A Social Vaccine for Globalization.Full paper.


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A Social Vaccine for Globalization:Through People-Led Health Promotion and Community Development

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A Social Vaccine for Globalization.Full paper.

  1. 1. A Vaccine for Globalization: Through People-Led Health Promotion and Community Development 2004 Produced by: Uthaiwan Kanchanakamol, Director of The Institute for Community Empowerment, Thailand and The Chiang Mai Health Promotion Network • Ban Mae Faek Mai • Ban Mae Huk • Ban Mae Jong • Ban Nong Wai (Muay Thai) • Ban Saluang • Ban San Pa Bao • Ban Sri Boon Ruang • Karen Hilltribes in Ban Mae Jaem • Karen Hilltribes in Ban Mae Pakee • Lahu Hilltribes in Pha Hom Pok Mountain • Society of Lanna Healers Research and Editorial Assistance provided by: Jennifer A. Meyer and Timothy A. Struna
  2. 2. A Vaccine for Globalization A Vaccine for Globalization: Through People-Led Health Promotion and Community Development ICE and the CBO’s hope that by documenting and sharing their experiences future public health and community development initiatives can build on their achievements and learn from their struggles. 2004 Produced by: Uthaiwan Kanchanakamol, Director of the Institute for Community Empowerment, Thailand And The Chiang Mai Health Promotion Network • Ban Mae Faek Mai • Ban Mae Hak • Ban Mae Jong • Ban Nong Wai (Muay Thai) • Ban Saloang • Ban San Pa Bao • Ban Sri Boon Ruang • Karen Hilltribes in Ban Mae Jaem • Karen Hilltribes in Ban Mae Pakee • Lahu Hilltribes in Pha Hom Pok Mountain • Society of Lanna Healers Research and Editorial Assistance provided by: Jennifer A. Meyer and Timothy A. Struna 1
  3. 3. A Vaccine for Globalization 2
  4. 4. A Vaccine for Globalization Preface and Acknowledgments S ince June 2001, the Chiang Mai area, Thailand, had been selected for a pilot project in which health-care was decentralized to local governments and community groups. Local area health-care was planned and programs implemented under the authority of provincial health boards consisting of representatives from local government, the communities themselves and the Ministry of Health. There was an urgent need to prepare the communities and their representatives to effectively participate in that new system. The participatory research project had been initiated in the year 2001, entitled” Challenges of health in a borderless world” under the support of Fulbright New Century Scholar program throughout the 2001-2002 grant years. Within the broad range of research project, the critical aspect had been focused on increasing community capacity and empowering community members to improve the health and well-being of Chiang Mai hill tribes and low-income groups in three Thai districts. The proposed research was participatory action in nature, aiming: to determine how to improve implementation and effectiveness in promoting the integral development of youth, seniors and women in Hill tribes and low income communities while increasing community cohesion and collaboration through cultural, political, social and artistic activities; to determine how to improve implementation and effectiveness in promoting development of skills among sub-district administration / organization and municipality personnel in the area of community development; to determine how to improve implementation and effectiveness in promoting creation of community partnerships by local actors for health promotion. This involves providing incentives, skills and strategies to community members to enable their effective participation in designing and implementing new autonomous health care and social service systems that meet local needs. This was especially crucial for disadvantaged groups like the Chiang Mai HillTribes and other low-income communities. Specifically, it was proposed that proven, effective participatory action techniques are utilized to educate, empowers, and involves members of these communities. These include training in the use of focus groups, Delphi methods, consensus development through negotiation/compromise techniques, participatory planning, needs assessment methods (with emphasis on "asset-based" methods developed by McKnight and Kretzman) and basic program participatory evaluation techniques. In addition, community organizations such as community hospitals, NGOs, local governmental groups were enlisted as collaborators in this learning process. Their involvement had the additional advantages of identifying issues early-on for discussion and resolution, enabling coalition-building and increasing trust between the three partner groups. In the year 2002-2003, the Thai Health Promotion Foundation provided funding for the strengthening Chiang Mai community health promotion network and monitoring and support for its project. The aim was to buildup a network of partners within an atmosphere of working cooperation characterized by solidarity. It was believed that this is partially attributable to the culture and traditions of Thai society, which are favorable toward working to build up health, together with the fact that the state is interested in 3
  5. 5. A Vaccine for Globalization health. Our participation in this study has led to an increased awareness of the dark side of globalization and the need to prepare the community people for building a community and social vaccine for combating those negative consequences. We believe that the social vaccine concept will help bring a multiplicity of perspectives and approaches to global health challenges and might be helpful to the south in setting priorities for defining the global health agenda in the future. Many people helped and encouraged us as we worked on this project. First we would like to thank all the community leaders, the brave and strong marginalized people who led health promotion and community development path by using asset-based, internally focused, relationship driven, including Mr. Intorn Kao-prated, Mr.Tanagorn Phomnuchanon,Mr.Preeda Thakrow, Ms.Phongpan Sakwongdaroon, Mr.Arnan Leraman, Mr.Adul Srisawat, Mr.Aphichart Chawwiang, Ms.Kommoon Intasit, Mr. Pa-ae Jalawpa, Mr. Pherapong Pattanaplaiwan, Ms.Prapai Armornsak, Mr. Phrommin Boacheanbaan, Ms.Sawart Jantalae, Mr. Sonthichai Somkate, Mr.Wasan Wiwatcharearn, Ms.Fongjan Wan-on, Ms.Narisa Pongsopa, Mr.Boonchoo Chantarabutr, Mr.Comchan Wichairat, Ms.Boonsri Chom-ngern, Mr.Boonmee Sangnoon, Mr. Decha Chotsooksiangwiwek, Ms.Boosaya Kunagornswat.Pra Pongtep Techakarugo We would like to provide special recognition to all the state and local public health leaders who have assisted us, including Dr. Amorn Nonthasute, ex-General Director, Thai Ministry of Health, Mr. Teerapan Techa, Ms. Nit Kao Sa-ad, Mr.Terdsak Seur-im. Within the academic community, we have many outstanding colleagues who have contributed to our work in a variety of ways. They include the 30 Fulbright New Century Scholars from all over the world especially Dr.Ilona Kickbusch from Yale University, the distinguished scholar leader, Assistant Professor Dr. Sasitorn Chaiprasit, Associate professor Dr.Songwut Toungratanapan, Assistant professor Vichai Wiwatkunuprakarn, from Chiang Mai University, Professor Dr.J.M.Navia and Professor Dr.David Coombs from University of Alabama at Birmingham. Finally, we would like to express our sincere gratitude to the Council for International Exchange of Scholars (CIES), The Fulbright New Century Scholar Program (NCS), Thai Health Promotion Foundation and colleagues, especially, Ms. Sirinapa Sathapornwachana whose tireless patient contributed this project, Mr.Chaiwa Sitkongtang, Ms. Jennifer A. Meyer and Mr. Timothy A. S. Struna who provided the fruitful research and editorial assistance. Uthaiwan Kanchanakamol DDS, CDPH, MPH Fulbright New Century Scholar 2001-02 Director, Institute of Community Empowerment (ICE), Chiang Mai, Thailand Chiang Mai Health Promotion Coordinator 2002-03, Thai Health Promotion Foundation 4
  6. 6. A Vaccine for Globalization 5
  7. 7. A Vaccine for Globalization Abstract In October 2001, the Institute for Community Empowerment (ICE) launched a Participatory Action Research (PAR) project. ICE used participatory techniques and Assets-Based Community Development (ABCD) strategies, for increasing community capacity and empowering community members to actively engage in a newly formed decentralized health care system. ABCD has been recognized by health and community development professionals as a valuable alternative to the traditional needsbased/deficiency-focused approach for health programming and community development. However, community members’ perspectives on ABCD are under investigated, and methods for evaluating the impacts of ABCD are only beginning to be addressed and analyzed. The purpose of this case study was two fold; first to build a more holistic understanding of ABCD programming by exploring community representatives’ perspectives on their own ABCD programs. And second to describe how 11 Community Based Organization’s (CBO’s) developed a method to identify and evaluate social changes within their communities by asking the question; “if the ABCD approach claims to lead to community empowerment and self-determination, as written in the ICE program ‘Increasing Community Capacity for Health Promotion and Well Being Project’ how can the participating CBO’s measure these potential changes in their communities?” Information for this case study was gathered over a four month period, December 2003 through March 2004, under the direction of ICE. The methods used to gather information were primarily qualitative including; document review, direct observation and participant observation. Community representatives described their experiences through a series of site visits, natural focus group discussions and semi-structured interviews. The results from this qualitative investigation indicate that the CBO’s in this case study expanded the standard process of building on ‘strengths’ (local assets, skills, local resources etc.), to also include cultural traditions (local music, dance and traditional healing methods). These cultural traditions go beyond traditional dance, health methods, and music to encompass a shared ‘way of thinking,’ living and viewing the world. It is here in the conservation of indigenous ways of thinking or being that we see the link to both health (physical, mental) and the environment (physical or social community development). Community members mentioned frequently one of their frustrations with health and community development programs in the past was they were limited to a specific age group, disease group, or gender. By mobilizing communities around shared traditional culture, in contrast to the standard approach of mobilizing around a specific problem or disease, more community members from all age groups came together for health promotion activities. Also, centering programs on their traditional/cultural ways of life was consistent with how individual community members identified themselves, thus 6
