Sm. Sci. Med. Vol. 35, No. 1 I, pp. 1389-1395, Printed in Great Britain. All rights reserved
0277-9536/92S5.00+ 0.00 Copyright Q 1992Pergamon Press Ltd
1992
DEVELOPING APPLIED MEDICAL ANTHROPOLOGY IN THIRD WORLD COUNTRIES: PROBLEMS AND ACTIONS PERTTI J. F'ELTO and GRETEL H. PELTO University of Connecticut, Storrs, CT 06269, U.S.A. Abstract-Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health. Key words-methodology, workshops
focussed
ethnographic
INTRODUCTION During the 1980s there has been a steady growth in demand for medical anthropologists in public health research, including research programs of the World Health Organization (WHO), projects funded from bilateral agencies, such as U.S./AID and IDRC, private foundations, and other agencies involved in primary health care in Third World countries. The interest in anthropological research reflects a growing realization on the part of health care planners and administrators that programs are likely to be more effective if they were tailored to fit more closely with peoples’ cultural beliefs and practices-information that is best gathered using ethnographic methodologies. North American and European anthropologists have been called on to play active roles in these program-related research activities, but most agencies would much prefer to recruit local (Third World) medical anthropologists and other social scientists for such endeavours. Usually, however, health and medical research teams and institutions operating in Third World countries have experienced serious difficulties in hiring well-trained, experienced medical anthropologists, even in countries with well established graduate programs in anthropology. The evidence to support this generalization is, for the most part, not documented in published sources but can be found in minutes and progress reports of projects funded by organizations such as those sponsored by ADDR (Applied Diarrhea1 Disease Research Project) and the Control of Diarrhoeal Diseases Programme of WHO. The lack of trained medical anthropologists would be expectable in many countries in Africa and SSM 3511I--F
studies,
qualitative
and quantitative,
training,
Southeast Asia where training in the social sciences has had very little time to develop. But countries such as Brazil, Mexico, India, and Peru have had their own anthropological training programs for many decades, in addition to which numbers of students from those countries have taken doctoral degrees in the social sciences abroad. In this paper we will explore some of the symptoms, explanations, and attempts to remedy what we perceive as serious gaps in training of medical social scientists, in North America and abroad. To begin it will be useful to describe the kinds of health care research projects to which we are referring. Many of these projects have broad similarities in structure and objectives: They are typically funded from international or external sources, such as U.S./AID, WHO, UNICEF, various European aid agencies, Ford Foundation, Rockefeller Foundation, and others. The projects usually have immediate practical objectives, often targeted health care programs in areas of child survival, maternal health and nutrition, or infectious disease. The research team is usually multi-disciplinary, with medical clinicians and epidemiologists playing central roles. Usually the director of the research has a medical degree. (In addition to these types of projects, some international health programmes such as the tropical disease research programme at WHO have explicit goals of funding more social science research in primary health care.) Social scientists are recruited into these research teams to provide additional data-gathering skills that are now regarded as essential for project success, including those that contribute to more effective communications with local populations (e.g. in design
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of interview questions and wording of health education messages). The research usually involves collaboration of European and North American researchers with local (Third World) health ministry and/or university personnel, health care practitioners and administrators. European and American researchers are frequently cast in the roles of ‘technical consultants’-in epidemiology, laboratory technoldata analysis. Often the ogy, or computerized European and North American researchers are prominently involved in the design of the research. Data collection is generally in the hands of local personnel, with strong emphasis on competence in local languages and dialects. Increasing attention is being paid to use of ‘culturally appropriate’ (local) interviewers and other data-gatherers. Equipment, including microcomputers and laboratory apparatus, is often brought in by the European and North American investigators, with the explicit intent that local personnel of the host country will receive training in the technical skills for operating it. The funding agency usually requires that projects must make explicit plans for institution development, which includes training of host country persons in advanced research skills. The training is expected to contribute to the capability of local researchers to carry out future research projects without outside technical assistance. With respect to method and theory, there are also commonalities in projects that cut across research topics: (i) Regardless of the specific health care topic involved, the research universe is usually seen to consist of households in designated communities or regions, although some projects focus on ‘the patients who come to -clinic or hospital.’ (An exception to this generalization about research design is seen in the increasing numbers of projects that focus on individual indigenous and/or cosmopolitan practitioners.) (ii) Most projects include a component of datagathering directed to ‘cultural belief systems and behaviors’ relevant to the primary research goals. This reflects some re-direction and re-defining of so-called ‘KAP studies,’ (knowledge, attitudes and practices). This sector of data is now seen to require the services of anthropologists or other social scientists. From the point of view of university training programs in Europe and America, the ideal professional to fill this role would be a medical anthropologist.
THE SCOPE OF THE PROBLEM
As noted above, there is little formal documentation or analysis of the problems health research programs have experienced in recruiting local (incountry) anthropologists or other qualified social scientists to work in multi-disciplinary projects.
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Therefore, the following items are offered as a preliminary inventory of issues for further discussion. In some of the developing countries of the world there are a small number of professionals who identify themselves as medical anthropologists. However, these few suitably trained medical anthropologists are in such high demand that they are over-committed and (usually) unavailable for new research initiatives. Many university-based undergraduate and graduate programs in the social sciences produce academically oriented theoreticians who have little training or inclination for applied field work. Apparently the concept of applied anthropology, or applied social sciences-whether in health fields or other areasstill carries a stigma of inferiority at major universities (in both industrialized and developing countries). Certain ‘traditional’ features of anthropology also seem to have negative effects on the suitability of anthropologists for multi-disciplinary health research. Many anthropologists maintain and teach the time-honored perspective of ‘holistic research,’ according to which any focussed research on specific health issues would first require many months of general ethnography. This perspective makes them unwilling to attempt the kinds of focussed, short-term research typically required by primary health care programs. In addition, there has been a tendency in some social science sectors to assume an adversarial stance toward medical and health care personnel, including epidemiological researchers. Medical practitioners are frequently portrayed as uniformly devoted to an organic, curative, high technology approach to health care. This stereotyping attitude leads to poor communication between the social scientists and clinical/epidemiological personnel in a research team. One of the more disturbing tendencies affecting medical anthropology has been the reluctance of many young anthropologists, including graduate students, to leave their urban bases to go out into rural research sites. In some instances it has even been difficult to get researchers into peri-urban communities. Part of the problem may be explained by the operation of structural constraints. Graduate students and young professionals often must engage in multi-job ‘moonlighting’ to meet minimal economic needs. They may be enmeshed in complex networks of obligations to part-time employers, odd-job opportunities, and other economic arrangements, which preclude their departure to distant communities. The problem is also exacerbated by a tendency in some metropolitan anthropological programs to favor ivory tower theorizing, which contributes to the perception that field research is of relatively little value. Another part of the problem is that many of the anthropologists who might be willing to participate are not fully qualified to function in such projects.
