To Our Readers

Much of the suffering, disease and conditiOli.s around them. death that the world currently expe­ This process may riences as natural is unnecessary and involve learning to pre­ preventable. And we have not even pare more nutritious approached the limits to what we as food or to immunize human beings can learn. The strong children, or it may linkages between education and involve learning to rec­ health result in synergies, which, we ognize and redress the believe, can transform the vicious social, economic and cycles of poverty, malnutrition, dis­ political causes of depri­ ease and ignorance into virtuous vation. cycles of learning and health, equity The idea that and sustainable development. We improving health is an understand development to be the educational process has The linkages between education and health are progressive realization of potential. several implications. mutual and complementary. People must be In that sense, health and education Both David Kahler's healthy to learn"and to take full advantage of avail­ are where human and national devel­ article and "Helping able learning opportunities. At the same time, edu­ cated people are better able to make good use of opment intersect. This issue of The Health Workers Learn" existing health technologies, and to avoid inappro­ FORUM is dedicated to crossing bar­ suggest that health priate use, as with the pacifier on our cover. riers between health and education. interventions are effec­ Improving health is, broadly, a process of education, We discuss synergies between educa­ tive to the extent that where we learn as individuals and families, as com­ tion and health in five main points: they are educational. munities and as a species to better care for our­ 1. The effectiveness of school The article by Beverly selves and our people. inputs to education depends, in large Schwartz, Susan Mid- part, on the health and nutrition sta­ dlestadt, Cecilia Verzosa and the responsibility for developing tus of learners. Beryl Levinger's arti­ material by Renata Seidel describe economic policies that benefit the cle reminds us that children do not health from a social marketing per­ poor, for providing education espe­ come to school as blank slates; much spective. To teach, you need to reach cially to girls and women, for pro­ of their "active learning capacity" is your audience; pedagogy must be moting the rights and status of already formed. The effects of school framed in the values and beliefs of women, and for ensuring delivery of inputs such as teacher training, text­ learners. In contrast, formal schools a basic package of public health and books and the like depend ultimately tend to frame their teaching accord­ clinical services to all. However, it is on children's capacity to learn from ing to the values and beliefs of the most common for all available them. Poor health and nutrition lead educator. resources to be spent lavishly caring to under-enrollment, poor atten­ As a species, human beings have for and teaching a few. In order to dance, poor learning capacity and learned to control much of the dis­ provide for all, the first call on social high repetition and dropout. Howev­ ease environment. Sometimes health resources must go to the most vul­ er, schools can learn to assess health solutions are obvious, as in the case nerable, not those best able to pay. and nutrition problems that prevent of vaccines. In other cases, patterns These disparities can be seen on a learning and implement cost-effec­ of disease can only been seen with global scale. The world as a whole tive interventions to address them. tools such as those of the epidemiol­ spent US$I,700 billion on public and Schools can modify instruction to ogist. Jonathan Mann describes the private health services in 1990, about better match the learning capacity of process of learning to see"acci­ 8% of total world product. High­ students. School feeding and oral dents," which are unavoidable, as income countries, however, spent supplementation programs, vision "injustices," which can often be pre­ almost 90% of this total, an average and auditory screening programs vented and for which society is of US$I,500 per person. The United should be viewed as educational responsible. In the US, for example, States alone consumed 41 % of the inputs. the Centers for Disease Control rec­ global total-more than 12% of its 2. Education can play multiple ognize violence as a public health GNP. Developing countries spent and important roles in preventing problem. It does not just happen but about 4% of GNP, an average of disease. UNICEF estimates that 15 can be mapped and predicted. It is US$41 per capita (World Bank, 1993). million children under the age of five subject to intervention, and often to Hope lies in the fact that we can die each year. Almost half of these prevention and treatment. do something about basic health. deaths are the result of diarrhea and 3. Health and education are most Good basic health does not require respiratory illness, made worse by effective when all members of soci­ great wealth. The World Bank esti­ malnutrition, all of which can easily ety receive (at least) basic services. mates that low-income countries, be prevented and treated. Improving The 1993 World Development for example, could implement uni­ health is a process whereby people Report, Investing in Health, stresses versal preventive and public health are empowered to learn to care for access for the poor. Its health recom­ themselves and to create healthier mendations assign governments Readers continued on Page 13 Nutrition, Health and School Performance by Beryl Levinger 2 Interventions to improve child quality as well as school quality

Helping Health Workers Learn a book of the Hesperian Foundation S Helping people gain greater control over their health and their lives

Models of Preschool Education in Colombia by Maria Ripoll 6 Educating children as part of their families de Urrutia and communities

Pedagogical Checklist for Teaching Adults by David Kahler 7 Health knowledge by itself has changed the behavior of very few people

8 Social Marketing Research on by Beverly Schwartz, Susan Educating Girls in Bangladesh Middlestadt and Cecilia Verzosa Fathers have to be persuaded if girls' enrollments are to increase

Social Marketing by Renata Seidel 8 Marketing techniques can be useful in the social realm

Schools as Health Intervention Sites by Ronald Israel 10 Schools as focal points for delivery of health services to students and communities

11 Health and Adult Literacy in Nepal by Cristine Smith Combining literacy with health education

14 AIDS Curriculum in Malawi's Schools by John Hatch An integrated national AIDS curriculum from year 1 of primary school

14 Lessons Learned from Developing drawn from a speech by William Mackie Elizabeth an AIDS Curriculum The World AIDS education planners must represent a broad spectrum of society Washington. DC. USA Noel McGinn Human Rights, Learning and AIDS by Jonathan Mann Harvard University 1S Cambridge. Massachusetts. USA The HIV pandemic flourishes where individual capacity to learn and respond has been constrained 16 Beating Our Pots and Pans Into Printing Presses by Jennifer Yanco Women becoming active participants in defining what is important about their own health is also an educational process 17 Additional Resources and Closing Thoughts

ABE L The Forum is published by the Harvard Institute for International Development for the Advancing Basic Education and Literacy Project (ABEL) in collaboration with the Academy for Educational Development, Creative Associates International, and Research Triangle Institute. The Forum informs educators worldwide of the latest innovations in basic education. The Forum publication is supported by U.S.A.I.D. Contract No. DPE 5832-Z-00-9032-00 (Project No. 936-5832). Research findings, views, and opinions expressed herein are solely those of the authors and no endorsement by U.S.A.I.D. should be construed. All individuals and organizations are encouraged to copy and distribute articles contained herein. Please acknowl­ edge the source as The Forum for Advancing Basic Education and Literacy. Copyright © 1994 by the President and Fellows IIAdvancin~ B:;~~c~ducation of Harvard College. Nutrition, Health and School Performance by Beryl Levinger

good school plant and high of a child's learning profile is "active Poor Health and Malnutrition quality instruction cannot learning capacity," defined as a child's Impede Learning produce learning when chil­ propensity and ability to interact Five sets of health and nutrition dren are too sick, weak or with and take optimal advantage of problems are particularly important in distracted to learn. Educa­ the full complement ofresources view of their prevalence, impact on Ation interventions have traditionally offered by any formal or informal learning and school performance, and ignored this simple fact. Recently a learning environment (see Box 1). The amenability to treatment (see Box 2). shift in thinking has occurred as poli­ critical difference between ALC and 1. Protein-Energy Malnutrition cymakers and educators have begun to educability lies in ALC's focus on the (PEM).Caused by poor diet, PEM is focus on the "active learning capaci­ quality of the child and what the child almost always linked to extreme ty" of the child (ALC). Attention is brings to school. poverty and the threats to a child's turning away from children's"educa­ The trend is toward interventions growth and development that such an bility" or "teachability," terms that that improve child quality as well as environment poses. Several studies imply a one-way process in which a school quality. Micronutrient supple­ examining the relationship between child passively receives information mentation, deworming programs, PEM and cognitive development in from a classroom teacher. In reality, early childhood projects and school infancy or early childhood have found optimal learning takes place when feeding are becoming important com­ that while mild to moderate malnutri­ children are actively engaged in plements to such efforts as curricular tion does not cause primary learning exploring stimuli, processing informa­ reform, teacher training, school con­ deficits, it does affect cognitive tion and exercising their creativity. struction and textbook distribution. processes. Mild to moderate PEM acts Thus, a more appropriate description synergistically with social and

