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

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

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  • 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. 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. A Vaccine for Globalization 2
  • 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. 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. A Vaccine for Globalization 5
  • 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. 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. 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. 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. 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. 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
  • 13. A Vaccine for Globalization 12
  • 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. 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. 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. 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. 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. 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. 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. 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
  • 22. A Vaccine for Globalization 21
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. A Vaccine for Globalization 32
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  • 55. A Vaccine for Globalization the evaluation report written by a contractor hired through the Thai Health Promotion Foundation. From a broad point of view, I considered whether Thai social systems were well matched for an ABCD approach. For example, more than one group described the importance of building their work on the traditional social systems of temple, school, and village. Therefore, when thinking about what ‘strengths’ to build upon, they reached back to the system of a traditional community. These community ties, they explained, had been breaking down secondary to shifts in the administrative structure, growth, development etc. Part of their projects was to restore those relationships between community resources. Similarly, many of the projects focused on teaching and promoting traditional health models. “Lanna health is focused on the four precepts for holistic health. A ‘happy life’ was to be achieved through the spirit, body, the community and the environment. Through spirit a human could reach the supernatural. The human body is described as containing the four elements; Earth, Water, Wind and Fire, and their balance a critical. Herbs are a part of the environment that can be used for health. And in a community people survive by helping each other. These are the four things that combine to make a healthy life according to Lanna principles” (4). Therefore, both traditional Thai social structure and the traditional northern healing philosophies include an emphasis on community relationships, which may have supported the transition to an ABCD approach for health promotion and community development. 54
  • 56. A Vaccine for Globalization 55
  • 57. A Vaccine for Globalization Chapter IV: Evaluation The purpose of this section is to address 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’, than how will these CBO’s measure these potential changes in their communities?’ An answer is provided by describing the efforts of ICE and the 11 CBO’s in developing an evaluation method. The evaluation method was based on the concepts of participation, empowerment and suitable in their community for taking on the challenge of identifying their program outcomes and impacts. For the purpose of illustration we chose to highlight the specific effort of the MaeChaem community, whose project was the Rehabilitation and Conservation of Herbal Medicine, to demonstrate how the evaluation was implemented. Development of the Evaluation The 22 CBO’s were entering their third year of ABCD for health promotion programming. They had already submitted project specific quantitative reports required by ThaiHealth for justification of funding. However, the CBO’s had not learned techniques to evaluate possible empowering or broad societal impacts in their communities as a result of this new approach to health development. ThaiHealth was anxious to determine if these changes were transpiring in the community and hired an external evaluator from Bangkok to assess the situation. The 22 CBO’s were exposed to an external process evaluation during the summer of 2003. The purpose was to evaluate outcomes, the capability of CBO’s, their effectiveness in modifying health habits, the capability of ICE, goal – objective – indicator alignment, identification of best practices and motivate a system of future evaluation among the CBO’s. Information collected was analyzed and each CBO was then quantified into three categories; Good, Fair, and Needs Work. 56
  • 58. A Vaccine for Globalization Several CBO representatives felt the external evaluator did not spend enough time in the community to gain a full understanding of what they were doing and how they were doing it. Several CBO members expressed the potential of losing identity if externally located NGO’s and GO’s used standards, based on their outside values, to judge the worth of their programs. Members of the CBO’s claimed that there were so many other things going on in their community that this externally conducted evaluation did not reflect. They expressed frustration that they can see changes, but don’t know how to express it on paper for the funders to see as well. Dr. Uthaiwan presented the idea of learning how to do participatory evaluations to the 22 CBO’s at the December 28th Network meeting. He informed the Network that these evaluations would supplement and not substitute their current program summary reports submitted to ThaiHealth. In response to Dr. Uthaiwans’ request, 11 of the 22 CBO representatives volunteered to attend workshops in order to learn participatory evaluation techniques. The CBO’s involved in the development of the evaluation method were; Saluang Group, MaeHak Group, BanMaiJong School, Lahu Group, Muay Thai Group, Three Age Group, MaePaKee Group, SanPaBao Group, SriBoonRuang Group, MaeSa Group, and the Mor Muang Group. Prior to the workshops, volunteer community representatives and ICE collaborated on developing a User-guide (see Appendix D) to assist in facilitating the evaluation workshops. The guide was based on participatory and empowerment evaluation, in addition to the ABCD approach in order to be consistent with the CBO’s health promotion program planning. It outlined a hypothetical path for developing and implementing the evaluation. The guidelines were flexible, however ICE felt it was important to put it on paper so the process was truthful and transparent. The guide was not handed out to the CBO’s during the workshops because ICE intended that the CBO’s would move through the process of developing a context specific and community owned method. 57
  • 59. A Vaccine for Globalization Background information The community of MaeChaem is approximately a 5 hour drive ‘up the mountain’ from ICE headquarters in Chiang Mai. There is one health post in the village that focuses on primary care. There are a total of 60 families in the village, which is an increase of 20 families over the last few years. In the past, families clustered to form compounds that tended to be far away from each other and scattered throughout the forest. Over the past 10 years, the village has gradually seen the development of roads and the introduction of electricity. The community has both a primary and secondary school. The CBO representative explained that the community has a strong local representation within the government and there is much less foreign missionary work in the area as a result. However, there are still strong ties with a Baptist organization that sends money into the area. The church is currently constructing a new clinic in the village. Analysis Plan Data collected and analyzed is presented in a chronological format detailing the evolution of the evaluation method. 1. A description of the Workshop; detailing the process of how ICE and the CBO representatives worked together in developing the evaluation method. 2. A description of the actual Evaluation Method steps; detailing each step of the evaluation as decided upon by ICE and the CBO’s at the workshops. 3. A description of how one CBO implemented, displayed and reflected on the evaluation method during their Community Meeting. (This group was singled out for description because an ICE coworker is from the community, they were the last of the 11 CBO’s to do the evaluation and they were one of the few groups that went deeper into the evaluation by defining indicators of a chosen variable.) 4. Finally, an Overall Summary of all Evaluation Results. All variables identified by the 11 CBO’s who conducted the evaluation were complied through a qualitative process of pile sorting. The process was repeated two times; once to sort according to social, physical, and mixed capital; a second time according to 58
  • 60. A Vaccine for Globalization similar themes. The final outcomes of the variable summary displays were agreed upon by a process of democratic consensus between the two researchers and ICE staff. Workshops The evaluation method was developed during a series of workshops attended by representatives of 11 CBO’s and facilitated by the director of ICE. Appreciative inquiry was the tool to address the challenge which faced the 11 CBO representatives in developing their own method, one that would best meet the needs of the community to identify, prioritize, measure, document in a format to help reflect on what was done, where they are today, which way they want to go, and how far they need to go and demonstrate impacts in their communities as a result of their health promotion programs. The evaluation method required a mechanism for involving stakeholders in recognizing, defining and measuring variables and indicators. ICE recognized that researchers and development workers have prefabricated long lists of variables and indicators for empowering and social changes. However, they felt that community involvement in variable and indicator identification needed to be developed and negotiated based on indigenous and experiential knowledge, taking into consideration the linkages between social, cultural, economic, political, and environmental systems in a community. ICE thought the process of identification would ideally lead to a better understanding of what caused the changes. The workshop began by posing the question; ‘what are different things that we can evaluate in our community?’ The 11 CBO representatives listed several possibilities; activities, social changes, what works and what doesn’t, and a combination of all three. They voted on trying to evaluate social changes. Then the 11 CBO representatives were asked ‘what questions do we need to ask in order to identify any social changes?’ Other questions and concerns raised and addressed at the workshops included; availability of resources required of the community to design, collect and analyze the data, an understanding of the amount of time that they realistically had to participate in the process, as well as taking into consideration that people participate in diverse ways, at 59
  • 61. A Vaccine for Globalization different times, with varying patterns, and through different structures within their context. Deciding how much time between information collection, analysis and reflection would pass. How to assure that the process was not associated with faultfinding or finger pointing, that people were not being monitored, if the findings will be abused or not, how to deal with a pull toward just looking at activities, how much information is needed, how precise does it have to be, and how will the results assist in creating common solutions and assist in bridging the communication gap between the CBO’s and their funders. The evaluation method slowly materialized over three workshops. Refinement and ongoing revisions were made according to continuous and flexible spirals or cycles of participatory learning; planning, acting, evaluating, and reflecting during the three workshops and during actual implementation. The resulting mission for the evaluation was, ‘To utilize an ABCD approach to empower community members to identify and evaluate common and unique community changes, secondary to their ABCD for health promotion programs.’ The final guidelines for developing and implementing the evaluation method were; o Communities will evaluate their own changes according to the values of their setting based on local knowledge and ideas, rather than judging their approaches according to outside criteria o The entire process will be collective and participatory, fostering selfdetermination, building capacity and putting control into the hands of the communities by first identifying and building on existing community strengths. o The evaluation method will be meaningful to the community, CBO members, the Network, and funders. o Methods will be sensitive to local settings, taking into consideration; time, language, education, etc o Methods will be adaptable for when perceptions and conditions change, and will reinforce community competence o Information will be collected in a collaborative manner 60
  • 62. A Vaccine for Globalization o Results will be both qualitative and quantitative because community perspectives through experienced based stories are crucial in helping to explain the situation behind the numbers. o Results will be easily displayed, understood, relevant, and highly valued by the community and their funders. o Results can be used to guide future decisions and community action to increase long-term sustainability of all health promotion initiatives, with hope of gaining an understanding of social reality. Evaluation Method The 9-step evaluation method developed at the workshops is described below for comparison to the user-guide presented in Appendix A. Step 1: Before The evaluation would begin by talking about the CBO’s program, framing everyone’s mind set around what they did. The facilitator would then ask everyone to think about what the community was like before this program. Everyone would write their responses down, one thought per page. Knowing that some community members can’t write, the group still felt comfortable taking this approach because there would be enough younger community members in attendance to assist. If this was not possible, responses could be taken orally with the facilitator writing them on a board. The purpose of this step was to ask a simple and open question, one that would allow for responses to range from possible outputs to impacts. Some members were concerned that by having such an open ended question, there was the potential to get answers that were not related to the project, for example; ‘I had only one child before the program and now I have two children.’ Despite this concern, the group decided the simple and open question would be the most effective first step and worthy of a try. Step 2: Cluster 61
  • 63. A Vaccine for Globalization The facilitator would then collect all the responses, read them aloud to the group, discuss each response and clarify meanings when appropriate. The group would collectively arrange all responses into similar categories and stick them to the wall. The basis for this idea came from a PRA method of pile sorting; however the group did this activity collectively. Step 3: After The facilitator would ask the group to think about what it is like now in the community, two years after our program started (similar to Step 1). Everyone was instructed to write their responses down, one thought per page. Step 4: Cluster Again, the facilitator would collect all responses, read them aloud to the group, discuss each response and clarify meanings when appropriate. The group would then stick each response on the wall if they related to the clusters already formed, or they would create new ones. Step 5: Categorize After all responses were clustered and stuck to the wall, the facilitator would negotiate a process of categorizing and defining each cluster with a neutral key word. The group felt it essential to use a neutral word so when it came time to rate the category one would have a nonbiased range to choose from; negative to positive scores. Step 6: Prioritize Once all clusters were categorized according to a general consensus of the group, they were each given two pieces of paper. The facilitator would then instruct each member of the group to walk around, read the responses and vote by placing each paper on the category that represented the most important change in the community. 62
  • 64. A Vaccine for Globalization The votes were tabulated and each neutral key word was listed in order of priority, based on the outcome of the voting. The facilitator would then have the group decide how many key words would be rated. Step 7: Rate The facilitator handed out an empty results form. Each member of the group filled out the left side of the form with the prioritized neutral key words. The facilitator would negotiate the meaning of each number on the rating scale from 1 to 7. Once a consensus was reached on the scale, each participant would rate each neutral key word and then justify their score with a personal story or experience written on the right side of the form. Step 8: Display Once all the scores were tabulated and averaged, they were displayed on a star plot. The idea for the star plot came from work by Rifkin and her efforts to evaluate participation, and the work of Chambers in his evaluation wheel (37, 43). Step 9: Reflect The star plot was displayed for the group and the facilitator asked participants to comment on what they were looking at, what they thought of the process, and what they can use the results for. Community Meeting The MaeChaem evaluation was conducted at the residence of the head CBO representative. The two CBO members who attended the workshops were running the local elections at the school and were not able to attend the meeting. A third member of the CBO, a local teacher, facilitated the meeting with assistance from Dr. Uthaiwan. Twenty-four community members attended the meeting and participated in the evaluation. The age of participants ranged from 11-75, slightly over half were teens and 63
