My First Week in Patna (Before Heading Off to the Communities!) – Blog Post #3

Continuing to post all my blogs 🙂 The following blog post was about my first week in Patna, before I headed off to the communities in Purnea – one of the three districts where Sashakt is taking place. I was able to spend the week speaking with Pathfinder’s Program Coordinator in Delhi to learn more about Sashakt and ask the questions I had, use Pathfinder’s office to learn about its past programs, use Arun Sir’s documents and additional pdfs I had downloaded before arriving in Patna to learn about India’s health infrastructure, Vikas Mitras, and receive more insight into the Mahadalit community.

Saturday, June 19th

Pathfinder’s current 1-year implementation project that I will be observing is funded by the David and Lucile Packard Foundation. They will be coming this week to check up on the work Pathfinder has been doing, and for that reason Arun Sir will be in Purnea from the 14th to the 16th (the next three days). He and I thought it would be best to first Skype with Dr. Mahesh, Pathfinder’s Program Coordinator in Delhi who I have been speaking with over the past year. I planned on using the rest of the week to search through the Pathfinder’s office and read up on the components of Sashakt and India’s healthcare system. I learned that the guesthouse had Wi-Fi I could use (although I would later learn that it was slow/spotty at times, and, least expected, that the Wi-Fi unit would have burned up by the time I returned from the communities in Purnea). Although I was hopeful about the trip, one thing from yesterday’s discussion with Arun Sir and his colleagues was making me nervous: Pathfinder’s staff would help me out as much as possible in the field, but they also had their own tasks and responsibilities. This was of course expected, but I understood it as I would have to be in the field alone sometimes, in an unfamiliar place with unfamiliar people. But I was yet to learn not only how incredibly supportive and encouraging Pathfinder’s team in Purnea would be in terms of my safety and the success of the research, but also how quickly I would feel comfortable working in the communities and speaking with community members. I also was able to chat with my uncle in India (who does a lot of medical charity work) and Professor Aday later in the week, who helped me think of some possible community members or locals who I could begin partnering with. This would not only reinforce my research as a collaborative effort and keep it going long-term, but I would also receive more guidance in the field (e.g. local angankaryakartas, or local Anganwadi Center workers).

The next day, I Skyped with Dr. Mahesh, excited to learn more about Sashakt and ask him about any questions I had. He was really happy that I was enthusiastic about the work and ready to begin. Although we lost connection halfway through the call, it went pretty well! Dr. Mahesh started off by telling me about Sashakt’s primary goal of promoting healthy timing and spacing of pregnancy (HTSP) in Mahadalit communities – a subset of Scheduled Caste/Scheduled Tribe communities (the most socioeconomically vulnerable groups in India). They hoped to delay womens’ first pregnancy and ensure the use of family planning methods specifically in Mahadait communities. He told me that there are 12-13 million Mahadalits in Bihar alone, and that with the 1-year implementation project, they chose to start in small geographical area: one block per district, with a total of three districts chosen for the project, amounting to about 100,000 community members. He said that getting data for the population per district is quite difficult given that even the census does not have all the details on this particular population. He said that Sashakt has been running for the past 6 months, and given that Packard funds annually, they hope to receive an extension for the following year to continue to scale up the project.

I then learned about the origins of Pathfinder and its previous project titled “PRACHAR,” Begun in 2001, the behavioral change project focused on both 15-24 year olds and those beyond the target beneficiaries, such as key decision makers, stakeholders, and leaders, to improve SRH outcomes. Implemented across five districts in three phases, PRACHAR was thoroughly evaluated (by in and out agencies as well) to develop Sashakt, which they also hoped to scale up in partnership with the government. The major conclusions they drew were:

  1. Interventions regarding HTSP have to start at adolescence and continue until age 24; targeting only married couples is not effective because it is too late by then.
  2. It is important to target both the husband and the wife.
  3. Apart from the couples, having interventions that target the entire population is not cost-effective. They saw that changes were made more quickly among those from higher castes/those who were more literate versus those from lower castes/those who were illiterate.
  4. A 360 degree approach has to be taken to the interventions. Using group discussions, home visits, and other components that are implemented at the community-level and offer a range of communication is best. Given limited financial resources, interpersonal communication is the most important component.

Thus, with Sashakt they focused on the Mahadalits, a population with high rates of illiteracy and poverty, and methods of interpersonal communication and small group discussions to improve knowledge, attitudes, and demand regarding SRH, outcomes, and related services. Dr. Mahesh broke down Sashakt into its two major components:

  1. 3-day life skill education sessions for unmarried, adolescents boys and girls to teach them about SRH and HTSP and
  2. interpersonal communication through home visits and group discussions with married youth under 25, done primarily by ASHAs and Vikas Mitras, who are provided additional training and supervision by Pathfinder staff.