·A.···.ctiveLearning9pacity (ALC) is a child's propensity and ability physical well-being the learner brings from home to the classroom. . }9interact with and take optimal advantag70fthe full comple­ These variables include health-nutritionst~tus, .. hungerlevelan.9.:~sy­ l11entof· resources off7red by any formal· or informal learning .envi­ chosocialsupport. They are determinedbys~chf~mily bac~gro~nd ronment. As a cbild'sALC· increases, his or her school achievement factors as family size, social class, iqcome,birth ord~raqdgende should also rise. Secondary variables focus on the cognitive characteristics thee I 1heALCfTlodei shown below portrays the dynamic and complex brings to the classroom. These variablesinClUqeprior'learning experi­ relati9nshipsam9ng determinants ofchild quality and educational ence, learning receptivity and aptitude.They:reflectthechild's rela­ outcomes. It is. useful in .linking community, family, national institu­ tionships with others and her or his qualitativecharaCteristics. tions,programs and policies in a non-linear format. It places the Mitigating variables are concerned with classroom processes and child in the. center oflearning processes which include active explo­ interactions, inCluding. quality of instruction, teacher quality, availabil­ ration,jnformation-seeking .and involvement in community,home ity of learqing l11aterialsand provision of direct services to school ands~h091.The modelfocuses on both child and school quality. children that reduce hunger, malnutrition, infection and sensory Three sets of variablesaffectALC..Primary variables affect the impairment.

~haracteristics Chi.ldrenBring to the Classroom

2 1 February 1994 1 The Forum For Advancing Basic Education and Literacy environmental factors. The risks for a retardation, mental and neurologic make appropriate selections from malnourished child in poverty are dalnage, cretinism and impaired information presented in classroom multiple, interactive and cumulative. hearing. Most vulnerable to iodine settings (Pollitt, 1990). Iron-deficient Research indicates that the effects deficiency are visual-perception children tend to be irritable and have of PEM depend on little engagement arid its timing. Early interest in immediate malnutrition can environments. Iron affect school deficiency can also be aptitudes, age of caused by helminthic enrollment, infections (worms) concentration and and malaria. attentiveness. The Vitamin A cognitive achieve­ deficiency often ment of children accompanies PEM. with severe under­ Vitamin A deficits are nutrition or low associated with acute height-for-age is respiratory infection inferior to that of and increased severity children in matched of measles and diar­ well-nourished com­ rhea. Vitamin A parison groups. Chil­ deficiency contributes dren with early to night blindness, childhood undernu­ limited peripheral trition can perform vision and in extreme successfulllyat cases blindness. Evi­ school. However, a dence also links vita­ complex treatment min A to growth, including brain program is required Photo: Meg Garlinghouse to overcome these growth, which con- problems. organization, visual-motor coordina­ tinues through ages 7-10 (Lockheed 2. Micronutrient Deficiency tion and, possibly, speed of informa­ and Verspoor, 1991). Disorders. The principal micronutri­ tion processing (Pollitt, 1990). 3. Helminthic Infections (Worms). ent deprivations affecting school pop­ Children with iron deficiencies Among school-age populations, hel­ ulations are iodine, iron and vitamin have low levels of alertness, attention minthic infections such as round­ A. Iodine deficiency is associated with and concentration (Lockheed and worm, whipworm, hookworm and reduced intelligence, psychomotor Verspoor, 1991) and are less able to schistosomes (bilharzia) generally lead to disease rather than death (Jamison and Leslie, 1990). Yet large parasite burdens­ especially severe hook­ worm infection - are associated with impaired cognitive function as well as absenteeism, under­ enrollment and attri­ tion (Bundy and Guy­ att, 1989). 4. Impaired Hearing &., Sight. Available studies strongly sug­ gest that visual and auditory deficits pose significant educational problems for school children. Reduc~d hearing and vision limit students' expo­ sure to classroom stim­ uli and may interact with vitamin A or iodine deficiency to

The Forum For Advancing Basic Education and Literacy I February 1994 1 3 create negative synergism for the child. 5. Temporary Hunger. Short-term hunger is an educational problem for well-nourished and malnourished children alike, when children come to school without breakfast. This short­ term fasting makes children more eas­ ily distracted by irrelevant stimuli (Pollitt, Liebel and Greenfield, 1983). This inattentiveness leads to poor school performance. Despite the probable benefits of extending health and nutrition pro­ grams to school-age children, most countries have been slow to do so. Reasons range from a reluctance to divert education funds to health, to a lack of information on micronutrient deficiencies and helminthic infection, to a lack of political will to fund cost-effective interventions for school children. However within the class­ room, teachers can modify instruction succeed, two conditions must prevail: References to better respond to students' atten­ 1) The innovation must contribute Bundy, D.A.P. and H.L. Guyatt, tion deficits (see Box 3). directly to educational outcomes, and 1989. Global Distribution of it must not drain educational Parasitic Worm Infections. Paris: Interventions to Improve resources. 2) Health sector personnel UNESCO. Child Quality need assurance that implementing Jamison, D. T. and J. Leslie, 1990. Interventions can be prioritized programs for school children will not "Health and Nutrition Considerations in Educational according to amenability of treatment be unduly cumbersome or costly and Planning: The Cost and Effectiveness and ease of implementation. Iron and that quality will not be sacrificed if of School-Based Interventions," Food iodine supplementation and deworm­ health services are delivered outside and Nutrition Bulletin 12: 204-215. ing should be given high priority due regular health care facilities. Lockheed, M.E. and A.M. Versp 0 or, to relatively simple population target­ 3. Design, test and actively pro­ 1991. Improving Primarv Education ing and modest absorptive capacity mote appropriate strategies for achiev­ in Developing Countries: A Review and infrastructure demands. Supple­ ing community participation in of Policv Options. Washington DC: mentary feeding to relieve short-term improving children's health and nutri­ World Bank. hunger and visual and auditory tion. There are many potential Pollitt, E., 1990. Malnutrition and screening should be given moderate avenues for community involvement Infection in the Classroom. Paris: priority. Supplementary feeding to including latrine constnlction, potable UNESCO. alleviate PEM sould get receive low- . water system development, processing Pollitt, E., R.L. Liebel, and D.B. priority due to logistical and infra­ of fortified foods and production of Greenfield, 1983. "Iron Deficiency in structure demands and high costs. nutrition-dense foods. Community Preschool Children," Nutrition and To be successful, school-based awareness and support are necessary Behavior I: 137-46. to facilitate the introduction of health and nutrition interventions This article is based on Nutrition. need to: school-based chemotherapy. Health and Education for All 1. Create mechanisms to improve. 4. Design and test promising (United Nations Development coordination between ministries of approaches for linking school-based Programme, 1994). Beryl Levinger health and education. Appropriate interventions and maternal-child works with Education mechanisms will vary from country to health programs. Many countries have Development Center, Inc. and also country. In some cases a formal body well-established health programs serves as Senior Advisor for of advisors may be best. In other situa­ aimed at mothers and young children. Education and Development for the tions, the best approach may be as These include growth monitoring, UNDP. Additionally, Dr. Levinger simple as appointing a liaison officer inoculation, promotion of breastfeed­ is Distinguished Professor of in each ministry. ing and oral rehydration therapy. Yet Nonprofit Management at the 2. Identify and develop strategies many school-age children face health Monterey Institute of International to deal with points of resistance from and nutrition problems that keep Studies, Monterey CA, USA. education and health sectors. Bureau­ them from taking full advantage of cracies tend to resist change, especial­ learning opportunities. Several of ly ministries of education, which face these conditions can be improved immense challenges with scarce through cost-effective interventions resources. For a health innovation to delivered at the school. .:.

