“We go to the doctor when we have money. When we don’t have any money, we just pray and do what we can to take care of it.”

Last week, Ugat ng Kalusugan returned to Barangay Bagong Silang to carry out a mini-survey among Badjao families. Like our first survey in Bagong Silang, our purposes for carrying out another survey were two-fold: we wanted to test out our community health survey, and we wanted to get more information on one purok (area) of Bagong Silang because it is a possible site for our work. Photos from our trip are here.

The results of our second survey are summarized below. As with our first survey, there are several caveats. These survey results are not representative of the whole Barangay. We only interviewed 11 women and one man from 12 different households, and only households in the Muslim, Badjao portion of the community. We employed convenience or accidental sampling - a type of nonprobability sampling wherein the sample (interviewees) are selected from the general population because they are readily available and convenient. There is an added bias to the group we interviewed: they were all mothers (or a father) whose children under five years of age were receiving their regular deworming and vitamin supplements distributed by the barangay health workers. We opted to accompany the barangay health workers as they went from home to home so they could provide an introduction for us to meet women within the community. Because our sample is comprised of women (and one man) whose children are being cared for by the health workers, it is important to remember that they and their children are likely much healthier and better off than their counterparts who do not access any health professionals or receive any free medicine.

While we cannot make any generalizations about the community based on our survey results, the results do offer some insights into this community, and we found some of the results interesting.

We interviewed 11 women ranging in age from 19 to 35, and one man who is 48. We generally plan to interview only women but in one household the woman we wished to speak to was sick and resting and her husband offered to answer our questions.

Family Planning

We asked the interviewees if they practice family planning. Two women answered that they do use contraception. One uses hormonal pills and the other uses the injectable DMPA (Depo Provera). Both women pay for the contraception themselves. One of the women is Catholic and the other belongs to the Iglesia ni Christo church.

The rest of the women in our sample do not use any form of family planning, artificial or natural. When asked why, every single person said that they do not use any form of contraception because it is forbidden as it is against Islam. Several of the women who do not use contraception because it goes against their religious beliefs are young (ages 19-21) and as yet each have only one child. Among the older respondents (ages 28-40) most women have had multiple pregnancies and children. Maida, who is 28, has 5 children. Sherwina is 29 and has four children but has had five pregnancies. Tina, who is 30, has three children. Her friend Adea, who is 32, has three children but has had eight pregnancies. Sandra is 35 and has had seven pregnancies and has six living children. 48 year old Cesar’s wife has had 13 pregnancies, and has nine living children.

We asked the respondents what they think the ideal number of children is and most of them answered that the ideal is between two and four children. Some of the women with multiple children said that two or three is ideal, but that they couldn’t achieve their ideal because using contraception is against Islam. One women said the ideal is two or three but she has had seven pregnancies. She says she is too scared to use contraceptives. Cesar’s wife has had the greatest number of pregnancies and children (13 and 9 respectively) and in answer to what his ideal number of children is, he said, “Allah forbids planning. But in terms of what I think, this number [9] is enough. We’re already having a hard time and more children would be difficult. But if it is Allah’s will, then we will have more.”

Islam and Contraception

While we were carrying out our surveys, we asked the interviewees their beliefs and practices and we recorded their answers. We did not question people further about their religious beliefs but I was very confused as to why everyone was telling me that Islam forbids the use of contraception. I didn’t think Islam forbade family planning, but I wasn’t sure, and even if I was, I did not feel that it would have been appropriate to give an impromptu lesson on Islam and contraception. We completed the surveys and upon returning to our office, I conducted some internet research and found that Islam very clearly allows the use of contraception. I was stumped and continue to be. How is it possible that a large population of Muslims in this one particular community believe that Allah and the Koran prohibit something that in fact is allowed? These Muslim families are some of the poorest in the province, and most households are too large to support with one or two people’s meagre salaries. Yet families are large because men and women wrongly believe that their God prohibits planning their families. I have to assume that this group’s imam or their community elders have received incorrect information about Islam’s view of family planning and have successfully spread this misinformation among the population. I suppose that spreading the misinformation could be intentional, though I cannot comprehend why anyone would do that. This remains a mystery to me and I hope to have the opportunity to speak further with some of the people we interviewed to find out more about how they came to have this erroneous belief.

