Mansa Health Care Assessment

This research study will engage 10 women that live in poverty in Mansa. Participants will each receive a digital camera along with photography training and orientation to the project. They will take photos that represent their experiences in accessing health care: the barriers, the benefits, what works well and what doesn’t.

The women will meet with me several times over a two week period to share and discuss their photos. They will eventually chose the most meaningful photos and, in a group setting, discuss their photos and the share their thoughts with the other women in the group. Lastly, they will provide captions to explain the meaning of their photos.

Selected photos will be printed and displayed at a public exhibition so that community members and health care leaders can hear the voices of these women through their photographs.

I hope that this project will benefit the city of Mansa by providing a starting point for examination and problem solving around issues of health care and by preparing community members to get involved and work toward change.

Assessing women's access to care in Zambia

What is it like in Mansa?

The area is one of the least developed areas in Zambia as measured by education, agriculture, health and road infrastructure.

• 129,000 people
• 1 hospital
• 80% live in poverty
• 70% have no access to clean water
• 70% of deaths occur at home 

Preparations

We arrived in Mansa yesterday after two 10 hours flights, one 90 minute flight and a 10 hour drive. We arrived with all cameras, printer and supplies intact after multiple TSA searches. Unfortunately the toothpaste that I inadvertently packed in the carry-on did not fare so well.

Today started out with an unexpected meeting with the 10 ladies that will be participating in the project. While I was very glad to meet them, I was surprised and unprepared when they arrived at 9:00. So I improvised and reminded myself TIA.

The rest of the day was spent checking the connections to the printer and projector and, reviewing the set up of the room, and organizing the food that will be served to the ladies for lunch over the next three days. Schola the cook for the orphan day care center prepared a menu and list of costs for each item for our review. For example, chickens for one of the lunches for 11 women was the equivalent of $8 US and rice $5 US. We then made a trip to the one grocery store in town - Shoprite - and bought the necessary food (along with sustenance for us as well).

The street that runs directly in front of the church/orphan center where we will be meeting with the women.

PhotoVoice Training - Day 1

Day 1 of training complete! John and I spent today getting to know the 10 lovely Zambian ladies that will be participating in the Let's Hear Your Voice project. After our awkward unplanned introductions yesterday where they pretty much just stared at me, I had quite a bit of trepidation.

The women really liked the initial icebreaker called Fire! Fire! (or Umulilo! Umulilo!). This required the women to get in different groups and answer questions about themselves (myself included). Some of the women know each other and others do not and they all seemed to enjoy and participate. Of course, none of this could be accomplished without translation from Delia. She is a charming and educated woman, probably about my age, but looks 10 years younger and she has 10 children. Her youngest child is the same age as one of her grandchildren. Her oldest daughter is also participating in the program. Translation is key as there are about a third of the women with very limited skills. Initially it was hard for me to ascertain this as they all give the impression that they speak the language well.

After introductions I gave an overview of PhotoVoice. I was uncertain if I could explain the idea in an articulate and culturally understandable way. Using a combination of resources from Rutgers, my coursework, and experience with culture of the Zambian people, I think that I was able to give a good basic overview. I did not present the information from a linear perspective, but tried to think more spherically (very unfamiliar to me!) and I think this was helpful. I revisited the same ideas several times from different aspects. I was pleased that I was able to generate engagement.

In the afternoon John went thorough photography basics using PowerPoints developed by Rutgers. This was a great resource to guide the discussion, however we were in a very hot room after lunch and I don't think that they relate to that style of learning. Although John did a great job, I think it was a little intimidating and somewhat hard for them to follow.

However all the women were very excited when we got to the hands on camera training. John went through all the functions of the camera and we provided individual instruction (it was a bit of chaos!). None of these women have ever used a camera before. Most of them have cell phone cameras, but were not familiar with zooming, setting up the focus, viewing the photos, etc.. About half of them caught on very quickly while the other half needed extra attention. Below are a few pictures of us during the camera training today. Sorry for the quality - the room we are in has terrible light.

PhotoVoice Training - Day 2

After spending the night violently ill and unsure if I was going to be able to conduct the training today, I managed to drag myself from bed and proceed as planned. 