41 February 1994 1 The Forum For Advancing Basic Education and Literacy -"

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•. ~:. Helping Health Workers Learn a book of the Hesperian Foundation

People usually teach in the way "teacher" and "student" is broken. health carebook Where There Is No they themselves were taught-unless The leader's role becomes one of ask­ Doctor by David Werner. Helping something either alarming or loving ing questions and identifying re­ Health Workers Learn concludes with happens to change the way they view sources. The most useful questions a list of addresses for teaching materi­ things and do things. help people see the world around als, a comprehensive index and an them as changeable. extensive annotated listing of net­ - David Werner and Bill Bower Helping Health Workers Learn works and resource organizations.•:. includes sections that discuss children elping Health Workers Learn as health educators, activities with HelpingHealth Workers Learn, is an educational and medical mothers and children, and teaching Where There is No Doctor, and resource for community aids that can be made from locally­ Disabled Village Children are avail­ health workers and those available materials. The book offers able from The Hesperian Foundation, interested in health and edu­ specific techniques for designing 2796 Middlefield Road, Palo Alto, CA cationHat the village level. Based on 16 games and using pictures, story 94306, USA. TEL: (415) 325-9017. years of experience with a villager-run telling, role-playing and"socio­ FAX (415) 325-9044. Hesperian also health program in the mountains of drama" as ways of bringing ideas clos­ provides information on education western Mexico, authors David er to villagers' lives. One section sug­ networks and appropriate health Werner and Bill Bower take a people­ gests uses of the companion village technology. centered, community-strengthening approach to iInproving health. Rather than listing "recipes" for training health workers, the authors see their Ask the discussion group to list the various causes of a particular illness in primary task and that of village health columns under the headings biological, physical, and social. For example: workers as helping people"gain CAUSES OF LUIS' DEATH: /cultural(C) greater control over their health and ~ economic (E) BIOLOGICAL PHYS ICAl ~-Politjc.al(p) their lives." ::J; ~ Though many of the teaching /. 'l:etanus I. Stepped on thorn I. father too poor to buy sandals (e bacteria 2. no sandals 2. father pays Y& harvest: to ideas were developed in Latin Ameri­ 2. lack of 3. diatance from health land holder (p) vaccinat.ion center and city 3. hUlth team neglects ca, the book discusses methods and at village hospital villagers (c) experiences from 35 countries world­ level ". dust.y, hot ". doctor won·t let midwife 3. lack of, road vac.cinate (p) wide. The book is written in clear tetanuS S. IdeI' char-glls too antitoxin at c. basic English for use by village health' center instructors who may have limited for­ mal education. Hundreds of drawings ~ LUIS WITH and photographs emphasize the key TETANUS points. The material may be copied or adapted to local needs by nonprofit organizations. Helping Health Work­ ers Learn has been translated into over 50 languages. Helping Health Workers Learn, P. 26·5 The first step to empowering peo­ ple is to educate them about harmful knowledge, attitudes, behaviors and Consider, for example, a village health worker who calls together a practices. Well-educated people plan­ group of mothers and gives them a 'health talk' like this. ning such education tend to assume YOUR CHILDREN GET SICK BECAUSE OF YOuR OWN that it is best provided in formal class­ DIRTY HABITS. of COURSE YOU DON'T MEAN ANY es. However most of the world's peo­ HA~M,yOU JUST DON'T KNOW ANY l!>ETTE.R. Bur I WI LL iELL YOU WHAT TO 00 I SO L.ISTEN ple learn more readily in less formal CAREFULLY! ways, through"stories and play, by watching, copying, and helping others work, and through practical experi­ ences." Formalleaming situations, in fact, may prevent rather than promote the changes necessary for long-term . health improvements. Underlying the book is a powerful way of thinking about the roles of community health workers, their instructors and village Helping Health Workers Learn, P. 1·1 participants. The line between

The Forum For Advancing Basic Education and Literacy I February 1994 1 5 Mod'els of Preschool Education in Colombia by Marta Ripoll de Urrutia

he primary responsibility for of directors administers the financial, • Despite considerable deprivation, pre-school education and child community and human resources of 95 % of program children have care in Colombia is borne by the program at no additional cost. weight-height ratios in the normal the government through the ICBF supervises the child care and ranges. " Instituto Colombiano Biene­ educates comlTIunity mothers. The Tstar Familiar (the Colombian Institute program works to meet children's Remaining Problems for Family Welfare or ICBF). Since educational and nutritional needs, to Despite these successes, poverty 1977 a comprehensive system of child improve the physical aspects of the still prevents some families from pro­ care has evolved into three models, viding adequate care. One in five which by 1993 provided care for houses benefiting from ICBF have almost 1.3 million children. We sand floors with a consequent risk to believe this work has played a major We have learned that we infants' health. Less than 300/0 of role in the decline of Colombia's those household heads have formal infant mortality rate from 59 per 1000 must work with the family, jobs and 370/0 are illiterate. In addi­ in 1980, to 37 in 1991. tion, community mothers have very that people learn mainly at little education, and, along with par­ Preschool Integral Care Institutes ents, need to understand the factors The Centro de Atenci6n Integral al that influence infant, family and Pre-escolar (Preschool Integral Care home and that children need social development. Institutes or CAIPS) was begun to pro­ One of the greatest difficulties of vide care and protection for children, nutritious, healthy and the program has been getting other aged 2 months to 7 years, whose par-, government agencies to focus activi­ ents work away from home. It pro­ pedagogically sound homes. ties on the same target population. vides children with nutrition, social­ Despite formal cooperative agree­ ization and psychopedagogic care. ments between health sector and CAIPS is unique in that all services community welfare homes at the fed­ are delivered by non-governmental home, and provide community moth­ erallevel, action is not always taken organizations, funded by ICBF. Unfor­ ers with social security and health. at the municipal level. tunately, CAIPS has suffered from: In FAMI community welfare The Community Welfare Home three major problems. First, it reaches homes, children under age 2 and their program was created to address the only 9% of the target population. Sec­ mothers are organized into education problem of mothers locking up their ond, it does not respect or consider groups that work together for 4 hours children while they went to work. the values, customs and ways of fami­ a week. In this way the program seeks Later, it was realized that community lies. Children are cared for, but fami­ to fortify the family relationship, welfare homes could provide nutri­ lies are not involved. Third, CAIPS is strengthen the emotional bonds tion, education, lessons in child-rais­ costly, leaving little room for expan­ between mothers and their children, ing and health education even for sion. promote nursing and generate a health non-working mothers. The goal now and nutrition culture. is to cover 1000/0 of the target popula­ Community Welfare Homes Community welfare homes have tion and to provide children with Community welfare homes were achieved a number of positive results: higher quality assistance. This will designed to support parents in require: fulfilling their parental responsibili­ • The length of exposure to the ties and duties, without pretending to program has been positively corre­ • Greater comlTIunity participation substitute for parents or take over lated with children's psycho-social to generate a greater sense of responsibility for raising children. The development. responsibility for the care of chil­ program was conceived as a joint pro­ dren in the community gram alTIOng family, community and • The personal growth, solidarity and state. There are two kinds of commu­ commitment to the group, and the • Strengthening of the bonds nity welfare homes: traditional and satisfaction of being useful to the between parents and their children family, women and infancy (FAMI). community has been very impor­ In traditional community welfare tant for community mothers and • Education of parents and adults on homes the community mother takes members of the boards of directors the rights of children in and cares for 15 children every day of parents' associations. in her own home. Community orga­ • Better nutrition for children nization is central to the program. • Increasing numbers of children Each community welfare home elects receive care, and government • Physical improvements in the com­ delegates to parents' associations, actions benefiting them have pene­ munity welfare homes which in turn elect a board of direc­ trated even marginal areas. tors for about 20 homes. This board