Developing
applied
Often they do not have the necessary training in research design, and are weak in both quantitative skills and qualitative data-gathering and analysis techniques. Increasingly, multi-disciplinary applied research has included systematic qualitative research that is closely articulated with quantitative data-gathering by epidemiologists [ 11. Therefore, medical anthropologists should have an understanding of the interrelations of qualitative to quantitative data, with methodological tools for achieving those linkages. Anthropologists are no longer given free rein to work in splendid isolation, to develop general ethnographic descriptions that will serve as an ‘introductory chapter’ to the clinical and epidemiological materials. Detailed ethnographic work on cultural health beliefs and practices is now expected to articulate directly with quantified survey research, and the anthropologist is usually expected to work closely with the epidemiologists in developing the more structured data. SOURCES OF THE PROBLEM
Given the multiplicity of factors involved, no single underlying process or principle can fully account for the problem of the ‘missing medical anthropologists’ in the Third World. However, we suggest that, to a large degree, the primary causes of the problem are to be found in the nature of graduate training in anthropology in North American and European universities. Anthropology programs in the Third World tend to be weak in applied training, weak in methodology, and generally lacking in effective training in medical anthropology (and related social sciences) because of the direct and indirect influences of the social sciences as practiced in North American and European universities. Some of the training of Third World anthropologists in American and European institutions comes about through contacts that are established when American and European social scientists conduct research projects in developing countries. Often the types of projects that lead to opportunities for training in the researchers’ home institutions are extensive, multi-year research projects organized and funded by North Americans and Europeans. Such projects have rarely been applied in orientation; more often they have been focussed on descriptive and theoretical work. (Projects in the heyday of applied anthropology at Cornell-notably the Vices Project and some of the work at Bang Chan in Thailand-are important exceptions to this generalization.) Even when the focus of work is on an applied problem, the North American researchers and their host country colleagues have tended to present their results in discipline-based academic publications, with less concern for inter-disciplinary communication of the type that can develop longer term applied teamwork. Also, applied anthropological re-
medical
anthropology
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search has often focused on ‘what went wrong’-with only peripheral collaboration or communication with the country-based organizations that carry out the applied programs. Anthropological studies of ‘what went wrong,’ in health programs have often been carried out with little knowledge or appreciation of the complex clinical and epidemiological issues. Even today many applied social scientists are ill-informed about the technical issues in health, agriculture, or economic development in which evaluations or critical assessments of programs are conducted. Most important, in our opinion, is the lack of adequate attention to methodology training that has characterized anthropology until quite recently. Like many North American anthropologists, Third World anthropologists, whether trained at home or abroad, often have not received training in research methodology. A recent survey by Trotter [2] demonstrated that even today many of our major graduate programs in anthropology include very little formal methodological training. The lack of effective training in, and appreciation of, quantitative research methodology seems to be even more serious in many Third Work anthropology departments than it is in North American academe. At the same time, recent developments in sophisticated qualitative research are very slow in reaching Third World academic centers, largely because they cannot afford to travel to meetings or acquire the journals and books in which the newest developments are reported. Attention to methodological training is stronger in sociology, but has not been particularly directed to applied research. Also, in sociology the qualitative and quantitative methodologies have tended to be sharply opposed to each other, without the blending of both approaches that is now developing in the medical anthropology of the 1980s and 1990s. Although our focus in this discussion thus far has been specifically directed to the lack of qualified medical anthropologists in Third World countries, the main issue is not a matter of a particular discipline, but rather, the practical needs for effective researchers in applied community health programs. The following section will address this broader area, with the assumption that medical anthropology has a major part to play in all areas of community health work. THE ROLE OF WORKSHOPS IN PREPARING SOCIAL SCIENTISTS FOR COMMUNITY HEALTH RESEARCH
Recently there has been a rapid growth in training workshops and other short-term training programs organized for the purpose of developing expertise in health-related social sciences research in Third World countries. A number of agencies and foundations that fund applied research in health care have sponsored workshops for developing methodological skills. We will discuss two examples of such efforts, in order to highlight some of the trends, and possible lessons, for the 1990s.