Care from Health Professionals

Eight of the women we interviewed had prenatal check ups with their last pregnancies. Among these eight women, none had regular checkups throughout her pregnancy. Most had only two or three check ups before delivering. The other four interviewees did not have any prenatal check ups and cited lack of money as the primary reason for not seeking care.

When asked what type of health professional they consult when they or their children are sick, six respondents answered that they seek care from Barangay Health Workers, four see doctors, and one goes to the City Health Center. One of the interviewees said, “We go to the doctor when we have money. When we don’t have any money, we just pray and do what we can to take care of it.”

When asked what type of birth attendant they prefer, eight stated manghihilot or traditional healer, two like doctors and one prefers a midwife. One respondent said she would really prefer to have a doctor, but her family cannot afford one so she uses a manghihilot or traditional healer.

Unlike their counterparts in other neighborhoods in Bagong Silang, the Badjao women we interviewed overwhelmingly prefer to give birth at home. When asked where their ideal birthing place would be, all but one of the interviewees said that they prefer to give birth at home. One women said she prefers the hospital. All the women who prefer home births did actually deliver their children at home, save for one woman whose parents took her to a birthing center because it was her first delivery. One interviewee noted that the home is best because their family does not have the money for a hospital birth, and another women said that she prefers the home because she is scared to give birth in a hospital.

Of the women we spoke with, only two had seen a health professional for a postnatal check up after their last pregnancy. These two women were the two women that gave birth outside the home - one at a birthing home and another at a hospital. None of the others had heard of the need for postnatal visits, and a few added that their health was fine after giving birth so there really was no need for a check up.

Beliefs about Family Planning

We asked the people we spoke with about their thoughts or beliefs relating to family planning. The following are some of their statements:

“It is forbidden by Islam to plan our families.”

“Islam forbids us to use contraception.”

“We don’t plan families because we are scared of Allah. We do not know more than Him so His will be done. Only God can let us survive.”

(-Cesar, whose wife has had 13 pregnancies and 9 living children)

You need to only have a few children so that you can

send them to school and feed them sufficiently.

(-Sonya, 19 years old with one child, not currently on any form of contraception)

“I’d like to give my children a good life -

have enough for them to go to school and to eat.”

(-Damesa, 21 years old with one child, not currently on any form of contraception)

“It’s better not to have too many children so that life isn’t too hard.”

(-Sherwina, 29 years old with four children, not currently on any form of contraception)

Beliefs about Pregnancy

We asked the interviewees about their beliefs regarding pregnancy. Most of the responses centered around a pregnant woman’s safety at night and included the beliefs that when you are pregnant you should cover your head if you go out of your home at night, that at night a pregnant woman should have garlic hanging in her house so that vampires will not be able to find her, and that generally pregnant women should not walk around at night. One woman said that pregnant women should not carry anything too heavy, and another said that when a pregnant woman reaches the month in which she will give birth, she should regularly drink ginger tea.

Immunizations

Like their counterparts whom we interviewed earlier in the week, all the children of the mothers we interviewed were up to date with their immunizations - or will complete them shortly (for babies under 1). These immunizations include BCG (Bacille Calmette-Guérin - a vaccine against tuberculosis), three doses of DPT (DPT refers to a class of combination vaccines against three infectious diseases in humans: diphtheria, pertussis [whooping cough] and tetanus), three Hepatitis shots, and three doses of the Polio vaccine. These results are probably not typical. It is important to remember that the women we interviewed were the mothers of children receiving medicine from the Barangay Health Workers. There is a bias here - these children are receiving care from the health center and thus are more likely to have completed all the requisite immunizations. If we were to randomly sample families within the community, we might not find 100% compliance with these immunizations.

