Cultural integration in CTC: Practical suggestions for project implementers (Special Supplement 2)

By Jamie Lee

The SPHERE guidelines touch only superficially on culture and the cultural acceptability of humanitarian assistance. However, in recent decades, the wider field of international health has produced a variety of initiatives intended to account for culture in the design and delivery of programmes. These include international research efforts in control of diarrhoeal disease, vitamin A deficiency and acute respiratory infections, and the promotion of family planning. The challenge posed by HIV/AIDS prevention, much of it focused around behavioural change, has further heightened the attention to culture. Thus, at least in the context of well-funded multi-country international health interventions, some form of integration into local cultural settings is becoming standard practice. However, the language of 'cultural integration' can be controversial. "Who", it might be asked, "is to be integrated into what, and on whose terms?" There is also concern about the focus on culture as a problem or obstacle to be overcome en route to compliance. Caution is required, if culture is not to become a stick with which we beat the 'victim'.

Since late 2002, CTC projects in Malawi, Ethiopia, and South Sudan have each tried to improve nutrition outcomes by undertaking an element of social or cultural research, in parallel with service delivery. Investigators have included specialized anthropologists as well as community development generalists, and African academics and practitioners as well as expatriates. The level of effort has ranged from rapid reconnaissance of two weeks, to more thorough ongoing investigations of several months duration. In each case, the underlying assumption has been that an appreciation of the beneficiary perspective on the project (its procedures, institutional alliances, demands and trade-offs of participation, and the acceptability of treatments) can improve access and impact. This approach is hardly new, but it remains underexploited in emergency programmes, where the ability to devote staff time and energy to non-core functions is still considered something of a luxury by many implementing agencies. This article tries to summarise some of the lessons and suggestions arising from this work¹.

An outreach worker meets with village elders in Ethiopia.

Take time to understand the context of the project - how do interventions relate to the wider range of options and pressures facing local people?

This requires little in the way of specialized skills, being primarily a matter of creating opportunities to consult with beneficiaries and other service providers. The general objective is to achieve a 360 degree picture of the interactions that individuals have with other services, with an eye toward minimizing mixed messages or contradictions. Doing this in Malawi quickly revealed that many children being screened for CTC were already subject to monthly growth monitoring from village health workers during vaccination days. Conflicting indicators used in the two programmes was causing frustration, as mothers whose children had, for some time, been judged malnourished on a weight-for-age basis, thought they were finally to be assisted when CTC arrived. But, on attending CTC screenings, they found that the same child was being judged healthy on a MUAC or weight-for-height basis and refused admission. Coming on top of long waits and sometimes lengthy treks to attend the screenings, this generated some bitterness and undermined interest in the CTC programme: "had they not been told to do something for the health of their child?" "Why, having acted on this advice and come all this way, were they being told to go home empty-handed?" Relatively little input quickly allowed project staff to make sense of the depth of community frustration at the rejection of children from the CTC screenings and take steps to reduce it. Similar findings from Ethiopia and South Sudan have pushed CTC towards a better harmonization of admission indicators with GM programmes, and in some cases, towards using MUAC alone as a screening and admission indicator.

Develop an understanding of the words and phrases used locally to describe wasting and swelling in children.

A member of the district health office meets with village elders to discuss the involvement of volunteers in the programme in Malawi.

In emphasizing community-wide coverage, CTC faces a dilemma: how to encourage wide participation of malnourished children at OTP and SFP screenings, without also attracting large numbers of the non-malnourished? Efforts at the outset to establish a clear and consistent message concerning eligibility help limit confusion, prevent project staff from being overwhelmed, and minimize the community disappointment and frustration resulting from non-admissions. But the particulars of such a message are not as obvious as they might seem. It has been found that it helps to devote specific attention to the local language concerning malnutrition. The term 'malnutrition' may undergo subtle shifts in meaning, as it is translated by the project into the language of beneficiaries (for instance, available local terms might stress the idea of food shortage over dietary quality). Even when terminology seems roughly equivalent, local beliefs sometimes ascribe causes other than poor nutrition to swelling or wasting in children. For example, in Chichewa-speaking areas of Malawi, swelling is believed to relate to the moral conduct of the parents. Consequently, when describing the target population it is best to refer directly to physical symptoms, rather than to issue a general call for "malnourished children". Even then, wasting and swelling may also be translated in a variety of ways, and where this is the case, discussions which centre around pictures of malnourished children can help to elicit the full range of local terms. Staff can then employ these terms in information meetings designed to explain the project to the community. This lesson, learned in Malawi, has enabled more recent CTC projects in Ethiopia to improve the rate of programme uptake and raise the ultimate coverage rates (see section 3.1).

List common beliefs concerning the causes and appropriate treatment of wasting and swelling.

Child eating plumpynut® in South Sudan.