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and
The Triangle Programme (Universities of Antwerp, Connecticut and Peradeniya, Sri Lanka) [3]
In the summer of 1990 a four week workshop was held at the University of Antwerp in which the participants were twelve Sri Lankan professionals in health-related research. The faculty consisted of social scientists and epidemiologists from the three participating universities, who presented a blend of quantitative and qualitative research methods in the context of research proposal design. The lectures, discussions and individual consulting sessions were evenly divided between anthropologists and epidemiologists. The Sri Lankan participants were recruited from anthropology, agriculture, community medicine, economics, pediatrics, psychiatry, and sociology. The outcome of the first workshop consisted of 12 completed proposals for field work. The second phase of the program is the field work in Sri Lanka. Each of the participants was assigned a modest budget for field personnel, equipment, supplies and transportation. They were expected to complete data collection over an 11 month period, with completion dates in the early summer, 1991. Members of the workshop faculty made site visits to Sri Lanka to advise on details of data-gathering and preliminary analysis. In the summer of 1991 the participants and faculty reconvened in a workshop in Antwerp to pursue data analysis and write-up of the individual projects. In addition to their resources, the participants have the support of a Resources Center, also funded by the training program. Microcomputer equipment, a parttime computer specialist, some community health and methodology literature, and other resources are available in the Resource Center. The Resource Center is managed by the Center for Intersectoral Community Health Studies (CICHS), which is an interdisciplinary group of faculty researchers at the University of Peradeniya. The initiative for the CICHS interdisciplinary group was developed primarily by researchers from the Faculty of Medicine. Building social science research for wornens’ reproductive health in India
Our second example also concerns training of researchers in South Asia-in India. Sponsored by the Ford Foundation, several non-governmental organizations (NGOs) are carrying out applied research in women’s health issues in a number of urban and rural sites. The research groups are multi-disciplinary and consist of various combinations of medical doctors, anthropologists, sociologists, social workers, and computer scientists. Unlike the individuals in the Sri Lanka training program, the researchers in India carry out their studies as group efforts. Furthermore, plans are being made for sharing of data among the several sites. The training workshops and site visits are carried out primarily by anthropologists from the Johns Hopkins School of Hygiene, with participation
GRETEL
H. PELTO
of faculty from India as well [4]. The first training workshop for the NGO groups was held in New Delhi in February, 1990, and follow-up workshops were held in Baroda (Gujarat) in October, 1990 and April, 1991. Since each NGO group includes clinical personnel, social scientists, and usually a computer specialist, the workshops have been rather large-20 to 30 participants. Visits to the various NGOs were carried out by the North American technical advisers, particularly during the summers of 1990 and 1991. These visits, at the invitation of the individual NGOs, are intended to provide instruction and advice concerning the on-going data collection, as well as assistance with computerized data processing and analysis. The workshops have emphasized qualitative ethnographic methodology, particularly because the research teams were already somewhat experienced in conducting structured, quantitative surveys. Because of the emphasis on focussed qualitative methods, most of the ‘faculty’ are medical anthropologists. Like the Antwerp workshop, the training program in India is considered interdisciplinary-“social science research in community health,” regardless of the composition of the faculty involved. The Antwerp-Connecticut-Sri Lankan Training program and the Ford Foundation workshops in India are but two examples of recent experiments aimed at enhancing social sciences research in community health in Third World countries. Other workshop activities of a similar nature include the proposal development workshops of the Applied Diarrhea1 Disease Research Project (ADDR), World Health Organization (programs in diarrhea1 disease, acute respiratory infections, AIDS and others), and a series of recent workshops conducted by Susan Scrimshaw and colleagues, which utilize the Rapid Assessment Procedures (RAP) [5].
The workshops and related training programs that have evolved in recent years tend to have several common features: Training is oriented to an interdisciplinary framework. Individual sessions may focus attention on specific anthropological or epidemiological materials, but the research tools are presented as a connected whole, in which data-gathering is directed to resolution of particular health problems, rather than discipline-specific theoretical issues. Trainees are from a mixture of disciplines-medicine, anthropology, sociology, economics, etc.-and those disciplinary backgrounds are regarded as equivalent in knowledge and legitimacy in relation to community-based health research. The participants are also a mixture with regard to their age and level of training. For example, in the Ford Foundation workshops, some of the participants have many years of experience as medical practitioners in community health contexts. Others, in both the Indian and Sri Lankan training programs are young newcomers to community health research.
Developing applied medical anthropology
Faculty, also, are usually from several disciplines, which are viewed as complementary in the complex mosaic of qualitative and quantitative research. Epidemiologists, anthropologists, sociologists, clinicians and biostatisticians teach and tutor in an integrated “social science of community health research.” The Ford Foundation program in India is an exception in this respect, as most of the faculty thus far have been anthropologists, because of the emphasis on qualitative research methods. The faculty in the Antwerp workshop included clinical, epidemiological, and social scientists from Sri Lanka. In the India workshops, too, the presentations and tutoring included Indian nationals. Training programs seek a balance between local and European/North American faculty. Such balance is perhaps most difficult to achieve in medical anthropology, due to the scarcity of well-trained, applied anthropologists discussed earlier. Workshop content includes instruction in the use of microcomputers for data entry, processing and analysis. Microcomputers are increasingly regarded as essential tools for community-based health care research, as they can ‘liberate’ small and isolated research groups from dependency on the bureaucratic complexities of mainframe computer use. The software programs for community health research (as well as other kinds of research) are increasing in sophistication, and that sophistication includes greater ease of use. Statistical programs, database management programs, procedures for indexing and searching text files, and a variety of other types of programs have been developed that are well-suited to community-based research. Some of the more useful general-purpose programs are in the public domain (notably the versatile EPI-INFO program developed at the Center for Disease Control [6], and a new set of computer tools for structured qualitative data called ANTHROPAC [7]. With respect to instruction in computer applications, the main difference between the Antwerp and India workshops is that the microcomputer work in India is largely devoted to management of fieldnotes and other textual data, while the computer instruction in Antwerp concentrated more on statistics. Both components are seen as necessary elements of effective community health research. The training programs are often directed to applied questions in the locations where the participants are currently involved. This pragmatic orientation is very useful in orienting and motivating participants and for identifying the optimal mix of training components. Despite the specific local focus, individuals are expected to generalize their research skills to other contexts and other questions. Sites for the training sessions have been selected to reduce transportation costs while insuring adequate facilities, including microcomputers, for effective training. Placing the workshop sessions near on-going community health projects makes it possible to include direct, field-
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based data collection in the training process. For example, in the Ford Foundation workshops, activities have included key informant interviewing and exercises in direct observation in community settings, in order to make the instruction as concrete as possible. Workshop length is somewhat variable, typically one to two weeks. However, the workshop in Antwerp was four weeks long, which permitted the faculty to cover a comprehensive range of topics in statistics, methodology, and microcomputer utilization, still leaving sufficient time for consultations on individual research proposals. This longer workshop was possible because the participants were mainly from an academic base. Researchers from NGOs usually work within stricter time frames, so that two weeks seems to be a maximum length.