  8. 8. A Vaccine for Globalization reinforcing their collective identity and self-esteem. Additionally, when CBO’s reached out to local and external resources for partnership or support they did so with compelling concepts in hand, thus leveling the playing field, or power structure. To explore the second question, 11 CBO’s developed an evaluation method, based on the concepts of participation and empowerment, to translate what they ‘see happening’ in their community into ‘measurable variables and indicators’ of outcomes and impacts. The evaluation method was developed during a series of workshops facilitated by the director of ICE and attended by CBO representatives. Their 9-step method consisted of identifying, clustering, categorizing, prioritizing, rating and reflecting on ‘changes’ that had taken place within their community since they began their health promotion and community development activities. The evaluation was implemented in 11 different communities during a community meeting facilitated by the director of ICE and 1-2 CBO representatives. The evaluation provided quantitative information by using a number scale from 1 - 7 to rate each identified change, and qualitative information by including community member comments related to each rating. The results of the 9 - step evaluation will be used by the CBO’s to supplement quantitative reports submitted to funders to show evidence of the broad social changes taking place in their communities. Secondly, the stories shared by community members to define each significant change will be used to assist in the design and implementation of future health promotion programs. Thirdly, the 9 - step method developed by the CBO’s during workshops will be incorporated into a facilitator guide produced by ICE to assist in conducting future workshops and evaluations. This case study concludes there is evidence from the perspective of community representatives that supports the utility of an ABCD strategy for community development and health promotion. This observation also reflected the main themes revealed through qualitative data analysis (community pride, traditional culture, freedom, community dialogue, and community power). In addition, the self-identification and definition of community changes; unity, local wisdom, warmth, etc., elicited through the facilitation of community dialogue during each evaluation, reinforces the theory and adds to the conclusion that when community members develop and evaluate their own health promotion initiatives there is a stronger chance for sustainable community growth, motivation for future health promotion efforts, and the creation of self-sustaining capacity building initiatives. The director of ICE, Dr. Uthaiwan Kanchanakamol commented on these phenomena and explained that by practicing health promotion and community development through the conservation of indigenous knowledge and traditions the CBO’s are effectively creating a ‘vaccine against the ill-effects of globalization.’ 7
  9. 9. A Vaccine for Globalization TABLE OF CONTENTS Preface and Acknowledgments Abstract Table of Contents List of Figures List of Tables Glossary 2 5 8 9 10 11 Chapter I: Introduction Thailand Chiang Mai ICE, Thai Health, and the Network Purpose of Study 12 13 14 14 19 Chapter II: Literature Review Community Participation Empowerment ABCD Appreciative Inquiry Educational Pedagogy Participatory Evaluation Empowerment Evaluation 21 22 22 23 24 26 27 27 29 Chapter III: Community Perspectives 32 Chapter IV: Evaluating Social Change 55 Chapter V: Limitations Chapter VI: Conclusions and Recommendations 89 92 References Additional Resources Appendix A: ICE Proposal Appendix B: Overview of Project Operations Appendix C: Example of Semi-Structured Interview Appendix D: ICE User-guide Appendix E: CBO Quantitative Evaluation Results Appendix F: Time-Line 96 100 108 116 123 125 146 156 8
  10. 10. A Vaccine for Globalization LIST OF FIGURES Figure Number Page 1. Mae Chaem Rehabilitation and Development of Herbal Medicine Group Variables of Community Change – Star Plot 73 2. Mae Chaem Rehabilitation and Development of Herbal Medicine Group Indicators of Coordination – Star Plot 76 3. Frequency Graph Summary of all identified ‘variables’ 85 9
  11. 11. A Vaccine for Globalization LIST OF TABLES Table Number Page 1. Results of Step 1 – Step 5 65 2. Results of Step 6 69 3. Results of Step 7 70 4. Results of Step 8: Variables of Community Change and Central Tendencies 73 5. Cooperation Breakdown 74 6. Indicators of Cooperation 75 7. Mae Chaem Rehabilitation and Development of Herbal Medicine Group Indicators of Coordination – Central Tendencies 76 8. Pile Sort 1 Summary of all identified ‘variables’ 78 9. Pile Sort 2 Summary of all identified ‘variables’ 79 10. Table of ‘Sorted Variables’ 81 11. Types of Community Development Approaches 102 12. Qualitative Inquiry Activities 103 13. Themes and Illustrations 104 10
  12. 12. A Vaccine for Globalization GLOSSARY ABCD: AI: CBO: DDP: GO: ICE: NFG: NGO: PAR: PHC: PRA: SAO: SBD: ThaiHealth: UNAIDS: UNICEF: WHO/SEARO: Assets Based Community Development Appreciative Inquiry Community Based Organization Department of Drug Prevention Government Organization Institute for Community Empowerment Natural Focus Group Non-Government Organization Participatory Action Research Primary Health Care Participatory Rural Appraisal Sub-District Administration Organization Strength Based Development The Thai Health Promotion Foundation Joint United Nations Program on HIV/AIDS United Nations Children’s Fund World Health Organization South East Asian Regional Office 11
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  14. 14. A Vaccine for Globalization Chapter I: Introduction Thailand The Thai government is a constitutional monarchy, and the country has progressively moved towards democracy over the last thirty years. About 18% of the 62 million people in Thailand live in urban centers. Approximately 85% share a dialect of Thai, in addition to 8% speaking Thai-Lao, found in the Northeast, and another 8% speaking Northern Thai, commonly referred to as Lanna. Thai-Lao and Lanna share some similarities linguistically, and in written form. The predominant religion is Theravada Buddhism, practiced by almost 95% of the population. The majority of Muslim’s live in the southern region and make up the next largest religious group at 3%, followed by Christians (1). Health statistics include a 92+% literacy rate for both men and women, with free compulsory education up to grade six. Thailand is well recognized for a dramatic reduction in their population growth from 3.1% in 1960 to about 1% today (1). At the end of 2001, UNAIDS estimated that 1.8% of the adult population are living with HIV/AIDS. This is one of the highest prevalence rates outside sub-Saharan Africa. Thailand’s current health system offers universal health care through a recently initiated policy known as the ‘30 baht program.’ Under this program, individuals can receive any service at the local public hospital or health station for a 30 baht fee (approximately 75 cents) (2). There is a specific list of drugs and services covered by this program. Private medical care is also available in the provincial capitals. According to Dr. Prawase Wasi (2000), a health care reform activist, Thailand has a sound health care infrastructure. However, he calls for a change in the ‘ill-health orientation’ of the disease control and prevention system to incorporate ‘good-health oriented’ systems of health promotion as well as continued health care reforms based on improved national health care research (3). The government health care system is based on the Western bio-medical model. Also officially recognized is the Aruvedic based Thai Medicine, ‘MorPatPhanThai,’ and 13
  15. 15. A Vaccine for Globalization Lanna or Northern Traditional Healing based on the holistic concept of “enhancing happy living through the spirit, the body, the community and the environment” (4). In the North, traditional healers are referred to as ‘MorMuang,’ and practice at the community level. Hill tribe groups also have local healers whose practices range from Shamanism to herbalism and massage. Chiang Mai Chiang Mai, known commonly as “The Rose of the North,” is located 700 Km north of Bangkok. Northern Thailand shares borders with Burma to the west and Laos to the east. The city of Chiang Mai is over 700 years old and was ruled by the Burmese until 1775. The provincial population is estimated at 1.6 million people, of which 160,000 live in the capital (1). For over two hundred years, semi-nomadic ethnic minority groups referred to as hilltribes have lived in the mountains of the northern region and along western borders. Currently, their combined population includes approximately 550,000 people. The Tribal Research Institute in Chiang Mai officially recognize 10 different hilltribes however, there may be as many as 20 (1). In terms of linguistic groupings among hilltribes, the most common are; Tibeto-Burman (Lisu, Lahu, Akha), Karenic (they refer to themselves as ‘Ba-Kur-Yoa’, or Garieng) and the Austro-Thai-Chinese (Hmong, Mien). The Karen are the largest group numbering around 322,000. In these high remote areas most people practice subsistence farming, while a small percentage engage in ‘for profit’ agriculture and recently, tourism. The predominant religions tend to be animist or ancestral worship, unless influenced by missionaries or Buddhism (1). ICE, ThaiHealth, and the Network The Institute for Community Empowerment (ICE) is a Non-Government Organization (NGO) directed by Dr. Uthaiwan Kanchanakamol. The organization promotes and practices health promotion through the concepts of Assets-Based Community Development (ABCD). Their purpose is to facilitate the internal processes of capacity building and empowerment among local communities through teaching the 14
  16. 16. A Vaccine for Globalization skills necessary to conceptualize, plan, implement, and evaluate health promotion and community development programs. ICE works with 22 Community Based Organizations (CBO’s) from three districts in the Chiang Mai province of Thailand. The 22 CBO’s are located in city, suburban, and hill tribe areas all defined as low income or ‘marginalized’ communities. In June of 2001, Chiang Mai and fifteen other provinces were selected as pilot sites in which health care service decision making was decentralized to the local provincial government and community groups. Decisions were to be implemented under the authority of newly created boards consisting of members from local government, representatives from CBO’s, and Ministry of Health officials. This national initiative recognized the need for not only the participation of health service professionals and local government officials, but the popular sector as well (see Appendix A). In order to prepare local communities, especially members of marginalized groups and women, with the skills necessary to act within this new system, ICE proposed a Participatory Action Research (PAR) Program entitled “Increasing Community Capacity and Empowering Community Members to Improve the Health and Well- Being of Chiang Mai Hill Tribes and Low-income Groups in Three Thai Districts” (see Appendix A). The ICE staff includes a director and two assistants. Most of their operations, including a community radio station focused on health promotion and community empowerment, are operated by volunteers. ICE’s founder and director was influenced by years of professional academic public health experience, environmental activism, as well as fieldwork among marginalized communities. The central themes of ABCD, or Strength Based Development (SBD), are present in the operations at ICE, while conceptual frameworks of the approach have been adjusted to fit the Northern Thai context. Unfortunately, a number of factors combined to breakdown the proposed Provincial board development. However, ICE continued its work building partnerships with CBO groups and assisting them in applying for health promotion program funding. ICE continues to concentrate its energies on working with 22 local CBO’s assisting them in moving through a relationship driven dialogue oriented process, in order to propose, 15
  17. 17. A Vaccine for Globalization conduct and evaluate their own community based health promotion and development projects. (see Appendix B) ICE was recognized by the Thai Health Promotion Foundation as a center for teaching community capacity building techniques, with a focus on health promotion and community development. The Thai Health Promotion Foundation, or ThaiHealth, was established in 2001 as a state agency. This agency was created as part of the national health care decentralization initiative to manage and distribute ‘sin tax’ money collected from the two percent taxation of cigarettes and alcohol. ThaiHealth was set up to encourage, support and fund health promotion activities for public health within the concept: “All Thai People will have a better life and can earn their living with wellbeing. This development will proceed through by the collaboration of all key factors and a unified intension. Through this concept Thai people can live well and be happy by relying on themselves.” (5). Operating dimensions emphasize healthy public policies, issue-based programs, and holistic ‘setting’ approaches. According to the ThaiHealth website, “Most of Thai people’s health problems and deaths result from their personal misbehavior, misbeliefs and other preventable causes such as smoking, drinking alcohol or traffic accidents.” They continue, “The World Health Organization (WHO) has defined the aim of public health not only to eliminate diseases from human life, but also to build up well–being for balancing the physical, spiritual and social health. Moreover, the WHO has declared health promotion strategies through the Ottawa Charter, and Thailand has responded by pushing the substantial movements for well–being of Thai people. Thai Health provides catalytic funding for projects that change public values, people’s lifestyles, and social environments” (6). The Ottawa Charter for Health Promotion called for renewed commitment; 1. for the development of healthy public policy, and equity advocacy in all sectors. 2. to counteract the pressures towards harmful products, resource depletion, unhealthy living conditions, and environments, and poor nutrition; and to focus attention on public health issues such as pollution, occupational hazards, housing and settlements. 16