Finances and Employment

Only two of the women we spoke with are currently employed. One delivers soap, and the other, who is the wealthiest of the women we surveyed, sells fish in the market. The man who we interviewed works as a street cleaner for the government. All of the other women have no work and expressed the desire to work in any kind of position that becomes available - especially being a saleslady or a maid.

Two of the people I spoke with have a monthly household income between P500-1,500 ($11-$32.) Three respondents have a monthly household income between P1,501-3,000 ($33-$64.) Two women reported a monthly household income between P3,001-4,500 ($64-$94.) Two of the families have a monthly household income between P4,501-6,000 ($94-$125.) One family’s monthly earnings totals P5,000 ($105). Another’s is P6,000-7,500 ($125-$161.) The wealthiest of the women represented had a monthly household income between P9,001-1o,500($188-$220.)

Supplemental Support

None of the children among the sample households we surveyed receives any regular supplemental feeding, despite the fact that Badjaos are referred to by city health officers as being some of the “poorest of the poor” and with some of the greatest number of children that are malnourished.

Most of the families do not receive any regular support from any outside groups but some families sometimes avail of services or food from the Department of Social Welfare and Development, Barangay Health Workers, from the city health center and from a nonprofit called Balikatan. One interviewee mentioned that her family sometimes receives free food when local officials celebrate their birthdays and feed the masses - an activity that is popular in Palawan and which Mayor Hagedorn and Governor Reyes both recently did for their birthdays.

“Life is very hard when you have too many children.”

Yesterday Ugat ng Kalusugan carried out a mini-survey in Barangay Bagong Silang. Our purposes were two-fold: we wanted to test out our community health survey, and we wanted to get more information on one purok (area) of Bagong Silang because it is a possible site for our work.

Bagong Silang is a sea-front community with around 5,000 people - a third of whom are Cuyunon (a native group in Palawan), a third who are Bisaya (migrants from the Visayas) and a third Badjao. The Badjao are a traditionally marginalized group, looked down upon by non-Badjaos even in Islamic areas. Badjaos tend to be very poor and uneducated and are frequently beggars. The majority of the non-Badjao men are fishermen, and women either sell fish at the market, work at the local department store, NCCC, or stay at home. Some children go to school but many do not. Average families in Bagong Silang have four or more children - a bit above the national average. The average age for a first child is 19 but there are also mothers as young as 14 or 15 - particularly among the Badjaos. To read more about Bagong Silang, click here.

The results of our survey are summarized below. Before sharing these, there are several caveats. These survey results are not representative of the whole Barangay. We only interviewed women from nine different households, and only households in the Catholic portion of the community. We employed convenience or accidental sampling - a type of nonprobability sampling wherein the sample (interviewees) are selected from the general population because they are readily available and convenient. There is an added bias to the group we interviewed: they were all mothers whose children under five years of age were receiving their regular deworming and vitamin supplements distributed by the barangay health workers. We opted to accompany the barangay health workers as they went from home to home so they could provide an introduction for us to meet women within the community. Because our sample is comprised of women whose children are being cared for by the health workers, it is important to remember that they and their children are likely much healthier and better off than their counterparts who do not access any health professionals or receive any free medicine. We do hope to accompany the health workers again when they do their medicine distributions among the Badjao population of Bagong Silang.

While we cannot make any generalizations about the community based on our survey results, the results do offer some insights into this community, and we found some of the results interesting.

We interviewed nine women ranging in age from 20 to 51.

Family Planning

We asked the women we interviewed if they practice family planning. Two women answered that they do not use any family planning. One did not explain why, and the other said she does not use anything because she doesn’t have a husband -- but she does have a two year old son.

The great majority of women do use some form of family planning. Two use natural methods (withdrawal and calendar method), three use pills, one uses an IUD and one used DMPA (Depo Provera). Of the women using artificial forms of family planning, only one pays for the medicine herself - the others rely on receiving them for free at the Barangay Health Center.

All of the women we spoke with think that the ideal number of children is between two and three. Just over half of the interviewees have the same number of children as this ideal, or one less child. Of the rest of the women, two reported having five children -- and they explained that they really wanted to have a baby girl, so they kept trying beyond the ideal number they desired. One woman with six children reported achieving her ideal of two or three children -- but did so with several different partners (!) One woman with five children said she had definitely wanted less children, but the five “had just happened”. She was one of the women who reported using contraception when it was given away for free.