Today we discussed about associating words and feelings with photos and did several critical thinking exercises. First, we did a word association with “health care” using sticky notes on the flip chart and then grouping in categories. There are definitely some in the group that found it challenging to think in this manner, but a few that jumped up and started moving the sticky notes around where they thought they belonged. The language barrier and dynamics of working with a translator add another layer of complexity.

For the “Found Photographs” exercise the women were split into two groups and they each had 10 photos to view. I said a word – like “angry” – and they had to choose together which photo best represented the word. They really enjoyed the exercise, but the pictures were too obviously associated with one specific word and this made it a bit simplistic and did not really accomplish what I was hoping to convey. I would definitely choose more complex and ambiguous photos in the future.

Lastly the women put together a variation of a mindmap where the research question was in the middle of a large piece of paper – “What are the barriers to getting health care?” The women then had to write three or four answers to that question and then think of ideas for one or two pictures that they could take to express their answer. This was understandably difficult and I acknowledged that it was okay of they couldn’t think of anything today. I walked around the room and tried to get them to think a little deeper. Many of them just said, “Lack of money” or “medication too expensive”, and I tried to get them to think of other or more specific ideas. This was a challenging exercise again made more complex by the language barrier. I began to get concerned that we would have 10 photographs of medicine bottles and kwacha.

So I had an impromptu “flipboard” discussion of:

• Where do you go when you are sick?
• Why don’t you get care when you are sick?
• What do you like about health care in Mansa?
• When do you seek health care?

This was very helpful for me to understand and it sparked a lively discussion (I asked each person to answer each question and then wrote it down on the flip chart). I think it also may have helped them think of “barriers” through a different perspective and realize health care is more than just the hospital and clinic. They asked for the list that was created through this exercise and thankfully our wireless portable printer is a champ and I was able to type up and print after the session as over.

An adorable petite woman named Precious made up a little song for me (at least I think she made it up) that they all sang/clapped together. It had something to do with being a graduate student and “you can” - basically meaning “you can do it!” The women here are so awesome!

PhotoVoice Training - Day 3

Training is complete! The ladies are launched into Mansa to take photos that answer the research question – what are the barriers to getting health care? As I told the ladies in closing today - I am done instructing them and now I will be the one listening.

Today was focused on photo exercises. John led the ladies in three activities where they could practice taking photos. In small groups the ladies first practiced taking pictures of each other in both dark and light locations. I’m not sure that they understood the purpose very well, but they enjoyed taking photos of each other. John (with help from Christo from AFnet) then reviewed all the photos. This involved taking the SIM card out of each camera, uploading their photos to a folder and using the projector to show images on the screen. Unfortunately the light and color that was projected was not the same as on the laptop. The next task was for them to take photos of objects and focus on composition: angles, rule of thirds and negative space. Again John, Christo and I provided individualized feedback. The women were visibly proud when John gave them praise for their work. There is definitely a whole different dynamic in the room when males are present. This worked very well for the photo training, but I am glad that any one-on-one or group sessions will be with the women only as they are much more relaxed and many more participate in discussions.

Lastly each of the three groups were given one word and they were instructed to go out in the community and take photographs of that word. Love – Family – Power. We reminded them of the three types of photographs that we have been talking about: reality, posed, or symbols. Many of the women took very literal pictures of their topic that were not very stimulating, but many did exhibit critical thinking and creativity.  A few are shown below:

LOVE

POWER

FAMILY

The photo exercises definitely took more time than I planned for and I would have devoted more time to this. It was also frustrating that we would ask them to only take eight photos and they would come back with 15-30 photos which we could obviously not review in a group setting in the given time. I am sure we missed reviewing some good photos. Despite repeated instruction about how to delete and how many to submit, it didn’t quite seem to sink in with them. I was also quite concerned when at the end of the day after many hours of discussion they could not tell me what the research question was. ACK! Hopefully I reinforced the question before they left.

At the close of the day, it got a bit disjointed and there was lots of confusion in Bemba about the schedule for the next few days and the consent. I definitely lost control! Tomorrow they will be “in the field” taking photos and Wednesday there will be a quick check-in to see if they are understanding the concept and allow them to ask questions. However I am not sure that they understood that this would be a quick drop-in check in and I am concerned they will ALL show up at 1:00PM. 

 Below is the group photo of these 10 beautiful lades and Delia our translator (next to me on the left).