by Shiban Ganju
Nothing seems to have changed in ten years since I visited this village – a dusty swathe of land, home to over eleven hundred people, who connect with the world via a newly built, one car wide, winding road. Cracks, loose stones and chunks of matted mud straddle its tarred surface. A sign at its junction with the main road, two kilometers away, reads: “Prime Minister’s Rural Road Plan”; an adjacent sign announces the name of the local muscle man who claims the credit for the new road. It reminds: we are in Uttar Pradesh, a northern state of India, where muscle power grabs political power. The road ends near the village community hall – a newly built large concrete cube with dirty white walls showing new cracks. Our SUV stops. We have reached. The ride, after ten years, was a road show of frustrating pace of progress; change is imperceptible here – until we meet the women.
Over a hundred women, young and old, most draped in bright colorful Sarees, a few in black burqas without head cover, have walked from surrounding villages to participate in the review meeting. They look different: gone are the veils and bashfulness; they are vocal and animated. A twenty years old articulate college student, who is a trained health activist, conducts the meeting. She introduces herself and other health activists, who take turns to recount their experiences and of their neighbors. The embellish their stories with songs about preventive health – all written and created by them. And then they hang big paper charts on the wall displaying hand written numbers to buttress their claims: maternal deaths are rare, girls do not marry before the age of eighteen, contraceptive use has increased and they campaign for equal treatment for girls. This is new – not what I had seen ten years ago.
Then, I was not sure how we would convince the women to adopt a few simple steps to curb rampant maternal deaths. (Detox Body or Mind?) (Save A Mother). We were novices. We borrowed wisdom from a few rural doctors and took inspiration from social workers who had been pioneers in the field of maternal health. Their integrity, sacrifice and charisma had propelled their success. But these leadership qualities were not replicable. We wanted to develop a frugal model of maternal mortality reduction by working with the community, especially women but had no established theoretical scaffold to hold us steady.
We were entering a no man’s land of healthcare – an unexplored space between a patient’s home and the doctor’s office. Traditional healthcare delivery model demands that a person should be sick to visit a doctor. The preceding causative events leading to sickness remain unattended in health delivery models, especially in low resource communities. Supply driven solutions are the norm for health care problems in the world. Increase in the supply of hospitals, clinics, labs, drugs, devices, X-Rays, ambulances, paramedics, doctors and nurses seems to be the perfect fit for one problem or the other. Apart from casting a cursory sympathetic glance, the established ‘rights based’ model does not lay enough emphasis on demand side – the consumers’ responsibility in improving their own health. This supply side, rights based model of health delivery would be too expensive to succeed in poor communities. Our starting assumption was that empowering the consumer with responsibility to change health seeking behavior could be the most cost effective way to reduce disease burden.
We started working with the community by spreading health literacy in twenty villages. Soon, we realized we were wrong; that mere information sharing was not enough; we needed to convert information into actionable knowledge. Unwittingly and unknown to us, we were entering the field of social behavior change – a relatively new field.
In a traditional medical practice setting, the physician is responsible for convincing patients – one at a time – of the benefits of healthy habits: good diet, sufficient sleep, regular exercise, abstinence from drugs and risky sex. Those of us who have worked for many years as physicians realize the limits of our convincing ability. Even after a considerable and sincere effort, smokers do not throw away cigarettes, overweight do not curtail calories and the sedentary do not leave the couch.
We looked around. Methods of individual behavior modification have succeeded to variable degrees in various disorders like ADHD, addiction and depression but little experience is available in their application to whole communities. Psychologists have developed multiple theories about behavior change; public health workers have created methods for change communication and entrepreneurs have developed social marketing techniques for healthcare goods. All these, while useful as complementary components, do not form the whole solution.
