Jonathan Hansen and Dr. Kirk Dearden, Health Sciences
Overview
Although there were many complications during the internship and research experience, which impeded the study’s progress, much of the preparatory work for the study was completed before departure. Before arrival in Bolivia we had basic surveys written and translated to Spanish. We had spent some time discussing the potential influences on how children receive medical intervention for ARI in El Alto, a local suburb of La Paz where the research was conducted.
In our first contact with the traditional women of Bolivia called Cholas through Promujer, the non-governmental organization I worked with, we could see that the surveys were out of touch with the real factors that would influence their health decisions for their children. Further, our concept of those involved in the child’s healthcare decisions expanded to include those in the community such as physicians, pharmacists, and herbalists. From this early contact, we established different areas of focus for the study: focus groups with women in El Alto, interviews with primary caretakers (usually mothers) of children that they had recently taken to clinics for treatment of ARI, interviews with primary caretakers of children encountered in the community with current ARI, interviews with fathers of some of the children with current ARI, interviews with physicians and nurses at clinics and hospitals in El Alto, interviews with pharmacists, interviews with herbalists.
Some of the most challenging work completed was the development of the survey instruments for the different components of the qualitative study. The main survey was composed of a series of three interviews to be done on the first, second, and fourth day after identification of a child with ARI. The other complimentary surveys were done to obtain a comprehensive evaluation of the pathway to survival. Outlines and parameters were established for focus groups and a general situational interview was created for pharmacists to be administered by local woman in the community. Together these instruments were designed and completed for implementation.
In order to create accurate, usable, meaningful results, which could then impact the approach to health in the community, we networked and collaborated with local NGOs, hospitals and the ministry of health in El Alto. Through the information and guidance they were able to provide a structure and basic framework for us to design our qualitative study in a way that would be functional for the local Bolivians. Meetings were held, letters of authorization were written, ideas were shared, and basic end goals were established throughout the process.
Due to the cultural differences and language barrier with Aymara, anthropologists were hired from the Universidad Mayor de San Andres in La Paz to carry out the surveys in El Alto with the families and fathers. We developed a nine-page contract to be used for our collaboration.
Several trainings were held with the three anthropologists in order to explain the background of the study along with the goals and desired end results. The anthropologists also reviewed the instruments and gave invaluable feedback on the cultural relevance of certain questions and topics and how to streamline the interviews for better communication. The trainings included: simulations of the situations that were conducted together with positive feedback and evaluation, discussion of logistics, situational options due to the political movements, and the general questions addressed.
The application of the instruments in El Alto was limited due to the inability for transportation and general access and availability of subjects, however one focus group was held in one of the local centers of ProMujer, along with one completed series of three home interviews. Several impromptu and informal interviews with pharmacists and traditional herbalists and doctors were also carried out. We were able to work with several hospitals in La Paz and two in El Alto to interview pediatricians, general physicians, and nurses.
Challenges and Changes
In our first meetings with Saiko at ProMujer, we discussed where we could carry out the interviews. While ProMujer offered a secure location with plenty of mothers of children under 5 and an environment in which they may be more trusting of those they met, there was potential bias for any questions in which we asked for their opinions of ProMujer’s healthcare services. We were concerned, however, about causing potential problems for the women by visiting them (as two young men) in their homes while their husbands may be absent. We discussed the potential for meeting the women at ProMujer and scheduling appointments to interview them in their homes, encouraging them to notify family members of our scheduled meeting. At this point, Kelly and Lorie also offered to help with the study and we decided that mixed gender pairs could be much better for such visits.
Early in our research we also were unaware of the research previously done on the topic. Through searches in local libraries and networking with various NGO’s we found a cluster of studies done mostly through MSH roughly ten years before. Study of their work opened up much of the discussion as well as relevant factors in these healthcare decisions by parents. The data from the various studies, however, did not agree on certain fundamental points. The best way to resolve this would be through closely examining such topics in our own research.
During our preliminary interviews with women at ProMujer, it was also difficult to find mothers of children with current ARI and seemed that it would difficult to verify the ARI efficiently. There did not seem to be a high enough volume of cases at any clinic. Furthermore, we realized through their responses that even the women that used the ProMujer services usually depended on other services for comprehensive healthcare. A community study would be far more productive than one that could at best understand a sliver of their healthcare decisions for their children. We decided to work through the community health clinics to find children that had already come in with ARI. We could interview the parents of these children to learn some of how they made the healthcare decisions that lead them to seek treatment for their child at the clinic. We could then work with these families to enter the community and find other children with similar infections.