6 I February 1994 1The Forum For Advancing Basic Education and Literacy • Better psychomotor and cognitive preparation of children.

We hope to achieve these goals by better supervising the community welfare homes and encouraging growth of multiple community wel­ fare homes to provide a broader range of children's activities.

Community Kindergartens Last year a new program, the Com­ munity Kindergarten, was instituted. Its main requirement is that mothers must commit to active participation in caring for children in the kinder­ garten. This addresses one of the greatest challenges of the Community Welfare Homes program, the lack of mothers' participation in nutritional and pedagogical activities.

What We Have Learned Initially, we assumed that our task was to work [only] with the children. "Educate the children because they are the future of society./I We have learned that we must educate the chil-

Communities are helped to reflect and examine their habits of childrearing and personal care, thus creating a culture of health and nutrition. dren as part of the family. Early in the CAIPS program, some mothers would wait outside the institutes looking in to see what was happening to their children. We have learned that we must work with the family, that peo­ ple learn mainly at home, and that children need nutritious, healthy and pedagogically sound homes. family directly. Instead, we went and personal care, thus creating a cul­ As educators, we have found that through the community mothers. ture of health and nutrition. •:. the best way to reach families is When we had convinced them that through community welfare home vegetables could be cooked in a way This material is based on a lec­ mothers. These women belong to the that children would eat them, we had ture given at the Harvard Graduate community and share a culture that 800/0 of our work accomplished. School of Education in November enables them to talk about the new The program is able to reach so 1993, sponsored by the Office of methods and ways. In the beginning, many people because it uses non­ International Education. Marta for example, some communities told professional community members Ripoll de Urrutia is Director General us that children would not eat vegeta­ to multiply the effect of inputs and of the Instituto Colombiano de bles, and so it was impossible to because it is educationally sound. Bienestar Familiar, Ministry of include vegetables on menus. We The program helps communities Health, AV. 68 No. 64-01, Santafe de found it very difficult to teach the reflect on their habits of child-rearing Bogota, D. C., Colombia.

The Forum For Advancing Basic Education and Literacy I February 1994 I 7 Social Mark~ting Research on Educating Girls in Bangladesh by Beverly Schwartz,' Susan Middlestadt and Cecilia Verzosa

angladeshi women have edu­ Secondary Audience, those who Even though most fathers stated cational attainment levels influence the primary audience. that their daughters' secondary school that are among the lowest in Benefit Statements, benefits that attendance was a joint decision, and the world. Despite recent accrue to the primary audience from mothers played a facilitating role, data successes in increasing prima­ suggested behavioral changes and are analysis revealed that the primary Bry enrollment, in 1991 only 140/0 of sufficiently compelling to overcome target audience was not the girls or school-age girls were enrolled in sec­ existing environmental barriers. their mothers but the fathers. We ondary school as compared to 25 % of Our research involved collection found that the father's decision deter­ boys. So as to increase girls' secondary and analysis of both qualitative and mined the daughter's educational school participation, the Government quantitative information. future. Thus, fathers became the of Bangladesh has initiated the Female Secondary School Assistance Project (FSSAP) to address the constraints that keep Bangladeshi girls out of school. To assist families with costs, the project plans to provide a graduat­ ed stipend for girls who enroll, attend and graduate from secondary school. To improve the school setting, the project aims to increase the number of teachers and the proportions of female teachers in grades 6-10. School water and sanitation facilities have been upgraded or constructed. An occupa­ tional skills component will help girls find work. Communications materials have already been disseminated to promote understanding about the project, the availability of stipends and girls' enrollment. However, sustaining girls' enrollment involves developing a community environment that sup­ ports girls' education, a process which challenges existing community norms. To achieve this purpose, the Female Education Awareness Program (FEAP) was developed, as part of FSSAP. FEAP adopted a social market­ ing strategy to achieve two primary goals: an increase in girls' secondary enrollment and positive long-term changes in family and community values about the benefits of educating women. This article highlights some of the findings in our social marketing formative research phase. Social marketing is a planning process which promotes voluntary behavior change based on building beneficialexchange relationships with a target audience. Therefore, a strate­ gy to achieve our goals required identification of: Prilnary Audience, those whose behavior is chiefly responsible for girls' enrollment or non-enrollment in school.

81 February 1994 1 The Forum For Advancing Basic Education and Literacy As a result, development of community and the marketing nation. Educated women would make strategy targeted good mothers, better able to educate several focused their children and to attend to the messages to the health of families and the community. fathers. Educa­ These values reflect conditions tion would facing family decisionmakers in enhance their Bangladesh. To create sustained daughters' behavior change,.social marketing chances of interventions must appeal to the "good" mar­ needs and values of those who must riages to more change. The primary audience must educated spous­ see that the benefits of female sec­ es from higher ondary education outweigh existing status or wealth­ cultural norms. •:. ier families. Education might This article describes part of the lower daughters' Female Education Awareness dowries. Program (FEAP), itself part of the "Marrying well" Female Secondary School Assistance might diminish Project, funded through the World Talking with a community leader Photo: B. Schwartz the possibility Bank. Beverly Schwartz is Director of that daughters Social Marketing, Susan Middlestadt primary target audience - those who would later become a financial burden is Vice President and Director of had to be persuaded if girls' enroll­ if they returned to their parents' Behavioral Research and Evaluation, ment was to increase. Further analysis homes due to failed marriages. Edu­ and Cecilia Verzosa was FEAP revealed that those who have the cated daughters would be better able Project Director at the Academy for mostinfluence on the father's deci­ to care for aging parents. To commu­ Educational Development, 1255 23rd sion to enroll girls in school, the sec­ nity leaders, the most effective mes­ St. NW, Washington DC 20037, USA. ondary audience, consists of commu­ sage appeared to be that girls, like Task Manager for the World Bank is nity leaders and elders, and the boys, should be educated for the sake Paula Valad. father's brothers, in that order. So, of future generations and for the instead of targeting the female/moth­ er-oriented audience as originally Formative research, talking with mothers of primary school girls thought, we aimed the program at fathers. This change had major impli­ cations for the strategic direction, messages and delivery system we employed. Additional research helped deter­ mine compelling benefits which would (hopefully) overcome both fathers' strong traditional inclination towards early marriage of their daugh­ ters and community leaders' support of this practice. We interviewed differ­ ent groups of people - fathers of girls in the last year of primary school; community leaders; potential future husbands and in-laws; and the girls themselves. Based on these data, we constructed specific benefit state­ ments which formed the basis for communications strategies with each audience. Many of the more com­ pelling beliefs seemed to revolve around the family's financial well­ being.. Fathers favored secondary edu­ cation if they perceived it as helping their daughters find work, improve their marriage prospects, reduce their dependence on the family, or bring the family fame, respect and honor. Photo: B. Schwa!