GUIDELINES
FOR FOCUSSED
DATA COLLECTION
ACTIVITIES
As stated above, new developments in applied research during the 1980s and 1990s include the perception that foamed ethnographic data on specific topics is needed by community health programs. Perhaps the clearest example is in diarrhea1 disease control programs, in which it now seems almost universally accepted that programs need to have specific information on local cultural terminology about ‘types of diarrhea,” as well as other aspects of cultural belief systems that constitute what Kleinman has referred to as ‘explanatory models’ of illness [8]. Many other sectors of community health research include similar needs for data about cultural belief systems and/or behaviors related to specific health problems. However, it has become increasingly apparent that few effective guidelines exist for specific, focussed data-gathering. Books and articles on ethnographic methods are usually intended for use by graduate students involved in theoretical, academic research. Until recently there have been very few ethnographic analogues to the nutritionists’ ‘24 hr recall method’ for food intake data, or the social psychologists’ specific protocols for observing and coding childrens’ play (for example). In earlier decades anthropologists used some highly structured personality tests adapted from psychology, but many of those research tools have been abandoned in the past two decades. The predominant view in anthropology has appeared to be that: (i) Many different methods and techniques are equally valid and useful for collecting the data about specific health belief systems. (ii) No useful purpose would be served, and perhaps harm might result, from attempts to standardize or ‘codify’ the techniques for collection of specific types of data.
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(iii) There is no need to test several different methods for their relative efficacy of data collection. (iv) Graduate students and other researchers can find out about the various alternative methods, or invent their own, without specific guidance or guidelines. In the applied community health research of the 1980s and 1990s this laissez faire attitude toward qualitative research techniques has become increasingly untenable. Applied programs need research techniques and guidelines that do not require great amounts of time, and which can be transmitted to non-anthropologist field workers. In programs such as the Ford Foundation sponsored work in India, the exchanging of data across several community-based research groups practically requires that they share some common data-gathering tools and language. Specific guidelines for ethnographic data-gathering are not wholly new in community health research. For example, at the beginning of the 1980s T. Marchione prepared a field manual with specific ethnographic research guidelines for a multi-nation study of infant feeding practices carried out under the auspices of the Population Council, Cornell University and Columbia University [9]. The field manual specified the numbers of informants to be interviewed and questions to be asked. Similarly, G. Pelto designed a field manual for ethnographic study of infant feeding practices in northern Cameroon [lo, 111. The RAP Manual [5] also presents guidelines for specific data-gathering, as well as models of data analysis, intended for ‘improving programme effectiveness’ in nutrition and primary health care. The appendix of the manual includes outlines for ‘exit interviews of patients’ (at community health centers), interview of staff of pharmacies, protocols for observing chnical encounters, and other specific data-gathering templates. The paper by Herman and Bentley in this volume also underscores the growing importance of data-gathering guidelines and manuals. Additional development of guidelines and protocols, as well as methodological studies of reliability and validity of specific data collection procedures, will be important future activities to further the development of applied medical anthropology in Third World countries. POST GRADUATE
TRAINING
NEEDS
Short term training workshops and research guidelines are tools directed to a larger issue, namely the matter of post graduate training for applied researchers. Almost no one today would deny that applied problems throughout the world-in health care and other sectors-are fraught with great complexity. Moreover, anthropologists have been among the social scientists most likely to point out those complexities. We wonder, then, why the field of anthropology has very little in the way of organized
H.
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post-graduate ‘continuing education’. Many other professional sectors, notably in clinical sciences, require their practitioners to periodically upgrade their knowledge and technical skills. Why not in anthropology? Traditionally, anthropological training has been based on the image of the lone fieldworker who learned all he or she needed to know through direct immersion in the field work experience. Third World anthropologists, often trained initially in North American or European programs, have suffered from the basic shortcomings of graduate training programs that fail to provide students with adequate methodological tools. In addition, they face the further disadvantage of having much less recourse to newer learning through publications, frequent colloquium speakers, and all the other high-cost communications features of modern university systems. Most Third World programs suffer from severe shortages in publications, lack of travel funds, and other handicaps that seriously hinder any attempts to upgrade professional expertise. We suggest that medical anthropology, and in fact the entire anthropological enterprise, needs to have a coherent system of post-doctoral professional training. Mertens and Pelto [12] have discussed the needs for such advanced training programmes in connection with interdisciplinary nutritional science research. They call for upgrading the basic structure of graduate training for nutritional anthropologists, in addition to which they suggest short-term workshops and other modes of advanced training for persons already fully involved in professional work. Similar advanced training programs are needed in all areas of applied social sciences.
