Month: September 2021

Participatory Learning & Action (PLA) Toolkit

WHAT IS PLA?

PLA stands for Participatory Learning & Action. These methods are involving end-line users of the service which we are either providing or planning to provide. These methods allow us to gather useful information without provider bias. As information is directly collected from the community, there is minimum distortion. Methods are so designed that even illiterate people can effectively participate.

Such methods were extensively used by the agriculture department for quite some time. They called them PRI methods. The health department has adopted them after suitable modification.

FOLLOWING ARE SOME USEFUL METHODS:

  1. Transect walk (Village walk)
  2. Participatory mapping
  3. Seasonality diagram
  4. Relative ranking
  5. Chapati (Venn) diagram
  6. Focused group discussion

Participatory Mapping:

This should be the first exercise when you are going to a new area.

OBJECTIVES:

  1. To know the geography and topography of the area of operation.
  2. To locate important places and institutions like dispensary, the residence of important people, offices, schools, etc.
  3. To find out an approximate number of people residing in a circumscribed area of the village.
  4. To find out the religious and socio-economical backgrounds of people residing in each sub-area.
  5. To find out area-wise facilities like water supply.
  6. To locate people and cases in the village.

METHODOLOGY:

Select some central place in the village and assemble 4-5 persons there. Alternatively, you may select people idling at some pan shop or a temple and go to them. Introduce yourself and tell the purpose of exercise/visit. Inform them that you need to know the topography of the area.

Now, either on a spreadsheet of paper or on the ground try to draw the place and street where you are standing. Tell them to assume we are here. Now, where would one reach if he walks through the street in either direction? Where are sideways located? How is the place connected to the main road or road leading outside the village? Where is the bus stop? This way try to put all roads on the map. Now pointing to each area separated by roads, ask if they are named. They might have been named by a community that lives in it or by some other name. You do not need to be a tracer or an artist to draw the map. It should tell you the same information that you need.

When you are trying to name plots or areas, ask “which community resides there and how many houses are there”. Write down the number of houses, also the resident community. Now plot-important places like dispensary, private doctors, leaders, the residence of service providers, Anganwadi, temple, mosque, school, etc. Also plot water tank, well, public utility toilets, etc. After they have understood what are you asking for, it is advisable if somebody takes overplotting.

If there has been an epidemic or you want to locate particular cases, take a line list of cases if you already have or ask the community, if they knew who were the children who suffered from measles recently or had diarrhea in the epidemic. Plot them on the map you prepared. If the original map was prepared on the ground, transfer it to paper.

SHORTCOMINGS:

There are shortcomings here also as anywhere else. People you have asked may not be very serious about preparing maps and may not provide accurate information. Sometimes people may not be knowledgeable about the direction. They may say this side or the other but when it comes to plotting, they may plot at the wrong place. Investigator being an outsider does not know many things about the village and if somebody does not volunteer information, the same may be missed. The investigator needs to be sensitive to this issue and ask open-ended relevant questions so that information that is vital to him may not be missed. Like he may ask which is the highest place in the village, where people take shelter at times of flood? Or “who are the people who are influential in the village and where do they stay?

 

Transect Walk:

OBJECTIVES:

The exercise is meant to achieve the following objectives:

  1. To have a first-hand feel of community on various aspects, economical, general well being, cleanliness, addictions, facilities, problems of health, the distance between different facilities, condition of roads, local customs, water supply, drainage, defaecation practices, solid waste disposal, etc.
  2. To have inputs and comments from members of the community about the same.
  3. Involvement of community members in the collection of information.
  4. Information sharing.

METHODOLOGY:

Take the help of two/three persons from the community and request them to come for walking across the village. Transect means cutting across. Before starting the village walk, talk to volunteers about your objectives in making such an exercise so that they can meaningfully share information.

Now, while walking through the streets, keep open eyes, ears, and mind. So that whatever you see, hear, or feel can be fully registered with exact meaning attached to it. One might feel that this exercise may be good for a person who is new to the area. But a regular health worker may not need the same because s/he is well versed with the area. But this is not the truth. Firstly, the worker may need to have such a birds-eye view in a different situation, maybe after floods, cyclones, or earthquakes so that he has a clear idea of what has happened. Let us put apart disasters, they are not a day-to-day occurrence. But daily a new heap of solid waste, cow dung etc. may develop, daily somebody might just put a pipe in the street to drain his sewage and such things may keep on happening. They are so insidious in onset that they are never eye-catchers and one is likely to overlook. If you have a habit of observations very frequently, you may notice and that too early enough so that it does not become a chronic issue or a major menace.

