Stanley, Otis L. DR, PH; Stanley, Mickey PhD, RN
Otis L. Stanley, DR, PH, received his doctorate in International Public Health from Tulane University, New Orleans, in 1990. He served 20 years as a Public Health Officer in the U.S. Army, where he conducted numerous overseas missions to improve the quality of life for rural people in underdeveloped nations. He teaches Public Health at the University of Southern Indiana in Evansville, Indiana.
Mickey Stanley, PhD, RN, received her doctorate in Nursing from the University of Texas, Austin, in 1988. She has served as a Parish Nurse for the past 8 years. She teaches nursing for registered nurses returning for the baccalaureate degree at Southern Illinois University Edwardsville.
NOTE: This article provides a great example of community health development in a developing country. The authors share a mission approach that focuses on health promotion rather than curative medicine and on building local capacity, meeting felt needs of the community in order to establish trust.
—Grace Tazelaar, NCF Missions Director
The desire to use one's gifts in service to the Lord on the mission field often surfaces when Christian nurses gather to fellowship, learn, and support one another. Although numerous opportunities exist to serve in America, there is nothing like the experience of witnessing the suffering that exists in the third world regions to open our eyes and fuel our desire to help others.
In 2005, we were asked to accompany a group of missionaries to assess the conditions in the rural fishing villages of Andhra Pradesh, India. The goal was to develop a plan to improve the quality of life for the people in this underserved area. An initial health assessment was conducted that focused on safe water, environmental sanitation, and nutrition, as well as general preventive and curative health services.
Evidence of contaminated water sources and lack of basic sanitation facilities (see figure above), lack of immunization programs, childhood undernutrition, and poor childbirth practices were found. The majority of the people in the villages were illiterate and had no access to government-sponsored healthcare services. As a result, health suffered due to dangerous folk practices such as withholding all feedings from newborns for 3 days, failing to cut the umbilical cord for up to 3 days, or using coconut oil, fresh mud, or mashed potatoes to coat a new burn wound.
Our project was sponsored by a local Christian pastor in Andhra Pradesh. Through several years of a stable presence in the villages to bring literacy training and feeding programs, together with church planting and evangelization, trust had been established between the local village people and the faith-based organization. Those who provided these services were local people who understood the culture and respected the people for their strengths and abilities. These individuals served as our sponsors. This was a critical component for the success of the health-related mission because it provided us with access to and acceptance by the village people.
The predominant religion in this region is Hindu. Unlike the Christian faith, in which Scripture provides guidance for all aspects of daily life and a sense of hope for today as well as the future, the Hindu faith is guided by a set of beliefs regarding the value of suffering for obtaining a better life when one is reincarnated. Despite these centuries old beliefs, we found that the people desired a better way of life and improved conditions for their families. As we served to help those in need, regardless of religious beliefs or background, we were well received.
Taking health-related projects to underserved areas is not a new concept. In fact, the literature is filled with reports of projects to provide clean water, sanitation, and clean childbirthing practices to areas such as India and Africa (Hossain, Bhuiya, Khan, & Uhaa, 2004; Rubardt et al., 1999; Schmid, Kanenda, Ahluwalia, & Kouletio, 2001). However, once the funding stream is removed and the foreign trainers have gone home, the initial progress is difficult to sustain (Goodburn, Chowdhury, Gazi, Marshall, & Graham, 2000). Therefore, the model chosen for this project was a bottom-up, capacity-building approach to prevention and health promotion. We emphasized the responsibility of the village people to identify and solve local problems using locally available resources. However, scientifically based interventions formed the basis of all the training.
For the recommended behavioral changes to be sustainable once we were gone, an important component was integrating culturally accepted practices when appropriate. For example, we understood that the rural fishing villages had a strong patriarchal structure. Therefore, we began each village visit with recognition for the importance of the village chief. Without his support and approval, our efforts would have been ineffective.
To ensure saturation of the health messages for all villagers, we wanted to capture a familiar theme that would easily integrate with the ongoing literacy evangelism program. We therefore designed a brochure titled Ten Commandments of Health: Guiding Principles for a Healthy Community (Table 1 on page 90). These 10 key messages were broad in scope, reflecting the assessment findings and priorities of the village people. The bulleted information below each key message provided additional details that needed to be addressed for healthier communities to be built in this rural setting.