  • 65. A Vaccine for Globalization young adults. There were 8 men and 16 women (1 older man, 2 teachers, and 4 married older women). The teacher opened the meeting with introductions and the community members participated in singing a song. Dr. Uthaiwan and the local teacher explained that today they will together think about their community, what it was like 2-3 years ago and what it is like now. The discussion started by thinking about the CBO program they were involved in and other projects that were implemented in their community the last few years. Initially they could not think of any other besides their own program. Then, one woman said there was a CARE project in the area that worked with the housewives group to assist with income generation projects. Another woman said that in the past a religious organization had a drug detoxification program nearby. They remembered the program started during the time when the government cracked down on opium growing by burning all the opium fields. At that same time, NGO’s were invited by the government to work with local groups to develop alternative income generation activities. They said the detoxification program lasted about 2-3 years, but was no longer running. They said they would like to transform the now unused site into an herbal garden area as an extension of their health promotion program. After this discussion the facilitators then started the evaluation method developed at the workshops (See Steps 1 – 9). The facilitators asked the group what it was like in the community ‘Before’ their program started. The facilitator asked them to think about it while he passed out blank pieces of paper. Responses were written in both Thai script and in BaKurYo. BaKurYo (Ba means ‘people’ and KurYo means ‘live easy/simply’) is how they refer to themselves, as well as Karen. The responses were read aloud and discussed. Then they were clustered (Step 2) by consensus into similar themes and posted on the wall. When this process was finished, the second question (Step 3) was asked relating to what it is like in the community ‘After’ this program has been running for 2 years. The responses were again read aloud, discussed and clustered (Step 4) into similar themes – using clusters already on the wall or adding new ones when necessary. The facilitator then had the group take each cluster and categorized (Step 5) or labeled them by consensus. Table 1 lists an example of what resulted from the first 5 Steps of the evaluation method. 64
  • 66. A Vaccine for Globalization Table 1: Summarized Results of Steps 1-5: Step 1 - What was it like ‘Before’ the project? Step 2 - Clustering similar themes. Step 3 - What is it like now or ‘After’ the project has been running for 2 years? Step 4 - Clustering similar themes. Step 5 - Categorizing all responses. *(number of times mentioned in brackets) Steps 1 and 2 -Before “We did not have any development activities” (2) “There were no changes in the village” “We did not have any development work, and don’t have any roads” Steps 3 and 4 -After Step 5 “The village development is better” DEVELOPMENT “We know more about development work” ACTIVITIES “The village has more development activities” 65
  • 67. A Vaccine for Globalization Table 1: (continued) Steps 1 and 2 -Before “In the village we had no cooperation” never helped “We others” “We had no cooperation” (4) “Health was not good” (3) “We did not have growth about health” “We did not have unity in Ban Jam Luang, we did not have unity together” “Little mouse thinks we did not have unity ka” “Not have much unity” “We did not have activity of conserving herbal medicine” “In the past our village did not know how to use herbal medicine” “We did not have any conservation activities of herbal medicine” Steps 3 and 4 -After “Now we have cooperation - for example building a new house and other activities like during Christmas time” “Now we have more cooperation - for example groups of housewives work in cooperation, and we have sports activities” “Now we can see clearly better cooperation for example at new years” “Now we have more cooperation” “Now we cooperate better” “The SSS project we cooperate and know more and we do activities and conserve and preserve our traditional culture and make conservation of herbal medicine and massage and take care of our health” “Now we know about curing health” “We have better health” (2) “We have more love and unity because we have a group” “Our village knows unity more than before” “Now know unity more” “Have more unity” (2) “Have unity together a lot more than before” Step 5 COOPERATION HEALTH UNITY “We know more about herbs” CONSERVE “Make everyone learn about herbal medicine” HERBAL “Health is better, not have pain and illness and know MEDICINE about how to use herbs more” “Know more about herbal medicine more and make not buy medicine” “Health is better and don’t have pain or illness” “Everyone learns a lot more about herbal medicine and we have more unity” “We have opportunity to use herbal medicine more and to massage and not have to go to the doctor far away” “Know more about herbal medicine” “Know about herbal medicine more” “Program led to knowledge and ability more for example knowing more about herbal medicine and having more unity” “We help preserve and conserve herbal medicine” “These days most of us use herbal medicine first” “Have more knowledge and have understanding and everyone knows about herbal medicine more” “Can conserve herbal medicine” “Have knowledge about using herbal medicine more” “Have use of herbal medicine more” 66
  • 68. A Vaccine for Globalization “Have activities of planting herbal medicine in the forest” “We have belief and knowledge about many kinds of herbal medicine” 67
  • 69. A Vaccine for Globalization Table 1: (continued) Steps 1 and 2 -Before Steps 3 and 4 -After “The village was not growing” “We did not have any growth” “We had little “Now we have more knowledge” knowledge and ability” “Now we can have more knowledge about many things” *(I probed to find out why they thought they had no knowledge in the past, they responded by saying, “before we had no roads - no way to get information, now our kids are going down to schools, and now we have our own schools.) “Love and happiness was “Have unity and love a lot more” “Have love a lot” only a little” “We did not have love for each other, now we have more love for each other, much more” “Travel was very inconvenient and made us not able to visit each other” “Now we have massage for health” “Now we have conservation of traditional culture” “We have more fun and amusement” Step 5 GROWTH KNOWLEDGE and ABILITY LOVE ROADS TRAVEL and MASSAGE TRADITIONAL CULTURE AMUSEMENT After each response was discussed, clustered, and categorized; the facilitator handed out two pieces of paper (cut into the shape of hearts) to each participant. The facilitator instructed each person to take their paper and stick it on the most important change (Step 6) that has taken place in the community since the program started. The facilitator explained to not vote according to what was the biggest or most significant change, but the most important change. The group walked up to the wall, had some discussion and each person voted by placing their piece of paper on the wall over the most important change for their community. Table 2 lists the results of Step 6. 68
  • 70. A Vaccine for Globalization Table 2: Results of Step 6 - Prioritize all Categorizes identified through Steps 1 -5: *(number of votes given to each Category in brackets): Development Work Growth Cooperation (12) Health Unity (8) Herbal Medicine Conservation (1) Knowledge and Ability Love and Happiness (2) Travel Massage activities Traditional Culture Amusement (1) After the voting, the facilitator handed out a blank form and asked the group to rate, on a scale of 1-7, how they thought the community was doing in regard to these changes today (Step 7). The facilitator negotiated a definition for each number (1-7) and when the group came to a consensus, they voted on the top 5 changes and were instructed to write a story next to the score to justify their response.Table 3 lists the results from Step 7. Table 3: Results of Step 7 - Rate the top 5 Categorizes followed by personal story to justify each score: *(score in brackets) *[number of times mentioned in brackets] COOPERATION (5) “When we have Christmas activities all of the villagers work together” (4) “Have cooperation not a lot and not a little because we don’t give too much cooperation to each other.” (4) “Because we have work we help each other” (4) “Have cooperation when we play sports” (6) “Help each other cooperate” (6) “Help to do” (5) “Help each other work” (6) “Cooperation for example when we build churches and schools” (5) “Cooperation have more” (5) “Working together” (5) “Work to build church and school” (6) “We have cooperation a lot better for example, working in groups” (5) “Because we have good cooperation in building houses and working in the field” (6) “Cooperation together for example building church and school” (5) “For example in working to build the church and houses” [2] (5) “Building a church and a school” (6) “Building a church and a school” (7) “It is the best thing” (7) “It is the most important for Karen” (5) “In village development” 69
  • 71. A Vaccine for Globalization Table 3: (continued) UNITY (5) “On the 25th of the month we have group village meetings and we see everyone has a lot of unity” (5) “New Years activities and building new homes we have good unity” (5) “If we have an activity we have unity more every time” (5) “If we have sports we have good unity” (4) “We help each other survive and have unity” (5) “Help each other do activities” (6) “We play sports activities” (5) “For example the meeting on the 18th was very interesting” (7) “We have more unity” (7) “We all have to have unity together” (6) “In the meeting everyone shows their interests in the community” (3) “For example in the meeting we have only a few people” (4) “Working in groups have unity” (5) “Our meetings every month show the interests of the community” (5) “In the village meeting the community is very interested” (4) “For example at Christmas we have good unity” (6) “We work together” (5) “We have unity in many activities” (6) “We know each other more” (6) “Unity of the community is better, love and unity together is better” (4) “Have more unity” LOVE (4) “When one person in the village does a good thing we all see and are glad and let them know” (5) “We understand each other” (5) “Peek at love” (6) “Love each other a lot” (5) “Love each other in the community” (5) “Have active compassion sharing and love” (5) “Getting along well, show our affection for each other” (5) “We have more love” (5) “Love is beneficial for us” (5) “Have love for each other” (3) “Love not a lot because not have enough knowledge” (5) “Love for each other” (4) “We help each other” [2] (5) “We help each other” [2] (6) “We help each other” (5) “Makes us know and endure more” (5) “The love of the village is better” 70
  • 72. A Vaccine for Globalization Table 3: (continued) CONSERVATION OF HERBAL MEDICINE WISDOM (5) “Conservation of the herbal medicine for example making a place for the conservation of herbal medicine (in the forest)” (5) “When we make a space and study herbal medicine conservation in the forest” (6) “If we are not comfortable we can use herbal medicine, we should conserve herbal medicine” (6) “Because we don’t have to go buy medicine” (5) “Conservation of herbal medicine” (7) “Herbs are medicine” (4) “It is medicine we can eat” (5) “Now we know how to use herbal medicine” (4) “Conservation of water and the forest” (6) “Development activities of herbal medicine” (6) “Using herbal medicine is very beneficial us” (4) “We need to conserve herbal medicine for the kids and relatives because it is beneficial/useful for use” (3) “Activities to conserve herbal medicine” (5) “Conservation of herbal medicine to save and make more” (5) “We are conserving herbal medicine for the benefit of all of us and all of our kids and relations always” (5) “Conservation of herbal medicine” (4) “Some people take medicine from the hospital and don’t get well, then they take herbal medicine and get better” (5) “We will conserve herbal medicine” (6) “Conservation of herbal medicine is very important for the people who are far away from the doctor” (6) “Want the conservation of herbal medicine to be sustainable” (5) “Want to use herbal medicine and want it to be sustainable” AMUSEMENT (FUN) (3) “When we have sports we go to give support” (5) “For example playing sports is having fun” (4) “For example we play sports and have fun” (4) “Help each other play football” (7) “Play sports” (4) “Play sports” [2] (5) “Plan activities all kinds” (4) “For example takraw” (5) “Play sports” [3] (5) “Play sports is a lot of fun” (5) “For example at Christmas we have sports” (6) “We have fun always” (5) “Christmas and sports” [3] (5) “Makes us happy - think well of each other” (4) “Christmas and sports” (5) “Play sports and Christmas” 71
  • 73. A Vaccine for Globalization The facilitator collected and tabulated all the scores. Table 4 depicts the central tendencies of each prioritized change. Each change identified through the first 7 Steps of the evaluation method were determined to be the ‘variables’ of changes that had taken place over the previous 2 years. The facilitator took the five prioritized ‘variables’ and with the help of some participants displayed the results on a star plot (See Figure 1). The facilitator asked the group if they were interested in taking one of the identified changes and repeating the evaluation process to further understand what the identified change means to the community. 72
  • 74. A Vaccine for Globalization Table 4: MaeChaem Rehabilitation and Development of Herbal Medicine Group Variables of Community Change Measures of central tendency and variability for ratings Concepts Cooperation Unity Love and Happiness Conservation of Herbal Knowledge Amusement Mean 5.25 5.04 4.75 5 4.75 Median 5 5 5 5 5 Mode 5 5 5 5 5 Range (min-max) 4-7 3-7 3-6 3-7 3-7 Variables of Community Change Star Plot Cooperation 7 5.25 Amusement 7 7 Unity 5.04 4.75 1 5 7 Conservation of Herbal Knowledge 4.75 7 Love and Happiness Figure 1: MaeChaem Rehabilitation and Development of Herbal Medicine Group 73
  • 75. A Vaccine for Globalization The group decided to explore deeper into the category of ‘COOPERATION’ by repeating Steps 1-8. The ‘Before’ and ‘After’ questions regarding the program were adapted to have the context of ‘COOPERATION’ in mind. The evaluation was adapted a second time and the facilitators conducted the process orally. The facilitators wrote the participants responses on a piece of paper stuck to the wall. Table 5 lists the results of this process. Table 5: Cooperation Breakdown by repeating Steps 1 and 3 COOPERATION Before (Step 1): ‘People in the community did not come in force to meetings’ ‘People did not come on time to meetings’ ‘Before we were not brave to present our opinions at the meetings’ *(this was probed further to get the response that they did not have any information and less schooling so we were shy to say something) ‘We did not have an introduction to making a group together’ ‘We were isolated from each other’ ‘People didn’t go to visit each other before because travel was very inconvenient’ ‘People didn’t go to funerals because they are afraid of ghosts’ ‘People move around’ After (Step 3): ‘Everyone goes to church more, and more willing to exchange information and ideas at meetings’ ‘Everyone came together to build the natural irrigation system in the community forest’ ‘Everyone can say good ideas in the meetings and some times it is hard to get people to stop talking’ ‘Have the activity of organizing groups’ ‘Travel is more convenient because of the roads and people can visit each other regularly’ ‘People go to funerals more because we have electricity so we are not afraid to walk at night’ ‘We don’t have gambling and also have songs, “utaa”-usually sung by the elderly, some drinking depending on religion’ ‘We go to work in the city and kids go to study in the city so they bring back information’ ‘We have active conservation of herbal medicine and use herbal medicine, planting at home and at school and in the forest’ 74
  • 76. A Vaccine for Globalization The facilitator then negotiated a ‘neutral key word’ to describe what linked the categories of ‘Before’ and ‘After’. Each term identified was determined to be the ‘indicator’ for ‘COOPERATION’. Table 6 lists what resulted from this process. Table 6: Indicators for Cooperation 1. 2. 3. 4. 5. 6. Coming together in force Brave to express Come together as a group Think/do/decide together In the habit of visiting each other Think/make/do/decide and use beneficially together The facilitator repeated Step 7 of rating where the community felt they were currently. Scores were given to each indicator on the same scale of 1-7, but the group did not write comments to justify their scores as they were running out of time. Table 7 lists the central tendencies of each indicator. A star plot was also displayed for group reflection (See Figure 2). 75