The Forum For Advancing Basic Education and Literacy 1 February 1994 1 9 Schools as Health Intervention Sites by Ronald Israel

growing body of evidence needs of at-risk student populations Students should learn new behaviors suggests that student nutri­ and the learning needs of malnour­ to reduce chances of future infection, tion and health status is an ished or ill students. such as not swimming in ponds with important determinant of Schools are a good place to do this. bilharzia. Classroom nutrition educa­ educational outcomes and When the US was developing its pub­ tion can play an important role in pre­ Aof the efficiency and effectiveness of lic health system at the start of this venting malnutrition and disease, investments in basic education: century, schools were designated as especially if linked to community the focal point for health service education and outreach. Reports from •A recent study in Honduras found delivery to students and comiTIunities. several states in Brazil, for example, that 35% of first graders were Schools could take on a similar role in indicate that schools serve as both below acceptable height-for-age the developing world. This idea, of the prevention and treatment centers. norms. The same population had school as a community health service They give health counseling and high rates of parasitic and respira­ advice to teachers, parents and stu­ tory infection. Children who caine dents and administer service delivery from the poorest homes and who Integrated intervention is programs. were stunted were twice as likely 2. Targeting services to the needi­ to repeat a grade as poor children important because students est sub-populations is an effective who were not stunted. Illness has a means of reducing costs. Government serious additional impact on the and donor support, for example, can school performance of already dis­ usually suffer from a web be directed at low-income areas with advantaged poor children. widespread nutrition or health prob­ of interrelated nutrition lems. A national school nutrition and •A study in Java, Indonesia found health program in Zimbabwe in 1990 that iodine-deficient children over would cost $US3 per child. However, age 9 scored significantly lower on and health disorders. if the neediest 200/0 of Zimbabwe's tests of intelligence, motor skills, school age population were targeted, concentration, perception, dexteri­ the cost would be $USO.60 per child ty and response orientation than a center, is being promoted by the per year, a fraction of the $147 annual matched group of children with World Health Organization. unit expenditures for primary educa­ adequate iodine. Three conditions characterize suc­ tion in the country. cessful school health and nutrition 3. The cooperation of teachers, •A study of children aged 5-15 in programs in developing countries: comlnullities and ministries is essen­ Baroda, India found that 73 % of the 1. Integrated intervention strate­ tial. Involvement of teachers is neces­ boys and 67% of the girls were gies are important because students sary for effective implementation and mildly to moderately anemic. usually suffer from a web of interrelat­ change in students' health behavior. Children deficient in iron show ed nutrition and health disorders. A In some instances teachers them­ less alertness, attention and con­ survey in Nkwale District, Kenya, for selves need nutrition and health ser­ centration, which hinder learning. example, found that 45-75 % of school vices. A recent Mexican study found children surveyed had schistosomia­ that many rural primary school teach­ •-School-aged children are likely to sis, 90% were infected with hook­ ers suffered from chronic illnesses, bear a population's heaviest worm worm; 50% tested positive for malar­ which affect their ability to teach. burdens. In Kenya, children with ia;over half had enlarged spleens; Parentsmust also be involved to large parasite loads performed less 60% had hemoglobin below 12; and ensure that children comply with pre­ well on tasks of visual discrimina­ 55 % were nutritionally wa~ted. scribed treatments and reinforce new tion and memory retrieval than a Because of other nutrition and health nutrition and health behaviors learned matched group of students treated problems, a single intervention pro­ in school. Parents can provide local with albendazole, an inexpensive gram aimed at deworming Nkwale resources to support provision of drug designed to flush out para­ students might have little impact on school nutrition and health services. sites. In Jamaica, removal of whip­ students' health or learning. Coordination among ministries of worms in a sample of school chil­ Economies of scale are gained by education, health and other concerned dren led to a significant improve­ providing multiple services. A school­ agencies is essential to successful ment in short-term auditory mem­ based deworming effort, for example, implementation and sustainability.•:. ory and retrieval of information can be piggy-backed on to a school from long-term memory. feeding program, as is being discussed Ronald Israel is a vice president in Jamaica. Health clinics can dis­ at Education Development Center These studies imply that educa­ pense Vitamin A when treating pupils Inc., 55 Chapel St., Newton, MA tional planners and policy-makers for acute respiratory infection. 02160, USA. Tel (617) 969-7100 Fax need to develop interventions which Program int~gration also means (617) 332-6405. address both the nutrition and health combining prevention and treatment.

10 I February 1994 1The Forum For Adva~cing Basic Education and Literacy ';N;' ~[~~ Health and Adult Literacy in Nepal by Cristine Smith

ommunity health volunteers (JSI), CHVs were trained to offer basic (CHVs) have become an inte­ health education to women in their gral part of primary health villages. The primary means was systems in most developing through monthly "Mother's Group" countries. CHVs are commu­ meetings, where 10-15 mothers would Cnity members trained-to provide basic gather to discuss health problems and preventive health care and education. issues-immunization of children, They are often villagers' first source of birth control options, etc. information and advice about health. In evaluations of the CHV pro­ Their responsibilities include dispens­ gram, village women described the ing medicine or family planning mate­ benefits of having fellow women to rials and keeping statistical records for consult about health problems. CHVs the health care system. However, expressed great satisfaction and com­ finding women to serve as CHVs has mitment, but indicated that illiteracy been a problem since literacy is often remained a barrier to effective health a prerequisite. In countries like Nepal, education-for them and for the where rural female literacy rates are women they taught. In response, the very low (less than 100/0), this criteri­ Ministry of Health and Ministry of on has prevented women, who are Education collaborated on a pilot pro­ well-qualified to provide health educa­ ject to combine health and literacy tion in sensitive areas such as family education for CHVs and the mothers planning and pre-natal care, from serv­ with whom they work. Photo: Jon Crispin ing as CHVs. Several years ago, Nepal's Ministry Project HEAL health knowledge of female CHVs and of Health tried to address this problem Begun in October 1991 and funded mothers in project villages. Over the by recruiting and training 27,000 illit­ by USAID through John Snow Inc. two-year pilot, 77 literacy classes erate female CHVs. Using a picture­ (JSI), the Health Education and Adult were started near three health posts in based training manual developed by Literacy (HEAL) project was intended Makwanpur, southwest of Kathman­ World Education and John Snow Inc to increase the literacy skills and du. Each class consists of members of the Mothers' Group and the local CHV. Prior to beginning the literacy course, an orientation is held for local health and education officials,who are introduced to the project and asked to discuss barriers to implemen­ tation. Their input leads to identifi­ cation of appropriate village sites. The literacy course itself consists of three phases (summarized in Table 1). Phase 1 is a basic literacy course teaching reading, writing and math using content based on situations in which learners live. The instructional strategy is participatory and hands-on; learners are encouraged to learn from one another, and learners take turns leading many lessons. The materials and course design were developed for the National Literacy Program and are used in both government and NGO literacy classes throughout N epa!. A local facilitator is nominated by the CHV and mothers' group and is trained to teach the basic course. Local teachers or health post staff are recruited as supervisors to visit classes twice a month with support and technical assistance. The CHV, Photo: Jon Crispin