All but one of the women we interviewed had prenatal check ups with their last pregnancy. Of those women who did get check ups, only one woman saw a doctor regularly from her first month of pregnancy until giving birth. The rest of the women saw a health professional between 2 and 4 times throughout their pregnancy.

When asked what type of health professional they consult when they or their children are sick, seven of the women answered that they consult doctors, three consult Barangay Health Workers, two consult a manghihilot (traditional healer), and one consults a nurse.

When asked what type of birth attendant they prefer, six stated doctors, two like nurses, and two women prefer midwives. One of the interviewees reported that for her last birth, she called a nurse to come but ended up having to give birth with a manghihilot (traditional healer) because the nurse got stuck in traffic and didn’t make it in time.

When asked where they prefer to give birth, two of the women listed their home and the local health center as places that would be ok, but 100% of the interviewees said that their first choice would be to give birth in a hospital. When asked why, most reasoned that a hospital setting is safest because there, they could have access to doctors and to any special equipment should there be any problems or complications with delivery. We did not ask the respondents where they did in fact give birth to their children, and will include this question in the next iteration of the survey.

Of the women we spoke with, only three had seen a health professional for a postnatal check up after their last pregnancy. None of the others had heard of the need for postnatal visits.

Beliefs about Family Planning

We asked the women we spoke with about their thoughts or beliefs relating to family planning. The following are some of their statements:

“I wanted to get a ligation but my blood pressure was

too high. So we just use the withdrawal method.

I don’t want to do pills or get the injectable type of

contraception - I heard those can lead to tumors.”

“You really should just have the right number of kids -

otherwise life will be full of hardship.”

“If your family is small, you’ll be able to satisfy the

needs of your family and be true to your beliefs.”

“It’s really hard to feed your family when you have too many children.”

“It’s good to plan your pregnancies because it is too hard

when the children come one right after another!”

“Life is very hard when you have too many children.”

Beliefs about Pregnancy

We asked the interviewees about beliefs they have regarding pregnancy. A few women answered that one should not drink or smoke while pregnant, and that one should always go for check ups and get a lot of sleep. We also heard the beliefs that a pregnant woman should never eat eggplant (no explanation) or drink cold water because that might make the baby get too big. Several women also said that a pregnant woman should wear black panties at night so that monsters or evil spirits will not be able to find the baby and harm it.

Immunizations

All the children of the mothers we interviewed were up to date with their immunizations - or will complete them shortly (for babies under 1). These immunizations include BCG (Bacille Calmette-Guérin - a vaccine against tuberculosis), three doses of DPT (DPT refers to a class of combination vaccines against three infectious diseases in humans: diphtheria, pertussis [whooping cough] and tetanus), three Hepatitis shots, and three doses of the Polio vaccine. These results are probably not typical. It is important to remember that the women we interviewed were the mothers of children receiving medicine from the Barangay Health Workers. There is a bias here - these children are receiving care from the health center and thus are more likely to have completed all the requisite immunizations. If we were to randomly sample families within the community, we might not find 100% compliance with these immunizations.

Finances and Employment

One woman’s monthly household income is P500-1,500 ($11-$32.) Another’s is P1,501-3,000 ($33-64.) Three women reported a monthly household income of P3,001-4,500 ($64-$97.) Another’s is P6,000-7,500 ($129-$161.) The wealthiest of the women represented had a monthly household income of PhP10,500-12,000 ($226-$258.) One of the women has no income and is being supported by her parents. Another woman had a monthly income of PhP1,500-2,000 ($32-$43) when her husband was alive, but he passed away last month and she and her two children are now being supported by her sister.