Working in the community also presented challenges of obtaining the necessary authorization and gaining the credibility necessary to be able to enter homes. Saiko was invaluable to the study in using her contacts with the Ministry of Health in El Alto. We wrote a simple letter of introduction that presented the project and our intended work in El Alto. With the letter of approval from the Ministry of Health, we had appropriate support to enter hospitals in El Alto and have better cooperation from the administration and staff. The letter from the Ministry of Health could also be used as a form of credentials to gain credibility in the eyes of the community members we would have to interview.
Working in the community presented further challenges difficult for us to overcome as interviewers. There was also a clear language barrier if we worked outside ProMujer. While most of the women at ProMujer spoke Spanish well, Aymara was more common as a language used in the community. Especially the large group of first generation migrants from the Altiplano would communicate most comfortably in Aymara. Even their ideas of etiology and treatment would be best expressed and understood in the language most closely linked to their culture. Even with the approval of the Ministry of Health and cooperation from families in the community we anticipated bias from mothers not feeling at ease to express themselves in the presence of two foreigners. Furthermore, interviewing ethnographically requires much from the perceptiveness of the interviewer. Much is gained or lost based on the interviewer’s sensitivity to the significance of cultural connotation and nuances of the interviewed person’s reactions. As outsiders it was unclear what we could do to properly contextualize the comments of the mother.
In Kirk’s discussion of the project with Martha Mejia at PAHO, it was determined that it would be impractical to use the students for the interviewing and far better to use local interviewers. Exploring options at the Universidad Mayor de San Andres in La Paz, we found a group of three local anthropologists with experience in health research. The anthropologists spoke Aymara, could more help the local mothers feel at ease in their discussion, and had a much better cultural context that would guide them in interpretation of the mothers’ perspectives and responses.
Our initial instruments were clumsy and excessively time consuming in our preliminary interviews. While we had begun the process of revision of the instruments, the anthropologists also provided valuable feedback. We worked with the anthropologists to prepare for and conduct preliminary focus groups that gave us a better grasp of relevant cultural background for the treatment of ARI in children. With this information and the help of the anthropologists, we adapted our instruments to better target the population and behaviors we were studying.
Even hoping to network through families of children with treated ARI, we anticipated difficulty in finding children with ARI. Martha Mejia suggested working with the Manzaneras of El Alto, women in the community working as neighborhood public health coordinators. While the program had not been well developed, the women were generally respected in their communities, and work with them would not only help our project but also show their potential effectiveness and provide a valuable arena for application of results. If the Manzanera program were properly functioning it could be a community-based means of helping identify children with ARI and seek proper healthcare.
Any discussion of challenges faced in our study would be incomplete without treatment of the protests. From early in our stay in Bolivia, the protests made it difficult not only to reach the study site, but provided a definite skew to information gained from interviews. One of the major benefits of working with the anthropologists was their ability to reach these communities in El Alto isolated by the roadblocks. It was difficult, however, even for them to reach the locations as they routinely spent hours walking to arrive at the project sites. Since our intentions were not to discover the impact of the marches on local healthcare, much of the information gathered from early interviews was also heavily skewed. Parents could not reach clinics because of roadblocks, pharmacies and clinics were closed, medical supplies and medications were out of stock, many parents were involved in the marches (as those who did not participate were usually persecuted and penalized by syndicate leaders). Unlike the other challenges, the protests were nothing that we could resolve during our stay. They would hopefully be resolved, but waiting time was necessary. Even early in the study, they made it more difficult to receive permission from the Ministry of Health, to interview at hospitals, to revise our instruments and to coordinate meetings with the anthropologists.
The solution then was patience on our part and planning the study to be carried out at a later time. We discussed possibilities of working with the anthropologists to carry out the study in our absence, but since we had not directly observed their work it was difficult for us to feel secure in analyzing and reporting their results. Furthermore, we wanted a better feel for whether the situation had normalized before going ahead with work that would be heavily influenced by the stability of the region. Waiting for a future point when someone from BYU could be present in Bolivia was the best option.
My experience in Bolivia has greatly impacted my near professional goals as well as the long-term professional aspirations. The biggest contribution relating to my professional growth is the confirmation of getting masters in public health in addition to a medical doctorate. The quick, yet memorable, six weeks gave me a view of international public health and inspired me to make a contribution to public health in my professional desires. The exposure of the differences in ideology and practice of public health and clinical medicine, particularly the international facet, really caught my interest and expanded my health horizon of knowledge. The research conducted in Bolivia also gave me a good feel for how qualitative public health research should be done that will be valuable to me as I work on a MPH. Finally, I also made many valuable relationships with successful people that will be excellent resources to collaborate in the future as well continue in our careers.
The study will be completed with its data collection the spring of 2006 and the research findings will be appropriately applied in order to reach the goals of the study. We will then be able to complete our original objectives of educating the public about new culturally sensitive solutions and collaborate with the health organizations we have already made contact with to make sure the problems are addressed and progress made in the area of ARI.