  18. 18. A Vaccine for Globalization 3. to respond to the health gap within and between societies, and to tackle the inequities in health produced by the rules and practices of these societies. 4. to acknowledge people as the main health resource and find ways to support and enable them to keep themselves, their families and friends healthy through financial and other means, and to accept the community as the essential voice in matters of its health, living conditions and well-being. 5. to reorient health services and their resources towards the promotion of health; and to share power with other sectors, other disciplines and most importantly with people themselves. 6. to recognize health and its maintenance as a major social investment and challenge. (Ottawa Charter link can be found at the ThaiHealth website) The founding board of ThaiHealth was very progressive and interested in funding local groups directly, bypassing the non-government organizations. Thus, it was important that these CBO’s learn to speak the language of the funder (and vice versa), striving to bridge this standard communication disconnect. ICE receives only travel reimbursement monies for their work from ThaiHealth, and all program operation finances are transferred and managed directly by CBO’s. This decentralized approach intended to give community groups the control to develop their own health promotion programs, and to seek out the assistance of NGO’s or Government Organizations (GO’s) to partner with, if appropriate. Prior to this paradigm shift, communities were dependent on these NGO’s and GO’s to meet the needs of their community. Recognizing the fundamental changes of this approach, ThaiHealth supported ICE and its program, ‘Increasing Community Capacity for Health Promotion and Well Being Program’. The goal of ICE’s project was to strengthen and empower communities to meet this new challenge. ICE invited CBO members, considered to be ‘natural leaders’ of their respective communities, to attend workshops on how to conceptualize, plan and implement local health promotion programs. There was no financial incentive for attending the workshops; the only incentive was knowledge. The community analysis 17
  19. 19. A Vaccine for Globalization and program planning phases occurred over approximately nine months before the CBO’s submitted proposals for funding and began implementation. Each CBO is represented by a “natural leader,” sometimes more than one person, and referred to throughout this document as a community representative(s). These leaders/representatives are not individuals who hold an official position in the community necessarily, but they are the community members that seem to ‘get things done’. The criteria ICE was seeking in a natural leader was someone who could; • Facilitate group discussions • Be a strong link between the community and resources • Stimulate participation • Catalyze and facilitate discussion • Be at ease during trainings • Comfortable working at the community level and • Effective in mediating conflict (Personal communication with ICE director) Beginning in late 2001, CBO representatives met for monthly workshops at ICE to learn assets building processes and participatory action techniques. Some traveled up to six hours one way to attend these sessions. During the first three months they learned how to conduct assets mapping in their own communities. During the second three month period they participated in future search conferences with local authorities from their own communities in order to build participatory planning strategies. CBO representatives learned about health promotion paradigms, advocacy, mediation strategies, team building techniques, social action strategies, and communication for social change. After workshops, these community representatives returned to their community to facilitate a process with other community members in conceptualizing and developing their own priorities, plans, methods, and budgets. During the second year various health projects were implemented. Examples of some health initiatives include; • Traditional exercise groups • Family strengthening programs 18
  20. 20. A Vaccine for Globalization • Cultural conservation programs • AIDS/drug prevention programs and • Herbal medicine conservation, teaching, and promotion projects During their second year, the CBO representatives and their partners formed the Health Promotion Network of Chiang Mai, and entered their second round of program proposals. The original participants of the workshops conducted in year one continue to meet once a month to offer support, share their experiences and learn from each other. Purpose of Study The aim of this report is to present examples of people-led heath promotion and local community development programs, in a specific cultural context, using specific strategies. Understanding the ABCD process, from the point of view of the community, can provide insights into how applications in other settings might be coordinated, supported, and directed toward improving the health of entire communities. By describing one groups’ effort, the authors hope to shed light on how an ABCD approach to health promotion programming is perceived by community representatives living, learning and practicing the process in their own communities. It is our perspective that the opinions of community representatives practicing ABCD based programming are unheard. By framing the problem as an under investigated area, the results can act holistically by adding diversity to the dominance of professional opinions about ABCD as an approach. The public health professional or community development worker can benefit from the information presented by learning more about how to support community based programs, and limit the difficulties encountered for communities practicing ABCD. The other beneficiaries of this work include ICE and the CBO’s, as the results obtained can assist in organizational and program development, as well as lessons learned. Despite the growing interest in evaluation, and the growing numbers of evaluation studies, there is still a lack of firm and reliable evidence on the impacts of NGO development projects and programs (7). The majority of evaluations focus on outputs 19
  21. 21. A Vaccine for Globalization achieved and not outcomes or broad scale impacts (7). Social, ecological, and cultural dimensions of reality have been overlooked or undervalued systematically by development professionals (8). Ideally, an evaluation includes an examination of the micro and macro-conditions of social, economic, and political environments in order to understand the constraints to development and identify possible actions to remove or lessen these constraints (9). The need to develop an evaluation method to explore these dimensions requires an approach that respects the extreme cultural diversity of ideas and practices to be found around the world. The challenge comes from acknowledging that culture will influence ones view of the world; based on the metaphor that ‘culture is a pair of glasses through which we see the world in a particular way – where the glasses are constructed of ones ideas, values, rules, customs, knowledge, beliefs and laws’ – thus one must critically question the utility of universal standards of acceptability, prefabricated variables and indicators of outcomes and impacts. Any development activity that seeks to improve the quality of life of marginalized people is rooted in the process of moving from a state of dis-empowered to empowered. In terms of evaluating this ‘empowering process’ many have concluded that based on its context specificity there is no universal model in which to measure this process (10). ICE and 22 CBO’s located in Chiang Mai Thailand accepted the challenge of developing a method to evaluate the potential outcomes and impacts of their ABCD health promotion programs. This case study describes the efforts of ICE and the CBO’s in developing, implementing and reflecting on their evaluation method and results. 20
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  23. 23. A Vaccine for Globalization Chapter II: Literature Review There is an enormous amount of information available pertaining to development, community health, empowerment, participation, and evaluation. For the purpose of this study, and in order to understand the approach taken by these CBO’s - key terms are defined and a short history of their use in the field of public/international health provided. Community The WHO defines community as: ‘a specific group of people, often living in a defined geographical area, who share a common culture, values and norms, and are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and norms, which have been developed by the community in the past and may be modified in the future. Community members exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them’ (11). Participation In regards to health, participation can be defined as a right and duty of people to be involved in decisions about activities that affect their daily lives (12). The WHO and the United Nations Children’s Fund (UNICEF) claim that participation enables even the very poorest sections of the community to take part in improving the health services available to them, and thereby create a precedent for their participation in wider community activities (12). The WHO mentions that the level of community involvement is an important indicator in attaining Health For All (13). The WHO declared community participation as a people’s right and duty in 1978 with the Alma Ata conference and the introduction of Primary Health Care (PHC) (12). Although the concept of community participation is universally accepted there appears to be a wide variety of interpretations in terms of its definition, practice, and evaluation 22
  24. 24. A Vaccine for Globalization (14). It seems the more one studies the concept of participation the more elusive it becomes (15). However, community participation might best be defined as a multidimensional concept that takes on different meanings and significance in different settings and circumstances (16). Experience has shown that community participation in all phases of a project or program – including evaluation – improves the quality, effectiveness, and is extremely important for long-term sustainability of the particular development initiative (17, 18). Empowerment Empowerment can be broken down into processes and outcomes. Empowerment is an enabling process through which individuals and or communities take control over their lives and their environment in hopes of solving their own problems (19, 20). The essences of development are dependent on these empowering processes (20). The outcome of this process is empowered individuals and groups who live in an environment that enables them to influence the path of their lives (19). Creating this environment that frees individuals to learn, participate in, critically reflect on, and take action in community health and development initiatives has been an elusive priority in public health for decades (19). The elusiveness of empowerment results from the countless factors of influence and their presence in several areas of development; including education, health, law, science, government and economics (19). Additionally, ‘empowerment’ can mean different things, at different times, to different people. It can occur at the individual, community, and societal level. There are no fixed and final definitions of empowerment, merely suggestions based on individual behaviors, community conditions and norms, environmental changes, and long-term changes in population health (20). Most importantly, problem-solving education, called conscientisation or self-reflected critical awareness of ones social reality and ones ability to transform this reality by collective action – must occur from within a person – it cannot be imposed from the outside (9). 23