, The Forum For Advancing Basic Education and Literacy I February 1994111 usually a participant in the literacy class, also serves as aide to the facilitator. The literacy course is supple­ mented with a health component, which is taught by the supervi­ sor and consists of 12 half-hour lessons on health topics such as oral rehydration, birth spacing and immuniza­ tions. Phase 2 is a post- literacy course devel­ oped for Project HEAL and based entirely on health topics. Class materials use the same format as the basic course-comic strips, stories, exercises and participatory activities. The same local facilita­ tor teaches the class, and supervisors contin­ ue to visit. The facili­ tator helps women read the materials, leads reading and writing games and conclusions about the effects of the particularly the continuing education discussions about health problems in project. materials, give CHVs new formats their village. This phase strengthens Health staff at all levels, from vil­ around which to organize their own participants' literacy skills and their lage CHVs to district public health health education programs. knowledge of health. The CHV officials, reported tha,t the literacy Women gain considerable health expands her role, assisting in small component has strengthened other knowledge from the course and are group work and teaching. health education and health services. motivated to continue to improve Phase 3 is a continuing education CHVs report that women from project their literacy skills. Preliminary phase. The CHV and Mother's Group villages come to them more often for analysis of test results indicates that meet once a month for 12 months to oral rehydration solution. Village participants have increased their study new health-related literacy health workers say they no longer knowledge of health concepts and that materials. The CHV runs these meet­ have to seek out women in HEAL literacy gains are equal to or higher ings, using the instructional materials villages for immunization clinics. than those in other basic literacy to start discussions. These classes are The project appears to have courses. intended to lead participants to con­ increased women's confidence and Participants remark on how much crete steps to improve the health of willingness to seek help. Women who they enjoy their classes, even though their families and village. have completed the course are more they atterid class after 12-hour work­ One innovation was the idea that direct in expressing their opinions, days and walk up to 1 hour to class. new literates should create their own more proactive in asking for advice Women in one village unanimously literacy materials. World Education and materials, and less shy about con­ agreed to meet every day for class dur­ and UNICEF staff led 3-day work­ ferring with outside health staff. ing the post-literacy phase, though the shops in which former participants CHVs were particularly forthright in class was intended to meet only 3 drafted stories, poems, songs and advocating for themselves and the times a week. At the end of each lessons around specific health topics. project. , phase, most women say they are eager A local artist helped create illustra­ CHVs in project villages are more to continue meeting and working tions. The material was then revised active in health education. Village together. and supplemented with additional Health Workers, who travel from vil­ Combining literacy education text and stories. lage to village and oversee the work of with health content strengthens both CHVs, report that Mothers' Group health and literacy components. More Project Impact meetings are now held more regularly importantly it increases the capacity Based on interviews, observations and that CHVs are more proactive in of village women to learn, to care for and focus group discussions, it is assisting village women with health themselves, their families and their possible to draw some tentative .problems. The literacy curriculum, villages.

121 February 19941 The Forum For Advancing Basic Education and Literacy What Worked care and nutrition, but often do not AIDS curriculum, now being imple­ Several factors contributed to the receive the support they need to care mented from the first year of primary project's success: 1) There was a for themselves or their families. As school through university. The demand for literacy. The project was Schwartz, Middlestadt and Verzosa Malawi program reminds us of the explicitly designed to meet requests show, the people who need to change importance of institutionalizing social by the CHVs, who were deeply may not be those with the apparent intervention. This project worked to involved in implementation. Women "problem," such as young women not establish the AIDS materials as a part participants were highly motivated by enrolled in secondary school, but of the formal school curriculum, thus the prospect of being literate. 2) The those who make decisions affecting making for long-term viability. Coop­ project built on existing programs and the young women - their fathers. eration leads to "ownership" on the networks. Existing literacy materials Discrimination is directly linked part of participants, thus promoting were used and supplemented with with health, and disempowered sustainability. The project's resident health materials. Classes consisted of groups usually lack access to the advisor stresses in a series of "lessons existing Mothers' Groups and CHVs. health information they need to care learned" the importance, in a conserv­ 3) The project used sound educational for themselves. Learning to be ative society, of consensus to imple­ principles. Each phase followed simi­ healthy, as discussed in the article by menting a school curriculum that dis­ 1ar instructional strategies. Literacy the Boston Women's Health Book cusses sexuality. and health lessons reinforced each Collective, may require organizing This is a unique point in history. other. 4) The project was run by expe­ individuals and groups at the "bot- . Cost-effective medical technologies rienced NGOs with a sincere commit­ tom." Those who receive services are have led to a situation in which orga­ ment to involving both ministry best qualified to define their needs, to nization, management and political officials and grassroots participants in acquire and share information, and to will may be as or more important design and implementation.•:. . add their concerns to public agendas. than financial resources in improving Networks of such groups have great health. Many countries much poorer For additional information about educational potential, especially with than the United States immunize Project HEAL, the literacy materials developments in desktop publishing. higher proportions of their children, or training manual, contact Cristine 5. Implementation of successful for example. Much of the success of Smith at World Education/JSI, 210 health and education interventions the expanded program of immuniza­ Lincoln St, Boston, MA 02111, USA. requires coordination and cooperation tion, described by James Grant of Tel (617)482-9485 Fax (617) 482-0617. among ministries of education and UNICEF as history's largest peacetime health; schools, parents, teachers and cooperative venture, is ~ due to orga­ students; NGOs, community health nization and political commitment. Readers Continued from Inside Cover workers, local communities and lead­ Despite wars, violence, and new and packages for an average of US$12 per ers; multinational corporations and yet incurable pathologies, average life person per year. Middle-income coun­ local businesses. Ronald Israel's arti­ expectancy last year was the highest it tries should be able to provide their cle, for example, views schools as a has ever been in human history. people with a basic health care pack­ unique focal point for delivery of Greater increases in life expectancy age at current levels of spendirig, if health services to students and com­ have been achieved in the last 40 spending is redirected to the most munities alike. Instruction, preven­ years than in all of previous history cost-effective health interventions. tion and treatment can reinforce each (World Bank, 1993). For the first time, Frequently cited are the experi­ other. Students can teach parents. Par­ there is enough money, knowhow and ences of China, Costa Rica, Sri Lanka ents can reinforce students' learning. food to provide good basic health and and Kerala, which have achieved far Effective health-education programs education for all. better health than expected given often work to empower existing social - James H. Williams, Editor their income. The critical elements networks, as illustrated in the articles appear to be high levels of literacy, by Marta Ripoll de Urrutia and References virtually universal provision of basic Cristine Smith. Urrutia describes the Caldwell, John, 1986. "Routes to and preventive health care, high levels evolution of Colombia's early child­ Low Mortality in Poor Countries, " Population and Development Review of social and economic participation hood care and education programs, 12(2). on the part of women, and relatively from a model that educated preschool UNICEF, 1993. State of the World's egalitarian social and economic sys­ children in school-like settings away Children 1993. New York, NY: tems (Caldwell, 1986). from parents, to one in which govern­ UNICEF. 4. Improving health is both a ment programs worked primarily to Williams, James, 1994. Healthy and social and medical process. Disease support family-community efforts to Wise: A Cross-National Study of occurs in populations, and knowledge care for and educate children. Smith Education and Infant Survival (doc­ is as contagious as infection. To a describes the synergies of combining toral dissertation, Cambridge, MA-: great extent, a child's chances of sur­ literacy and health in training com­ Harvard University). vival and development still depend on munity health volunteers and com­ World Bank, 1993. World the population as well as the family munity "mothers' groups" in Nepal. Development Report 1993: Investing he or she is born into. Women are par­ The importance of a broad social in Health. New York: Oxford ticularly important in improving the consensus is essential to major or con­ University Press. health of populations. Women bear troversial change, as in John Hatch's the primary responsibility for health description of Malawi's school-based

