clean and dirty.

e) When a key behavior is introduced that may require a new household item, such as soap, towels, a ladle, etc., ARCH should sell items at a subsidized cost at the session, and inform villagers that these items are always available with the HW, just like the medicines.

4) Follow-up activities each month

a) In the weeks following the introduction, the HW and coordinator will conduct follow-up activities – planned in advance for each village – to reinforce the focus messages of that particular month, and to personalize prevention solutions for villagers.

b) HWs try to reach as many villagers as possible through these activities, and will visit each hamlet to observe behaviors.

c) HWs are compensated for their efforts.

5) Reporting and planning meeting

a) At the end of each month, HWs and coordinators report back to ARCH community health staff about their experiences. Together they record barriers as well as progress in each village.

b) Using the experiences of the last month, plans will be made for the next month’s activities.

In this pilot program, health topics will be introduced according to the season in which they are relevant. The calendar as it stands now:

January Introduction for selected people
19 Nagariya
25 Mamabhacha
27 Malgar
29 Reporting and planning (all at ARCH)
February Hamlet-wise intro meetings
Nagariya (first day)
11 Malgar (first day)
17 Mamabhacha (first day)
March Skin and oral hygiene
April Respiratory
May G.I.
June Deficiency diseases
July Malaria
August Evaluation and planning next phase

If you’re still reading, I can’t believe it. Hopefully you skimmed some of that…. Anyways I have been working hard on some visuals – refreshin the ol’ Photoshop skills – to use at the introductory meetings. I got them ready for the supervisors to practice on the health workers this week. Watching the ARCH staff coach this 40 year old on public speaking was not only a reminder of the incredible quality of education I take for granted, but also of the little moments of empowerment that come to individuals in unlikely places.

It’s a whirlwind of unplanned planning sessions, transferring files from one computer to another on a pen drive, and trying to strategize for this impossible task with people who barely speak my language. But it feels like everything in my life as someone who dreams of adventures, improving people’s lives, communicating across cultures, and learning about the world has lead me to this. I can’t believe how lucky I am.

That’s all for now, I’m off on a 4 day tour of Gujarat with 50 teachers tonight and ending at the national kite festival in Ahmedabad with my American friends!



  1. After finishing Three Cups of Tea today, I realized that you remind me of Greg Mortenson; promoting education that will save lives on the other side of the planet.

    During our faculty conferences, I’ve noticed that the staff responds positively toward little things, such as food and get-up-and-move activities, engaging the agenda or topic of the day.

    You have been working really hard on this I see. I know it will work out for the best. Your work is purposeful and inspirational. Keep on keeping on!

  2. um, you are the dudh. fo sho.

  3. Lily, ,
    I’m awed by your work (and play!). It sounds like an ongoing process of puzzle-solving–challenging, stimulating…You’re just the person for the job. Go, Lily!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s


%d bloggers like this: