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!

Bakungan

On September 9, 2009 (090909!) Marcus, Lyn-Lyn and I accompanied a group of Palawan State University second year nursing students on one of their outreach trips to a Barangay called Bakungan. Bakungan is about a 40 minute drive from the center of Puerto Princesa, and is a somewhat rural location. The nursing students have been conducting survey work in this Barangay all semester and have been going from house to house interviewing residents and carrying out basic health checks (like checking blood pressure). We wanted to get an idea of what some of these rural households look like so we shadowed some of the students as they carried out their work.

Palawan’s National Highway is a pretty good road and is paved most of the way to Sabang – location of the underground river, Palawan’s number 1 tourist attraction. Bakungan is about halfway to Sabang, so the roads were great up until the turnoff for the Barangay. Once we got off the National Highway, we were on unpaved, muddy dirt roads. We drove to a community center hut within the Barangay and watched as the students prepared their survey materials and got ready to begin their work. Many of the students rolled up their pants, took off their shoes and changed into flip flops, as some of them had to wade through a stream in order to get to some of the households.

The Barangay church

Every Barangay in the Philippines has a basketball court! Loved this makeshift one...

In the first household our group went to, the students interviewed a woman caring for an 8 year old boy who is her youngest child as well as a 4 year old girl who is her granddaughter. The woman looked older than her 42 years and seemed tired, though happy to speak with the students.

Her husband supports their family of 9 on P8,000 pesos a month – the equivalent of about $165. The woman said she practiced family planning and used birth control pills, though right after reporting this, said that she had 6 children. I wished that the nursing students asked a follow up question of whether those 6 pregnancies were planned but unfortunately this question wasn’t part of their survey tool. Many Filipinas I’ve met use the pill, but don’t use it regularly. If money is tight, it is understandably spent on food rather than on contraception.

In another household we visited, a 38 year old woman was caring for her 6 year old son and her 10-month old daughter. Again, this woman reported practicing family planning, and said that she had 5 children. Her husband is the household breadwinner and supports the family on P7,000 pesos a month.

I came away from this trip with a feeling of guilt at how much I have and how little many of the people in this community have. I cannot imagine a family of 9 living off P8,000 a month, but these families do it, and hard as it is to imagine, these families are better off than many others. I really wished I could have asked the women more questions about their desired family size and their contraceptive use and any education they had and about any desires to work. When we do our own data collection in the community we are going to work in, I will definitely speak with women about these things.

One thing from this trip that really made an impression on me and Marcus was the effort that people in the community put into taking care of their homes. All the homes we saw were very simple and sparse, but they were clean and tidy and a lot of thought had been put into decorating the spaces with whatever materials could be found. Also, the homes all had lovely gardens with lots of flowers and pretty plants. I know this sounds terribly cliché but it really reminded us to be thankful for all that we have, and it left us with a desire to try to simplify our lives and do more with less stuff. As my mom always liked to tell me as I was growing up, “Live simply that others may simply live.”

Trip to Bagong Silang

Last week Susan, Lyn Lyn and I went to Barangay Bagong Silang so I could have a look around, learn more about the barangay, meet some of the people within the community, and learn more about the health services available.

The community has around 5,000 people and about a third of them are Badjao. The Badjao are a Filipino tribe of sea gypsies. They are a traditionally nomadic group of people whose origins are within the Sulu archiapelago. They are a Muslim group and were displaced by the conflicts in Sulu and other Muslim areas. They are a marginalized group, looked down upon by non-Badjaos even in Islamic areas. Badjaos tend to be very poor and uneducated and are frequently beggars. These factors all contribute to the discrimination that many non-Badjao’s have against this group.

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, particularly among the Badjaos. Badjao children are frequently seen selling plastic bags at the market, or begging. Bagong Silang received funding from Puerto Princesa Mayor Hagedorn to fund a preschool/day care center in the community which some children do attend. The day care center serves 57 students - children aged 3 and 4 in the mornings, and children aged 5 in the afternoons.