  25. 25. A Vaccine for Globalization Development Approaches and ABCD The type of program approach in public health, community and international development have been passionately debated for decades. Methods for achieving various visions of a better future range from those bound by romantic idealism, to those pragmatically focused on hard economic realism. The past several decades of traditional top-down and trickle down development programs, have yielded dismal results (21, 22, 23). “Barring some exceptions, most development initiatives, have often increased the vulnerability of the most vulnerable: The poor, the illiterate, the women, the children, and the marginalized. Strident questions have been raised about development for whom, with what purpose, through what means, and for what ends?” (24) The dominant bio-medical approach has become systematized into local, national and international development and public health initiatives. Often this approach refers to the view that a community, or ‘target population,’ is lacking something, most of the time it is ‘knowledge’ or ‘resources.’ Generally, this ‘deficiency’ orientation provides an easy opportunity for ‘experts’ or professionals to confirm their authority, without much regard for the practical experiences of that target group, and ignores the underlying socioeconomic and political causes of ill health (26). An alternative to this needs based approach is the strength or assets based community development approach, which starts with what is ‘present’ in a community (not absent), more specifically with the capacities of its residents and builds on the natural associational base in a community (27). An ABCD approach stands in contrast to the ‘deficiency-oriented’ approach based on surveying ‘needs’ and ‘problems’ of communities, which often results in the building of patron-client communities (27). “Public, private and nonprofit human service systems often supported by university research and foundation funding, translate the programs into local activities that teach people the nature and extent of their problems, and the value of services as the answer to their problems” (27). In some extremes, the members of patron-client communities begin to identify themselves as fundamentally deficient, with needs that can only be met by outsiders. 24
  26. 26. A Vaccine for Globalization Other authors have echoed similar concerns in the field of International Development. For example, Burkey (1993) writes, “all too many development professionals unconsciously believe that rural development will be achieved through the efforts of government and development agencies. They do not reflect on the possibility that sustainable rural development will only be achieved through the efforts of rural people themselves working for the benefit of themselves, their families, and hopefully their communities. Government and agencies can assist this process, but they cannot do it themselves. Unfortunately, after decades of this type of paternalism (top-down) all too many rural people have also come to believe - they have been told so many times - that this government or that agency is going to ‘develop’ them. The result is apathy interspersed with small peaks of expectation as one or another new development program comes their way. Rather than promoting development such programs have ended up developing dependency thinking.” Kretzmann and McKnight (1993) point out that if the problem focused approach is the only one available to communities, there is a clear risk for the unintended side effect of further breaking down community capacities such as, problem solving skills and self sufficiency. Communities depend on associations with ‘experts’ instead of building relationships locally. This process can devalue, deconstruct and delegitimize local wisdom, culture, and identity, by placing control outside of the community. Kretzmann and McKnight (1993) are careful not to advocate complete rejection of the outside resources, only a balancing of the equation by strengthening local resources and associations. Advocates for ABCD have increased over the last decade largely because development workers are thirsty for an alternative to the needs-based approach (28). Part of the attraction to ABCD is the central focus that the community can drive their own self-reliant development by discovering and utilizing residents’ assets and resources (28). ABCD is a response to the observation that communities are becoming passive consumers of services instead of active problem solving citizens (27). Mathie and Cunningham (2002) note that perversely these institutions (GO, NGO, donors and academic researchers) have developed a systematized interest in maintaining this patron- 25
  27. 27. A Vaccine for Globalization client approach. ABCD is an effort to take back and build upon a community’s wisdom and problem solving capabilities. According to Mathie and Cunningham (2002) ABCD relies on in five critical elements; 1. Use methods to draw out strengths and successes in a community’s shared history as its starting point for change (as in Appreciative Inquiry). 2. Pay particular attention to the assets inherent in social relationships, as evident in formal and informal associations and networks. 3. Active participation and empowerment (and the prevention of disempowerment) are the basis of practice. 4. A strategy directed towards sustainable economic development that is community-driven. 5. Rely on linkages between community level actors and macro-level actors in public and private sectors. Foster active citizenship to ensure access to public goods and services, and to ensure the accountability of local government. It therefore contributes to, and benefits from, strengthened civil society. Appreciative Inquiry Appreciative Inquiry (AI) is important to define because it is part of the first step in the ABCD approach. Its’ main purpose, according to author Charles Elliot, is to find the necessary energy for change and its two main tools are memory and imagination (28). “According to Elliot, AI assumes that reality is socially constructed, and that language is a vehicle for reinforcing shared meaning attributed to that reality. Communities that have been defined by their problems (malnutrition, poverty, lack of education, corruption) internalize this negativity. What the appreciative approach seeks to achieve is the transformation of a culture from one that sees itself in largely negative terms – and therefore is inclined to become locked in its own negative construction of itself – to one that sees itself as having within it the capacity to enrich and enhance the quality of life of all its stakeholders – and therefore move towards this appreciative construction of itself” (28). 26
  28. 28. A Vaccine for Globalization AI draws on theories of empowerment, knowledge construction, and educational psychology regarding sources of individual and collective motivation (28). The essence of popular education practice rests on the concepts of learning from experience and dialogue (29). Freire (1970) argues that people have developed their own way of seeing and understanding the world according to cultural patterns marked by the dominant ideology. Through the process of coming together and reflecting on their lives, people can learn about their larger socio-political, cultural and economic environments. This combination of learning as experience and dialogue results in the development of critical consciousness, which means a more in depth and reflective comprehension on the broad social, cultural, political and economic conditions in which people live. It is this raised level of consciousness that leads to group self confidence, and eventually collective action (29). Educational Pedagogy and Participatory Development Similar to Freires’ educational pedagogy and liberation through critical consciousness, participatory development also places people at the center of the process. Participatory development is based on the premise that the people in marginalized communities are not the target of development projects, but rather they are the ones who determine, drive, and control the entire development process (30). Participatory development starts from the assumption that marginalized and low-income people better understand the problems they face, and how to fix them (29). For an overview of the definitions, strengths and weaknesses of four types of community development see Table 11. Participatory Evaluation There is an increased emphasis and a growing recognition that the evaluation of community-based initiatives should incorporate the participation of beneficiaries (10). In projects where participants took the lead in all aspects of program design and implementation, conventional evaluations were protested because the evaluations done by outsiders failed to capture the specific meaning that the project (processes and results) 27
  29. 29. A Vaccine for Globalization had for its participants (31). This dissatisfaction stimulated the movement toward a different approach to evaluation and has been explored throughout the nineties. Participatory evaluations are typically done by community members, project staff, or facilitators. At its most fundamental level, it is investigative, educational and capacity building (32). It is a transparent process of self-evaluation using simple methods adapted to the local culture to empower local people to initiate control and take corrective action based on findings (33). Participatory evaluation embraces the concept of giving people a voice and placing them at the center of all stages of an evaluation process. By assessing the intended or unintended impacts of ones’ own program there may be a greater potential to provide a more accurate representation of the values and concerns of the multiple groups involved in decision-making, to promote the empowerment of marginalized groups previously left out of the process, and increase the utilization of the evaluation results through a sense of ownership of the results (17, 32, 34, 35, 36). There are five general interdependent and overlapping functions of participatory evaluation; impact assessment, project management and planning, organizational strengthening or institutional learning, understanding and negotiating stakeholder perspectives, and public accountability (10). With regards to an impact assessment of a program carried out under the full or joint control of local communities, the community participates in the definition of impact indicators, selecting and building methods, developing the questions, collecting data, analyzing data, communicating assessment findings, and designing actions to improve the impact of future development interventions (10). The participatory evaluation process is in constant motion, taking paths that may seem uncharted, and is as diverse as the number of contexts in which it is applied (32). There are a variety of concepts, methods, and applications developed in hopes of engaging stakeholders to participate in producing useful participatory evaluation results (10). The evaluation is built on the concerns, issues and problems that present themselves through discussion, dialogue and interaction – which are considered the main tools to active participation (9, 32). Participatory approaches require a commitment of time and energy as conflicting perspectives can slow or stop the process. It also requires 28