When you cut across the village, you come to know approximate population size, economical situation, areas where downtrodden populations and marginalized families live, at-risk areas, general cleanliness, shops, types of vegetations, are there kitchen gardens, area infested with rats, snakes etc., cattle, phone and television cables, vehicles, some facility in the village-like school, temple, well etc., drainage, heaps of garbage, defecation practice, etc. Each of these could be very important information for you when you are planning to implement some program.

Keep on discussing with volunteers accompanying you on the walkabout your observations and invite their comments. Be careful in selecting accompanying persons. They must be knowledgeable about day-to-day happenings in the village, its geography and topography, and that too in minute details. They should be aware of sociological happenings and customs. They also must be intelligent enough to understand your concern and respond to that on basis of their observations. Like this, you will be able to discover many things about the area irrespective of your being a novice or familiar with it.

SHORTCOMINGS:

There are shortfalls in this exercise and a manager needs to be aware of the same. If the person accompanying you does not have the proper information, you will be misguided.

If the accompanying person is biased, like a health worker, he may deliberately avoid some of the problem areas and you might be under a false sense of everything being OK

You may not cover the entire village and hence some important observations might be missed inadvertently.

Information so collected could be seriously jeopardized.

 

Seasonality Diagram:

OBJECTIVES:

  1. To list incidences that have either perennial or seasonal occurrences.
  2. To know what incidence is occurring in major magnitude at which time of the year.
  3. To know the relative magnitude of the problem (like cases of a particular disease or symptom) in each season.
  4. To sensitize participants about the magnitude of the problem in a particular season and to forewarn them to be prepared (like in a training program).
  5. To undertake an epidemiological study of diseases.

METHODOLOGY:

While on transect walk, assemble some people. Now tell them that you want to assess the situation of the prevalence of disease according to seasons. Now draw two axes like a graph. On the horizontal or X-axis, you plot seasons (or months if you so need) and on the Y axis, i.e. longitudinal axis number of cases in the community. Now by asking which are the diseases prevalent in the community, list out all diseases. Lay people will tell you by symptoms or names of disease. Confirm whether they understand the disease when they have given a name e.g. malaria. Now take one item after the other. Say if you have selected cough/cold, ask how many cases you usually have in winter. Ask them to suggest how long should be a bar on a graph depicting that condition in winter. Then ask its relative gravity during summer and monsoon. Now take another condition, say diarrhea. Ask in which season its gravity is greatest. Now ask relative magnitude in comparison with the highest occurrence of both diseases. Say cough/cold is maximum in winter and diarrhea in monsoon. Ask if cough/cold in winter is hundred or a rupee, how much is diarrhea in monsoon. Drawbar according to this magnitude. Similarly plot bars for each disease in each season.

SHORTCOMINGS:

The first shortfall of this exercise is laypeople’s definition of the disease may not be as accurate and also their estimate of a particular disease caseload may be faulty. If their family has suffered, they feel that magnitude is high and if nobody of the family has suffered an episode of disease, they feel the magnitude to be small.

 

Relative Ranking:

OBJECTIVES:

  1. To list all problems as perceived by a community
  2. To find out the relative gravity of problems as perceived by the community.
  3. To help problem-solving.
  4. To impart health education.

METHODOLOGY:

Assemble a group of 10-15 persons. Ask them that you want to find out what are their health problems. You would like to have an in-depth understanding. Hence they may not hesitate in telling something. Their problem is unique for them and others do not have any business in deciding the worth of problems and hence if they perceive some problem, it is there and needs to be addressed. Tell them areas that are included in health, otherwise, they may not consider some issues like childbirth, growth monitoring etc. Now let them come out with some points. When they say a point, write it down on a chit of paper of the size of a playing card or another suitable size. Let them think over and over so that all issues of concern come out. For this purpose, ask “anything else?” Take care to ask shy participants in particular otherwise they will not open up and their problems will remain unenumerated. At the end of this activity, you will have some cards with one question on them. Take out any single card randomly. Put it on the table/ground. Now tell people who are participating that if another problem is more important to them, it will be placed higher up than previous, if it is less serious, it will be placed lower down. Now take out another question, read it aloud. Ask if it was more important or less than the previous one. Place this paper according to the merit given by the group. If so needed, you may explain that water is more important than medicine. But the problem of availability of water vis a vis problem of availability of drugs, which is more serious and what you want to be addressed first? Maybe that scarcity of water is not very serious as the non-availability of drugs and people may want to address the issue of drugs in priority. Participants may answer like that. Otherwise, you are not supposed to intervene and take the verbatim opinion of the participant community. As in asking questions, some may be shy in allocating importance, ask them specifically. If unanimity does not prevail, ask repeatedly. If this attempt also fails, take a majority. Keep this in mind, you will address this later. If a group can not decide about priority and two issues are ranked equal, place these cards at the same level. Whenever a new card is taken, ask them where to place it and specifically tell them that they can place this new card anywhere in between also and not necessarily above or below. Meaning thereby they may place it at any place from beginning to end. Now at the end of placement of all cards, if there are two or more cards at the same level, again ask if second thought would lead to giving priority. Now ask is there any second thought, and they would like to reorder cards before priority is finalized. If yes, do that. Give the number on each card. This will give you a ranking on the priority of each of the felt issues as perceived by the community, at least a group of people.