An iterative process of discussion with local families can be used to list the names of conditions, perceived causes and common treatments, resulting in a composite picture of malnutrition from the perspective of local parents. This is usually sketchy and cannot hope to reproduce the cultural meaning of illness or healing that might result from true ethnographic study. However, experience has shown that it is often sufficient to reveal the points of divergence from biomedical practice.

The nature of the revealed differences can have implications for conducting CTC. Where there is association made between malnourished children and the moral conduct of their parents, for instance, case-finding and outreach need to be conducted with due regard for family and community sensitivities. Where there appears to be a long interval between local treatment of kwashiorkor or marasmus cases and their presentation, there may be opportunities to engage local folk practitioners in early case referral to the project. Where several types of healer appear to be involved in treating malnutrition, approaches to the 'traditional' health sector may need to be broadened beyond the minimal contacts (often with TBAs) established by clinical health services. This type of collaboration with folk practitioners is for the moment, more of a potential than an actual feature of CTC but, in both Malawi and Ethiopia, healers have proved to be surprisingly approachable. And as CTC looks beyond emergency interventions towards integration with longer-term programmes, there may be opportunities to explore with host communities the possibility of more effective linkages between folk and modern practitioners in the treatment of malnutrition.

Use information on local beliefs and practices to map out critical linkages with other services, where these exist.

An investigation of the treatment of kwashiorkor in Sidama, Ethiopia, revealed that food proscriptions may exacerbate malnutrition. This suggested an important focus for eventual nutrition education work. In other examples, from both Malawi and Ethiopia, discussions with mothers about marasmus pointed to early complementary feeding as a possible health concern. Further investigation revealed that complementary feeding, in turn, was conditioned by a variety of concerns - including the possible 'spoiling' of breast-milk through conception of a second child. Consequences for the child who consumed the spoiled milk were thought to include severe diarrhoea. This finding highlighted the need to complement standard CTC interventions with instruction for care-givers in the control of diarrhoeal disease and the production and timely introduction of complementary foods.

Once project messages have been clarified, consider whether there may be local formal and non-formal channels of communication that can be utilized to explain CTC objectives and procedures.

As a matter of first principle, the CTC approach attempts to align projects with existing clinical services (see section 5.3). These often have their own means of outreach to the community (Village Health Committees, Community Health Workers, and other extension agents). In addition, experience to date has shown that there are less obvious cultural channels of information, authority, and decision-making. In African settings, these are usually systems of authority, built around clan or lineage. The relationship of these systems to the official government apparatus has ranged from active collaboration in some countries, to uneasy accommodation in others. In Malawi, 'Traditional Authorities' (TAs) are on the payroll of the state, and in the early stages of CTC, found themselves in an awkward position, mediating between government workers and project staff on one hand, and frustrated communities on the other. Based upon the rapid investigation described above, effort were made to understand the causes of frustration, which resulted in the design of a handbill to guide project staff in a series of meetings with the TAs. By respecting the TAs, and by responding systematically to the concerns of their constituents it was possible to secure their cooperation in initiating a series of cascading meetings with allied village headmen. A rapid increase in coverage followed these meetings.

However, the mere existence of 'traditional' systems of communication and authority may not be sufficient reason to invoke them in every case. Agencies implementing CTC must weigh potential benefits against other considerations, including consequences to the existing order. Whereas relief agencies may think of their actions as neutral humanitarianism, deepening community involvement may be read by host governments as a political act beyond the purview of the agencies. In Ethiopia, where government exercises strong oversight of emergency nutrition activities, CTC implementers in one region opted not to approach tribal authorities due to the political climate, which was characterized by a pervasive fear of local ethnic nationalism on the part of local government. In this case, a network of project outreach workers was already doing an effective job of expanding coverage, so forgoing contact with traditional leaders was not a significant handicap.

Understand the limitations of qualitative research.

Qualitative methods offer insights into beliefs and practices but cannot by themselves assign priority to project responses. Research has helped to illuminate a variety of ways in which local people may respond to symptoms, or to CTC interventions. However, these insights are not usually sufficient to suggest the most efficient use of project resources. For example, it is relatively easy, with minimal qualitative research outlays, to catalogue local names for symptoms of severe malnutrition and use these to foster communication and understanding. However, acting on other observations might not prove to be cost efficient. Developing a culturally appropriate nutrition education campaign which addresses complementary infant feeding issues would, for instance, be a multi-stage process requiring considerable resources. Before doing this, qualitative insights would need to be paired with rudimentary quantitative methods, in order to assess the true magnitude of the problem. The resource implications of such alternative programming choices are likely to loom larger, as CTC moves beyond an initial emphasis on coverage towards the integration of nutrition into longer-term care.

¹Observations relating specifically to the theme of community mobilization are dealt with separately in section 5.1.2