  • 77. A Vaccine for Globalization Table 7: MaeChaem Rehabilitation and Development of Herbal Medicine Group Indicators for Cooperation Measures of central tendency and variability for ratings Concepts To attend in force Participation Dare to express/Brave to perform Come together as a group Think/Do/Decide together Visiting each other as habit Working together for the benefit of the community Mean 5.13 4.96 4.67 5.83 4.75 4.88 5.17 Median 5 5 5 5 5 5 5 Mode 5,6 5 5 5 5 5 5,6 Range (min-max) 2-6 1-6 2-6 3-7 2-6 3-7 2-6 Indicators for Cooperation Star Plot To Attend in Force 7 Working together for the benefit of the community 7 7 5.13 Community Participation 5.17 4.96 Visiting each other as habit 7 1 4.88 4.67 7 Dare to express/ Brave to perform 4.75 5.83 7 Think/Do/Decide together 7 Come together as a group Figure 2: MaeChaem Rehabilitation and Development of Herbal Medicine Group 76
  • 78. A Vaccine for Globalization At the end of the meeting the facilitator hung both Star Plots on the wall and completed the evaluation methodology by having a reflection (Step 9) on the process and results of the evaluation. The local teacher commented that the process was “not all easy and not all hard, but now it is enough for us to go ahead on our own”. Another teacher in the group said she listened to what was happening and in the beginning was not sure where the process was going, but in the end it gave her new creative ideas for doing things in the community. A woman from the housewives group commented that “we never did anything like this before, it is too good.” Another member of the participants stood up and said “everyone is very satisfied with what happened today, and it is much different than someone coming here and saying this is bad or that is good - today everyone learned something.” Another member of the group said “now we can see ourselves - it is very good - and we can see in the future where we should go and how far - for myself I have not cooperated much, now I see and want to do more, I heard many things today, it gave birth to much imagination. I believe our community will be strong.” Overall Summary of Evaluation Results Eleven of the 22 CBO’s participated in implementing the evaluation method created during a series of workshops. The 11 CBO individual results are displayed in appendix E for review. All variables of community change, identified during the implementation of the evaluation, were pile sorted into Social, Physical and Mixed capital. This procedure was done by three members of ICE’s evaluation team. The three members of the evaluation team compared results and came to a democratic consensus. Table 8 lists the results of this process. 77
  • 79. A Vaccine for Globalization Table 8: Pile Sort 1 – All ‘Variables’ pile sorted into Social, Physical and Mixed Capital (number of times mentioned by a CBO in brackets) Social Capital Physical Capital Mixed Unity (8) Participation (2) Cooperation Participation/Cooperation Community Power Togetherness Know Friends Thinking and Deciding Together Wisdom of Local People Self-care with old wisdom Hill Tribe Culture Culture Conservation of Herbal Knowledge Self-care with Health Leadership in Group Health Status Physical Health Community exercising groups Sports Interest Strong Health Physical Exercise Mental Health (2) Strong Community Family Warmth (2) Active Compassion Compassion Kindness Human Relationships Love and Active Compassion Happy, Joy, Gay (2) Love and Happiness Amusement Community Relations Family Life (2) Strength Revitalization Education Knowledge about Health Interest in Learning Learning Knowledge about Drugs Knowledge Drug Prevention Responsibility by Community and Family Place to Play Resources (Funding) (2) Local Growth/Development (2) Networking (2) Decreased Illness Economic Situation Decreased Stress (2) Stop using Addictive Drugs Using Free Time Gangs 78
  • 80. A Vaccine for Globalization Each member of ICE’s evaluation team (3) pile sorted all variables from the 11 CBO’s, with out any restriction. The three members of the evaluation team compared results and came to a democratic consensus. Table 9 lists the results of this process. Table 9: Pile Sort 2 – All ‘Variables’ pile sorted into similar themes * (number of times mentioned by a CBO in brackets) Unity (8) Community Power Networking (2) Togetherness Know Friends Strong Community Community Relations Human Relationships Strength Wisdom of Local People Self-care with old wisdom Hill Tribe Culture Culture Conservation of Herbal Knowledge Self-care with Health Health Status Physical Health Community exercising groups Decreased Illness Strong Health Mental Health (2) Decreased Stress (2) Revitalization Leadership in Group Responsibility of Community and Family Family Warmth (2) Active Compassion Compassion Kindness Love and Active Compassion Happy, Joy, Gay (2) Love and Happiness Family Life Education Knowledge about Health Interest in Learning Learning Knowledge about Drugs Sports Interest Resources (Funding) (2) Local Growth/Development Community Development Economic Situation Participation Cooperation Participation/Cooperation Thinking and Deciding Together Outliers: Amusement Drug Prevention Use of Addictive Drugs Place to Play All ‘variables’ were then compiled into a chart, based on the result of the final pile sort, to display the frequency of similar identified ‘variables’ from all 11 CBO’s. The quantitative results were then averaged to provide a display of scores given to each of the 9 identified themes of community change. Table 10 lists the results of this process. Results of all the CBO’s identified ‘variables’ were then graphed, based on the final pile 79
  • 81. A Vaccine for Globalization sort, in order to visualize similarities and frequencies of identified changes and their current self-assessment score among all CBO’s participating in ABCD for health promotion (See Figure 3). See Appendix E for individual quantitative results for all 11 CBO’s who participated in the evaluation. 80
  • 82. A Vaccine for Globalization Table 10: All ‘Variables’ identified by the 11 CBO’s and their average ‘Score” Concepts 1-9 1. Unity o o o o o o o o o Unity (8) Community Power Networking (2) Togetherness Know Friends Strong Community Community Relations Human Relationships Strength 1 Community Groups 1-11 2 3 4 5 x x x x 6 7 8 x x x x x 9 10 11 x x x x x x x 4.11 4.38 5.41 6.63 5.73 5.48 x 6.49 5.55 5.04 2. Warmth Family Warmth (2) Active Compassion Compassion Kindness Love and Active Compassion o Happy, Joy, Gay (2) o Love and Happiness o Family Life o o o o o x x x x x x x x 4.39 5.68 4.67 5.71 x 5.57 4.75 81
  • 83. A Vaccine for Globalization Table 10: Continued Concepts 1-9 3. Local Wisdom Community Groups 1-11 1 2 3 4 o Wisdom of Local People x o Self-care with old wisdom o Hill Tribe Culture o Culture o Conservation of Herbal Knowledge o Self-care with Health 4 4. Education o o o o o o Education Knowledge about Health Interest in Learning Learning Knowledge about Drugs Sports Interest 5 6 7 8 9 10 11 x x x x 6.63 6.64 4.88 x 5.73 5 x x x x x 5.2 x 5.77 6.08 6.09 82
  • 84. A Vaccine for Globalization Table 10: Continued Concepts 1-9 5. Physical Health Community Groups 1-11 1 2 3 4 5 6 7 8 9 10 11 x o Health Status o Physical Health o Community exercising groups o Decreased Illness o Strong Health x x x 6.14 4.55 x 6.29 5.11 6. Resources o Resources (Funding) (2) o Local Growth/Development o Community Development o Economic Situation x x x x x 4.82 2.88 5.27 7. Mental Health o Mental Health (2) o Decreased Stress (2) o Revitalization x 4.45 x 4.44 x x 6.11 x 6.23 83
  • 85. A Vaccine for Globalization Table 10: Continued Concepts 1-9 8. Participation Community Groups 1-11 1 2 3 4 x Participation Cooperation Participation/Cooperation Thinking and Deciding Together 4.44 9. Leadership o o o o x o Leadership in Group o Responsibility of Community and Family 3.71 Outliers 5 6 7 8 9 10 11 x x x 5.35 5.25 6.18 x 5.4 Amusement Drug Prevention Use of Addictive Drugs Place to Play 84
  • 86. A Vaccine for Globalization X=frequency of prioritized changes as identified by the CBO’s Y= frequency of current scores given to identified change as determined by the CBO’s Outliers: Local Wisdom Unity Warmth Phys. Health Education Ment. Health Resources Amusement Drug Prevention Use of addictive Drugs Places to Play Leadership Participation Variables of Change Figure 3: Frequency of CBO identified and prioritized ‘Variables’ vs. the current ‘Score’ 85
  • 87. A Vaccine for Globalization Evaluation Discussion ICE and the 22 CBO’s wanted to develop an evaluation consistent with their ABCD approach to health promotion. The workshops were designed to practice a thinking process of participatory learning and collective decision-making by providing an environment for dialogue. Some might criticize the concept of having the ‘questionmakers’ also be the ‘question-answers’. However, others point out that when a community has the chance to examine itself through questions created and asked to itself, there is potential to lead to a new consciousness of ones surroundings (9). This approach taken by ICE opened the door for the discovery of new and innovative ways to evaluate broad societal impacts, and assisted the CBO’s in explaining these impacts to outside funders. During the workshops health professional and non-health professional; native Thai, English and Lanna speakers engaged in a discussion of local health issues and evaluation techniques. Universal terminology was an obstacle to overcome. For example, the word ‘Empowerment’ is not a native Thai word. There was much debate regarding the meaning and possible translation of this word and others. The process was slow, and at times appeared to move in circles, but in the end it contained a great deal of potential for the CBO’s to take ownership in learning how to self-examine their situation. The development of the evaluation method was a learning experience for everyone involved in the process, from community representatives to workshop facilitators. The evaluation method developed at the workshops strongly resembles a sixelement process for empowerment evaluation described by Fawcett et al. (19). These steps include; determine where you are now, where they would like to go, how to get there, monitor to make sure you are on track and making progress, collect and analyze data along the way so you can adjust course, and apply what you have learned to strengthen the organization for the next program (19). It also relates to what Green and Kreuter detail in the Precede-Proceed Health Promotion Planning Model, specifically when forming a social diagnosis (44). The social diagnosis phase of the Precede-Proceed Model is the identification and analysis of social and economic conditions, perceived quality of life or the aspirations of the target population (44). This phase is necessary for any thorough health promotion planning process (44). 86
  • 88. A Vaccine for Globalization The 9 steps developed by the CBO’s stands to be criticized for its lack of scientific rigor and objectivity. However, with regards to objectivity, it has been argued that perhaps objectivity is gained not through detachment from the setting via an outsider, but through intimate involvement in and reflection about the setting (19). Additionally, the CBO’s felt a complex methodology with statistically measurable objective data gathered solely through quantitative means, similar to their current summary reports, would defeat the purpose of a community-wide, user-friendly and community-owned process for evaluating broad scale societal impacts. Thus, the simplicity of the method was its strength. During the implementation of the evaluation method; the quality of the evaluation was largely dependent on the facilitator. The specific skills of the facilitator directly reflected on each community’s results, the amount of reflection and the potential utilization of findings. For example, the clustering and categorizing steps were easily monopolized by a few individuals if the facilitator did not make direct efforts to bring all community members into the decision making process. A few CBO’s took the evaluation process further by repeating the 9 steps and developing indicators for achieving one specific identified variable. This additional process turned out to be one of the most enlightening phases of the evaluation. However, to deeply explore into the meaning of each variable was time consuming and challenging. It was initially the most confusing phase because they were attempting to define and measure very intangible concepts, i.e. ‘COOPERATION’. The process of gathering the qualitative data was essentially much more important then the actual scores given to each variable. The results were completely community specific and subjective. ICE is unable to generalize or compare results among different communities because each community defined their own variables, indicators, and standards of acceptability. This will also make tracking changes over time difficult because the majority of identified variables were not static, i.e. love, unity, etc. The data did provide answers to what the changes were, however an understanding of why the changes occurred remains up to the participants of the evaluation to determine. The CBO’s wanted the results to be put together in an easy and understandable format. The displayed results would be a starting point for discussion and action. Action 87
  • 89. A Vaccine for Globalization to either change the evaluation steps to meet their needs (i.e. writing down their answers to the before and after questions or doing the process orally), to address areas of identified importance for future projects, and to improve current efforts. The Star Plot provided this, however some CBO’s decided that the next time they wanted to try to display the results in a different format. The intention of ICE was that the evaluation method would function as a benchmark in which CBO’s can revisit and repeat independently. However, only 11 of the 22 CBO’s participated in the workshops and implemented the evaluation in their communities. The 11 CBO’s who did not participate in the process expressed concern that this author was going to ‘steal their ideas’ return to the US, patent them and leave them empty handed. Despite ICE’s constant reassurances this was not the intention of the author, some remained steadfast in their refusal to participate. A representative from ThaiHealth was invited to attend the Network meeting when the 11 CBO’s shared their evaluation results and reflected on the process. The 11 CBO’s who did not participate did not attend the Network meeting when the evaluation results were presented. However, the participating CBO’s proudly discussed their results and several different CBO representatives engaged in dialogue regarding what each others definition of similar identified variables were. The ThaiHealth representative was impressed with what the CBO’s had accomplished, and was glad to see a renewed appreciation for evaluation among the CBO’s who participated. She was excited to hear that one CBO had repeated the evaluation method with another community program, without the facilitation of ICE. 88
  • 90. A Vaccine for Globalization 89
  • 91. A Vaccine for Globalization CHAPTER V: LIMITATIONS Limitations Overall, the study was limited by time, language, availability of CBO’s, and personal bias. Race, gender and nationality may have influenced how people responded to questions, or how much they shared about their opinions. Translation should also be mentioned as Thai is not our first language for the assistant researchers; therefore errors of interpretation may have occurred. The 3 months time frame limited the depth of knowledge obtained by this study and limits the ability to analyze the utility of the 9-step evaluation results, as this will be evident by future program proposal writing and evaluation. Researchers spent only one or two days in different community settings and recognize this provides only a glimpse into a communities’ reality. The primary limitation for data collection was not being able to interview all CBO representatives. The CBO’s moving through the ABCD based process for health promotion with more success were more likely to be present at the Expo, meetings, participating in developing and implementing the evaluation, and invited us to visit their community. Therefore, it is possible we missed collecting information from groups that may have been less successful. It is impossible in qualitative research to remove every threat to validity (45). Although we tried to construct an objective account, our personal views may have colored the interpretation of the data. There is no guarantee that a different investigator would have interpreted the data in the same way. Field notes and transcripts are available for others to analyze. Attempts to maintain internal validity were obtained by constantly reframing and restating an interviewee’s words during the conversation, in order to confirm intention and concept links, and by immediate transcription. External validity of the conclusions could be increased by another study using the same methods under similar circumstances in another location. The conclusions are not generalizable, they are only specific to the groups encountered and addressed in the case study. However, the processes and insights 90