RELATIONSHIP!3
OF METHODOLOGY
COMMUNITY
HEALTH
AND THEORY
IN
TRAINING
The workshops in Antwerp and India, and similar workshops elsewhere, typically include very little discussion of theoretical models and frameworks. There are several reasons for this: Many of the people involved in community health programs, are suspicious of academic ‘theorizing’, and feel that any research should be pragmatic, focused on ‘just the facts’, so discussions about theory would be a waste of time. Also, it can be argued that most of the basic research tools-key informant interviewing, direct observation, structured surveys, and focus group discussions-are data-gathering techniques that can be considered ‘theory-neutral’. That is, they are useful techniques regardless of the theoretical perspectives that are used in data analysis and interpretation. In reality, however, every instance of research, no matter how applied, involves some theoretical assumptions. The growth of interest in cultural belief systems, ‘explanatory models’, and other ideational materials is based on theoretical assumptions con-
Developing applied medical anthropology cerning the importance of cultural factors in explaining health seeking decisions and other behaviors. Similarly, most community researchers collect information on differences in occupations, material goods, and other indicators of ‘socioeconomic status’, because of assumptions about the significance of material factors in affecting health behaviors. Statements by community health researchers are often laced with assumptions and statements that represent (often unrecognized) theoretical models. The paper in this collection by Stanton, Black, Engle and Pelto [13] examines some of the different theoretical perspectives that may be useful in various aspects of applied research in community health. There is clearly a growing need for theory-building in this sector of community health programs. On the other hand, the experiences in recent methodology workshops suggest that training in specific datagathering techniques can be carried out with only minimal reference to theoretical frameworks and models. SOME DIRECIXONS
FOR THE FUTURE
We will conclude this brief overview with a list of suggested skill- and knowledge-development components for facilitating effective social science research in community health programs:
(i) Basic training in research design, with particular (ii)
(iii)
(iv)
(v)
(vi)
attention to the need to integrate designs with contemporary thinking in epidemiology. Skill development workshops in up-to-date methods of systematic qualitative assessment of cultural belief systems and related behaviors. Skill development workshops in quantitative, field-based data gathering, including both structured interviews and structured direct observations of behavior. Basic training in statistics, with particular attention to the needs of researchers who work with relatively small samples, multiple variables, and nominal/ordinal levels of measurement. Skill development in the use of microcomputers for both qualitative and quantitative data analysis. Workshops on recent developments in key areas of medicine and health care, including diarrhea/ ORT, acute respiratory infections, AIDS, tropical fevers (malaria, dengue, etc.) and latest concepts in the nutritional sciences.
It should be apparent to the initial training,
that these components apply as well as the continuing
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education of, medical anthropologists and other social scientists in the arena of community health (primary health care). Moreover, with the exception of the specific contents in the last item, these suggestions apply as well to the training and professional upgrading that should take place in all graduate programs in the social sciences.
REFERENCES
1. Trostle
2.
J. Anthropology and epidemiology in the twentieth century: a selective history of collaborative projects and theoretical affinities, 1920-1970. In Anthropology and Epidemiology (Edited by Janes C. R., Stall R. and Gifford S. M.), pp. 59-96. Reidel, Dortrecht, 1986. Trotter R. T. Research methods training requirements
in anthropology (commentary). Anthropol. Newsleft. 29, (7), 28, 1988. Programme of 3. Lewis J. and Peters R. The Triangle Health Social Science Research & Training. Proposal funded by ABOS (Belgian aid organization), VLIR (Flemish Inter-University Council) and the EEC. Denartment of Communitv Medicine, University of Connecticut, Farmington, CT 06032, 1990. J. Building Social Science 4. Bentlev M. and Gittelsohn Resea&h for Women’s Reproductive Health in India. Proposal to Ford Foundation/New Delhi, India, 1990. S. C. M. and Hurtado E. Rapid Assessment 5. Scrimshaw Procedures: For Nutrition and Primary Health Care. United Nations University and UCLA Latin American Center, Tokyo, 1987. 6 Dean A. G., Dean J. A., Burton A. H. and Dicker R. C. EPI INFO, Version 5: A Word Processing, Database, and Statistics Program for Epidemiology on Microcomputers. USD, Inc. Stone Mountain, GA, 1990. S. ANTHROPAC. (Software program for I Borgatti management and analysis of structured qualitative data). University of South Carolina, 1989, 1990. A. Patients and Healers in the Context of 8. Kleinman Culrure. University of California Press, Berkeley, 1986. T. Ethnoaraohic studv: Phase I. Field 9. Marchione _ . manual. Infant feeding practices -study. Population Council/Columbia University/Cornell University. Unpublished Technical Paper, 198 I. 10. Pelto G. H. Consultant Report for Cameroon. Project on Effect of Food Availability and Infant Feeding Practices on Nutritional Status of Children O-23 months. Report one. Newton, Mass: Educational Development Center. (Dept of Nutritional Sciences; University of Connecticut, Storrs, CT 06269) 1983. Studies of the Effects of Food 11. Pelto G. H. Ethnographic Availabilitv and Feedina Practices. Food Nurr. Bull. 6, (1) 3343: 1984. 12. Mertens M. L. and Pelto G. H. Training and personnel issues in the introduction of social and behavioral components into nutrition programmes and research. Food Nutr. Bull. 10. (4). 16-19, 1989. B., Black R.; ‘Engle P. and Pelto G. Theory13. Stanton driven behavioral intervention research for the control of diarrhea1 research. Sot. Sci. Med. 35, 1405-1420, 1992.