This exercise can be used as a problem-solving exercise. We need to identify a real bothering problem. For which relative ranking is an answer. Sometimes there are multiple answers to one question. We can relatively rank one of the solutions.

We can make use of this exercise as sensitization in health education. If people do not recognize some problem at all, take a list of problems as perceived by them, get them ranked and then put the problem (like population explosion) which is not perceived as a problem. Now give a talk full of argument how all other problems are less important.

SHORTCOMINGS:

This exercise has some shortfalls. Perception of problems and priority is unique to participants. The same may vary according to a group of participants. If youth are participating their problems will be different than elderly people. Womenfolk will have problems unique to them. Labor class, farmers, service class, everybody will perceive problems differently. When problems are different, naturally if they are common in everybody’s list, they will find their place at a different level of priority.

Out of the same group, some strong persons will be very vocal and nobody will dare to differ. They will stall the show. In the end, you will find ranking not according to the opinion of the group but the opinion of the person. Ranking would differ in the same type of group in different areas of the village. For example, some areas might have deep wells in each house, they may not find water supply to be a problem. They might have some nuisance in the neighborhood which is most bothering.

 

Chapati (Venn) diagram:

OBJECTIVES:

  1. To make a comprehensive list of all people who are perceived to be useful in the service provision of health issues.
  2. To find out their relative weightage on the community.
  3. To find out the warmth in their relationship with the community.
  4. To find out their relationship amongst them.
  5. To decide the plan of action how to make use of these findings in favor of operationalization of the program.

METHODOLOGY:

Assemble a group of people. Tell them that you need to analyze the prevailing situation. Also, tell them that their opinion is greatly respected even if it is a single person’s opinion. Tell them that there are always various people who are involved in the actual delivery of services about health and at the same time there are many people who directly or indirectly help people in availing facilities. In the list of those who help indirectly, we may include opinion leaders also. We do not want to miss out on any person, what so ever small contribution he may have. So prepare an exhaustive list by keeping on asking anybody else? anybody else? Also, take care to ask silent and shy people specifically, otherwise, their opinion will remain unnoticed.

Once a full list is prepared, start finding out their weightage in the community. Take one name. Have pre-prepared round discs. Write name on it. Now take another name. ask people if this person has more influence on the community or less. The person who is more influential and respected will have a larger disc. These round discs are similar to chapatti of Indian food. Cut these discs according to perceived influence, as perceived by members of the community. At the end of this part, we will have one chapatti for each person. The size of this is directly proportionate to the influence they exert on the community.

Next comes placement. On the ground, in the center of some area, label a round disc as a community. Now those who have a very cordial and warm relationship will be placed close. Those who have a very warm relationship with the community will be placed close to the community. If some of them have close ties, they will be placed close according to their relationship. On the contrary, if two people are not on talking terms or have a very poor relationship, they will be placed opposite to each other on one side each of community.

In the end, we will come out with a complete picture that tells us who are the people who help in getting health and related services. Who has got how much influence with the community and who bears what type of relations with whom.

Now how to decide on a plan of action. Suppose a dai is placed very near to the community and it is apparent that our female worker is unable to discharge her duties without dai. But dai does not influence the community. She is perceived as a lesser person by the community. So what we need to do is to raise her status in the community. This can be done in many ways. Write on wall slogans that so and so the lady is a government-recognized birth attendant. You may honor her at the time of some campaign. You may expand her services by opening up a depot of contraceptives and ORS at her place. You may also conduct clinics and sessions at her place. This will lift her image in the community and people will start valuing her. This will have a positive impact on our programs also. We will be able to easily penetrate the community through her.

If a private doctor or Sarpanch is high on influence but is not having cordial relations with our workers. We can intervene and bring them closer. If he directly does not come closer, we develop cordial relations with one of his close acquaintances. This way we bring him in our favor so that his influence is utilized for purpose of our programs.