  • 92. A Vaccine for Globalization presented here may be easily transferable to another setting practicing ABCD based approaches to health promotion and community development. Additionally, aspects of the evaluation building process and final steps may be transferable to other settings. Insider/Outsider Issues As a result of the participant observation and NFG’s, community representatives appeared to feel at ease, perhaps trusting, when talking with me about their work during the semi-structured interviews. Many became excited and animated while telling the story of how their community worked on their projects. They appeared comfortable with my ability to speak their language, and ask questions about the projects with the same words CBO representatives and community members used. As the researchers gained acceptance into their group, reactivity declined. The participant observations and NFG’s also helped shape the questions for the semi-structured interviews. This was fundamental for gaining insight into how they viewed their work, where ideas came from, and how they framed struggles and successes. 91
  • 93. A Vaccine for Globalization 92
  • 94. A Vaccine for Globalization CHAPTER VI: CONCLUSIONS AND RECOMMENDATIONS Conclusions This case study has provided valuable information about community perspectives related to ABCD approaches and a context specific method to evaluate social changes among people-led community health and development programs in Chiang Mai Thailand. The original purpose of this case study was two fold; first to describe one group’s effort in hopes of shedding light on how the ABCD approach is perceived by community groups, and the second refers back to 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 these CBO’s measure these potential changes in their communities?’ Based on analysis of the data, every CBO who was part of this investigation believes their ABCD based approach to health promotion and community development is; leading to positive changes in their communities, and different from other health and community development programs they were exposed to in the past. Perhaps this is because they now have an alternative to hold up against the standard needs-based approach, making comparison and contrast meaningful. Additionally, the resulting evaluation method, based on the concepts of participation and empowerment, incorporated social, cultural, environmental and political factors into the evaluation of outcomes and impacts of their health promotion programs. Despite the lack of generalizability, ICE and their research assistants pile sorted all variables resulting in 9 separate categories; unity, warmth, local wisdom, education, physical health, resources, mental health, participation and leadership. When looking at the three most identified changes; unity, warmth and local wisdom, which can be classified as social capital, can we answer yes to the question; Does ABCD approaches lead to empowerment and selfdetermination? We believe the answer is a resounding yes and will argue that the ABCD approach does in fact lead to empowerment and self-determination as evidenced by the top three mentioned variables; unity, warmth and local wisdom. Therefore, ICE and the 93
  • 95. A Vaccine for Globalization CBO’s were successful in developing a way to evaluate and translate what they ‘see happening in their community’ into ‘measurable variables and indicators’. The evaluation results will be used to supplement quantitative reports submitted to funders for the purpose of showing evidence of the broad social changes taking place in their communities. The self-identification and definition of these community changes; unity, local wisdom, education, love, etc., elicited through the facilitation of community dialogue will be used to assist in the design and implementation of future health promotion programs. The 9 – step evaluation method developed by the CBO’s during three workshops will be incorporated into a facilitator guide produced by ICE to assist in conducting future workshops and evaluations with local CBO’s. The process of developing and implementing the evaluation has potential to lead to improved future development practices because community specific, reliable methods were created to gather data that is meaningful to the community, in addition to being respected by the ‘professional’. Perhaps someday, overwhelming evidence will exist to shift the balance of health services and community development initiatives from top-down, problem-oriented, outsider defined, funded and researched, to a more local bottom-up, strength-based orientations. Otherwise, institutions will continue to teach deficiency oriented methods as the preferred approach for public health and community development, thus making sustainable empowering community development an unattained dream for the majority of the world’s people, most especially those groups considered marginalized. Recommendations Recommendations for ICE include focusing on the difficulties mentioned by CBO representatives including the issues of time, communication, and evaluation. Communication alternatives could be explored by rotating the location of the monthly meetings. Coordinating the development of CBO and Network timelines detailing upcoming deadlines might also be considered. Providing representatives with more workshops on negotiation and leadership could also be explored. Many CBO representatives stated program writing and evaluation were areas they wanted to improve. The second purpose of this case study was to describe how ICE and 11 CBO’s 94
  • 96. A Vaccine for Globalization successfully developed a method to identify and evaluate social changes within their communities secondary to their health promotion programs. The CBO’s accepted the challenge of learning how to evaluate outcomes and impacts of their programs with the hope of generating action to transform social structures and conditions that oppress them. ICE could have easily compiled a prefabricated list of variables and indicators, based on a literature review, and conducted an evaluation to identify outcomes and impacts with the mindset of “Why do these CBO’s need to develop and implement their own evaluation?” This author feels there are reasons, too many to count, for why these CBO’s are labeled ‘marginalized’ and considered hopelessly stuck in the ‘vicious cycle of poverty’. The most significant reason for what keeps them ‘stuck’ or ‘marginalized’ is their dependency on local and international ‘elites’ or ‘professionals’ (9). However, one is naïve to think that global interdependence is not an inevitable fact of life. With these factors in mind, ICE and these CBO’s collectively believed the key to stopping the ‘vicious cycle of poverty’ lies in trying to balance the equation of inside and outside responsibility in order to break the cycle. They understand that empowerment and development cannot be transplanted from the outside, but instead must come from within. This case study hopes to raise critical consciousnesses of health professionals, both practitioners and community development workers in respecting people-led processes, working to counter institutions and systems whose aims are to derail and devalue the process, and recognizing that the creation of an environment which allows for genuine dialogue, or two-way communication, holds potential to lead to group cohesion, maintenance of cultural identity, sustainable social transformation, and increased quality of life. Additionally, efforts should be made to balance the overwhelming dominance of needs based public health programming by finding ways to include or collaborate with those interested in ABCD based strategies. The process clearly takes time, as all are engaged in co-learning; however, based on the case study presented here the benefits clearly outweigh the investment. Continued efforts to make community representatives voices, opinions, critiques and insights part of the community development and public health dialogue are fundamental. 95
  • 97. A Vaccine for Globalization References 1. Cummings, J., and Martin, S. (2003). Thailand. Melbourne: Lonely Planet Publications. 2. WHO/SEARO Providing Health Security for the People. Retrived May 16, 2004, produced by the Information Unit and written by Aphaluck Bhattiasevi. Website: 3. Wasi, P. “Triangle that Moves the Mountain and Health Systems Reform Movement in Thailand” Human Resources for Health Development Journal (HRDJ) Vol. 4 No. 2 May - August 2000: 106-110. 4. Layraman, Anand. (2001). “Chiang Mai Traditional Healers Fellowship: Kreu Kai Mor-Muang Chiang Mai.” Private office document distributed during personnel communication, December 2003. 5. ThaiHealth Home Page. Accessed 4/15/04. 6. Thai Health Promotion Foundation. About Thai Health. Retrieved May 10, 2004. Link can be found for the pdf version of the Ottawa Charter for Health Promotion, WHO, November 17-21, 1986 Ottawa, Canada. Retrieved May 10, 2004. Website: 7. Kruse, S.E.; Kyllnen, T.; Ojanper, S.; Riddell, R.C.; Vielajus, J. Searching for Impact and Methods: NGO Evaluation Synthesis Study. Institute of Development Studies (IDS / KMI), University of Helsinki. 1997. 8. Bellows B. Proceedings of the indicators of sustainability conference and workshop. SANREM Research Report No. 1-95. Washington State University. Resources Institute, University of Manitoba, Winnipeg, Manitoba, R3T 2N2, Canada. 1995. 9. Burkey, S. People First – A Guide to Self-Reliant, Participatory Rural Development. ZED Books. 1993. 10. Estrella, Marisol and John Gaventa. Who Counts Reality?: Participatory Monitoring and Evaluation: A Literature Review. Brighton: Institute of Development Studies at the University of Sussex. 1998. 11. Dr. Helena Restrepo. Increasing Community Capacity and Empowering Communities for Promoting Health, Draft technical report, Fifth Global Conference on Health Promotion, Mexico City, June 5-9 2000. 12. Susan B. Rifkin. Community Participation in Maternal and Child Health/Family Planning Programs. World Health Organization, Analysis Based on Case Studies. 1990. 96
  • 98. A Vaccine for Globalization 13. World Health Organization. Development of Indicators for Monitoring Progress towards Health for All by the Year 2000. Geneva: WHO. 1981. 14. Detlef H. Schmidt and Susan Rifkin. Measuring Participation: Its use as a managerial tool for district health planners based on a case study in Tanzania. International Journal of Health Planning and Management. Vol. 11, 345-358. 1996. 15. Morgan, L. Community Participation in Health: Perpetual allure, persistent challenge. Health Policy and Planning: 16(3): 221-230. 2001. 16. United Nations Children’s Fund: Programme Division. An inventory of tools to support household and community based programming for child survival, growth and development. UNICEF, December, 1999 17. "Who Are the Question-makers? A Participatory Evaluation Handbook". Office of Evaluation and Strategic Planning (OESP) Handbook Series, UNDP, New York, NY, 1997. 18. Precis NUMBER: 138. Participatory Evaluation for Rural Development in Sri Lanka. Operations Evaluation Department 03/01/1997 19. Minkler, M. Community Organizing & Community Building for Health. Rutgers University Press. 1999. 20. A. Hardon, P. Boonmongkon, P. Streefland, M. Lim Tan, T. Hongvivatana, S. van der Geest, A. van Staa, C. Varkevisser. Applied Health Research Manual: Anthropology of Health and Health Care. 1995 21. Crewe, E. and Harrison E. (1998). Whose Development? An Ethnography of Aid. London: Zed Books. 22. McKee, N. et al. (2000). Involving People Evolving Behavior. New York; UNICEF. 23. Fraser, C., & Restrepo-Estrada, S. (1998). Communicating for development: Human change for survival. New York: I.B.Tauris. 24. Singhal, Arvind. “Facilitating Community Participation through Communication,” Submitted to GPP, Programme Division, UNICEF, New York. 2001 25. Burkey, S. (1993). People First: A guide to Self-Reliant, Participatory Rural Development. London: Zed Books. 26. Ndekha, A. et al. (2003). “Community Participation as an Interactive Learning Process: Experiences from a Shistosomiasis Control Project in Zimbabwe,” Acta Tropica 85; 325-338. 97
  • 99. A Vaccine for Globalization 27. Kretzmann, J. & McKnight, J. (1993). Building communities from the inside out. Chicago, IL: ACTA Publications. 28. Mathie, A. and Cunningham, G. “From Clients to Citizens: Asset-Based Community Driven Development as a strategy for Community Driven Development” Occasional Paper Series January 2002, The Coady International Institute, Nova Scotia: Canada. 29. Castelloe, P., and Watson, T., (1999). Participatory education as a community practice method: A case study example from a comprehensive Head Start Program, Journal of Community Practice, 6(1), 71-90. 30. Chambers, R. (1997). Whose reality counts? Putting the first last. London: Intermediate Technology Publications. 31. Cristina Bosio de Ortecho. Participatory Evaluation for Community Development. Centro Experimental de la Vivienda Economica Cordoba, Republica Argentiina. 1991. 32. Fetterman, D. Collaborative, Participatory, and Empowerment Evaluation. Accessed 12/14/03. 33. Natayan-Parker, D. Particpatory Evaluation: Tools for Managing Change in Water and Sanitation, World Bank Technical Paper 207, Washington DC: World Bank. 1993. 34. Brunner, I. and Guzman, A. Participatory evaluation: A tool to assess projects and empower people. In R.F. Conner and M. Hendricks (eds), International Innovations in Evaluation and Methodology: New Directions for Program Evaluation, 42, San Francisco: Jossey-Bass, 9-17. 1989. 35. Fetterman, D, Kaftarian, S. and Wandersman, A. (eds). Empowerment Evaluation. Thousand Oaks: Sage. 1996. 36. Papineau, D. and Kiely, M. Participatory evaluation in a community organization: Fostering stakeholder empowerment and utilization. Evaluation and Program Planning, 19 (1), 79-93. 1996. 37. Chambers, R. Participatory Workshops: a sourcebook of 21 sets of ideas & activities. Earthscan Publications. 2001. 38. Fetterman, D. Empowerment Evaluation: Collaboration, Action Research, and a Case Example. Action Evaluation Project, ARIA Group. 1996. 39. Fetterman, D. The Foundation of Empowerment Evaluations. 2000. 40. Lederach, J.P. Preparing for Peace: Conflict Transformation Across Cultures. Syracuse, N.Y., Syracuse University Press. 1995. 98
  • 100. A Vaccine for Globalization 41. Freire, P. (1970). Pedagogy of the oppressed. NY: Continuum. 42. Zimmerman, M. A. and J. Rappaport (1988). “Citizen Participation, Perceived Control, and Psychological Empowerment.” American Journal Community Psychology 16(5): 725-750. 43. Susan Rifkin, Frits Muller and Wolfgang Bichmann. Primary Health Care: On measuring participation. Social Science Medicine. Vol. 9, 931-940. 1988. 44. Green, L. and Kreuter, M. Health Promotion Planning an Educational and Enviornmental Approach. Second Edition. Mayfield Publishing Group. 1991. 45. Huberman, M. and Miles, M. (2002). The Qualitative Researcher’s Companion. Thousand Oaks: Sage Publications. 99
  • 101. A Vaccine for Globalization Additional Resources: Alinsky, S. D. (1971). Rules for Radicals. NY: Vintage Books Armstein, Sherry R. "A Ladder of Citizen Participation. “Journal of the American Institute of Planners. July, 1969, pp. 216-224. Castelloe, P., Watson, T., & White, C (2002). Participatory change: An innovative approach to community practice. Journal of Community Practice, 10(4), 7-32. Community Based Monitoring and Evaluation Team: Sleeping on our own Mats: An Introductory Guide to Community Based Monitoring and Evaluation. The World Bank, Rural Development II, Africa Region. October 2002. Community Tool Box. Accessed 12/2/03. Cooke, B. and Kothari, U. Participation the New Tyranny? St. Martin’s Press, New York, NY. 2001. de Negri, B., et al., (1998). Empowering Communities: Participatory techniques for Community Based Program Development. Volume 1(2): Trainer’s Manual. Nairobi, Kenya: Center for African Family Studies in Collaboration with Johns Hopkins University Center for Communication Programs and the Academy for Educational Development. Elliott, C. (1999). Locating the energy for change: An introduction to appreciative inquiry. Winnipeg, MB: International Institute for Sustainable Development, (in Mathie, A. and Cunningham, G). Fetterman, D. (2001). Foundations of Empowerment Evaluation. Thousand Oaks: Sage Publications. Freire, P. (1985). The Politics of Education: Culture, Power, and Liberation. NY: Bergin and Garvey. International Institute for Sustainable Development. Appreciative Inquiry and Community Development. Retrieved May 1, 2004. Website: Participants at the 1994 Indicators of Sustainability Conference and Workshop organized by SANREM (the Sustainable Agriculture and Natural Resource Management Collaborative Research Support Programme) 100
  • 102. A Vaccine for Globalization Patti-Jean Naylor, Joan Wharf-Higgins, Lynne Blair, Lawrence Green, Brian O’Connor. Evaluating the participatory process in a community-based heart health project. Social Science and Medicine. Vol. 55, 1173-1187. 2002 Robert Chambers. Whose Reality Counts? Putting the First Last. Intermediate Technology Publications, 1997. UNAIDS Thailand : Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections 2002 update FactSheet - 1/1/2002 –UNAIDS, UNICEF, WHO. Retrieved May 10, 2004. Website: sheets01/Thailand Varkevisser C.M. et al. Designing and Conducting Health Systems Research Projects. International Development Research Centre, Ontario, Canada. 1991. Werner, D., (1997). Questioning the Solution: The Politics of Primary Health Care and Child Survival. Palo Alto: HealthWrights. 101