0277-9536/92S5.00+ 0.00 Copyright Q 1992Pergamon Press Ltd
1992
DEVELOPING APPLIED MEDICAL ANTHROPOLOGY IN THIRD WORLD COUNTRIES: PROBLEMS AND ACTIONS PERTTI J. F'ELTO and GRETEL H. PELTO University of Connecticut, Storrs, CT 06269, U.S.A. Abstract-Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health. Key words-methodology, workshops
focussed
ethnographic
INTRODUCTION During the 1980s there has been a steady growth in demand for medical anthropologists in public health research, including research programs of the World Health Organization (WHO), projects funded from bilateral agencies, such as U.S./AID and IDRC, private foundations, and other agencies involved in primary health care in Third World countries. The interest in anthropological research reflects a growing realization on the part of health care planners and administrators that programs are likely to be more effective if they were tailored to fit more closely with peoples’ cultural beliefs and practices-information that is best gathered using ethnographic methodologies. North American and European anthropologists have been called on to play active roles in these program-related research activities, but most agencies would much prefer to recruit local (Third World) medical anthropologists and other social scientists for such endeavours. Usually, however, health and medical research teams and institutions operating in Third World countries have experienced serious difficulties in hiring well-trained, experienced medical anthropologists, even in countries with well established graduate programs in anthropology. The evidence to support this generalization is, for the most part, not documented in published sources but can be found in minutes and progress reports of projects funded by organizations such as those sponsored by ADDR (Applied Diarrhea1 Disease Research Project) and the Control of Diarrhoeal Diseases Programme of WHO. The lack of trained medical anthropologists would be expectable in many countries in Africa and SSM 3511I--F
studies,
qualitative
and quantitative,
training,
Southeast Asia where training in the social sciences has had very little time to develop. But countries such as Brazil, Mexico, India, and Peru have had their own anthropological training programs for many decades, in addition to which numbers of students from those countries have taken doctoral degrees in the social sciences abroad. In this paper we will explore some of the symptoms, explanations, and attempts to remedy what we perceive as serious gaps in training of medical social scientists, in North America and abroad. To begin it will be useful to describe the kinds of health care research projects to which we are referring. Many of these projects have broad similarities in structure and objectives: They are typically funded from international or external sources, such as U.S./AID, WHO, UNICEF, various European aid agencies, Ford Foundation, Rockefeller Foundation, and others. The projects usually have immediate practical objectives, often targeted health care programs in areas of child survival, maternal health and nutrition, or infectious disease. The research team is usually multi-disciplinary, with medical clinicians and epidemiologists playing central roles. Usually the director of the research has a medical degree. (In addition to these types of projects, some international health programmes such as the tropical disease research programme at WHO have explicit goals of funding more social science research in primary health care.) Social scientists are recruited into these research teams to provide additional data-gathering skills that are now regarded as essential for project success, including those that contribute to more effective communications with local populations (e.g. in design
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of interview questions and wording of health education messages). The research usually involves collaboration of European and North American researchers with local (Third World) health ministry and/or university personnel, health care practitioners and administrators. European and American researchers are frequently cast in the roles of ‘technical consultants’-in epidemiology, laboratory technoldata analysis. Often the ogy, or computerized European and North American researchers are prominently involved in the design of the research. Data collection is generally in the hands of local personnel, with strong emphasis on competence in local languages and dialects. Increasing attention is being paid to use of ‘culturally appropriate’ (local) interviewers and other data-gatherers. Equipment, including microcomputers and laboratory apparatus, is often brought in by the European and North American investigators, with the explicit intent that local personnel of the host country will receive training in the technical skills for operating it. The funding agency usually requires that projects must make explicit plans for institution development, which includes training of host country persons in advanced research skills. The training is expected to contribute to the capability of local researchers to carry out future research projects without outside technical assistance. With respect to method and theory, there are also commonalities in projects that cut across research topics: (i) Regardless of the specific health care topic involved, the research universe is usually seen to consist of households in designated communities or regions, although some projects focus on ‘the patients who come to -clinic or hospital.’ (An exception to this generalization about research design is seen in the increasing numbers of projects that focus on individual indigenous and/or cosmopolitan practitioners.) (ii) Most projects include a component of datagathering directed to ‘cultural belief systems and behaviors’ relevant to the primary research goals. This reflects some re-direction and re-defining of so-called ‘KAP studies,’ (knowledge, attitudes and practices). This sector of data is now seen to require the services of anthropologists or other social scientists. From the point of view of university training programs in Europe and America, the ideal professional to fill this role would be a medical anthropologist.
THE SCOPE OF THE PROBLEM
As noted above, there is little formal documentation or analysis of the problems health research programs have experienced in recruiting local (incountry) anthropologists or other qualified social scientists to work in multi-disciplinary projects.
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Therefore, the following items are offered as a preliminary inventory of issues for further discussion. In some of the developing countries of the world there are a small number of professionals who identify themselves as medical anthropologists. However, these few suitably trained medical anthropologists are in such high demand that they are over-committed and (usually) unavailable for new research initiatives. Many university-based undergraduate and graduate programs in the social sciences produce academically oriented theoreticians who have little training or inclination for applied field work. Apparently the concept of applied anthropology, or applied social sciences-whether in health fields or other areasstill carries a stigma of inferiority at major universities (in both industrialized and developing countries). Certain ‘traditional’ features of anthropology also seem to have negative effects on the suitability of anthropologists for multi-disciplinary health research. Many anthropologists maintain and teach the time-honored perspective of ‘holistic research,’ according to which any focussed research on specific health issues would first require many months of general ethnography. This perspective makes them unwilling to attempt the kinds of focussed, short-term research typically required by primary health care programs. In addition, there has been a tendency in some social science sectors to assume an adversarial stance toward medical and health care personnel, including epidemiological researchers. Medical practitioners are frequently portrayed as uniformly devoted to an organic, curative, high technology approach to health care. This stereotyping attitude leads to poor communication between the social scientists and clinical/epidemiological personnel in a research team. One of the more disturbing tendencies affecting medical anthropology has been the reluctance of many young anthropologists, including graduate students, to leave their urban bases to go out into rural research sites. In some instances it has even been difficult to get researchers into peri-urban communities. Part of the problem may be explained by the operation of structural constraints. Graduate students and young professionals often must engage in multi-job ‘moonlighting’ to meet minimal economic needs. They may be enmeshed in complex networks of obligations to part-time employers, odd-job opportunities, and other economic arrangements, which preclude their departure to distant communities. The problem is also exacerbated by a tendency in some metropolitan anthropological programs to favor ivory tower theorizing, which contributes to the perception that field research is of relatively little value. Another part of the problem is that many of the anthropologists who might be willing to participate are not fully qualified to function in such projects.