  30. 30. A Vaccine for Globalization a high level of trust and some consider the results less objective than traditional evaluation as there are many barriers that could prevent the effective development of the process – political, academic, personal, environmental, financial, and cultural to name a few (9, 17). Differences in opinion and confusion can occur early and often in the evaluation process because it involves collaboration and negotiation among individuals who may have not worked closely in the past. The effort requires patience and flexibility in order for collective evaluation questions to take form. One of the primary goals of a participatory evaluation is to share control of the evaluation process, by placing control (power) in the hands of the community while removing it from the outside evaluator (32). The premise behind participatory processes is the progressive shift of power, with a sequence from control to empowerment (37). The professional must talk less, dominate less, and control less, to empower and trust others (37). Facilitating others analysis means disempowering ourselves, leading by withdrawing, waiting while others think before they talk and act (37). Participatory evaluations challenge conventional evaluation practices which were founded on the tradition of scientific investigation. Conventional or ‘top-down’ approaches to evaluation can be broadly characterized as; focused on complex procedures to measure cost and production outputs against predetermined indicators, oriented to the needs of funders and policy makers to determine accountability and continued funding, seeking information that is objective, value-free, and quantifiable, and usually contracted and conducted by outside experts seeking to maintain a distance between evaluator and participants (10). Arguments against the conventional evaluation includes; they are costly, fail to involve program beneficiaries, the outside evaluator is too far removed from the ongoing planning and implementation of development initiatives, and the emphasis on quantitative measures tend to overshadow the qualitative information which tend to provide a deeper understanding of outcomes and processes (10). Empowerment Evaluation Community empowerment and participation are the twin pillars of health promotion and defined as a process of enabling people to increase control over and to 29
  31. 31. A Vaccine for Globalization improve their health (19). Empowerment evaluation is the use of evaluation concepts and techniques, highlighting the importance of context – social, political, and value systems – and incorporates it into the evaluation process (38). Empowerment evaluation embraces the concept of sustainable human development – the strengthening of individual identity and capacities to learn, adapt, and innovate along with the acquisition and internalization of knowledge and information – must be part of any development process (8, 9). The process helps beneficiaries by self-consciously guiding a program, rather than solely judging its accomplishments (10). The theory behind an Empowerment Evaluation, as defined by Zimmerman, focuses on processes and outcomes. As stated earlier, an empowerment process attempts to gain control, obtain needed resources, and critically understand one’s social environment (39). The process is empowering if it assists people in developing skills so they can become independent problem solvers and decision makers. Empowerment outcomes are consequences or effects of interventions designed to empower or gain control (39). Fettermen adds an additional theoretical foundation of empowerment evaluation; one that is based on self-determination, defined as the ability to chart one’s own path in life (39). The empowerment theory consists of many interconnected capabilities; the ability to identify and express needs, to establish goals or expectations and a plan of action to reach them; to identify resources; to make rational choices from various alternative courses of action; to take appropriate steps to pursue objectives; to evaluate short and long term results, including reassessing plans and expectations and taking necessary detours; and to persist in the pursuit of goals (39). If anyone of these links break down it can reduce the likelihood of being self-determined (39). Empowerment evaluation has its roots in community psychology and influenced by action research and action evaluation (38). The purpose is to produce context-specific definitions of success to allow program or project participants to determine their own standards (39). The empowerment evaluation embraces the concept that participants evaluate their own action and behavior according to the standards and values of their setting, rather than judging according to outside criteria articulated by experts from a 30
  32. 32. A Vaccine for Globalization distance (40). Defining success appears to be dependent on whom you ask. The question of ‘who measures’ results and ‘who defines’ success is the critical issue addressed with Empowerment Evaluation (10). 31
  33. 33. A Vaccine for Globalization 32
  34. 34. A Vaccine for Globalization CHAPTER III: COMMUNITY PERSPECTIVES ON ABCD Information presented in this section is in raw data format, including participant observation, community discussion and natural focus group results from four different communities. Reflections from the qualitative researcher are also included. The purpose is to give the reader a sense or glimpse inside how community representatives think about their programs, the ABCD approach, and how it is similar or different to other approaches they have experiences in the past. Methods Qualitative methods were appropriate for eliciting perspectives from CBO representatives (informants), and community members. Data collection methods included; participant observations, natural focus groups, and semi-structured interviews. Participant observation was selected as a data collection technique in order to engage in CBO activities, become familiar (thus reducing reactivity) and understand more about the socio-cultural context. This process continued on a daily basis throughout the entire three month study period. The purpose of natural focus groups (NFG’s) was to build on what was uncovered during participant observation. NFG’s occurred in community settings, and I was frequently invited to CBO representatives’ homes. The ICE director was not present during NFG’s, in hope of achieving a more natural setting for truthful responses. Usually elders, youth, monks or others would join our discussions, and frequently offer unsolicited commentary. These community visits allowed insight into how CBO representatives interacted with their fellow community members. Four visits are profiled to demonstrate the diversity of local settings. Based on results of the participant observations, NFG’s and community visits, questions for the 12 semi-structured interviews were formed. All but one of the interviews occurred at the Expo, which was a two day event coordinated by CBO representatives in which CBO groups presented their work, shared and exchange ideas. 33
  35. 35. A Vaccine for Globalization Therefore, CBO’s that did not attend the event were not interviewed. Semi-structured interview questions were written in English and Thai and pre-approved by the director (see Appendix C). Prior to asking questions, I explained I was interested in learning about their opinions regarding the process they used for building their community health promotion programs. Data Management, Quality and Analysis Responses to interview questions and two NFG’s were tape recorded and translated from Thai to English by the researcher. During the translation process unclear or unfamiliar words were reviewed with a native speaker, and final English transcription was reviewed by the director of ICE for clarifications. Afterwards, the transcriptions were printed for coding by hand. Qualitative analysis was done using open coding by two English speaking researchers. Results are presented using quotes and long narratives in order to illustrate relationships between the data, themes elicited and remarks in the discussion section. For a table of qualitative inquiry activities including respondents’ roles see Table 12. Results Participant observation CBO representatives were observed during meetings, workshops, and when interacting with others in their own communities. For example, the groups were preparing for their exhibition at the end of 2003; however a very active member heading up the planning for this event died suddenly, about three weeks before the event. The CBO representatives, over 22 people, worked together to select new leadership and make group decisions about new plans for the Expo. This was a difficult time as many members were close to this individual; he was respected, and well liked. Although some CBO representatives were visibly upset during meetings, they successfully reorganize a new Expo event within a six week period. In another example, CBO representatives were in the process of reorganizing themselves as a Network. This occurred because during the second round of funding 34
  36. 36. A Vaccine for Globalization some groups had received approval for their requests, while others were denied. By observing their reactions it was clear this was a significant blow to the group. During the first year they had moved through the learning process together, built relationships, and learned from each other. Now, it looked like they were breaking up into funded groups, possibly funded groups, and non-funded groups. They had to reach a consensus regarding whether they would continue on as a Network, separate into clusters, or work individually. In the end, they decided to remain together and elected a Network leader. Group dynamics were also observed during Expo planning meetings. During these meetings they debated the budget, organized the site and a schedule of activities. Only one of these meetings was held at ICE, while the others were conducted at the Expo site, in SanSai District. During the participant observation process it was noted who was more active and opinionated about certain issues, the researcher listened and made small talk during coffee breaks, and started the beginnings of relationships with people. Observing the director of ICE during these meetings was crucial for assessing how ABCD was being facilitated. It was noted that he did a number of things very effectively. For example, he spoke very little and never stated his point of view unless pressed by others. He spent most of his time listening, and asking questions which kept the group focused. Often when disagreement was upon them, he restated the question verbally or wrote the options on a white board in order to help the group visualize what they were struggling with. Overall, he was able to encourage dialogue by asking inquiring questions and assisted with mediation when necessary. Among CBO representatives some were more outspoken then others. Discussion and decisions were conducted in a friendly professional manner. When decisions needed to be made individuals voted by raising hands. Initiative leaders were selected through nomination and voting. The person elected had the option of acceptance or not accepting the position. A note taker produced meeting minutes for CBO representatives who could not attend. Most of the time meetings were taped for assistance in writing up the minutes. CBO representatives tended to arrive fifteen to twenty minutes late and dressed casually. 35
  37. 37. A Vaccine for Globalization Natural Focus Groups and Community Visits There were four primary site visits in which NFG’s occurred. Selection of these sites was dependent on invitation by the CBO representative, and the availability of transportation. The site visits included four CBO’s: 1. Drug Prevention Demonstration Project (Rural, SanSai District), # 3 on Table 12. 2. Nong Hoi Community (Urban, Muang District), #12 on Table 12. 3. SaLuang (Rural, Hmong, Karen and low-land Thai), #11 on Table 12. 4. Karen Mae Chaem Group (Rural, Karen, Mae Chaem District), #1 on Table 12. The following narratives are included verbatim in order to show exactly how CBO representatives were describing what they were doing, and what was happening in their communities. This was important for conclusions to be drawn about how ABCD was taking place, what kind of participation was occurring, and what they thought about the process. After presenting the prominent results from each of the sites the researchers’ immediate interpretations from the field are also included, and written in the first person. 1. Drug Prevention Demonstration Project The first site visit was attendance at a village presentation for the Bangkok Department of Drug Prevention (DDP). This village was selected as a demonstration site because of their success in reducing the amount of drug trafficking, drug use, and improving prevention and rehab activities. This project was spearheaded by the village headman, who is also the CBO representative working with ICE. On display was an impressive wall of posters and pictures describing their activities for drug prevention. I had a chance to eat lunch with the CBO representative, the village health worker and his coworker, and talk with them about the project. Later, the CBO representative and the two health 36
