This program is brought to you by Emory University. Hi, I'm Jenny Foster. I am an Associate Clinical Professor in the Nell Hodgson Woodruff School of Nursing, and I'm a nurse midwife and a cultural anthropologist. This week, we're going to talk about an essential ingredient to improve the health of mothers and babies around the globe. The approach of community mobilization and participatory learning and action to enact positive change. To get started, I will talk about what we mean by those terms, and then the steps in the change process. Then, I want to introduce to you a successful and well-known project that began over 20 years ago. The Warmi Project in Bolivia. It has been a model for many participatory projects for maternal newborn health around the world. After that, we will see how effective participatory projects have been in Nepal, India, Kenya, Bangladesh, and Malawi. Then we'll circle back again to the Americas to see some participatory project examples in real life. One in Atlanta, Georgia in the United States, and one in the Dominican Republic in the Caribbean. Finally, we will conclude this module by discussing what some of the best thinkers in global health believe is the mechanism for the sustained empowerment of communities. Their ideas are thought provoking and press us to rethink many previously held ideas about development. Of which safe motherhood is a central component. What is community mobilization? According to the United States Centers for Disease Control, community mobilization engages all sectors of the population in a community-wide effort to address a health, social, or environmental issue. It brings together policy makers and opinion leaders, local, state and federal governments, professional groups, religious groups, businesses, and individual community members. Community mobilization empowers individuals and groups to take some kind of action to facilitate change. Community mobilization is a challenging process, and it's a process that is easier in some communities than others. We know that the poorest communities are the very same communities where maternal and newborn death and illness are highest. Why is this? Theologians and critical social theorists have long observed that it is no coincidence that the poorest communities are the ones with unequal access to healthcare. As well as unequal access to many other benefits of society. Some of you may know the book, Mountains Beyond Mountains. Which is a popular account of the life and work of Anthropologist and Social Medicine Physician, Dr. Paul Farmer. The author highlights the link between social injustice and social inequality to something he calls structural violence. And structural violence is a term first coined back in the 1950's. By Johan Galtung, a Norwegian sociologist and mathematician and the founder of the Peace Research Institute. Structural violence refers to our economic, political, religious, legal and cultural structures that produce an arrangement of social life that puts some people in harm's way, invisibly. That is, structures of society become organized in such a way that certain groups of people cannot achieve their full potential. This is what happens in those communities within every country, where maternal and newborn death are highest. The poorest communities are likely places where outsiders don't want to live. But the people who live in the poorest communities have strengths and assets that are often undiscovered or ignored by outsiders. Also, many of the very people who live in these places have internalized the idea, that since they live in these impoverished places, they must not have any assets. And thus feel hopeless or disempowered. Empowerment is necessary for social change. Empowerment is a construct much talked about, but hard to define and even harder to measure. A former professor of mine, Dr. Carl Taylor of the Johns Hopkins University School of Public Health, proposed the idea that empowerment is best measured by proxies. That is, measures that are the consequences of empowerment. These measures include increased mobility, influence in decision making, readiness to seek help, and expanding education. When people dedicate their energy to adjusting the relationships within their own social system, they mobilize for action and change through participatory learning and action in a cyclical process. I encourage you to read the book Dr. Taylor and his son and grandson wrote about mobilizing human energy for positive change. Their book is titled, Empowerment on an Unstable Planet: From Seeds of Human Energy to a Scale of Global Change. We'll touch upon some of the basic ideas in the book later on. But first, what do we mean by participatory learning and action cycles? In every country, healthcare systems for the public are in need of improvement. In some way or another, there's a movement within each nation to improve the system of healthcare for its people. One of the organizations, the International Healthcare Improvement Institute, or IHI, has defined the cycle of change into four phases. I encourage you to go to the website of the IHI. Participatory cycles work not just in healthcare institutions, but also in communities. The cycle has four phases, which is sometimes called plan, do, study, act. Or PDSA cycles. In our area, phase one identifies and prioritizes problems during pregnancy, delivery, and postpartum. This requires knowledge, but very often community members have much knowledge about which problems are the priority. And they are open to learning about what others know. Phase two plans what to do about the problems. Phase three implements locally feasible strategies to address the priority problems. Phase four evaluates the activities to see what worked, and what did not. And so what needs to be changed again to make improvements. And so the cycles continue. Likely this sounds to you like any problem solving process, and people in many different professions use this process. Business, nursing, and engineering. Just for a few examples. The difference in our discussion is that the people affected by the problem are completely involved as equal players in this process, which ironically has not historically been the case, in the vast and varied programs to improve the outcomes of child birth globally. There are many examples where donors, governments, as well as well-intentioned non-governmental organizations, or NGO's, create plans for the community. But in true participatory learning and action, community people play the biggest part. This doesn't mean that donors, governments, and/or well-intentioned outsiders are not important or don't play a part. They certainly do, but they need to work together in authentic, equitable partnership. Lets go back for a minute, to what my old professor Doctor Taylor and sons wrote about the framework, or the principals, to grow true empowerment. First, one must build from the success of the actual, present day achievements of communities. This is key. Begin with what people are already doing and focus on what they do well. Second, there needs to be a three-way partnership formed from the Bottom-Up, from the Top-Down, and from the Outside-In. The Bottom-Up is the community, the people who live with the challenge of poor outcomes for mothers and babies. The Top-Down is usually the local, regional, or national government. And the Outside-In includes the people who bring in new ideas, possibly trainings, and include NGOs, researchers, donors, businesses, activists, visitors, and so on. In the beginning formation of partnerships, each of these actors have their own viewpoint. If they work together, there becomes a meshing of viewpoints. Third, decisions need to be based on evidence, not on politics or power or money. When we talk about evidence, we mean things that the community, or Bottom-Up sector, can know is true. True from experience, and experience elsewhere. True from information they've collected themselves. Remember that the evidence that is spoken about by researchers comes from the outside. From the Top-Down, or Outside-In sectors. It's not that evidence they have generated is not valuable, it certainly is. And we will talk about some of it in the next section. It's just that the evidence that's generated by the Bottom-Up sector is what grows empowerment. And finally, behavior change is the fourth principle. Too often donors and governments have looked at outputs as measures of success. Like the number of clinic visits or immunizations delivered. The important outcome of mobilization is community change to improve childbirth. Here's a quiz to help you review what we've discussed so far, and then we'll turn to some real-life examples.