There are *so* many children in this community.

In 20 minutes of walking around, I counted more than 80 kids who look to be around 13 years old or below. Most of the small children were in various states of nakedness, were dirty, malnourished, and looked visibly sick.

The community has some people who are better off than others: many people have actual houses made of concrete. But the poorest members of the community, a disproportionate number of whom are Badjaos, live in bamboo shacks built over the beach leading into the ocean. The shacks are stacked up on each other and have no sanitation facilities. People throw their trash and all their waste through the cracks into the water below. When the tide comes in, the waste is washed to the sea. It was low tide when we arrived and the stench was pretty awful. This community is a water and sanitation nightmare! Because the shacks are right up on the ocean, the homes are vulnerable to the elements. The week before we visited, a storm had destroyed a number of homes which had yet to be rebuilt. I’m not sure where the inhabitants of those homes are now.

Because of the extreme poverty of this community they have received some funding from the national Department of Social Services and from the local City Health agency to fund a small clinic to serve the local population. The funding is by no means adequate to support community needs, but the community health workers (CHWs) staffing the center make do with what little they have. The center provides immunization, prenatal care, and family planning services. Immunization services and prenatal activities are conducted every first week of every month. The CHWs provide information on family planning and can assist with IUDs and other injectable types of contraception, but these and birth control pills must be purchased by the clients, and most of them cannot afford the costs. There are many pregnancies in the community and most women give birth at home, sometimes with a midwife.

The CHWs also reported that through a special grant they obtained funds to run a feeding program for 2 months. They said that in the community there were only 50 cases of malnourished kids (my casual observations point to a far greater number!) and their program is feeding 25 of them. Of the 25 only 3 kids are Badjao.

The CHWs were extremely friendly and eager to speak to us about their activities. I was impressed with how organized their small center was, and they seem to have good records of the people availing of their services. We will return next week and they have promised to share their data with us -- an invaluable favor as we compile data for our needs assessments!

I think it would be very interesting to work in this community, not only because of the demonstrated needs, but also because of the presence of a marginalized group (the Badjao) among the already-marginalized poor. Part of me hesitates because the community already has some services being provided to them, but another part of me knows these services are nowhere near adequate or sustainable. It may also be more effective to work within a community that already has some services set up. It would make our service delivery more effective. In addition, in the future, the process this barangay went through could serve as a guide for us in establishing services in other communities without any . However, I wonder whether it would be more important to start providing services in communities where there are none. There is a lot to think about and no doubt we will have a lot of discussion when we conclude our needs assessments and decide which community to work in.

Roots of Health - the Adventure has Begun!

Now that Marcus and I are finally here in Palawan, the work of Roots of Health / Ugat ng Kalusugan has started in earnest.

In the next few months, Ugat ng Kalusugan will begin conducting reproductive health trainings with students and future partners at Palawan State University and will be completing more comprehensive needs assessments of various communities in Puerto Princesa in which we may conduct our activities. My mom, Susan, has conducted a needs assessment of Barangay Bagong Silang, and we may well do our work in this community as they very clearly need the support, but there may be other communities in which our activities would be more beneficial, so we will take the time to gather data on other communities before deciding exactly which community to work in.

We will gather data from the government City Health agency, through Palawan State University College of Nursing and Health Sciences (they do needs assessments for their students’ practicum programs) and by going into the various communities and speaking with the community leaders, health workers (if any) and local residents.

As we go through this process, we will also conduct reproductive health trainings with students within PSU’s school of nursing and midwifery and school of social work. While PSU students are elites in the sense that they have education, many of them come from the communities we are considering working in, and many of them lack the same knowledge regarding reproductive health (yes, even the nurses!)

We hope to complete our needs assessments by November, and begin working in the community we select in the same month. We will begin with our reproductive health outreach and our healthy pregnancy program, and will plan to introduce the nutrition program in late December or early January 2010.