Developing
applied
Often they do not have the necessary training in research design, and are weak in both quantitative skills and qualitative data-gathering and analysis techniques. Increasingly, multi-disciplinary applied research has included systematic qualitative research that is closely articulated with quantitative data-gathering by epidemiologists [ 11. Therefore, medical anthropologists should have an understanding of the interrelations of qualitative to quantitative data, with methodological tools for achieving those linkages. Anthropologists are no longer given free rein to work in splendid isolation, to develop general ethnographic descriptions that will serve as an ‘introductory chapter’ to the clinical and epidemiological materials. Detailed ethnographic work on cultural health beliefs and practices is now expected to articulate directly with quantified survey research, and the anthropologist is usually expected to work closely with the epidemiologists in developing the more structured data. SOURCES OF THE PROBLEM
Given the multiplicity of factors involved, no single underlying process or principle can fully account for the problem of the ‘missing medical anthropologists’ in the Third World. However, we suggest that, to a large degree, the primary causes of the problem are to be found in the nature of graduate training in anthropology in North American and European universities. Anthropology programs in the Third World tend to be weak in applied training, weak in methodology, and generally lacking in effective training in medical anthropology (and related social sciences) because of the direct and indirect influences of the social sciences as practiced in North American and European universities. Some of the training of Third World anthropologists in American and European institutions comes about through contacts that are established when American and European social scientists conduct research projects in developing countries. Often the types of projects that lead to opportunities for training in the researchers’ home institutions are extensive, multi-year research projects organized and funded by North Americans and Europeans. Such projects have rarely been applied in orientation; more often they have been focussed on descriptive and theoretical work. (Projects in the heyday of applied anthropology at Cornell-notably the Vices Project and some of the work at Bang Chan in Thailand-are important exceptions to this generalization.) Even when the focus of work is on an applied problem, the North American researchers and their host country colleagues have tended to present their results in discipline-based academic publications, with less concern for inter-disciplinary communication of the type that can develop longer term applied teamwork. Also, applied anthropological re-
medical
anthropology
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search has often focused on ‘what went wrong’-with only peripheral collaboration or communication with the country-based organizations that carry out the applied programs. Anthropological studies of ‘what went wrong,’ in health programs have often been carried out with little knowledge or appreciation of the complex clinical and epidemiological issues. Even today many applied social scientists are ill-informed about the technical issues in health, agriculture, or economic development in which evaluations or critical assessments of programs are conducted. Most important, in our opinion, is the lack of adequate attention to methodology training that has characterized anthropology until quite recently. Like many North American anthropologists, Third World anthropologists, whether trained at home or abroad, often have not received training in research methodology. A recent survey by Trotter [2] demonstrated that even today many of our major graduate programs in anthropology include very little formal methodological training. The lack of effective training in, and appreciation of, quantitative research methodology seems to be even more serious in many Third Work anthropology departments than it is in North American academe. At the same time, recent developments in sophisticated qualitative research are very slow in reaching Third World academic centers, largely because they cannot afford to travel to meetings or acquire the journals and books in which the newest developments are reported. Attention to methodological training is stronger in sociology, but has not been particularly directed to applied research. Also, in sociology the qualitative and quantitative methodologies have tended to be sharply opposed to each other, without the blending of both approaches that is now developing in the medical anthropology of the 1980s and 1990s. Although our focus in this discussion thus far has been specifically directed to the lack of qualified medical anthropologists in Third World countries, the main issue is not a matter of a particular discipline, but rather, the practical needs for effective researchers in applied community health programs. The following section will address this broader area, with the assumption that medical anthropology has a major part to play in all areas of community health work. THE ROLE OF WORKSHOPS IN PREPARING SOCIAL SCIENTISTS FOR COMMUNITY HEALTH RESEARCH
Recently there has been a rapid growth in training workshops and other short-term training programs organized for the purpose of developing expertise in health-related social sciences research in Third World countries. A number of agencies and foundations that fund applied research in health care have sponsored workshops for developing methodological skills. We will discuss two examples of such efforts, in order to highlight some of the trends, and possible lessons, for the 1990s.
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and
The Triangle Programme (Universities of Antwerp, Connecticut and Peradeniya, Sri Lanka) [3]
In the summer of 1990 a four week workshop was held at the University of Antwerp in which the participants were twelve Sri Lankan professionals in health-related research. The faculty consisted of social scientists and epidemiologists from the three participating universities, who presented a blend of quantitative and qualitative research methods in the context of research proposal design. The lectures, discussions and individual consulting sessions were evenly divided between anthropologists and epidemiologists. The Sri Lankan participants were recruited from anthropology, agriculture, community medicine, economics, pediatrics, psychiatry, and sociology. The outcome of the first workshop consisted of 12 completed proposals for field work. The second phase of the program is the field work in Sri Lanka. Each of the participants was assigned a modest budget for field personnel, equipment, supplies and transportation. They were expected to complete data collection over an 11 month period, with completion dates in the early summer, 1991. Members of the workshop faculty made site visits to Sri Lanka to advise on details of data-gathering and preliminary analysis. In the summer of 1991 the participants and faculty reconvened in a workshop in Antwerp to pursue data analysis and write-up of the individual projects. In addition to their resources, the participants have the support of a Resources Center, also funded by the training program. Microcomputer equipment, a parttime computer specialist, some community health and methodology literature, and other resources are available in the Resource Center. The Resource Center is managed by the Center for Intersectoral Community Health Studies (CICHS), which is an interdisciplinary group of faculty researchers at the University of Peradeniya. The initiative for the CICHS interdisciplinary group was developed primarily by researchers from the Faculty of Medicine. Building social science research for wornens’ reproductive health in India
Our second example also concerns training of researchers in South Asia-in India. Sponsored by the Ford Foundation, several non-governmental organizations (NGOs) are carrying out applied research in women’s health issues in a number of urban and rural sites. The research groups are multi-disciplinary and consist of various combinations of medical doctors, anthropologists, sociologists, social workers, and computer scientists. Unlike the individuals in the Sri Lanka training program, the researchers in India carry out their studies as group efforts. Furthermore, plans are being made for sharing of data among the several sites. The training workshops and site visits are carried out primarily by anthropologists from the Johns Hopkins School of Hygiene, with participation
GRETEL
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of faculty from India as well [4]. The first training workshop for the NGO groups was held in New Delhi in February, 1990, and follow-up workshops were held in Baroda (Gujarat) in October, 1990 and April, 1991. Since each NGO group includes clinical personnel, social scientists, and usually a computer specialist, the workshops have been rather large-20 to 30 participants. Visits to the various NGOs were carried out by the North American technical advisers, particularly during the summers of 1990 and 1991. These visits, at the invitation of the individual NGOs, are intended to provide instruction and advice concerning the on-going data collection, as well as assistance with computerized data processing and analysis. The workshops have emphasized qualitative ethnographic methodology, particularly because the research teams were already somewhat experienced in conducting structured, quantitative surveys. Because of the emphasis on focussed qualitative methods, most of the ‘faculty’ are medical anthropologists. Like the Antwerp workshop, the training program in India is considered interdisciplinary-“social science research in community health,” regardless of the composition of the faculty involved. The Antwerp-Connecticut-Sri Lankan Training program and the Ford Foundation workshops in India are but two examples of recent experiments aimed at enhancing social sciences research in community health in Third World countries. Other workshop activities of a similar nature include the proposal development workshops of the Applied Diarrhea1 Disease Research Project (ADDR), World Health Organization (programs in diarrhea1 disease, acute respiratory infections, AIDS and others), and a series of recent workshops conducted by Susan Scrimshaw and colleagues, which utilize the Rapid Assessment Procedures (RAP) [5].