  38. 38. A Vaccine for Globalization workers addressed the representatives from DDP and community members in a common area located in from of the CBO representatives house. During discussions with the village headman and community health workers, they explained there were about 208 families and 689 persons in this village. One health worker stated, “The village leader would come to me often before this project and we would exchange ideas about how to build a healthy community. He would go back to his team (representatives from the youth, elderly and women’s groups) and talk it over, and then he would come back to me with more ideas. The village leader also contacted ICE to ask the director if he has any good programs to strengthen the community.” Here I concluded this was a very active CBO representative who was seeking out information, sharing it within the associational network of the community, and in the process building relationships with internal and external resources, such as the health worker and ICE. I asked the CBO representative if he could tell me about how his community decided to work on drug prevention he said, “There were people in the village addicted to drugs and selling. The community ‘team’ met to discuss the problem, where does it come from and how to work on it.” He explained that the results of their discussions were many activities. For example, making community rules posted on a sign explaining what would be tolerated and what would not be tolerated in their village. They also decided to have activities to “strengthen families.” When I asked him why he explained that the people in the community believed drug use was becoming a problem because families were breaking down. To counter this they decided to have an activity bringing the elders of the community together with the children to teach them how to play traditional instruments, thus strengthening family relationships. They also developed a system for assisting addicts who returned to the community after incarceration or detox. This process involved coordinating a system for returning community members to live with someone other than their family for at least the first three months. This was an effort to manage the tendency to fall back into old patterns and minimalize quarrel. He went on to explain about the youth group activities, including a ‘friend’s corner,’ where the youth 37
  39. 39. A Vaccine for Globalization could gather and spend time talking about drug issues with their trained peers and health workers. I inquired about how many people in the community were participating in project activities and the health worker said he thought perhaps 60%. He explained, “If 60% of the community participates then it is good enough, if there is more than we make merit.” He also said, “You can say or write community participation, but if it is not in your heart it won’t happen.” I asked what he thought of this project and he said, “It’s very hard work and requires lot of meetings and discussions, but I am very happy. In my twenty years as a health worker I have never seen anything like this.” At this comment I was immediately struck by the sense that this health worker, who had been working at the community level for over twenty years, thought what was going on here was different then what he had been involved in previously. This significant statement was explored further in each of the semi-structured interviews. Then I asked him what made this project work here, and he said, “The health worker (referring to himself) uses common sense, and the village leader is interested.” During the addresses to the community members and the DDP representatives the health worker said, “This model of community development is strong and means bringing different groups together to work. The villagers have done this themselves with the assistance of the community health worker to advise them on understanding the current problem. There is no end to this process. The community does not have to wait for the government, they can do it themselves. The villagers here are very determined and happy for your encouragement. We are proud of how we received the money. Every group here knows how much money there is and what they have decided to do with it. We (the health professionals) join with the community to eat and drink and discuss all of our ideas, not just accept orders, we can dialogue together. I am very proud we can communicate like this. I am an assistant only to the community.” The village leader/CBO representative echoed these words by stating, “When we meet and discuss what and how to do things we use the words “we will try” not “you should.” I observed consistency here in what the 38
  40. 40. A Vaccine for Globalization health worker and the CBO representative were telling me over lunch, and what they later told the DDP representatives and the 200 members of the general community also in attendance. I inquired about the role of ICE and they explained that both the CBO representative and the health worker attended the workshops coordinated by ICE for learning community development facilitation skills, and how to communicate and exchange information and ideas with other CBO groups. They went on to explain that they had raised money for this project from the Provincial Health Promotion office, DDP, and through village donations, thus illustrating the multiple sources of fund gathering. I noticed with this community, independence. For example, the CBO representative had initially come to the health worker and ICE for “advice on how to build a strong community.” Therefore, the capacity building instincts were already there. They could have been quickly squashed had ICE and the health worker not possessed a complimentary philosophy. 2. Nong Hoi Community This community is located on the outskirts of the main city of Chiang Mai. In attendance were two government health officers, a retired nurse, and retired teacher who help with the project activities, two police officers and members of the youth and elderly groups. They had just presented their work to some government officials who had already left when our group arrived. They began with an introductory speech, delivered by the local monk, and the CBO representative. The group was seated at a large table and had lunch after the monk took his food, which is customary. The meeting was at the home of the CBO representative. I was introduced as a student working with the director of ICE. The monk began by explaining that in their community they have about 700 permanent residents and 300 transitory residents. He spoke about the importance of working within the three institutions of the community the temple, home and school. “The Temple is 39
  41. 41. A Vaccine for Globalization very important as it is the center of moral and social development. Three years ago the community headman was responsible for the community. Now the central government has decentralized power, but the community is still unaware of their rights. They have no representation. Also, three years ago drugs started to enter the community and there was a need to help adolescents and witnesses to drug selling know what they can do. They started to organize and promote activities, but they have no money. We try to use all social structures in the community to get a wide picture of what was going on, and come up with ideas to strengthen the community. We started groups for promotion of nutrition, exercise, AIDS and drug prevention. We have a Little Doctor Competition to encourage young people to become health promoters within their families. For example, with mosquito prevention, we use a traditional method and have a contest for who can collect the most (dead mosquitoes). We do this work because community members, police, teachers and parents are closer to the villagers, and know the problems better, political representatives only talk.” The CBO representative then spoke, “the concept is the facilitation of bringing multiple community groups together, and if we do this we improve the quality of life for our community. We study and learn about problems and solutions together through community participation from different sectors of society. Our vision is to work together, coordinate people, and not separate them.” I asked if there were any problems while doing this program and the CBO representative said, “Our community has no office for our work, we would like some money to buy land so our children will have a place to continue conducting community activities. Also, they (community members) didn’t know how to work together at first. They all have hearts, but it is difficult to find time to talk together because people have different schedules. We have to meet on Saturday or Sunday. We have to help people understand it is important to love themselves, love their families, and love their communities, if we don’t love our community who will?” 40
  42. 42. A Vaccine for Globalization The retired teacher explained, “In Thai society we don’t have a sense of teamwork. So now we use activities like competition (little doctor) to create a sense of belonging in our community, maybe this will start improving.” I tried to probe further by asking how they will know if there is a growing sense of belonging. The CBO representative responded, “The villagers think and try to solve their own problems. When we do an activity lots of people come to see. Now more community members are presenting their ideas at meetings. Before they were quiet, now they dare to share their ideas in the room. We don’t say whether on is right or wrong, we say what everyone has to say is useful, and let someone try their idea. For example, in the rural areas we have natural cures, ‘oopanya’ we are sharing this knowledge to promote health. We are manufacturing a small amount to sell.” What I learned here was that through this community dialogue process people had the potential to engage and share their own ideas as a member of the community. I began to wonder what prevented them from doing that before. I asked how will they see the benefits of your work. The CBO representative commented, “The drug problem has stopped, but we always have to keep our eyes open. We have observed diabetes reduction and cholesterol reduction and less depression among the old people. For example, some of them could not walk before our group exercise program, now they are able to do more movement. Our younger generation is studying meditation and now they are getting better grades. The hardest part is getting that initial financial assistance to start, and then you have to show people that you really mean what you say you will do, and that you are really interested in improving community health and family. The beginning is the most difficult. We, are worried about our future, we might get a little more money from the drug prevention department, but what about all of our other work?” Here I observed the potential to measure the effect of there programs based on bio-medical markers for example, blood pressure, cholesterol levels, etc. Ironically, in the same breath the discussion turned to funding, and concerns about sustainability of their programs. 41