During the first visit, consensus was reached with the village people on the need for safe sources of water as the initial priority. In each village visited, both the village chief and the people told us that the water was making the people sick and causing the deaths of many children. Although use of a bleach solution to disinfect the existing wells is recommended by experts around the world (Hossain, Bhuiya, Khan, & Uhaa, 2007), this approach was not acceptable to the people of the villages. Instead, the people voiced a strong preference for drilled wells. Through church sponsorship, funds were raised to equip a team of village men to drill these shallow wells.
Not only were the people provided with safe drinking water, but the drilling teams were able to earn a salary to support their families, resulting in a greater sense of community pride. By addressing the most pressing concerns of the local people in a manner acceptable to them based on their belief systems, a measure of trust was established that opened the door for future work.
In January 2007, an educational program was launched for the men and women of these rural fishing villages based on the Ten Commandments of Health. The church structure was used to provide a village meeting place for weekly lessons open to all faith groups on a variety of health-related topics. Initially, a public health nurse with experience training villagers in underdeveloped regions of the world conducted classes through local interpreters.
A guiding principle for this program was to use only locally available resources in the training process, thus eliminating any dependence on foreign trainers or funding. In each village, one or two members of the village were selected to receive individualized teaching and to assist the trainer with making teaching materials. For example, to facilitate the training in cardiopulmonary resuscitation (CPR) and care of a drowning victim, a CPR doll was made by a local tailor using old clothing from the villagers. Each village named its CPR doll and retained this teaching tool for the villagers' future practice. The intent was that those trained during this phase would teach their neighbors and other family members in the techniques or approaches demonstrated by the trainer (see figure above).
Illiteracy rates are high in Andhra Pradesh, approaching 90 percent. To facilitate the spread of the Gospel, the church initiated a literacy evangelism program 5 years ago. This program is being used to integrate health messages into the lessons for all age groups regarding personal hygiene practices; the role of mosquitoes in the spread of such diseases as malaria, dengue fever, Japanese encephalitis, and chikungunya (Centers for Disease Control, 2007); and the importance of sanitation and good nutrition. The technique of storytelling is being used to develop classroom materials that are age appropriate for the different groups in the local schools and orphanage. The scriptural basis of the lesson allows for the integration of the Christian worldview with the public health message so that “they will prosper and be in health, even as their souls prosper” (3 John 2). Figure 1 contains an example of one story.
Changing health-related behaviors is difficult. We know that simply providing evidenced-based health information and expecting people to change ingrained habits are ineffective among educated individuals. The goal of integrating health initiatives into rural village life must be based on an understanding of the culture and the belief systems of the people. Health behavior change requires the development of simple messages with a multitiered delivery system. The Ten Commandments of Health were distributed as plaques to each village chief as a gesture of respect and a symbol of our commitment to improve the lives of his people. In addition, they were fashioned into a brochure that was distributed widely in the local language of Telagu. The Ten Commandments of Health formed the structure for the ongoing village education program that began in January 2007. And they continue to guide the stories being developed for the children of these villages.
Traveling halfway around the world to help people of another culture improve the quality of their lives is one of the most rewarding and most difficult experiences imaginable. It forces us to distill all the scientific evidence we have gained into simple relevant messages that can be applied directly with locally available resources by people who often are illiterate and desperately poor. We hope and pray that our efforts in this area will benefit others who are likeminded and headed for the mission field.
Goodburn EA, Chowdhury M, Gazi R, Marshall T, & Graham W. (2000). Training traditional birth attendants in clean delivery does not prevent postpartum infection. Health Policy and Planning, 15(4), 394–399.
Hossain SM, Bhuiya A, Khan, AR, & Uhaa, I. (2004). Community development and its impact on health: South Asian experience. British Medical Journal, 328(7443), 830–833.
Hossain SM, Bhuiya A, Khan, AR, & Uhaa, I. (2007). Bringing safe water to remote populations: An evaluation of a portable point-of-use intervention in rural Madagascar. American Journal of Public Health, 97(3), 398–400.
Rubardt M, Chikoko A, Glik D, Jere S, Nwanyanwu O, & Zhang W (1999). Implementing a malaria curtains project in rural Malawi. Health Policy and Planning, 14(4), 313–321.
Schmid T, Kanenda O, Ahluwalia I, & Kouletio M. (2001). Transportation for maternal emergencies in Tanzania: Empowering communities through participatory problem solving. American Journal of Public Health, 91(10), 1589–1590.