  • 103. A Vaccine for Globalization Table 11: Types of Community Development Approaches: Definitions, Strengths and Weaknesses (Adapted from Castelloe and Watson 2002, and Mathie and Cunningham, 2002) Community Organizing (Alinsky, 1973) Popular Education (Freire, 1970) Participatory Development (Chambers1997) Assets Based (McKnight and Kretzman, 1993) Definition An outside organizer enters a community, and mobilizes citizens around a particular injustice. Involves education and dialogue based on interactive colearning, resulting in raised levels of critical consciousness, leading to group action. Community members control, develop and organize their own development, thus building capacity and sustainability. Starts with what is present in a community by building on individual and community talents, skills and assets (rather than problems and needs). Internal focus on forming local relationships, communitydriven development, and limits dependency on external agencies Strengths -Reaches out to citizens by forming a group. -Focused on building strategies for fundamental system change. -Useful if groups already exist. -Dialogic co-learning promotes equity. -Group process as a focus. -Emphasis on analyzing broad social constructs that result in injustice. -Focus usually on -Less emphasis on only one issue. guiding how a project -Lack of focus on might flow. broad social issues. -Little discussion on -Less emphasis on actual group building. individual learning. -Uses PRA for assessment, planning, implementation. -Control by the community. -Emphasis on the capacity of grassroots groups in an effort to ensure sustainability. -Provides a method to construct a shared meaning. -Recognizes the value of social capitol. -Values strengths regardless of power imbalances. -Avoids dependency on outsiders. -Emphasizes local networks for economic development. -Rarely used to analyze social, cultural, political or economic forces that result in oppression. -Varied definitions of participation. (*see appendix, C) -Level of interaction with external resources unclear. -Need to ensure inclusion of marginalized groups. -Concern over participation given cultural hierarchies. -Need an enabling environment. -No clear direction in terms of what happens if leadership becomes formalized. Weaknesses 102
  • 104. A Vaccine for Globalization Table 12: Qualitative Inquiry Activities CBO Participant Informal Observation Discussions and (IFGD) Site Visit 1. Mae X Chaem X X 2. Mae Ba X Kee X x 3. Yang X X Nong X 4. Ban HuayBong X x 5. Ban Nong X Wai (muaythai) 6. X SriBauLuang 7. Ban X MaeJong x x x 8. Lanna X Healer Fellowship x 9. Ban X BinDok 10. Society X of Lanna Healers 11. SaLuang X x X X 12. Nong Hoi X X Semi-Structured Interview Respondent(s) and their role in the community X (2 CBO reps who are teachers in the community and approx 8 teens) X (2 CBO reps; 1 Teacher of religion and 1 Comm Dev Volunteer, and 8 teens X (1CBO rep who is a part time community health worker) X (1 CBO rep who is a village health volunteer) X (1 CBO rep who is a coach of Thai boxing X (1CBO rep who is a farmer) X (1 CBO rep who is the principal of the school and 3 teachers) X (1 CBO rep who was the leader of the Lanna Healer Fellowship) X (2 CBO reps; 1 village headman and 1 active community member X (1 CBO rep who is a Lanna Healer) X X (2 CBO reps; 1 Lanna Healer and 1 Comm Dev Worker) 13. Sri Poom X X (2 CBO reps both teachers, and 8 teens) (The small x refers to visiting that site, but with the purpose of doing a different activity.) 103
  • 105. A Vaccine for Globalization Table 13: Themes with illustrations Themes Example (I1, I2 means interview one, interview two etc.) “The project came from the ideas of the community, they wanted to do this. It is the thinking of the villagers” (I1) Independent Ideas “It is the ideas of the villagers, they are the ones that decide (freedom-‘eesalaa’) what to do and they talk to understand the problem. It is not from the top (upstairs), no one is going to make us live the way they think by giving us a project, we came together to do this the way we though we should, and we did it together…”(I2) Co-operation “Many groups came together to do this, youth, elderly, (‘quamruammeugan’ directly translated women…”(I1) means, a feeling of all “we accept anyone who is interesting in doing hands together) something…”(I2) “All hearts together and all thinking together, if we don’t we can’t live together.” (I7) Acceptance “no one is left out…”(I6) “The villagers used to accept programs from the top all the time…now they think themselves and propose programs to the System reversal (examples here are top.” (I1) macro I1 and micro “If we don’t begin to do this, we would not be able to get I2) anyone together in order to think about some of our current problems, and the problems will stay.” (I2) “They are proud of themselves, they did not think they could to it…now they can see it with their face and eyes that the Pride/Esteem (pride-‘poomjai’ jai is community can do it…The work they do leads to peace and the word for heart, pride for the community” (I1) poom is similar to full or swollen, so together “If it is their own thinking they will be proud of themselves, is means a full hearted and they will have the experience of problem solving, this will be a fire and let them to do good things in the future, when feeling.) they encounter a difficulty they will be able to use the experience for solving problems.” (I5) “…we (the community) feel proud, proud, proud, they (the members of the community) feel they can help themselves, teach others and help their families (using herbal medicine).” (I10) 104
  • 106. A Vaccine for Globalization Themes Community Dialogue (These examples show relationship building, recognition of social assets and the development of critical consciousness). Example (I1, I2 means interview one, interview two etc.) “When they meet they are able to speak and listen and exchange together…” (I1) “We think together, we want the home family and school to work together, (teachers, monks, parents, youth,) we all come together to discuss the current problem, where they come from and why…” (I5) “Working in the community is the most difficult because we have no right to be there, we are not the leaders of the village. Collaboration in our own villages can be a problem; (at the same time) collaboration is probably what made the program work.” (I5) “You have to do this kind of work with your heart, and have unity in making a network for your project, the funding is important we can’t do it by ourselves, villagers don’t have the money to support this work directly…” “People started communicating.” (I11) Community Power (empowerment?) (‘palang’ is the word for power, ‘chumchom mi palang’, means the community has power. There is no native for word empowerment, the translation is ‘serm sang palang’, ‘serm’ means fill or renovate and ‘sang’ is to build. So, it is to renovate or build power that may already be there.) “In the past the villagers did not know the power of community, now they have a group that brings them together…everyone is accepted.” (I1) “we have more power from pride, we can’t study very high, and we don’t have a monthly salary in the 10,000’s we make enough to keep our families, we want to use our time to work for others, and that we have a lot, this is our pride (motivation) and we can do it, this is what we want to do the happiness of the people in our village, our friends, it is our happiness as well. This is the kind of power that we have, and the power that we have not yet used.” (I2) “This is a good project for everyone, because it builds individual and community power for health promotion and better development…and the kids learn leadership skills…” (I10) 105
  • 107. A Vaccine for Globalization Themes Example (I1, I2 means interview one, interview two etc.) Traditional Culture (culture- watanatam”) “The study of wisdom of the old culture is a big concern because now everyone is studying high tech and the traditional wisdom is being lost, there is no school requirement for this.” (I5) “We are similar (to other health programs) because we are working on issues like drugs, AIDS, and using time usefully, but different because we recognize that no one wants anyone else to know they are involved in something related to a problem. So, we look to our traditional way of life, see what we can learn from our culture, and build activities around those positive things.” (I4) Thoughts on Outsiders “why don’t they (funders) support us why don’t they give it to us, in our village our own donations are so little, people here have bad economic situations and only make enough to eat. The problem is they (the funders) don’t’ believe that we can do it, why is that? Why don’t they believe in us? That is the problem.” (I2) “Maybe there is funding from the outside, but I don’t want it, why is it that our own country of Thailand is not helping us.”(I2) “The only thing the community learns from programs coming from the outside is to wait, wait, wait for the next program to come and give you something. We have forgotten to think for ourselves.” (I7) 106
  • 108. A Vaccine for Globalization Themes Example (I1, I2 means interview one, interview two etc.) “Because now we have friends that feel the same way we do, How do you think and we have a network for loving the environment, we can your community is think and plan activities together…” (I4) building or renovating “Absolutely! From this experience students will have power in power their hearts and bodies for working in the community and (empowerment)? society. They will have the experience of thinking for themselves, and doing things for themselves.” (I5) “If it is their own thinking they will be proud of themselves, and they will have the experience of problem solving, this will be a fire and let them to do good things in the future, when they encounter a difficulty they will be able to use the experience for solving problems.” (I5) “This process is empowering because people accept their own problems, identify their own knowledge, set their purpose and goals, choose methods for problem solving and do by themselves. They have the experience from their efforts and they evaluate what they have done by themselves.” (I6) “Because it builds the feeling of conservation and uses things that we already have for a benefit.” (I4) “it builds unity with nearby villages, before we were isolated from each other and never had any coordinated activities to raise consciousness about nutrition and health” (I7) “We show other villages the elderly group here, and they get excited and go to the office and make their own group.” (I11) “Because we (parents, development workers, village headman) are working together honestly, and we all understand each other better.” (I3) 107
  • 109. A Vaccine for Globalization Appendix A: ICE Proposal The Research Proposal “Challenges of Health in a Borderless World” TITLE Increasing Community Capacity and Empowering Community Members to Improve the Health and Well-Being of Chiang Mai Hilltribes and Low-income Groups in 3 Thai Districts TYPE OF RESEARCH Participatory Action Research OVERALL GOALS • • • To determine how to improve implementation and effectiveness in promoting the integral development of youth, seniors and women in Hilltribes 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. PROJECT SIGNIFICANCE AND HEALTH ISSUES INVOLVED Recently, Chiang Mai was chosen as the pilot province from which to implement universal coverage health insurance beginning June 1, 2001. Apart from this national innovation public health project, Chiang Mai pilot is one of 15 sites throughout the country, which form part of an initiative for health-care decentralization to local government and health-care reform. This project will be launched in October 1, 2001. The innovation model of this health decentralization is establishing of the new form of health local autonomy which called “ The Area Health Board or the Provincial Health Board .” The Area Health Board will be comprised of 3 parties, namely representatives from local government organizations, representatives from the popular sectors in communities or civil society and representatives from the ministry of public health. It means that the current health system reforms in Thailand need to be contributed by the popular sector. And yet, there is still a desperate need to encourage strategies of increasing and strengthening community capacity and empowerment given the persistence of inequities in health. Producing better health and improving quality of life at individual and collection levels need building community capacity for action oriented at changing living conditions. Community participation is not possible in a vacuum, people need incentive to participate and the best incentive is to provide the opportunity to solve problems and issues that effective daily life. All activities in this project will be focused on inspiring experiences of community participation and empowerment of powerless and marginalized groups those who are in highland communities (hilltribes), sub-urban communities and urban communities. In working with communities to promote health, several abilities and skills from diverse disciplines and fields are needed. For example include advocacy, negotiation, policy formulation, strategies for community development of social networks, participatory techniques and social 108
  • 110. A Vaccine for Globalization action communication. Concentrating in the problem-solving capacities of communities is essential for obtaining success in participatory work. Increasing and strengthening community capacity will help powerless people to help themselves. Not only addressing poverty and social need at local level but also address the complex subject of building community capacity for action oriented at changing living conditions, producing better health and improving quality of life at the individual and collective levels. Recognizing almost all action as political, participatory action-research assumes that work has implications for the distribution of power in society and that control of the production of knowledge is central to the maintenance of power. Attempts to upset the status quo and introduce more democratic procedures necessitate active involvement in distribution of power, relation between social groups, and the production of knowledge. THE SPECIFIC ACTIVITIES: 5. 1 How will the project be implemented? To make communities get involved and develop their own capacity: Participatory Action Techniques, e.g. focus groups, Delphi, consensus development, participatory planning, future search conference and logical framework etc., will be used to stimulate community participation, the focus to be maintained is the assessment of the situation and prioritization of needs and problems made by citizens. Identification of problems and needs is the best starting point for community capacity building and the goal is the participation of those who have never had the opportunity of being heard; A new strategy, “asset-based community development” developed by Kretzman and Mcknight (1993) will be used. It is an innovative methodology that “leads toward the development of policies and activities based on the capacities, skills, and assets of lower income people and their neighborhoods”. The map of community assets provide a tool for discovering individual and collective capacities and talent, as opposed to the usual practice: making an inventory of deficiencies of individuals or communities. It recognizes that each individual has talents, abilities, interests, and experiences that constitute a valuable arsenals that can e used for community development. The “alternative path of asset-based, internally focused, and relationship-driven” map is a comprehensive inventory of all possible capabilities of a local community. The community assets map includes not only individual’s strengths but also citizen associations like churches, clubs, cultural groups, and local institution like schools, libraries, hospitals, parks, etc. Internally focused refers to concentrating on the problems solving capacities of the community. Together they provide answers for building or rebuilding relationships between and among individuals, local association organizations and institutions. The community epidemiology approach will be applied by using small communities/groups as the starting point to build larger and multi centric aggregates, where the individuality and cultural characteristics of a given group are not lost or subsumed. This approach allows moving progressively towards great integration between communities. All partners will be expected to reach consensus and committed themselves to achieve their desired health goals. Development of community partnerships. For the real approach to community participation, the commitments should be made for establishing “co-partnership” in health. This approach implies community involvement at high decision making levels in health service administration, in quality control activities and in establishing transparent financial resources management procedures at institutional levels. 109
  • 111. A Vaccine for Globalization At the community level, workshops and education activities for improving community organization and support, technical assistance for community groups and provision of appropriate spaces for discussions, negotiation and consensus building will be implemented. Strategies, skills, and resources for working together; Health care institution like community hospitals and health centers will invite NGOs and CBOs to join partnerships as “co-partners”. Workshops for health workers in community participation methods and strategies as a way to improve the health of the communities will be conducted. Skills such as advocacy, mediation, social action communication, negotiation, policy formation, abilities in resolving interest conflicts and consensus building will be trained as participatory action learning. 5.2 How will the proposed activities promote dialogue and dissemination of information about development ? By providing local-local dialogue meetings workshops, seminars and future search conferences participants will conduct 2 ways communications, participatory planning process and participatory action-learning which promote dialogue and dissemination of information about community development; 1-With culture and socio-political approaches, participants will gain the maturation of community participation process and strategies as a way to improve the health of communities; 2-It is believed that local-local dialogue creates awareness, develops communication and forges collaboration among local actors. In some cases, it can be described as a forum for conflict resolution, providing an opportunity to forge partnerships where mistrust and conflict have prevailed and to focus community action on issues that directly affect everyone. 110