The Forum For Advancing Basic Education and Literacy I February 1994113 ~'~'.,'·'.·.·'.·c:.··.~"·'·'."'.'\".".'.'·'·'.·~ ~..;....·.....E·.,',....·,.·•.c•.•••.'••.•.'.•..•.,'•...'.··.··1.. AIDS Curriculum in Malawi's Schools by John Hatch

The spread ofAIDS can be con­ for Social Research of the University conduct focus group research with trolled, however, by giving people cor­ of MalaWi instituted a nationwide students, parents and teachers. Stu­ rect information. It is important that knowledge, attitudes, beliefs and prac­ dent texts were drafted at workshops AIDS education be introduced in tices (KABP) survey. At the same three months later, and within a year schools so that students can protect time, a broad consensus was reached final drafts of all 13 curriculum units themselves and help teach others among the ministries, donors and were ready for field testing. Desktop about the disease. important religious groups about the publishing capabilities enabled the - Introduction importance of introducing AIDS edu­ work to proceed quickly. The third AIDS Education for Primary School cation. Despite traditional norms year began with field tests in 19 sites, Teachers' Guide for Standards 5-8 against talking about sexual matters, revision and printing. In January 1992, religious elders, traditional and gov­ over 200 Regional Education Officers his and companion publica­ ernment comlTIunity leaders, and and District Inspectors were given tions represent a unique effort teachers all actively cooperated in training in the use and training of for education in Malawi in developing and supporting behavioral­ teachers in use of the materials. In two ways. First, they are part ly-oriented materials which would: August UNICEF-sponsored work­ of an integrated national AIDS shops provided one teacher from each Tcurriculum being implemented from • Increase students' knowledge about primary school with follow-up train­ the first year of primary school HIV/AIDS and correct their mis­ ing in use of the materials. In Septem­ through university. Second, the AIDS conceptions ber, 250,000 booklets, pupil and teach­ curriculum resulted from cooperative ers' guides were distributed to efforts of the Ministry of Health's • Use peer influence and behavioral/ Regional Education Officers and then AIDS Secretariat, its Health Education social norms to encourage behav­ to schools. •:. Unit, the Ministry of Education and ioral change Culture, the Ministry of Community For additional information, see Services, the Malawi Institute of • Change attitudes about AIDS, peo­ William Smith, Michael Helquist, Education and donor agencies ­ ple with AIDS, perceived risks and Ann Jimerson, Katheryn Carovano, UNICEF, WHO and USAID through condom use Susan Middlestadt, ed., A World the AIDSCOM Project. Against AIDS: Communication for While many countries have devel­ • Help students understand how to Behavior Change (1993) available oped AIDS education programs, most talk to their partners about sex and from the Academy for Educational have not made such programs part of to use condoms correctly Development, 1875 Connecticut Ave the school curriculum. Only Malawi NW, Washington DC 20009, USA. is known to have included the AIDS Workshops were held to draft Tel (202)884-8000 Fax (202)884-8400. curriculum in national examinations. teachers' guides and help educators Malawi, a socially conservative and poor nation with an estimated AIDS seroprevalence of almost 100/0, decid­ ed to confront AIDS through a variety Lessons Learned from Developing an AIDS Curriculum of education activities. drawn frorn a speech by William Mackie In 1989, Malawi's National AIDS Control Committee called for intro­ • Accept at the outset that AIDS • Be sure the teams who will write duction of a school-based AIDS edu­ education is multidimensional. AIDS education materials represent cation and prevention program. The CuItural, historical, political, a broad spectrum of society, includ­ Committee felt that schools were a social, economic and religious ing those with reservations about good venue for AIDS education: issues must be considered along the project. Criticisms should be Malawi's population is young; 48 % is with medicine and pedagogy. worked out beforehand in the draft­ 15 or younger; and statistics indicate ing committee not in public once that half of secondary school boys and • Early on, confront difficult issues teachers have begun to teach the one-third of secondary school girls and provide answers to questions curriculum. require treatment for sexually-trans­ such as when should topics such as mitted diseases. sexual transmission and condom • Mobilize religious groups early to AIDSCOM facilitated the curricu­ use be introduced. Malawi has reduce resistance and create allies lum development effort in collabora­ faced this issue forthrightly. during implementation. tion with the National AIDS Commit­ Educators decided to introduce the tee and other government bodies. The topic of sexual transmission of HIV • Make sure the project has the full process began with a workshop review and thepreventive role of condoms support of educational authorities of existing AIDS education materials in the fifth year of primary school. to guarantee incorporation of AIDS from developing and developed education into the regular school countries. Simultaneously, the Center curriculum and examinations.

14 1 February 1994 1 The Forum For Advancing Basic Education and Literacy • Solicit the support and cooperation of parents to create an atmosphere in which teachers and school administrators feel free to discuss culturally-sensitive issues, such as sexual behavior, in the classroom.

• At every opportunity, stress to the public, particularly parents, that AIDS education is not intended to encourage promiscuity, but to pro­ vide young people with informa­ tion they need to save their lives and those of others. Malawi's cur­ riculum promotes abstinence before marriage, monogamous rela­ tionships and responsible sexual behavior. However, this emphasis does not do away with the need for clear instructions on condom use.

• Use multiple channels of commu­ nication for complementary mate­ rials. Support the school curricu­ lum with other materials about HIV such as posters, charts, car­ toon booklets, cassette tapes and photographs.

• Seek ways to extend the materials to out-of-school young people. In Malawi, this is done through radio, video, distribution of materials to youth clubs and organizations and use of the AIDS curriculum in literacy classes.

• Monitor carefully. At the outset, arrange systems to monitor the impact of materials. Regular moni­ toring permits modifications of the materials based on field experience. Plan for teacher input to ensure that teachers' comments are heard.

• Institutionalize the curriculUlTI. Foster close relationships with the Ministries of Health and Educa­ tion, and with religious institu­ tions. Identify at the outset which public and private sector institu­ tions will need to be involved to ensure institutionalization. •:.

This material was drawn from a speech by William Mackie, resident advisor for AIDSCOM in Malawi, at the Annual Conference of the Confederation of African Medical Associations and Societies, 1992.

The Forum For Advancing Basic Education and Literacy I February 1994115 Beating Our Pots and Pans Into Printing Presses by Jennifer Vanco