SHORTCOMINGS:

This exercise also has some shortfalls and an investigator needs to be vigilant about the same. When it comes to influencing, some people are stakeholders. They may claim to be important which they are not. Their supporters will strongly claim for their leaders. This is true for all in general and political leaders in particular. Again we need to undertake this exercise at various points of the village and involve all types of people. There are some areas which exclusively take medical help from government set up, they will say it is very useful and influential. While others who go to the private sector will say it to be useless. Individual variation also is there.

 

Focussed Group Discussion (FGD):

OBJECTIVES:

  1. To understand a problem in-depth and study all its facets like

a) Problem as perceived by a community

b) Concerns of the community regarding issues about it.

c) Different solutions to the problem

d) Plus and minus points of each solution

e) Social systems that prevail and have an influence on the problem

f) Strength and weakness of proposed solutions and systems to implement

  1. To sensitize group of people on some issue
  2. Impart health education
  3. Problem-solving

METHODOLOGY:

Select an issue that has many facets and no direct clear-cut solution. Now assemble a group of people. You will need a team of two group guides. One will be a moderator and the other will be a reporter. When you decide on some issue for discussion, prepare a list of questions you would like the group to address. If during discussion such issues do not surface, ask them. Let the group discussion of its own. The role of a moderator is only to keep the group on track. When you participate, keep in mind that your participation should be as neutral as possible. If the group realizes you are in favor of a particular answer, they might all sing with the tune. When you need to ask a question, this is even more relevant. The question should be carefully framed so that people would give their free and frank opinion. Reporting person should keep on writing whatever is discussed, along with the name of the person who spoke. He also should write in brief the tone of voice and a particular gesture that was obvious. Better if you can record on audiotape what was being discussed. You would need to keep two tapes, one running on battery and the other on electricity. Both of them are likely to fail. So if one fails, the other will act as backup. Another tip is that do not to start two fresh tapes simultaneously. Should the discussion continue for more than 30-45 minutes, you will need to change sides. The conversation that has occurred during the time for changing side or entire tape will be lost. You may keep 30 minutes tape in one recorder and 45 minutes tape in another one. Please test that recorders are running properly before initiation of discussion.

After the discussion is over, run the tapes and transcribe voice on paper. Play it twice or thrice to confirm that nothing is missed. Also, match it with your notes. While transcribing, add comments about tone or gestures.

SHORTCOMINGS:

Some people are talkative and strongly put forward their ideas. If some persons are shy, they may not come out with their ideas. When there is an atmosphere of ridicule, somebody may not come up with an innovative idea. Such ideas otherwise have the potential of changing the complexion of the issue. If only like-minded people are assembled they are likely to have similar concerns and similar solutions. This is a drawback of a homogenous group. Plus point is that because they are all from the same backdrop, they openly discuss, which may not be possible in a heterogeneous group. So if you can have many discussions, you may have some homogenous and some heterogeneous groups. If you can afford only one or two, heterogeneous groups are the only way. If you are using FGD for sensitization, heterogeneous groups may be preferred. So that participants get other’s points of view. Here you may consider plotting other people who are trained by you to put their point forward. So that you do not end up in hot conversation and also another person (other than the group to be sensitized) does not get hurt.

Group discussions tend to run away from the track. Full vigilance and shrewdness on part of the facilitator are required to keep the discussion on track.

In short, this is a very useful, multifaceted activity but requires good training for best results

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Healing Through Distance

India with over 1.3 billion population and a major part of it living in rural areas, faces concerns of inequitable healthcare due to greater demand, very crucial infrastructural challenges including poor access, and cost heavy medical facilities. Providing primary healthcare to one and all in our country is a Herculean task as the number of patients is more and diseases are varied in nature. The Doctor-Patient ratio indicates a huge divide and even urban-rural and gender gaps are major hurdles.

During Covid-19, the country saw that a surge in demand for healthcare and medical help was being sought by a greater number of people than ever before. To cater physically to a huge population became too much of a burden. Providing faster and quicker medical solutions, also accurate and efficient, posed a big challenge. That is where Telemedicine became handy. Those patients who needed hospital and personal medical attention were being catered to, but some patients could be handled online. Telemedicine, a digital healthcare system and effective communication technology, could serve a large number of patients regardless of their location, gender, age, class, or race.

First started with the support of ISRO (Indian Space Research Organization), Telemedicine got a boost when the Apollo group of Hospitals started using it. National Health Policy -2017. It advocated the extensive deployment of digital methods in healthcare. In 2019, Telemedicine guidelines for Health and wellness centers for Ayushman Bharat were released. The Prime Minister announced the National Digital Health Mission on 15th August 2020. Bharat net aims to cover 2,50,000 Gram Panchayats through Optical Fiber Network.