  • 112. A Vaccine for Globalization 5.3 Describe the project timeframe on how the it will take place? A one-year project timeframe in which the project will take place. Month 1 2 3 Activities 4 5 6 7 8 9 10 11 12 1. Asset-based community development - Develop the community assets map in 5 sub-districts of Mae Cham district and 2 municipalities of Muang and Sansai districts. - Community epidemiology approach. 2. Future Search Conferences among NGOs. CBOs, local authorities in participatory planning - Two (3 days) meetings in Mae Cham district - A 3 days meeting in Muang District - A 3 days meeting in Sansai District 3. Training Workshop on: - Health Promotion: New Public Health - Advocacy & Mediation - Team Building and Leadership - Social Action Communication - Community Radio (CR): How to be the local DJ and produce good CR program 4. Coordinated Action by multiple actors, sectors 5. Monitoring and Evaluation participatory ME Team by 6. Evaluation Conference (2 days) 7. Reporting 5.4 Organizational Arrangement and Autonomous Provider Network: 6 TARGET • Twenty-one community based organizations in 3 districts will be setup.The youth, seniors and women in low income communities would actively involve in public decision making processes to ensure that practical gender and group interests are adequately address to appropriate healthy public policies and programs conducive to their own positive health and quality of life; • Five local administration organizations and 2 municipalities in 3 districts will be provided with training in principles of community development and health education. The Sub-district Administration Organizations (SAOs) and municipality members, community leaders include 111
  • 113. A Vaccine for Globalization • youth, seniors and women would develop community capacity include community participation, leadership, rich social networks, ability to articulate values, sense of history, sense of community, critical reflection, ability to bring in sources, skills, and ability to exert power; Co-ordinated actions by multiple actors or sectors in 3 districts will be performed. At local level, local actors which are CBOs, NGOs, SAOs and municipality members, would work together to improve the conditions of rural poor and to influence healthy public policy at local and provincial levels. 7 EVALUATION What are the specific outcomes and how will these be tracked and measured? Describe who the activities will benefit and the expected impact of activities; Describe how you will measure the effectiveness of your activities. SAOs and municipality members involved in the project will gain skills and abilities necessary to identify and analyze community problems; with particular concern to working plan training and using development program to help solve community problems. CBOs members involved the project will directly gain skills and experiences in working together. Low income and marginalized populations involved in the project will acquire instruments to reduce the burden of poverty and other causes of social exclusion. The expected impact of activities is concrete mechanism to energize social change. The most practical approach to success is to stimulate and support participatory movements at the community level. It is expected that CBOs, and local authorities will create the right opportunities for participation, negotiation and consensus building not only in health issue but also environmental protection and resource management issues. It is rather difficult to measure the effectiveness of activities in this project because they are cultural-socio-political interventions. Anyhow, several key aspects need highlighting here. First, it should be based on the contextual situation of each place where the project is implemented. In other words, there is not a unique list of indicators for evaluating cultural-socio-political processes. Second, evaluation should be participatory. Community should be involved in the evaluation process. Third there is general agreement that evaluation should be both quantitative and qualitative. Fourth, this communitybased project is given-short-term funding and insufficient time to develop the groundwork. Just as the seeds for change are beginning to be established project money is withdrawn. It is important to find out appropriate criteria of evaluation of the effectiveness of the project activities. Measurement of changes in community capacity is still many ways in their infancy. Anyhow, an attempt will be made to assess community participation, which illustrate enhanced community capacity: Extension: who participate and who does not? Depth of intensity: in which type of activities do they participate? Modalities: in what ways do people choose to participate? Impact: what are the impacts of achieving health goals? Sustainability: how is better participation assured for the future? 112
  • 114. A Vaccine for Globalization New-conceptualizations of community building stress many of the same principle within an overall approach that focuses on community growth and change from the inside through increased group identification discovery, nurturing and mapping of community assets, creation of critical consciousness, all toward the end of build stronger and more caring community Participatory, empowering type of evaluation are especially suited to the principles, goals and methods of community initiatives, all of which include collaboration and capacity building as desired out-comes. There is 6-element process for empowerment evaluation. These 6 steps provide the framework for the following dissension of empowerment evaluation methodology, using the metaphor of the process as a journey. Participants determine where they are now (Step I), where they would like to go (Step II) and how to get there (Step III), they monitor the journey to make sure that they collect and analyze making progress (Step IV). They collect and analyze new information a long way so that the project can adjust its course, if necessary in response to changing conditions or unexpected results (Step V). Finally, they support what they have learned to strengthen the organization and prepare for the next journey (Step VI). The ‘participant’ referred to have included volunteers, staff, organizers, and members of the community active in the project and intended beneficiaries. Support team referees to the professional evaluators and related staff. Step I: Assessing community concern and resource. Where we are now? The support team assists local participants in doing and inventory community asset needs program strengths and weakness. It is critical that the local community becomes involved and gains trust and ownership of the evaluation process during this initial period. Methods Community meeting Focus group Interview Survey Community mapping Step II: Setting a mission and objectives. Where do we want to go? Community members lay the foundation for evaluation by establishing realistic criteria for success and improvement. The principle activities if this step is a facilitated group meeting that includes creative brainstorming, sorting and categorizing of ideas critical discussion and prioritizing based agreed-upon criteria, and reach of consensus. Step III: Developing strategies and action plan. How will we get there? Community members develop a set of strategies for accomplishing project goals and objectives. The outline of action plans can be sketched out in the strategy development meeting, with detail determined latter by smaller subgroups. Step IV: Monitoring process and outcomes. How do we know we are on track? Evaluators help participants determine what type of evidence is needed to document progress toward their goals. The team must develop monitoring systems that are realistic and make best 113
  • 115. A Vaccine for Globalization use of community resources. Documentation include periodic written activity logs or reports tracking of key events, port folios, interviews, surveys, observation and community data for change such as in the rate of disease or injury. Step V Community information to relevant audiences. Who need to be notified along the way? Participants and community at large can be engage in reflection, interpretation of meaning, problem-solving, based on evaluation data, to improve the project or take advantage of new opportunities. Communication method can include written reports, community meetings, newsletter, and presentations at meeting coalitions and other forums. Step VI: Promoting adaptation, renewal, and institutionalization. How can we use what we have learned to prepare for the next journey? Evaluation findings must be acted upon to be useful to the community. Evaluators help participants use the lessons learned to strengthen future action. The support team uses organization development, facilitation, and training skills to help strengthen its leadership and structure, integrate evaluation into ongoing operations. Building capacity includes striving for sustainability of hard-won improvements. 8 PARTNERSHIP TO IMPLEMENT ACTIVITIES Partnership to implement activities will comprise of NGOs, CBOs and local authorities in 3 districts of Chiang Mai Province. NGOs include the Campaign Committee for Local Autonomy (CCLA), the Pgazk’ Nyau Association for Social and Environmental Development (PASED), Institute of Community Empowerment (ICE) and the Northern Co-ordination Center for Community Based Organizations (NCCCBO) will link with networks and facilitate workshops and assist in technical skills. CBOs include members of youth, senior, and women community based organizations from 5 subdistrict in Mae Cham District and 2 sub-district in Muang District will take strong participation and mobilize community. Even though they lack participatory experiences, poor organization skills, poor networking, and lack of collective initiative, activities in this project will help build networks, build organization skill and build collective initiative. Local Authorities include members of CAOs from 5 sub-district in Mae Cham District and members of municipality from sub-districts in Muang and San Sai Districts will participated in decision making processes, implement project and sustain project. Although they lack technical capacity, lack credibility with community activities in this project will help initiate dialogues, encourage co-operation with CBOs and NGOs. 9 EXPANSION After the participatory action process, participants will use the lessons learned to strengthen future action. Crucial future expansion of the project will be in strengthening networks among communities not only for health, but also for environmental issues and education. The success of this project in terms of concrete improvements in the health and educational status of community members will persuade popular sectors of the possibilities for real community participation in the future. At the end of the one year program, it will be expected that grass-root groups would recognize and develop their assets and abilities in order to participate in decision – making. Genuine 114
  • 116. A Vaccine for Globalization participation will in turn provide opportunities to choose healthy lifestyles and practical methods for developing programs to enhance community development. When a community shares ownership of goals, process, and skill, the loop of community capacity begins to move like a spiral rotation creating accelerated movement. Community-wide initiatives and community organizing typically address complex problems with multiple interrelated causes in a trial and error fashion. Success requires patience, persistence and compromise because multiple constituencies may be affected in multiple ways. With respect to the innovative aspects of this proposed project for increasing community capacity and community empowerment, best practices will be documented and replicated to hopefully provide other communities with alternative models. After exchanging ideas and learning from this project, other communities may adopt this innovative model as “early adopters” to help themselves in community development. 115
  • 117. A Vaccine for Globalization Appendix B: Overview of Project Operations Duration for all projects was May 1,2002-April 30, 2003 Data for this table was obtained from the translation of an external evaluation document completed at the request of the Thai Health Foundation. Some data may be missing secondary to translation errors. Overall Summary of Projects and Activities Classification (topic focus) Exercise Promotion Health Education Narcotic Prevention Conservation of Local Wisdom Community Care for Health Total Number of Projects 2 8 3 7 2 22 Classification (target focus) Traditional Medicine Youth Group Elderly Group Tribal Group Special Project 5 7 4 4 2 Project Name Location 1. Developing Potential T. San Pa Pao among the Elderly for A. San Sai Health (578) Budget (40baht=$1) 44,500 B, $1112.50 Budget (40B=One dollar) 156,107B 764,170B 337,115B 1,098,295B 172,800B 2,526,587B ($63,164.68) Activities Target Group Actual -Elderly meetings -Seminars -Income generation activities 60 persons 89-100 persons 116
  • 118. A Vaccine for Globalization Project Name Location 2. Lanna Healer A. Muang Community Health Promotion (561) Budget (40baht=$1) 659,100B, $16,477.50 Activities Target Group Actual -Promotion of Fong Gern (Lanna movements) for exercise -Self and family massage -Health Care by Lanna Wisdom -Teaching and Learning Promotion of Health through Lanna Wisdom -Herbal garden promotion. 330 200 330 360 250 80 30 25-30 -Lanna Medicine Campaign -Lanna Medicine Quality Development -Study and breeding stock of rare herbs 3. Self Reliable T. HangDong Community Health A. HangDong Development (570) 105,00B, $262.50 28 villages, (more than expected) 532 Families no specific in general numbers of men and women numbers are about equal available -Seminars for Traditional 15 Medicine exchange -Demonstrations -Courses of instruction 30 massage, 45 including; compress making, herb use. 15 70 10 (30elderly, monks, 8 students, government 5 officers) 117
  • 119. A Vaccine for Globalization Project Name Location 4. Herbs for Health T. SaLuang (573) A. MaeRim Budget (40baht=$1) 104,400B, $2610 5. Restoring Knowledge T. SanSaiLuang 52,600B, $1315 of using Herbs in the A. SanSai Family and Traditional Medicine Promotion (574) 6. Promoting, Restoring T. SanSai and Conserving Thai A. Prao Traditional Medicine and Wisdom (575) 53,400B, $1335 Activities Target Group Actual -Village Meetings -Trekking to Survey Herbs in the Forest -Newsletter -Herb Text Book -Food Contesting -Seminars -Village Meetings -Herbal Book -Study Visits 120 70 150 100 200 500 100 200 50 100 -Study Tour -Student Training Breeding Plants 55 elderly in the village, 25 family of the elderly, and 10 interested others 60 and 60 14 villages 7. Creating Supportive T. MaeFaekMai 104,112B, $2602.80 Relationships for Health A. SanSai between Children, Youth and Elderly (576) -Village Meetings -Elderly Group Meetings -Traditional Music Activity -Family Camp Overall more than 100 72 38 9 villages 40 40 85 joined by 85 joined by 5VHW 5VHW 50 youth 30 youth 30 Families 10 Families 118
  • 120. A Vaccine for Globalization Project Name Location 8. Research for Health T. TaladYai Promotion in School and A. Doisaket Community 9. Health Promotion in the area of Sri Boon Luang Health Station 10. Promoting Exercise for Health and Development of Learning Process Among 3 age Groups 11. Building the Strength of Spiritual Leaders Network “Dtala” among Lahu Tribe (580) 12. Restoring and Developing Indigenous Knowledge for Community Health Care (581) Budget (40baht=$1) 80,000B, $2000 Activities Target Group Actual Students 50 50 Community 1800 1800 T. Mae Lao A. Mae Eye 55,100B, $1377.50 now 26 Dtala from Network -Village Meetings connects 48 villages -Follow up meetings for 16 villages problem solving T. Jam Luang A. MaeJam 60,845B, $1521.13 -Recover and Reinforce Elderly Wisdom -Transmit Wisdom to Teacher 5 youth Student 17 -Study Tour 17 Teacher 5 Student 20 25 119
  • 121. A Vaccine for Globalization Project Name Location 13. Restoring and T. SanSai Developing Leadership A. Prao Capability for Community Health Care of MaeBaKee (582) 14. Herb Conservation T. SanPaPao and Caring for Health A. SanSai (583) Budget (40baht=$1) 62,555B, $1563.88 Activities 63,000B, $1575 Target Group -Herbal Seminars -Fence building and trash disposal -Herbal Medicine instruction -Leadership development among youth -Reproductive health education for youth 30 elderly, 60 housewives, 50 youth 50 -Trekking to Survey Herbs -Use of Herbs Training 15. Encourage and Support for training youth in Thai Boxing in order to oppose narcotics (584) 16. Lively Family Development for Strong Community free from Narcotics (585) T. MaeFak A. SanSai Actual 50-60 104,122B, $2603.05 T. NongYang A. SanSai 63,000B, $1575 15/day 15/day 40 (6 female) -practice Thai Boxing -morality camp 40 (6 female) -Re-entry program for (208 Families) returning addicts 50 youth -Village Standards 30 120