hough women may live longer experiences with health than men, they experience far care. The women agreed more health problems. Many on the lack of comprehen­ AnD TH~Y SHaLL E~AT THEIR POTS of these problems are related sive, comprehensible, An}) PAns InTO p~mTlnG PRSSS&S to women's place in society. woman-centered informa­ TWomen provide most of the world's tion about their own .~ ~C==~ agricultural labor. Almost every­ bodies. They had all where, women have the major respon­ experienced condescend­ Ii!!! /'W"",,- ~ :; I sibility for raising the young and car­ ing and paternalistic med­ ing for the old. Women bear the risks ical care. Women's bodies of pregnancy and childbirth, and the and sexuality had been vast majority of the world's women defined, primarily by professionals, satisfaction with the book: "Now I have no choice whether and when to most of whom were men. can give my daughter a book that become pregnant. These risks are So began an educational process answers all her questions often made worse by hard labor and which led these women to redefine scientifically, objectively and without poor nutrition. Throughout the world important health issues, informed by making her feel ashamed of her own women are victims of violence - in their experience, and to discover and body or self." * the wars that rage around them as create the information they needed. Recent advances in desktop pub­ well as in their own homes. The idea that women should be active lishing have it possible for grassroots In most societies, women have participants in defining what is impor­ groups to produce their own publica­ very little access to information about tant about their own health was, at tions - publications which speak to their own bodies. Women's concerns that time, revolutionary. But the idea their own needs in language which is are often ignored or minimized. Infor­ has resonated with women the world accessible and appropriate. Getting mation is critical to health, yet a pro­ over. What first appeared in 1970 as a up-to-date health information is no fessional elite has monopolized the typewritten manual is now in its 4th longer an expensive expert-based production and dissemination of (1992) revision as The New Our Bod­ process. Now, it be can be done by health information. As a result, this ies, Ourselves !NOBOS) . NOBOS has those best qualified to do it: members information has failed to meet many sold 4 million copies and been adapted of the community itself. Women's of women's health needs. However, into 15 languages including Braille. groups in other countries are produc­ this is beginning to change, as women BWHBC's experience is that a ing much-needed health materials join forces to gather information, to group's needs are best defined by its which are adapted to their social, cul­ find and articulate their voices and to own members. Frequently, the politi~ tural, linguistic and material contexts. make their concerns heard. cal act of organizing has enabled peo­ Women who are not literate can get One of the early women's health ple to articulate and to begin to ex­ useful information through pictorial groups to find its voice through pub­ plore ways of meeting their needs. For materials which are well-suited to lishing was the Boston Women's this reason, BWHBC stipulates that conveying health information to liter­ Health Book Collective (BWHBC). other language versions of their books ate and non-literate alike. In a number Through its publications, BWHBC dis­ involve women from those cultures of places, booklets on women's health seminates information that women and reflect the specific realities of the are used to teach literacy. Women­ need to make informed decisions women concerned. Also important, centered, women-produced health about their own health and to adaptations must be produced by fem­ materials can be strong incentives for influence public policies affecting inist groups - rather than just med­ developing literacy skills. their communities' health. This ical, health or translation profession­ The Women's Health Information includes information on sexuality, als. A group of women in Armenia is Center is the nucleus of BWHBC. In pregnancy and childbirth, contracep­ now working on an Armenian adapta­ addition to commercial publications, tives, sexually-transmitted diseases, tion. Feminists in Moscow have pro­ it houses materials published by HIV, cancer, the politics of medical duced a Russian edition, due in Fall women's groups throughout the care and organizing for better health. 1994. Some groups have drawn on world, including 100,000 articles, BWHBC is probably best known NOBOS or the NOBOS methodology pamphlets, conference papers, reports, for Our Bodies, Ourselves, a compre­ to produce their own publications - a newsletters, clippings and notes. hensive, non-technical book on wom­ series of booklets on particular health Increasingly, grassroots groups are en's bodies, sexuality and health writ­ topics, for example, or a different sort producing materials, thus multiplying ten by women who were not health of women's health resource book. possibilities for fruitful exchange. The professionals from their own point of In 1991 a feminist collective in Cairo global exchange of information and view as women. Our Bodies, Our­ published an Arabic-language strategies among women's groups is selves has been called"the Bible of women's health book inspired by greatly enriching the women's health women's health." It started simply NOBOS, Women's Lives and Health movement. BWHBC maintains con­ enough. A group of women got togeth­ in Egypt. An Egyptian woman with a tact with 1500 grassroots women's er and began to talk about their 13-year old daughter expressed her health groups worldwide.

161 February 19941 The Forum For Advancing Basic Education and Literacy Yetall kinds of people find this of California. An overview of tech­ direct and decisive measures to pre­ approach useful. A male health work­ niques for determining the social and vent disease, or to tum it around er from an NCO in Benin City, Nige-· cultural'appropriateness of planned before it is too late. ria writes: "The book [Our Bodies, interventions. - Lewis Thornas Ourselves] has been useful to us in our counseling work, particularly on U.S. Committee for UNICEF, 1993. You can't educate people if they're topics like female sexuality, birth Facts for Life. New York: U.S. unhealthy, and you can't keep people control, abortion, and ante-natal care Committee for UNICEF. Clear state­ healthy if they're uneducated. as well as sexually-transmitted dis­ ments of essential health messages. - W. Joycelyn Elders eases. It has helped us improve our United States Surgeon-General approach in questioning and counsel­ Warwick, Donald P., 1982. Bitter ing the women we deal with daily." Pills: Population Policies and Their The most important health worker for Implementation in Eight Developing the child is the mother. * Quote from: "By and for Women: Countries. Cambridge, England: - A. Barerra Involving Women in the Cambridge University Press. A com­ Development of Reproductive Health parative study of population policy It is clear that good health is not a Care Materials" Ouality 4:1992 using a generalizable framework for natural spinoff of economic develop­ (New York, NY: The Population understanding project/program ment...what [poor health achievers] Council). implementation. lack is a broad social consensus that top priority should be given to educa­ Jennifer Yanco is international pro­ Networks tion-particularly female education. grams coordinator at the Boston Instructional materials including Women's Health Book Collective, - John C. Caldwell PO Box 192, Somerville, MA 02144, inforrnation on CHILD-to-Child USA. TEL (617) 625-2622 (E-Mail materials: A male-dominated society is a threat [email protected]) FAX (617) Teaching Aids at Low Cost (TALC), to public health. 625-0294. Those wishing alist of Institute of Child Health, PO Box 49, - Jonathan Mann women's health information centers St. Albans, Herts ALl 4AX, United in their regions should write her. Kingdom. When considering your effectiveness as a health educator, ask yourself, Innovation in health and other fields: "How much does what I do help the ADDITIONAL RESOURCES Ashoka Innovators for the Public, poor gain more control over their 1700 North Moore Street, Suite 1920, health and their lives?" In addition to the reading matter and Arlington VA 22209,· USA. - David Werner and Bill Bower organizations cited in the articles, TEL: (703) 527-8300.. interested readers may wish to refer to the following: Child well-being: Periodicals Consultative Group on Early Child­ Hygie: Internationallournal of hood Care and Development, ERRATA Health Education (official organ of UNICEF, 3 United Nations Plaza, In Vol 2, No 4, we referred to the the International Union for Health New York, NY 10017, USA. 1989 draft rather than the formal Education) 15-21, rue de l'Ecole de TEL: (212) 326-7000. published version of Marlaine Medecine, F-75270 Paris Cedex 06, Lockheed and Adriaan Verspoor's FRANCE. Tel: (33-1) 43 26 90 82 book, Improving Primary' CLOSING THOUGHTS Education in Developing Books and Articles Countries (Oxford University Hawes, H. and C. Scotchmer with When medicine has really succeeded Press, 1991). Our apologies to the collaboration of A. Aarons, D. Morley brilliantly in technology, as in immu­ authors. and E. Young, 1993. Children for nization, for exarriple, or antibiotics, Health. London: The Child-to Child or nutrition, or endocrine-replace­ Trust in association with UNICEF. ment therapy, so that the therapeutic measures can be directed straight at Myers, Robert, 1992. The Twelve the underlying disease mechanism Who Survive: Strengthening Programs and are decisively effective, the cost of Early Childhood Development in is likely to be very low indeed. It is the Third World. London: Routledge when our technologies have to be applied halfway along against the Scrimshaw, S. and E. Hurtado, 1987. progress of the disease, or must be "Rapid Assessment Procedures for brought in after the fact to shore up Nutrition and Primary Health Care: the loss of destroyed tissue, that Anthropological Approaches to health care becomes enormously Improving Program Effectiveness, " expensive. The deeper our under­ UCLA Latin American Center standing of a disease mechanism, the Publications. Los Angeles: University greater are our chances of devising

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