Only three of the women we spoke with are currently employed. One is a Barangay Health Counselor (and is the woman with the highest monthly household income), another takes care of pigs and another sells fish at the local market. One woman does laundry for her neighbors but does not have regular clients and sometimes has no work. Of the rest of the women without work, two expressed the desire to work if it was something they could do at home so they could care for their young children. Another respondent would like to be a saleslady and two expressed the desire for any kind of work - becoming a maid, a laundry washer, participating in a buy and sell scheme (like Avon) or anything else.

Supplemental Support

None of the children were receiving regular supplemental feeding, but a few of the children occasionally get some extra food from special feeding programs that the Barangay Health Center sometimes has funding for.

None of the families receive any regular support from any groups, but some have sometimes been able to avail of medical services or food from medical mission trips carried out by both foreign and local groups.

Walking on unsteady wooden plank bridges over the ocean to get to the houses

Conducting surveys

Trash on the ground is a common sight

Out on the water, space is at a premium

One of the mothers we interviewed with her baby girl

Another mother with her son and nephew. Her son has a growth on his face -- we didn't really

understand what it is but we are hoping we can find a doctor who will be able to take a look at it.

More homes

Conducting a survey outside a home. Notice the beautiful orchids by the side of this house. People really put in a lot of effort to beautify their environment.

A lot of fishermen live in Bagong Silang - this is the kind of boat a lot of them use when they go out to the sea.

Myths and Misinformation at PSU

One of the primary goals of Roots of Health is to provide educational outreach about reproductive health to women and girls. Once we begin our direct service, we will be working with underserved communities and with participants who have likely not had any formal education since grade school. We are currently still creating and tweaking our materials, so when we were invited to teach a two-day seminar at Palawan State University on reproductive health, we jumped at the chance to test our materials. The students were from the College of Nursing and were three years into their coursework. In the Philippines elementary school only goes up to 6^th grade and high school only up to 10^th grade, so students enter college at age 16. So despite being third year students, my seminar participants were only 18 or 19 years old. I assumed that, being nursing students, the participants would have already covered a lot of the material I was presenting. I was wrong!

I was shocked at the levels of knowledge, or lack thereof, that the students had about general reproductive health and HIV. Here are some of the highlights:

• Nearly 20% of the students believe that you can not get pregnant the first time you have sex, and 70% of them believe that you can not get pregnant while breastfeeding a baby.

• Only half the group believes that the condom is the only type of contraception that can prevent pregnancy and also prevent the transmission of sexually transmitted infections.

• More than 50% of the participants incorrectly identified saliva and urine as modes of transmission of HIV.

• Only 1/3 of the participants correctly identified breast milk as a possible mode of transmission of HIV for babies born to HIV+ mothers.

• Less than half of the participants believe that someone can have a sexually transmitted infection without manifesting any symptoms.

When it comes to attitudes about sex, the Filipino “macho” culture and gender expectations really emerged.

• One in three students do not believe that a girl can force her boyfriend to use a condom if they are having sex.

• One in four students believe that there is nothing a girl can do to prevent pregnancy if her partner refuses to use a condom.

• One in six students believe that a girl does not need to worry about sexually transmitted infections if her partner promises that he is being faithful.

• And finally, almost all the students stated that premarital sex is bad, but one in three respondents thinks it is ok for an unmarried boy to have sex, compared to one in six believing the same thing for unmarried girls.

At the close of the workshop I administered the same survey I gave the students at the beginning of the two day seminar. Attitudes did not change a great deal but some knowledge did increase, and many of the misperceptions students had about basic reproductive health and HIV were corrected.

This experience was very positive in that the students were thoughtful in their discussions and appreciated the chance to speak freely about issues that are seen as taboo. And I think many of them really learned some new things that hopefully will help protect their health. The experience also reinforced the immense need for disseminating information about reproductive health. The students I met are not necessarily wealthy, but they are much more privileged and educated than the communities we will be targeting in our work. When future nurses know so little, it is likely that individuals without any formal training or education will know even less. We have a lot of work to do!

A Day at the Dump

There is a nonprofit orphanage here in Palawan called Aloha House that conducts an outreach feeding program twice a month in a Barangay called Santa Lourdes. This past weekend Marcus, Susan and I joined Keith (Aloha’s founding director) Sheila (Aloha’s social worker) and their staff and observed their feeding outreach to get a feel for how we might want to run our programming.