  • 122. A Vaccine for Globalization Project Name Location 17. Glorification of T. NongYang A. SanSai Non-Narcotic Community (586) 18. Life skills training T. HarnKeaw for narcotic prevention A. Muang and health promotion among children and youth of Chiang Mai (588) 19. Modern Youth T. Sripoom Caring for Health and A. Muang Environment (589) 20. Youth Network for A. Muang Health (590) Budget (40baht=$1) 68,675B, $1716.86 202,240B, $5056 Activities Target Group Actual -Practical Training -Youth Training -Against Drug Sticker -Health Files -Non-Narcotic Banner -Friends Corner 25 40 200 25-30 40 200 117 117 100 114 5-12 48 youth 5Female/10male 360 5-12 98 5 360 64 360 175F and 200M 30 30 30 30 3000 3000 1200 1200 -Teamwork and skills workshops -First Camp Leadership -Camp Development -Run Camp Two by themselves -Activities about Lanna Traditional Ways of Life 107,765B, $2694.13 150,000B, $3750 -Summarize Lessons Learned -Radio Program and DJ training -Radio Scheduling training -Web site development 121
  • 123. A Vaccine for Globalization Project Name Location 21. Strengthening T. Nong Hoi Community Network of A. Muang health promotion by personal Communication Media (593) Budget Activities (40baht=$1) 119,950B, $2998.75 -Participatory Training -personal Communication training -activities in community -observation and study tour Target Group Actual 30 35 25 20 640 640-700 100 22. Studying and T. SanPaPao Developing non- A. SanSai poisonous production of fruits and vegetables (596) 144,300B, $3607.50 -manure making, study, 170 theory, and practice -youth camp -customer/consumer 500 workshop 250-300 122
  • 124. A Vaccine for Globalization Appendix C: Example of Semi-Structured Interview แบบสัมภาษณ การประเมินโครงการขวงสุขภาพ ครั้งที่ 2 ณ ขวงบานศรีบุญเรือง ต.ปาไผ อ.สันทราย เชียงใหมวันที่ 24-25มกราคม 2547 Project: (ชื่อโครงการ) Community: (ชื่อชุมชน) What is your role in the community? (ทานมีบทบาทอะไรในชุมชนของทาน ?) ( Health worker, Farmer, Leader…) Please tell me about your community? (ชุมชนของทานมีลักษณะเปนอยางไร ?) Health,ดานสุขภาพ Social ดานสังคม environment ดานสิ่งแวดลอม Please tell me about your community project? (โครงการสรางเสริมสุขภาพที่ทานทําอยูเปนอยางไรบาง ?) How is this project similar or different from community development/health promotion projects done in the past? (โครงการนี้ แตกตางจากโครงการสุขภาพอื่นๆ ในอดีตหรือไม?) How? 123
  • 125. A Vaccine for Globalization (อยางไร?) Now that you have this project what has happened in your community? เมื่อทําโครงการไปแลวมี อะไรเกิดขึ้นบาง ? What do you think helped to make the project work (or not work)? (มีอะไรบางที่ทานเห็นวาไดชวยใหโครงการไปไดสวยหรือ…..ไมสวย ?) How and why? (อยางไร และ ทําไม? ) What do you think was the most difficult thing about doing this project? (อะไรที่ทานเห็นวาทํายากที่สุดในโครงการนี้ ?) What has your group done to overcome this difficulty? (ทีมงานของทาน เอาชนะมันไดยังไง ?) What are the community plans for the future? (ทานมีแผนที่จะทําอะไรในชุมชนของทานในอนาคต?) How do you plan to do that? (ทานวางแผนกันยังไง?) Do you think that we are empowering ourselves ? (ทานคิดวาเรากําลังเสริมสรางพลังของเราเองหรือไม) How ? (อยางไร ?) 124
  • 126. A Vaccine for Globalization Appendix D: ICE User-guide A User-guide for developing: A PARTICIPATORY EVALUATION ON EMPOWERMENT For: THE INSTITUTE OF COMMUNITY EMPOWERMENT AND COMMUNITY FACILITATORS INTRODUCTION Participatory evaluations challenge conventional evaluation practices. Although a participatory evaluation of social changes (empowerment) is an uncharted process, it has the potential to catalyze a community or group to learn more about what they have achieved and foster community consciousness. This interest can lead to improved future development initiatives if community specific and reliable measurements can be developed to gather data that is meaningful to the community. The guide was created for use in facilitating a participatory evaluation of empowerment by Community Based Organizations (CBO’s) affiliated with the Institute for Community Empowerment (ICE). The participatory evaluation guide is presented in three sections: 1. Background: a) Definitions of Terms and Tools 2. Planning, Process and Reflection: a) b) c) d) Phase 1: Establish Community Evaluation Team Phase 2: ICE Workshop for Community Facilitators Phase 3: Community Meeting - Evaluation Phase 4: Community Evaluation Team – Reflection 3. Attachments 125
  • 127. A Vaccine for Globalization Participatory evaluation asks one important and fundamental question: “Whose questions are being asked and answered in the evaluation?” 1. BACKGROUND a) Definitions of Terms and Tools The following is a collection of brief definitions intended to provide a basic understanding of some key terms used in participatory evaluation. • A facilitator is a person who is knowledgeable about a specific topic or process. In this case the facilitator is knowledgeable in participatory evaluation methods. However, knowledge is not enough; the facilitator must be genuinely committed to the nature of participation. Important characteristics of a facilitator include; a) Create an environment of sharing and reflection – asking open-ended questions. b) Encourage trust – validating everyone’s opinions and ideas, be non judgmental. c) The capacity to listen – letting everyone finish thoughts without interrupting. d) Help the group to ask key questions – see Appreciative Inquiry. e) Guide discussions – keeping the group focused on topics and mediating conflicts. f) Plan actions to help bring together the viewpoints of the various stakeholders. g) Delegate tasks and responsibilities – once plans are crystallized make sure responsibilities are equitably distributed among the group. Additionally, the facilitator is both a catalyst and a manager of the evaluation without controlling the process. Their primary function is to release the creative energies within people. The facilitator plays an important role in assessing the levels of understanding, the perceived benefits of participatory approaches, and promoting capacity building among participants. This can be done through greater ownership of the results of the evaluation effort and use of those results to create more effective future programming. • Appreciative Inquiry (AI) is a process based on the idea that human systems grow toward what they persistently ask question about. This concept is paramount for the facilitator to embrace if they are going to help a group navigate their way towards positive change. 126
  • 128. A Vaccine for Globalization • A stakeholder is an actor that has a vested interest in a given project, activity, or issue. Stakeholders may include groups affected by development actions, such as the poor, women, workers, farmers or the community at large, as well as other actors that can affect the outcome of a project, i.e., government officials, institutions, and project personnel. In participatory evaluations, stakeholders assume an increased role in the evaluation process as question-makers, evaluation planners, data gatherers and problem solvers. • Quantitative methods utilize numerical analysis to gather information from stakeholders. Data collection methods include surveys, attendance records, statistical and epidemiological data. • Qualitative methods minimize the use of numerical analysis. Data collection methods include techniques such as; observation, semi-structured and open-conversation interviews, testimonials and focus groups to gather information from stakeholders. • Baseline data is a description of the conditions at the beginning of a program or project. Data collected later can be measured or compared against baseline data to assess changes. In a participatory evaluation, it is important that stakeholders identify important factors or sources of information and the indicators required for measuring the results of their work. Baseline data serves as foundation material for future evaluations. • Triangulation is the process of using different methods of data collection to crosscheck and cross-validate existing information. • A Beneficiary Assessment involves the participation of beneficiaries in evaluating a planned or ongoing development activity and builds on the experience of participant observation. Assessing the value of an activity as it is perceived by its principal users, by letting beneficiaries' voices, values and beliefs be expressed. Methods include direct observation, conversational interviews, and participant observation. Beneficiary assessment is an approach to information-gathering that places the emphasis on the perceptions of the principal actors. • Direct Observation is a data gathering process where a person takes field notes while observing an activity without participating. • Participant Observation is when an outsider lives and learns in a community for a period of time ranging from several weeks to months. • A Semi-structured Interview are less formal than a structured interview and allow for conversation to be the method of learning. Preparation usually involves outlining the broad areas of inquiry, leaving specific questions to be formulated during the 127
  • 129. A Vaccine for Globalization interview itself. The questions should be sequenced with the easier questions coming first and more difficult or personal coming later thus allowing the interview time to gain the confidence of the person being interviewed. The questions are open-ended and seek to collect in-depth information on attitudes, opinions, thought processes, and knowledge. • Listening sessions are public forums you can use to learn about the community's perspectives on local issues and options. They are generally fairly small, with specific questions asked of participants. They can help you get a sense of what community members know and feel about the issue, as well as resources, barriers, and possible solutions. • A Focus Group brings together a representative group of 10 to 15 people, who are asked a series of questions. A facilitator guides discussion. Focus groups can be used in the field to build project designs or help to assess project performance. They can be used in an evaluation as a means of starting a discussion, identifying needs and clarifying key points. • Mind Mapping is a tool used at various stages of a project. It involves participants in drawing maps of thoughts, ideas, terms, definitions and concepts on the floor, ground or paper. Mapping can provide insight into the meaning of identified issues within the community. The importance of ensuring a good cross section of participants in a mapping exercise and different gender interpretations of one's community is critical. • A Testimonial records a person's thoughts, feelings and experiences in the first person narrative style. It is a way of learning about a project or its impact through the voices of participants and stakeholders. They can also help to corroborate other sources of data and information and provide a more personal insight into a project's achievements. • A Venn diagram, of usually circular areas, can be used to look at relationships within institutions or relationships between the community and other organizations. It illustrates different participant perceptions of access to resources or of social restrictions. Circles of various sizes are cut out of paper and given to participants, who are then asked to allocate the circles to different institutions, groups or departments. The larger the circle the more important it is. The circles may overlap, showing the degree of contact between institutions or groups. 2. PLANNING, PROCESS, AND REFLECTION This section provides general steps that a facilitator can use to build an evaluation method to measure social changes (empowerment) within the community. The section is presented in phases and steps, but this is not meant to show the process to be linear. Remembering that participatory evaluations and the nature of social changes 128
  • 130. A Vaccine for Globalization (empowerment) within the community are context specific there cannot be one tool or recipe, no strict course or syllabus that the facilitator can follow. The facilitator and the community members invited are learning as they move through the process, but the facilitator needs to be responsible for altering steps according to the context of the community and the flow of the meetings discussion. The following is a visual aide to help conceptualize the section. Each phase is described in detail. 129
  • 131. A Vaccine for Globalization Establish a Community Evaluation Facilitation Team (CEFT) Phase 1 Phase 2 Workshop provided by experienced Facilitators (CEFT) attends a Workshop on Facilitating Participatory Evaluations Facilitators conduct a meeting with their community members/groups to build the evaluation tools Phase 3 Immediately collect evaluation tool responses at the meeting Phase 4 Workshop provided by ICE or Make a plan to use the evaluation tool in the larger community to collect responses. Facilitation Team and/or Community Members analyze the responses and plan how to communicate what they learned to the community and other interested groups Facilitation Team meets to reflect on the process, share lessons learned and discuss recommendations for future plans with their communities, the Fellowship and IC E. 130
  • 132. A Vaccine for Globalization a) Phase 1: Establish Community Evaluation Team Purpose: To identify a group of community members interested in facilitating a participatory evaluation of social changes (empowerment) within their community. This group will be called The Community Evaluation Team and will be trained as evaluation facilitators. Objective: • Establish a community based evaluation team (4-6 members) Activities: o Make contact with community groups Identify and contact 4-6 representatives from different community groups in order to ensure an understanding of various community programs, the local power structures, and different socio-cultural group perspectives within the community. These individuals will make up the Community Evaluation Team. o Invite them to the ICE facilitator workshop Materials: • None b) Phase 2: ICE Workshop for Community Facilitators Purpose: The facilitator workshop will orient the group to the process of doing a participatory evaluation of social changes (empowerment) within the community. This team will be responsible for returning to their communities and facilitating a meeting to collaboratively make decisions about how the evaluation will be designed, conducted, analyzed and presented. Objectives: • Clarify roles of the facilitator. 131
  • 133. • • A Vaccine for Globalization Exchange knowledge regarding participatory evaluations of social changes (empowerment). Facilitators feel prepared to return to their communities to facilitate their own evaluation process. Activities: o Explain to the team why they are here and what they will do; 1. To do an evaluation of community changes that have occurred as a result of the community driven development programs. 2. Sometimes these community changes are easy to see, but difficult to explain. Through this participatory evaluation process we hope to find a way to identify, describe, evaluate, and share with others what has happened in our community. 3. Make sure team members understand that there is no best model of doing a participatory evaluation. 4. Flexibility during the process is important. 5. The evaluation tools developed and the methods used will depend on the communities’ interests. o Get an idea of what the group knows about participatory evaluation; 1. Find out if anyone has experience in doing evaluations. 2. If so, have those with experience share their thoughts about the strengths and weaknesses of the methods they used. o Review the role of the facilitator in conducting and finalizing a participatory evaluation: 1. Understand that the validation of community members’ experiences is the basis for building and conducting the evaluation. 2. Motivate community members to find solutions and act on them. 3. Assess constraints and resources or enabling and inhibiting factors of conducting the evaluation. 4. Define parameters for the participatory evaluation (i.e., what can and cannot be achieved based on time and local resources). 5. Facilitate the collective identification for the focus of the evaluation. 6. Identify when training in data-gathering methods is necessary. 7. Facilitate the collective date gathering process. 8. Facilitate the collective analysis of the data. 9. Facilitate the coordination of resources for resolving problems identified during the evaluation. 10. Facilitate how to take collective action. 132
  • 134. A Vaccine for Globalization 11. Understand that a participatory evaluation is dependent on the skills and interest of the community team. 12. See Facilitator in Terms and Definitions for more information. o Review the following steps with the facilitator: 1. 2. 3. 4. 5. 6. 7. Planning the Community Meeting How to explore the meaning of Social Changes (empowerment) How to prioritize the identified terms How to develop questions to identify each term How to develop a tool or method based on these questions What is required to conduct the evaluation The importance of reflecting on the process once completed o Are we ready? c) Phase 3: Community Meeting – Evaluation Building Overall Purpose: This meeting will be held to develop the evaluation tool for measuring social changes (empowerment) within the community. Overall Objectives: • Explain to the community members purpose of the meeting. • Collectively define social changes (empowerment). • Collectively prioritize the top 2 or 3 terms. • Collectively develop questions to identify these changes. • Collectively develop an evaluation plan. • Delegate responsibilities to carry out the evaluation. Overall Materials: • • • • Meeting area Snacks and water Large pieces of paper Small pieces of paper 133