  43. 43. A Vaccine for Globalization Then the Monk followed up by explaining, “Number one, the community has gained more knowledge about health, the environment and community development. Number two, they own this problem and they know best how to solve the problem. Through good participation they build a sense of belonging and care for each other. And three, they are responsible as a group.” In this community I learned that they were mobilizing resources and perspectives from three segments of society, the temple, school and family. Building on multiple points of view and community ideas they were selecting their own program activities. They are excited about the results they are seeing. Some of the problems include, funding, having space for a community center, and concerns about sustainability. How they are going about their work is consistent with the ABCD model. 3. SaLuang On the day I visited the SaLuang District, about a half and hour from the city of Chiang Mai, the community was celebrating Children’s Day, a national holiday. I had a chance to join in those activities of music, games, eating, and comedy show. Additionally, I stayed over night with the CBO representative and his family. Upon arrival, I spoke with one of the natural healers working in an alternative health center built alongside the government health station, and eat lunch with the director of the health station. The CBO representative and the natural healer explained that three groups were in their district; low-land Lanna/Thai, and the high land tribes of Hmong and Karen. The talked about how representatives from these groups came together to discuss ideas and resources for a health promotion project. It turns out there is concern among these groups about pesticide contamination. Especially, for the low land people who eat foods irrigated in mountain run off, which they think contains high amounts of pesticides. They decided to combine their knowledge of herbal medicines into one book for use by the community to encourage organic growing and conservation of traditional treatments for common ailments. 42
  44. 44. A Vaccine for Globalization The CBO representative explained, “At first there was me, and our team included about 10 other people and the director of the health station, who you will meet in a little bit. Our experiences before were always working with the communities all the time. Then we got together and talked about our community. In our community, we saw that people were being exposed to a lot of chemicals. Like when they eat vegetables that have been grown with a lot of pesticides. So then we sat together and talked about what we could do to encourage our community to use herbal medicine and plant organically. If they do this they don’t have to take the foreign medicine, or visit the doctor at the big hospital. Our plan was to use herbal medicine and to help ourselves so we don’t have to waste a lot of money or gold for the price of medicine. That was our idea, and that is what we talked about together…. The ten others are from different groups in the area; from the local healer group in the sub district area here, and the adolescent group.” The Lanna Healer explained, “There are lots of different groups, the village leader group, and the elderly group, the natural healers in all villages and the Community Development Department workers. In these statements, there is evidence of local relationship building and community dialogue. I asked about how they learned about ICE and the Thai Health Foundation Funding. The CBO representative responded, “we talked for a while here and there, and then a doctor at the health station said she has a friend who is a coordinating work with the Office of Health Promotion who told her about the Thai Health Foundation. Our team of 4-5 came together to talk about how to put the project together so we could request funding, We waited for 3 months for funding approval. And then we called our team of 10 people to come together and talk. We explained we now had the funding to do this project, but it was up to them to figure out how to do it. We had to figure out how to collect the information about herbs from throughout the community. From the old books written on bamboo, in the Lanna language. The old healers would write their knowledge down in small books. ” 43
  45. 45. A Vaccine for Globalization This group brought together interested community members including youth to visit natural healers in all three areas and collect information about the plants they use and various formulas. The CBO representative explained the steps they took for the project. “We collected information from throughout the villages by mobilizing the adolescent group to travel around and write down the information from all those who had any. The next thing we did was travel to the forests in the mountains with people who knew where to find the plants and photograph them. After that, we brought together all the information we had collected from all the local healers, and typed it into a computer, then we had it printed into a book. But we did not have them printed to sell. The books are available throughout the community at schools, temples and all the local healers have one. We had the book printed in Thai script but here are Karen and Hmong words included. For example, if you look here we have the name for this herb in four different languages, Hmong, Karen, Thai, and the English scientific name.” In addition to discussions with the CBO representative about the project, I also had the chance to stay with him and his family and discuss his views on development. He had many insightful comments that are worth sharing. “The community became tired of outsiders coming in and taking information from us, then writing something and getting famous, while not doing much for the community. These outsiders tend to do things for a short period of time and then leave. They are not doing the work honestly. We realized over time, that it is much better if we do it ourselves. If we do it ourselves we know that we are doing it for the love of the community, and not for any other reason.” “Outsiders think they know how to change things for the better, but we the local people know better. It’s like trying to tell someone how to move around in their own house, it is my house, who knows better where all the windows and doors are but me.” 44
  46. 46. A Vaccine for Globalization “The only thing the community learns when programs come from the outside is to wait, wait, wait for the next program to come and give you something. We have forgotten how to think for ourselves.” I asked him to comment on the ABCD approach, he said “With this approach the community gets to use their own thinking, and the development worker becomes the coordinator. Often the weakness in the community is that they have lots of ideas, but don’t know how to coordinate things to make it happen.” “One of the problems with the way things were done in the past is that when the funding for the project ended, so did the project. With this new approach the projects don’t end with the funding cycle. The project will continue because community members came up with the idea, they believe in it and will try to find money from other sources, maybe even locally. I think this would be the best way anyway, if the money came from local sources.” I asked him “when you get money from outsider funders like in Bangkok or other countries, what do they want to see in evaluations?” He said “We usually have to do an evaluation that follows this long process and ends up not meaning very much to the community. It is very confusing for us and very difficult trying to give them what they want. I think it is better to evaluate a project using the communities own words, very simply and summarize easily. That is how I do my evaluations. Sometimes I have to explain to the funder why this is important for the community, and I make them understand before I get money that they will get this type of evaluation. Sometimes I feel if we meet half way, 50% what they want and 50% what the community wants that is usually the best.” “When doing a community project we have to be careful about 2 things: 1. who we get the money from, and 2. what kinds of rule or limits with they make that might impact the freedom we need to make the project appropriate for our own community. When they get 45
  47. 47. A Vaccine for Globalization money from far away, follow up is difficult. To call Bangkok can cost 100-200 baht per phone call, and that is a lot of money for rural people.” He explained that when he found out that the Thai Health Promotion Foundation did not have their names on the list for next year he and seven other representatives from different Chiang Mai CBO groups went to Bangkok to, “pound our fists on his desk” and talk with the health promotion representative for 2-3 hours. We had to, “make him understand what and why we were doing things this way, and to show the benefits of this kind of work. I told him he has never even been to our community to see whether or not the program has been beneficial or not, so he can’t pass judgment on it without even visiting once.” He explained that later they heard the proposals for 8 groups have passed the first tier for approval, now they are waiting for final approval. “In the past the government in Bangkok would write a program and tell us the top priorities. We did not have any freedom in what to work on or how to do things and this is a very limiting approach to working in our community. Now, the communities are writing the programs and sending the proposals to the government which allows for much greater possibilities in terms of projects.” I asked him this new way of doing things works better then the old way of doing things. He said, “this new way works ‘because we see it’, and we don’t have to wait around for someone to do it for us.” Based on our discussions, it appears this CBO representative and community members are critically reflecting on their social assets, how to mobilize them, as well as weighing the pros and cons of the different approaches to community development. During this site visit I was able to capture more about how this CBO was operating in the community, how they viewed their roles, how they thought the ABCD process was affecting their community. For example, the CBO representative explained that because the three different groups (low-land Lanna, Hmong and Karen) came together to work on 46
  48. 48. A Vaccine for Globalization this project together, members of the high land groups are much more likely to come down and join in community events these days. The statement, “this new way works because we see it” implored me to wonder what else he meant, and how he could illustrate to others the changes they were seeing. Additional awareness was raised about the concept of freedom, and it became more obvious how adapting projects locally is crucial to community success. The issue of passivity vs. pro-activity was also prominent. For example, “we don’t have to wait around for someone to do it for us.” Sustainability issues were explored in the statements, “One of the problems with the way things were done in the past is that when the funding for the project ended, so did the project. With this new approach the projects don’t end with the funding cycle. The project will continue because community members came up with the idea, they believe in it and will try to find money from other sources, maybe even locally.” 4. Mae Chaem - Karen Group This village is located about five hours from the main provincial city. I was invited to visit during the Christmas Holidays. The missionaries were active among the Karen groups and in this village and they had a mass attended by 100-150 people. After a community breakfast on Christmas day, I visited the CBO representative’s house, and served tea. I was joined by a few other community members including 3 elderly men, 3 adult men and two adult women. Their roles in the village were not identified, but they knew about the work of the health promotion program. The conversation was tape recorded and resembled a natural focus group. I did not have any specific questions prepared, and I didn’t anticipate the discussion to include 10 people. The Karen speak their own language when talking to each other. Most of the men can speak Thai, and some women. Young people of both sexes have been schooled in Thai and shift easily back and forth. I asked questions in Thai and they were translated into Karen by one of the adult men. In this setting I learned how they viewed ABCD, how it compared to other health promotion work they had seen in community, how they viewed their medical system, and the health status of their own community. The health promotion program in 47