The actual neighborhood that the feeding program takes place in is called “Dumpsite.” It is in fact the city dump and the residents there make a living by sorting and separating the trash, cleaning out the plastic and glass bottles, and salvaging anything that went into the trash that can still be used. Much of the actual waste then goes into a nearby "sanitary landfill" (more on this later!) Most of the people living in this location live in huts scattered around the hillside. Many of the residents keep pigs and we also saw some goats and a couple of turkeys.

Walking into the residential area

One of the many pigs in the area

When we arrived at Dumpsite we pulled up to the local church – a building with a cement floor and a nipa ceiling and walls (nipa is a type of straw commonly used here for structures.) The church was pretty dusty but as soon as we got there, a handful of mothers appeared and started sweeping the floor and setting out the plastic chairs stacked in one of the corners of the room. The Aloha staff unloaded the food they had brought – two cauldrons of food and two large jugs of fresh milk – and started setting up the bowls, cups and utensils. The food they serve is a very high nutrient porridge made of brown rice with mongo (mung) beans, malungay (moringa, a leafy green), and ground beef. The Aloha staff also brought a large container with boiled eggs cut in half, and each bowl of porridge was topped with half an egg.

The kids trickled into the church slowly at first but soon there were well over 50 kids ranging in age from under 1 to about 12 or 13. Because this population is so poor and underserved, Aloha doesn’t impose an age or weight cut-off. Once every couple of months they take down the children’s names and weigh them, but any child that comes to the feeding gets fed.

Keith noted that when they first got started, it was pretty chaotic but on the day that we went, we were impressed by how orderly and efficiently the feeding was carried out. Three Aloha staffers manned the table with the food and dished out the porridge and eggs and handed them to the kids, who by this point had lined up and were waiting patiently for their bowls. Once the kids got their bowls, they sat in chairs and waited for the go signal to start eating. The first child to finish eating is given a prize – that day it was a box of crayons. The contest to see who can finish eating first doesn’t seem like the best idea but I imagine they do this as a way to have all the kids wait and start eating at the same time, which makes it easier to ensure that everyone has had their first bowl of food before the Aloha staff start dishing out second helpings. Some of the kids were satiated by a single serving (the porridge is very heavy and looks quite filling) but many did ask, and were given, seconds. When the kids returned their empty bowls, they were given a glass of milk.

Sheila serving up the porridge

Some of the little ones

Eating in their little chairs

The little boy on the left was feeding the smaller boy on the right

More kids drifted in as the feeding was underway and by the time the feeding portion was through, Aloha staff had fed around 65 children, plus maybe 3 or 4 adults who were helping distribute the food. Once all the kids had been fed, the Aloha staff led them in some singing and some games before the staff packed up and left.

We interacted with some of the kids and they were all quite friendly. We were struck by how unhealthy they all looked though. They were pretty dirty and thin, and they looked much worse off than the kids that we’ve seen in Bagong Silang and in Bakungan. We had not been previously planning to consider this Barangay as a potential location in which to start our programs, but now we think it might be a really good place to work. The community is very poor and faces additional health issues due to their proximity to the trash and toxic waste. We don’t believe anyone has done any work with this community outside of the Aloha feeding so we will likely have to conduct our own surveys to get data on reproductive health needs and general community health. We didn’t have the chance to meet many of the mothers in the community but we’re hoping to meet more when we do return to start gathering data.

After the feeding program was over, we drove a short distance from the residential area to the actual landfill. The sanitary landfill claims to be the first of its kind in the Philippines. The funding for it was provided by a German organization and while the technology used at the landfill is appropriate for colder climates, it is apparently not terribly well suited to the trash and climate situation in the tropics. We’re not sure exactly how everything works and how many people are officially employed at the landfill but it looked pretty organized. We were amazed by the stunning views visible beyond all the trash. I’m looking forward to doing more research into this location and community and will keep you all posted on what I find!

The trash

This photo does it no justice but the view from the dumpsite is amazing!