Over sixty years ago, social psychologists developed ‘Health Belief Model’ (HBM) for the US Public Health Service. HBM posits an explanatory framework, useful to understand determinants of health behavior. The model has evolved by its extensive and diverse application in public health. The HBM contains six constructs to understand health seeking behavior:
1. Perceived susceptibility to risk of disease
2. Perceived severity of the disease
3. Perceived benefits of action to restore health
4. Barriers: perceived negative effects of action
5. Cues that trigger the action
6. Self-efficacy in belief that one could accomplish a modified behavior
While HBM could help improve methods of communication, it does not detail the process to modify social behavior. The mediatory influencing power of these six factors – in parallel, sequence or as hierarchy – is not clear.
We searched for social behavior modifiers in the history. Organized religion – for good and bad – topped the list. A commonality emerged in their methods: they deliver simple messages repeatedly to young and old, they campaign relentlessly on flimsy pretexts, they have no preset end-point to terminate the religion or its campaign and they promise reward and punishment in afterlife. All these methods are eminently applicable to healthcare with one difference: reward and punishment is readily available within nine months in case of pregnancy.
And here we were in 2008, in twenty villages, with a declared mission to reduce maternal mortality. We carried sincerity with us but a limited theoretical architecture and an undefined process of social behavior modification. Our redemption lay in the accumulated knowledge of the biology of pregnancy. We knew women in poor communities died in child birth and pregnancy due to iron deficiency anemia, excessive bleeding at birth, sepsis, obstructed labor, adolescent age, malnutrition and comorbidity. All these were preventable, if we could lift their veil of ignorance.
We had no option but to experiment and develop a social behavior modification process, pertinent to our context. We chalked out the guiding principles: the process had to be simple to implement, sustainable through community ownership and scalable by encouraging voluntary responsibility. We would borrow from the experience of others, iterate our methods as we learned and validate our results.
We compressed the information about healthy pregnancy into six actionable steps: four antenatal checkups; consumption of at least one hundred iron folic acid tablets, good nutrition, immunization against tetanus, child birth in a hospital and forty-eight hour stay in the hospital after delivery.
Our supervisors trained local women volunteers as change agents who delivered these messages to all – young, old, women and men. They organized interactive group meetings, which would be recurrent. (For instance, in 2014, we held over 9,000 community meetings in 167 villages). The women converted the messages into songs and slogans with a hope they would become a part of transgenerational oral culture.
The impact was beyond our expectations. We could reduce maternal mortality by 90 percent in three years. To validate our result, we replicated the program in two southern states of India with different cultures and languages. In 2012, we started the program in 167 villages of Gadag, a district in the state of Karnataka. The maternal mortality rate – defined as maternal deaths per 100,0000 child births – was about 188 in 2011. After five years of the program, in 2017, there were no (zero) maternal deaths. We compared the program with the government maternal health program in adjacent villages. Our impact was at least thirty percent better. With success, we ordained our process as, Effective Social Persuasion (SAM-ESP).
We needed more validation. We tried the platform of volunteer community health activists to reduce neonatal mortality, control TB and stabilize population. Neonatal mortality decreased by 60 percent and TB detection increased by 30 percent. Before the program, only 10 percent of the couples in reproductive age used contraceptives. Four years later, 60 percent couples used contraception.
Starting with 20 villages in 2008, SAM has expanded to 1100 poor villages. SAM has trained 30,000 volunteers out of which about 3000 are active.
And now the cost: SAM accomplishes all this in less than 25 cents per capita per year or one hundred fifty dollars per village per year or six dollars per pregnancy. The expenditure goes for the salary of trainers, field supervisors and for community training. Addition of other programs like TB control do not increase the cost significantly.
We stumbled into the social behavior modification process and it was not a stroll in the mall. We struggled, erred, learned, retried and found some success the hard way. Our impact has thrown up more questions: can ESP be an antidote to non-health issues? Can we apply it in richer societies? When do we leave the community on their own?
I wrestle with these teasers as I travel through the rural misery, where progress has halted but awakened women are scurrying on a road that is new.