  49. 49. A Vaccine for Globalization this community was centered on restoring and promoting native Karen wisdom about herbal medicine. In their view, the predominant mode of treatment for forest people is herbal medicine cures that have been passed down from generation to generation. They commented that western medicine came from the missionaries, and when the roads came people tried to get the medicine from the ‘doctors’ at the government health stations, “Most of the time they (their elders) would find herbal medicine in the mountains, they would boil the herbs and use the Karen knowledge because most of the time the doctors in Chiang Mai don’t come here. In the past for our parents, aunts and uncles, the roads did not reach here, they couldn’t get here. It was very inconvenient… When people died they thought it was because of a spirit (‘rok pee’) had entered their body and killed them. About two years ago the government health stations arrived and one young man commented, “The patients should have enough medicine to cure their disease, but it is not enough. By the time they need it the medicine has expired, like 6 mo or 10 mo or 2 years past expiration. That is one of the problems. They use medicine that has already expired and it does not cure them. These days’ things are a little better, but the villagers still need to use herbal medicine to supplement, a lot.” In regards to the development of the program the CBO representative said they wanted to, “improve the community by looking after the culture through the conservation of herbal knowledge.” The CBO representative explained, “Using the medicine from the hospital, it’s good, but there are side effects. If you take too much you have a problem, if you don’t take enough you won’t get the curing effect of the medicine. In the past our relatives used herbal medicine and they survived, and didn’t need to go to the hospital. So for kids these days if they have a swelling or a cold and take the hospital medicine sometimes they have problems. But with herbal medicine you can take a lot and it won’t cause harm…. for our lives maybe we can use our local knowledge to teach our children about herbs, massage, and poultices, ,,,we already have these true medicines, we don’t 48
  50. 50. A Vaccine for Globalization have to buy them or go to the hospital. Why do we have to do that? So, that is how this project got started.” He went on, “what can we do is make sure that the next generation knows how to use and conserve the herbal medicine cures that we used in the past. Before we didn’t have any hospitals around here or any doctors, and we survived, we didn’t die, sometimes we died if it was a very difficult disease, or if we didn’t treat it in time, but for treating common disease, coughs, colds, sore throats, headaches, and rashes, we can use what we have always used…,” I asked how this program was similar or different from others, one man stated, “It is like this, the state programs are only interested in the outputs of their work. If they come and test us they come once, this is not sustainable or useful. It is because the staff person is only interested in the output of the work, not interested in the sustainability of the program. But this type of program was concerned in doing whatever you want just please make it beneficial, and please make it sustainable in the community. It is different because there is much more freedom. If it was a state program there would be many limits and rules, and after the program it would be over, because the staff is only interested in the outputs of the project, and not interesting giving too much else. After the program it would end.” He continued, “If I look at the big picture, the state works health programs and then it is up to the staff person to implement the program for the community…But, in terms of herbal medicine, I think that if we have knowledge about herbal medicine it is good, because you can take care of yourself, this is much better then waiting for some worker to come take care of you.” I asked them to talk about how they thought this project was affecting their community. At this the CBO representative said, “We see the villagers helping themselves, they don’t have to always go to the health station, they know the plants and they know how to use them. The students know. They don’t have to go to the hospitals and take the poisonous medicine. We also see the students teaching other students. For example, if one of their friends has a headache they show them which plant to use and how to make it.” 49
  51. 51. A Vaccine for Globalization Form this site visit it started to become clearer how critical cultural identity was for their programs. Not only were CBO’s moving and mobilizing local social assets in the form of native wisdom, they were developing associations with other communities through the vehicle of health promotion program for herbal medicine conservation. They were engaging in community dialogue and discussion right there in front of me! There were many breaks in the discussion in which different people disagreed with what another was saying. The disagreement didn’t cause uproar or chaos, instead it appeared to stimulate more dialogue. Most importantly, they were reaching back to their own cultural identities and building from there. Semi-Structured Interviews 12 semi- structured interviews were conducted with CBO representatives. After analysis, re-reading and coding of transcripts, themes became salient and are presented in Table 13. In addition to the themes presented, a list of concepts that representative’s mentioned during interviews regarding what they thought helped to make their programs work, and what made them difficult was formed. These questions were asked directly during the interview. Included in these lists are concepts mentioned by more than one CBO representatives. 50
  52. 52. A Vaccine for Globalization Issues that made ABCD for health promotion work: 1) The ability to think and do for oneself 2) Groups decision making 3) Multiple activities under one project 4) Having those activities firmly fixed in native culture/community identity 5) Inclusion of all age groups 6) Funding and support from local and external resources Difficulties of ABCD for health promotion: 1) Time 2) Communication 3) Group Decision Making 4) “Spoiled” by standard Development Approaches 5) Program Writing and Evaluation One of the most frequently sited difficulties was the issue of time. Any effort to gather community people together for community discussion was difficult secondary to schedules, jobs, and family responsibilities. Other difficulties included communication. Many communities were very far from the provincial center and ICE. Making phone calls is very expensive and transportation can be long, uncomfortable, and costly. Practicing mediation and consensus in decision making was also mentioned. The process of reaching consensus and conclusions can be difficult if there were varied views among community members. The issue of evaluation came up more than once. Some representatives commented that they were interested in knowing more about evaluation. There was frustration expressed over not being able to explain or show funders the “good things” their programs were doing in their communities. The uncertainty of funding resources was another major difficulty mentioned since the announcements of which groups were funded and which were not was occurred prior to the expo. Another representative expressed the “conditioning of NGO’s” as a difficulty to over come. He noted in his community, “they are spoiled by the NGO, so all they 51
  53. 53. A Vaccine for Globalization (community members) know is how to do is spend money.” By practicing ABCD they “have to learn how to plan, report and evaluate their work.” He also mentioned that the project ideas and activities were too big and there was not enough leadership, negotiation strategies or skills among the group members. In the same case there was concern about the ideas for activities coming from only one or two people instead of a community group. Interestingly, the individual in the representative position for this CBO has a long 30 year history in the NGO field. He sited himself as a difficulty, because of his NGO training, and was planning to remove the difficulty by removing himself from the CBO representative position. Discussion The information elicited from the semi-structured interviews was consistent with the information drawn from participant observation and the NFG’s. The semi-structured interviews were useful for ICE in terms of citing weaknesses and strengths of the process. The NFG’s and participant observations provided more in-depth information related to socio-cultural context and insider perspectives. Some initial assumptions were confirmed in the data and support its validity. The consistent statements from community representatives, “we did it ourselves,” “it was the ideas of the villagers,” “we are proud” and “they are proud of themselves” provide convergence when triangulated with ABCD methods, and the theories of selfactualization and self-sufficiency (41, 42). Based on the principles of ABCD and the theoretical constructs of educational psychology, self-efficacy, and empowerment, the themes generated from the semi-structured interviews are also consistent and confirmatory. The primacy of traditional culture and cultural identity appear to be critical pieces of CBO program building, and provide evidence of a difference between the ABCD processes as described by Kretzmann and McKnight, and the process being supported by ICE. Kretzmann and McKnight emphasize the mobilization of resources (capacities, skills) and local relationship building. In this cases study there is evidence of resource mobilization and local relationship building, with the explicit emphasis of traditional 52
  54. 54. A Vaccine for Globalization culture as strength through which health promotion and community development are taking place. Based on this observation, I believe what is happening among the groups in this case study may be even stronger than the ‘standard’ ABCD approach. CBO’s are conserving indigenous knowledge and traditions through health promotion and community development programs, therefore preventing the identity destroying aspects of rapid growth. As the director of ICE often stated, “what they (CBO’s) are doing is a vaccine against the ill-effects of globalization.” Additionally, by expanding the process of building on ‘strengths’ (local assets, skills etc.) to also include cultural traditions (local music, dance, traditional healing methods) this allowed CBO’s to reach out to local and external resources with something compelling in hand, thus leveling the playing field, or power structure. Therefore, through the ABCD approach, as practiced here, there was a better chance for more equal partnerships between CBO’s and local and external associations. Mobilizing around traditional culture brought more people together, from all age groups, since the focus was not on a specific problem or a disease. Centering on traditional ways of life was also more in line with how the community, and individuals, identified themselves, thus reinforcing their collective identity and self-esteem. These inferences were based on the interpretation of how CBO representatives and community members described themselves, or in other words, an ‘emic’ perspectives of their own community. Although these groups are considered ‘marginalized’ by professional development standards (based on income access to resources, education etc.), when they described their communities, none described themselves as poor, weak, impoverished, or through a list of problems. For example, “we are Karen, we live like Karen, we live comfortably” or another “we are a typical Thai community, and the environment is good because we live out in the countryside” or “our community is in a rural are and we live using the rural ways of life.” A similar phenomenon occurred when trying to investigate community identified health problems. I often asked community members to tell me what kinds of health problems there were, and most frequently they responded by stating “we don’t have any.” This was also confirmed in 53