He explained the roles of the ASHAs and Vikas Mitras in further detail as well, which was really interesting to learn because I was starting to build a better picture of India’s health and local government infrastructure. But I was a bit surprised to learn that even Pathfinder knows that ASHAs have been ineffective in the past in terms of reaching out to the Mahadalit communities. Dr. Mahesh explained that this can be, for example, because of a clash regarding social norms or because ASHAs may feel that bringing about change in these communities is tougher and they do not want to spend that much time. I was a bit confused as to why Pathfinder is still working with ASHAs to help them carry out Sashakt, but I guess it makes sense in that they are trying to improve the approach that the ASHAs have and are specifically trying to work with ASHAs from the Mahadalit communities, so that community members are more trusting. Nonetheless, the literature on lay community health workers is not supportive.

What was also interesting to learn was how exactly the Mahadalit communities are identified for Sashakt and what the shared community beliefs seem to be regarding early marriage, SRH, and HTSP, based on the work Pathfinder has done thus far. He told me that there are groups of houses, or habitations, in rural areas according to caste/community. Each village may have people from different castes, but the habitations are what matter and Pathfinder reaches out to the Mahadalits in those habitations through the ASHAs and Vikas Mitras. The ASHAs and Vikas Mitras know, in their respective villages, which habitations are Mahadalit. He said that based upon their formative research, the prevalence of early marriage is still quite high by 12-16 years of age and that there are many social and cultural norms that play into this. Women have to prove their fertility, which is why HTSP methods are not well accepted. Often, a teen is married and has a child within the first year of her marriage. They should be aware of family planning practices and understand the importance of adopting these practices. I asked if women’s views are really represented in these communities with regards to these issues. Dr. Mahesh responded telling me that there is not much discussion on these topics. Gatekeepers are not very passionate about it and social norms are accepted, so no discussion. Parents believe, for example, that a girl’s security and chastity should be preserved. They perceive many risks and as such, their girls drop out of school early and marry early. Gatekeepers provide broad guidance, but do not interfere in personal decision making. They are there to provide macroguidance on social norms and cultures. Overall, there are many cultural beliefs regarding early marriage (which Arun Sir commented on the previous day, saying that I will find a wide range of reasons as to why early marriage is practiced in the communities, with each community member saying a different reason):

  • Early marriage allows for preserving a girl’s security (or purity/chastity).
  • Early marriage allows the parents to find a groom that is earning good money.
  • If they feel that their daughter is at risk of eloping, parents will want to have their daughter marry early. This seems to be one of the most common reasons.
  • The parents may feel that their daughter is an economic burden.

He ended with telling me that there are multiple NGOs also working on these issues, and that currently, they are partnered with the NGO named “CADAM,” to mobilize the unmarried adolescents for the 3-day life educations sessions (which I will elaborate on in future blog posts). The government has also developed many schemes for the Mahadalits to not only discourage early marriage and improve health outcomes, but also to assist them in sectors such as agriculture, housing, and education. Finally, I told him that I would really like to speak with a variety of key informants to better understand shared community beliefs regarding early marriage and consequences for SRH/HTSP, such as the community members, ASHAs, Vikas Mitras, Anganwadi Center workers, and members of the Panchayat. He too recommended that I speak with service providers such as ASHAs, Vikas Mitras, the Auxiliary Nurse Midwives (ANMs), decision makers/government leaders at the block and district levels, and community leaders and gatekeepers.

The rest of the week, I reviewed over my notes from the Skype session with Dr. Mahesh and visited Pathfinder’s office to see if I could get more information on the different components of Sashakt, finding a document on ‘Advancing Sexual and Reproductive Health in India”. Arun Sir returned from Purnea yesterday (Friday), and I was able to speak with him in more detail and plan out my next few weeks. I was able to ask him more detailed questions on the Bihar Mahadalait Vikas Mission, CADAM, the roles and responsibilities of ASHAs, Vikas Mitras, and ANMs, how Mahadalit youth are being engaged in the project, especially in content design, and the 3-day life education sessions, home visits, and group discussions. Not only did he provide me with documents that were very informational (e.g. “The Roles and Responsibilities of Different Categories of FLWs,” a ppt presentation on the Primary Health Centers, and two detailed documents in Hindi on the Mahadalit Vikas Mission), but also shared with me the presentation he shared with the Packard foundation. The presentation was extremely helpful in getting me up-to-date in terms of what had been accomplished in the past 6 months and giving me a preview of all the components of Sashakt, from the adolescent training sessions to the training sessions for the ASHAs and Vikas Mitras.

What I was most excited to find out was that I would be leaving for the communities tomorrow (Sunday)!! I would be meeting with the Block Project Coodinators (BPCs), Ravi and Prabha, who would help me with the research and guide me through the communities. Arun Sir was also very kind and arranged all of our accomodations for our stay in Purnea. I was able to Skype with Professor Aday and begin thinking more about the conversations I would be having with community members. I can’t wait to finally begin some field work!