Democratic and universal, without physical pressures of logistics and infrastructural support, telemedicine reached out to people in cities, in villages, or any other remote and far-flung areas. No worries of transportation, no queues, no long wait for appointments; just by using simple online methods like WhatsApp, emails, or google hangouts a patient could get real-time medical solutions. Telemedicine companies swung into action; well equipped with the most advanced information and smart techniques, less burdened and faster in delivering medical support including diagnosis, referrals, offering medicinal support, guiding for the right kind of health facilities and where one could get it. Telemedicine also takes care of investigation and medical research and evaluation.

SO HOW DOES IT WORK?

Telemedicine delivers healthcare services by medical professionals using Information Communication Technology (ICTs) for the betterment of any patient, exchanging information, which is fast, accurate, and timely. It offers:

  • EQUITY

  • QUALITY

  • COST-EFFECTIVENESS

  • REALTIME INFORMATION

WHO has mentioned telemedicine as its recommendation for essential services to strengthen the healthcare rapid response in COVID-19. It can also serve as an important tool to identify hotspots, estimate the burden of disease and provide very easy solutions digitally.

During lockdowns and pandemic situations, telemedicine became one of the most trusted and sought-after services. Tests of all kinds, maintaining social distancing, and teleconsultations made it quite a comfortable digital medium to rely on.

WHAT ARE THE BENEFITS?

  • More accessible in rural areas

  • More women and young people can get medical advice

  • No transportation worries

  • Saves time

  • Reliable medical solutions provided

Many telemedicine companies are now working in India providing digital health solutions. Specially designed apps have come in which suit the requirements of the stakeholders.

Intelehealth is one such non-profit that provides robust telemedicine solutions by empowering NGOs , government and multilateral organization in setting up high tech and innovative telemedicine programs in rural and urban poor population.

Recognized by NITI Aayog and World Economic Forum, Intelehealth has developed an open-source digital health & telemedicine platform that empowers local community health workers in rural communities to provide access to primary care for patients in their communities. The platform consists of a mobile app for health workers and a cloud based electronic health record system as a backend (OpenMRS). The app works with very low bandwidth connection as well as offline.

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How Progressive Web Apps are used effectively in Telemedicine

Intelehealth is a Telemedicine platform that serves the last mile population where there are no doctors by enabling NGOs & Governments. At Intelehealth, Progressive Web App (PWA) is used with an aim to have easy access to the Intelehealth Doctor’s portal with just a click through the already installed light-weight PWA in any PWA-enabled device. If you are offline, you will not miss any notifications due to the streamlined firebase cloud messaging notifications. This feature will queue up all the notifications which will be visible to you whenever you  are next online.

WHAT IS PWA?

Progressive Web App (PWA) is a term used to denote a new software development methodology. Unlike traditional applications, progressive web apps are a hybrid of regular web pages (or websites) and a mobile application. This new application model attempts to combine features offered by most modern browsers with the benefits of mobile experience. It works on different platforms in every modern browser.

KEY ADVANTAGES:

  1. User can install PWA on the phone while browsing the website

  2. Provides fast loading, and efficiency of using services anytime, anywhere

  3. Lightweight and easy to install

  4. Works efficiently across all platforms

  5. Easily maintainable

  6. Low deployment cost

  7. Works in offline mode

  8. Supports push notifications like native apps

  9. Reduces device storage up to 25 times

  10. It can be installed in any low-end android devices

LET’S DIVE INTO THE DETAILS OF PWA’S –

The basic components are:

Service workers – Mainly for offline support architecture and background tasks. Rapid loading is also possible with service workers. It works in the background and performs Cloud notifications, Background sync, Background fetch, Offline Support, etc which a real application does, making it similar in working to a native application.

Web app exhibit – The web app exhibit is used to build the app with native-like features having an app icon on the home screen, UI, and which is nothing but web pages serving in offline mode, with support from a service worker.

It is not available on Play Store or Microsoft store as it is an actual website that behave and feels like a native app which gives you an option to install it. In the mobile app browser, it prompts at the bottom to ‘Add to the Home Screen’ while on the PC it will appear in the address bar and looks like a download button.

Here are some popular brands, who are using PWA’s –

  1. Google

  2. Instagram

  3. Uber

  4. Pinterest

  5. Twitter Lite

  6. Make my trip

  7. Forbes

  8. Progressive Web Apps are a new trend in web development. This technology brings incredible results, both for marketers and users. Efficient functioning together with quick and easy access to required data, make it User and Publisher friendly. All things considered, its likely to be the future of mobile websites and app development.

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Together we can make telemedicine reach the last mile

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