  • 135. A Vaccine for Globalization • Marking pens • Name tags (if appropriate) • Pins or tape • Board Outline of Meeting: 1) Introduction o We are trying to do an evaluation of community changes that have occurred as a result of the community driven development programs we have been doing the last 2 years. o Explain that sometimes these community changes are easy to see but difficult to explain. Through this evaluation process we hope to find a way to identify, describe, evaluate, and share with others what has happened in our community. o Make sure everyone understands that there is no best way to show these changes, but we are going to take a collective attempt to do it. o The evaluation tools or methods developed today will depend on our interests. o Flexibility during the process is important. 2) Explain the role of the facilitator o Give brief description of what your role will during the meeting. 3) Get an understanding of what evaluation means to the group Purpose: Determine what the group knows about evaluations and if they consider them important and if important, to who and why. Objectives: • Define evaluation. • Who are the stakeholders in the evaluation. • What will the evaluation results be used for. 134
  • 136. A Vaccine for Globalization Activities: o Mind Mapping: Ask the question: “What does evaluation mean to our group?” (This will provide each member an opportunity to explain what it means and will allow the group to come up with a collective and working definition of evaluation-making sure everyone is clear) o List on the Board: Ask the question: “Who wants to know the results of our evaluation? (This will provide a list of stakeholders, and who the questions should be asked to and who should be invited to future meetings) o List on the board: Ask the question: “Is it useful for us to observe or evaluate social changes within the community (empowerment)?” (This will provide an understanding of interest in continuing with the meeting and a list of ways to use the results of the evaluation) Materials: • • Large pieces of paper Marking pens 4) Explore the meaning of empowerment or social changes within the community Purpose: Explore the meaning of empowerment, or social changes in the community. The facilitator directs the focus of the group towards defining and understanding this concept based on individual and community experiences. Objective: • Collectively define empowerment, and identify important social changes within the community. Activity: (there are two possible ways to do this) 1. Mind Mapping: Ask the question: “What are examples of things that have changed in our community since doing our projects?” (Either break up into small groups of 4-5 or keep the group as one) 135
  • 137. A Vaccine for Globalization A F E Social Changes/ Empowerment B D C • An example might look like this: Group Discussion: The facilitator can ask the group to discuss the map and share their ideas about each response. Then, each response needs to be narrowed to a key term or word. The facilitator can ask for further description of what they means by asking the questions: “Lets talk more about C and what it means? “How do we see C in our community?” “What are some examples of C in our community?” Materials: • • • • Large and small pieces of paper Making pens Pins or tape Board 2. List on the board: Ask the question: “What was it like in your community before this program, and what is it like now?” 136
  • 138. A Vaccine for Globalization Have each group member write on one pieces of paper “what it was like before the project” and on the other paper “what was it like now”. Then pin these responses up on the board in two columns; Before and After 137
  • 139. A Vaccine for Globalization • An example would look like this: A B D Before After C E F Group Discussion: The facilitator can ask the group to discuss each response and share their ideas. Then the facilitator will draw several arrows connecting the Before and After and ask for further description of what each response means in order to get to the root term or word which will be labeled on each arrow. A B D Term 1 Before C After Term 2 Term 3 E F Materials: • • • • Large and small pieces of paper Making pens Pins or tape Board 5) Choose the top three changes/terms to define further Purpose: 138
  • 140. A Vaccine for Globalization Limit the focus of the evaluation down to two or three important terms representing social changes or empowering factors. Objective: • Choose three factors/changes that the group feels are the most important to evaluate. Activities: o Group discussion and vote to choose the top two or three terms/changes • Decision making can be either consensus or majority. The vote can be done in a variety of ways. For example, voting by raising hands. Or writing on a piece of paper the top two or three terms and counting the votes. Or asking the group to choose the best, and see the natural breakdown of the top three through this voting process. Materials: • • Small pieces of paper Pens 6) Develop questions for each identified term Purpose: Continue to build the evaluation tool by getting the group to further define what each of the three identified terms mean and how they can be evaluated in the community. Objective: • Discuss how the identified community change is experienced in the community. • Discuss the different levels or the range of the identified community change. Activities: o Group discussion: Ask the questions “What are the different ways people in our community experience ________?” • Facilitator writes these comments on the board 139
  • 141. A Vaccine for Globalization “What are the different levels or the range of ________?” i.e. good to bad, 0 to 100… • Facilitator writes these comments on the board “What does each level mean and what are some examples of each?” i.e. 0 means ?, 100 means ?... an example of 0 is ?, an example of 100 is ? … • Facilitator writes these comments on the board Materials: • • Large pieces of paper Pens 7) Develop a tool for assessing the identified terms in our community Purpose: Summarize ideas and build a form that will be used to measure the identified social community changes (empowerment). Objective: • Develop an evaluation tool for measuring community changes or empowerment. • Make it easy and clear. Activities: o Group Discussion: The facilitator needs to ask questions that will help the team take the identified terms and develop a tool to use in the community. This process can begin by summarizing the identified terms and defining specific experiences and a range that best describes each term on the board. o Group Discussion: The facilitator leads the group in a discussion of what questions we need to ask to learn where our community is today based on each term identified. This can be done by asking the question: “How can we find out how members of our community are experiencing Term 1?” See Appendix 1 for an example Range vs Experience Tool 140
  • 142. A Vaccine for Globalization o Group Summary: The facilitator summarizes what the group has come up with for each term. The facilitator will help the group choose which questions they like the best and help the group finalize the evaluation tool. The facilitator can ask the following questions: “Do we want to collect simple answers to each question or do we want to have people tell us stories about each term based on their experiences, or do we want to do both?” “For example, tell me a story of how you feel about term __1__ based on personal experiences (if the experience they mention is not listed on our evaluation tool, can we add it later or do we have a section called other?) We document what they say. Then, show the range we developed today and have them rate their experience accordingly.” Materials: • • Large pieces of paper Pens 8) Develop and Evaluation Plan Purpose: To collectively decide on an evaluation plan. Clearly identify the tasks needed to be completed for the evaluation. Objective: • Who is going to do it? • When is it going to be done? • Who are we going to ask the questions to? • How many do we need to ask the questions to? • Who will analyze the data collected? • When will the results be given to the community? • Who will the results be given to? Activities: 141
  • 143. A Vaccine for Globalization Group Discussion: The facilitator asks the group to discuss how to do this evaluation in the community. The following questions can be asked: • • • • • • • • Who do we ask these questions to? How many people do we need to ask? Who will ask the questions? When will we ask these questions? Who will analyze the data? When will we analyze the data? How will we document and display the findings? When will we share our findings with the community? Materials: • • Pens Large pieces of paper 9) Closing Remarks- set a date for a reflection meeting The facilitator needs to question any weaknesses in the evaluation tool, and how it will be conducted prior to final approval. d) Phase 4 – Community Meeting: Reflecting on the Evaluation Process Purpose: To have a discussion about how the evaluation process went and determine if we want to do it again. By virtue of the participatory methods used to develop the evaluation, facilitators need to know that good feedback is achieved when one feels they can openly criticize the process without fear of any bad feelings or repercussions, and that their suggestions will be acted on. Objective: • • Identify lessons learned Discuss recommendations for the next evaluation. Activity: Group discussion: • • Has the participatory evaluation process been effective? What would its long-term impact be? 142
  • 144. A Vaccine for Globalization • • • • • • • • • • • • How did we identify the major stakeholders? What steps were taken to include or exclude various stakeholders? What conclusions can we make about the stakeholders' roles as question-makers and question-answerers? What would we have done differently? What difference(s) might our decisions have made? Discuss and analyze the strengths and weaknesses of the data-gathering process. Discuss the documentation and display of the evaluation findings. Discuss how we used our findings. Discuss the overall management of the participatory evaluation. What can you say about the various elements, including: o evaluation tool building workshop timing o selection of participants o group dynamics o overall organization Do we want to repeat this evaluation process in the future? What resources or support might be needed to repeat the participatory evaluation in the future? What would we recommend other communities to do if they are interested in doing a participatory evaluation of empowerment? Materials: • Large pieces of paper and Pens 143
  • 145. A Vaccine for Globalization Attachment 1: Example of Rating Evaluation Tool Variable Range 1 = and 2 = and 3 = and 4 = and 5 = and its its its its its Meaning Meaning Meaning Meaning Meaning Stories 144
  • 146. A Vaccine for Globalization Attachment 2: Example of Data Display – Star Plot Experience 5 Experience Experience 5 5 1 5 5 Experience Experience 5 Experience 145
  • 147. A Vaccine for Globalization Appendix E: CBO Quantitative Evaluation Results SaLuang Herbal Medicine Group Variables of Community Change Measures of central tendency and variability for ratings Concepts Mean Unity Participation Wisdom of Local People Resources (Funding) Leadership in Group 4.11 4.44 4 2.88 3.71 Median 4 5 4 4 4 Mode 4 5 3,5 4 4 Range (min-max) 3-5 3-5 3-5 1-4 3-4 Star Plot Unity 5 4.11 Leadership 5 5 Cooperation 4.44 3.71 1 2.88 4 5 Funding/Resources 5 Conservation of Local Wisdom 146
  • 148. A Vaccine for Globalization Mohr Muang Group Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Physical Health Unity Strong Community Mental Health Family Warmth Active Compassion 4.55 4.55 4.21 4.45 4.45 4.33 Median 5 5 4 4.5 4 4 Mode 5 5 4 5 4 4 Range (min-max) 4-5 4-5 3-5 3-5 4-5 4-5 Star Plot Physical Health 5 4.55 Active Compassion 5 5 Unity 4.55 4.33 1 4.45 Family Warmth 4.21 5 5 Strong Community 4.45 5 Mental Health 147
  • 149. A Vaccine for Globalization SiBaoRuang Elderly Group Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Unity Cooperation/Participation Local Growth/Development Resources Mental Health Economic Situation 6.63 5.35 5.06 4.89 4.44 4.50 Median Mode 7 5 5 4.5 4.5 5.5 7 5,7 4,5,7 4 3 6 Range (min-max) 2-7 2-7 3-7 3-7 1-7 1-7 Star Plot Unity 7 6.63 Economic Situation 7 7 Cooperation/Participation 5.35 4.5 1 4.44 5.06 Mental Health 7 4.89 7 Community Growth 7 Resources 148
  • 150. A Vaccine for Globalization SanPaBao, Elderly Group Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Community exercising groups Family warmth Happy, Joy, Gay Decreased Illness Decreased Stress Revitalization Self-care with old wisdom 6.75 5.94 5.41 5.52 5.74 6.47 6.63 Median 7 6.5 5 5 6 7 7 Mode Range (min-max) 4-7 2-7 3-7 3-7 3-7 5-7 5-7 7 7 5,7 7 7 7 7 Star Plot Community coming together to exercise 7 6.75 Self-care with old wisdom 7 7 Family warmth 6.63 5.94 1 Revitalized 7 5.41 6.47 7 Happiness, joyful, and gay 5.74 7 Reduced stress 5.52 7 Reduced illnesses 149
  • 151. A Vaccine for Globalization MaebaKee Health Promotion and Leadership Development Projects Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Community Development Knowledge about Health Unity Health Status Education Hill Tribe Culture 5.27 5.11 5.41 5.11 5.29 4.88 Median 5 6 5 5 6 6 Mode 5 6 5 5,6 6 6 Range (min-max) 2-7 3-7 4-7 3-7 2-7 1-7 Star Plot Community Development 7 Hill Tribe Culture 5.27 7 7 Knowledge about Health 5.11 4.88 1 5.29 5.41 Education 7 7 Unity 5.11 7 Health Status 150
  • 152. A Vaccine for Globalization Three age groups working towards Health Promotion Projects Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Unity Compassion Community Power Happiness Networking Togetherness Decreased Stress 6.23 4.67 4.86 5.82 5.95 5.86 6.23 Median 7 5 5 6 6.5 6 7 Mode Range (min-max) 1-7 2-7 3-7 3-7 3-7 3-7 3-7 7 6 5 7 7 6,7 7 Star Plot Unity 7 6.23 Decreased Stress 7 Compassion 7 6.23 4.67 1 Togetherness 7 4.86 5.86 5.95 7 Networking 7 Community Power 5.82 7 Happiness 151
  • 153. A Vaccine for Globalization Muay Thai Group Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Drug Prevention Place to Play Sports Interest Strong Health Kindness Human Relationships Know Friends Interest in Learning 6.33 5.71 5.78 6.29 5.71 5.33 5.62 5.75 Median Mode 7 6 6 7 7 5 6 6 7 6 6 7 7 5 7 7 Range (min-max) 3-7 4-7 3-7 4-7 3-7 3-7 3-7 2-7 Star Plot Drug Prevention 7 6.33 Interest in Learning 7 7 5.75 Know Friends 7 Place to Play 5.71 5.62 5.78 7 Sports Interest 5.33 6.29 Human Relationships 7 5.71 7 Strong Health 7 Kindness 152
  • 154. A Vaccine for Globalization Lahu Group for the Promotion of Dala Spiritual Leader for Drug Prevention Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Unity Thinking and Deciding Together Culture Strength Learning Networking 6.55 6.18 6.64 6.18 6.08 6.73 Median 7 6 7 6 6 7 Mode 7 6 7 6 7 7 Range (min-max) 5-7 5-7 5-7 5-7 5-7 5-7 Star Plot Unity 7 6.55 Networking 7 7 6.73 Thinking and Deciding Together 6.18 1 6.09 6.64 Learning 7 7 Culture 6.18 7 Community Strength 153
  • 155. A Vaccine for Globalization BanMaeJong School Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Family Life Using Free Time Gangs Knowledge Exercise Participation 5 5.58 4.46 5.78 6 5.25 Median 5 6 5 6 6 5 Mode 5 6 5 5 6 5 Range (min-max) 4-6 4-7 1-7 4-7 5-7 4-7 Star Plot Family Life 7 5 Participation 7 7 Using Free Time 5.58 5.25 1 4.46 6 Physical Exercise 7 7 Gangs 5.78 7 Knowledge of Drugs 154
  • 156. A Vaccine for Globalization Mae Hak Group Variable of Community Change Measures of central tendency and variability for ratings Concepts Mean Unity Responsibility of Community and Family Love and Active Compassion Community Relations Use of Addictive Drugs Knowledge about Drugs Self-care for Health Family Life Median Mode 5.45 5.4 6 5 6 5 Range (min-max) 4-7 3-7 5.73 5.64 5.7 6.09 5.73 5.4 6 6 5.5 6 6 5.5 7 5,6,7 5 6 7 7 4-7 4-7 4-7 4-7 3-7 3-7 Star Plot Unity 7 Family Life 5.45 7 5.40 Self-care for Health 7 5.73 7 Responsibility of Community and Family 5.40 5.73 7 Love and Active Compassion 5.64 6.09 Knowledge about Drugs 7 5.70 7 Community Relations 7 Stop using Addictive Drugs 155
  • 157. A Vaccine for Globalization Appendix F: Timeline o December 1 – 27: Collect background information of ICE and the CBO projects via document analysis and non participant observation of community meetings, activities and ceremonies. o December 28: Meeting with all CBO representatives to discuss developing and implementing participatory evaluation of social changes. Establish time for workshops and pilot community to conduct the first evaluation. o December 29 – January 14: In collaboration with ICE staff, create first draft of a Facilitator Guide which includes a methodology for conducting a workshop on participatory evaluation of social changes. o January 9 – 10: Site visit with pilot community to build relationships with members of the CBO and to get understanding of how they feel about the evaluation. o January 15: First evaluation workshop. o January 16: Compile evaluation methodology for Pilot CBO. o January 17: Workshop for 5 CBO members from the pilot community who will facilitate their community groups in doing the evaluation. o January 18 - February 7: Incorporate changes into the evaluation methodology based on the outcome of the workshop and further discussions with the facilitators. o February 8: Community meeting with 30 members of the Herbal Project participates in the Pilot evaluation process. Representatives from 18 other CBO’s observed the process and 11 asked to go through the process in their communities. o February 11: Workshop for the 11 CBO’s, decide on when to do it. o February 17: Second group o February 18: Third and Fourth Groups o February 22: Fifth group o February 23: Sixth and Seventh Groups o February 25: Eight Group o February 27: Ninth and Tenth Groups o February 29: Eleventh Group o March 1 – 6: Summary of Evaluation Data o March 7: Meeting with CBO representatives, Thai Health Foundation, Ministry of Public Health Representative, other interested individuals to present the Summary of Evaluation Data and get feedback regarding the process; strengths, weakness, and recommendations. 156
  • 158. A Vaccine for Globalization 157