The workshops and related training programs that have evolved in recent years tend to have several common features: Training is oriented to an interdisciplinary framework. Individual sessions may focus attention on specific anthropological or epidemiological materials, but the research tools are presented as a connected whole, in which data-gathering is directed to resolution of particular health problems, rather than discipline-specific theoretical issues. Trainees are from a mixture of disciplines-medicine, anthropology, sociology, economics, etc.-and those disciplinary backgrounds are regarded as equivalent in knowledge and legitimacy in relation to community-based health research. The participants are also a mixture with regard to their age and level of training. For example, in the Ford Foundation workshops, some of the participants have many years of experience as medical practitioners in community health contexts. Others, in both the Indian and Sri Lankan training programs are young newcomers to community health research.
Developing applied medical anthropology
Faculty, also, are usually from several disciplines, which are viewed as complementary in the complex mosaic of qualitative and quantitative research. Epidemiologists, anthropologists, sociologists, clinicians and biostatisticians teach and tutor in an integrated “social science of community health research.” The Ford Foundation program in India is an exception in this respect, as most of the faculty thus far have been anthropologists, because of the emphasis on qualitative research methods. The faculty in the Antwerp workshop included clinical, epidemiological, and social scientists from Sri Lanka. In the India workshops, too, the presentations and tutoring included Indian nationals. Training programs seek a balance between local and European/North American faculty. Such balance is perhaps most difficult to achieve in medical anthropology, due to the scarcity of well-trained, applied anthropologists discussed earlier. Workshop content includes instruction in the use of microcomputers for data entry, processing and analysis. Microcomputers are increasingly regarded as essential tools for community-based health care research, as they can ‘liberate’ small and isolated research groups from dependency on the bureaucratic complexities of mainframe computer use. The software programs for community health research (as well as other kinds of research) are increasing in sophistication, and that sophistication includes greater ease of use. Statistical programs, database management programs, procedures for indexing and searching text files, and a variety of other types of programs have been developed that are well-suited to community-based research. Some of the more useful general-purpose programs are in the public domain (notably the versatile EPI-INFO program developed at the Center for Disease Control [6], and a new set of computer tools for structured qualitative data called ANTHROPAC [7]. With respect to instruction in computer applications, the main difference between the Antwerp and India workshops is that the microcomputer work in India is largely devoted to management of fieldnotes and other textual data, while the computer instruction in Antwerp concentrated more on statistics. Both components are seen as necessary elements of effective community health research. The training programs are often directed to applied questions in the locations where the participants are currently involved. This pragmatic orientation is very useful in orienting and motivating participants and for identifying the optimal mix of training components. Despite the specific local focus, individuals are expected to generalize their research skills to other contexts and other questions. Sites for the training sessions have been selected to reduce transportation costs while insuring adequate facilities, including microcomputers, for effective training. Placing the workshop sessions near on-going community health projects makes it possible to include direct, field-
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based data collection in the training process. For example, in the Ford Foundation workshops, activities have included key informant interviewing and exercises in direct observation in community settings, in order to make the instruction as concrete as possible. Workshop length is somewhat variable, typically one to two weeks. However, the workshop in Antwerp was four weeks long, which permitted the faculty to cover a comprehensive range of topics in statistics, methodology, and microcomputer utilization, still leaving sufficient time for consultations on individual research proposals. This longer workshop was possible because the participants were mainly from an academic base. Researchers from NGOs usually work within stricter time frames, so that two weeks seems to be a maximum length.
GUIDELINES
FOR FOCUSSED
DATA COLLECTION
ACTIVITIES
As stated above, new developments in applied research during the 1980s and 1990s include the perception that foamed ethnographic data on specific topics is needed by community health programs. Perhaps the clearest example is in diarrhea1 disease control programs, in which it now seems almost universally accepted that programs need to have specific information on local cultural terminology about ‘types of diarrhea,” as well as other aspects of cultural belief systems that constitute what Kleinman has referred to as ‘explanatory models’ of illness [8]. Many other sectors of community health research include similar needs for data about cultural belief systems and/or behaviors related to specific health problems. However, it has become increasingly apparent that few effective guidelines exist for specific, focussed data-gathering. Books and articles on ethnographic methods are usually intended for use by graduate students involved in theoretical, academic research. Until recently there have been very few ethnographic analogues to the nutritionists’ ‘24 hr recall method’ for food intake data, or the social psychologists’ specific protocols for observing and coding childrens’ play (for example). In earlier decades anthropologists used some highly structured personality tests adapted from psychology, but many of those research tools have been abandoned in the past two decades. The predominant view in anthropology has appeared to be that: (i) Many different methods and techniques are equally valid and useful for collecting the data about specific health belief systems. (ii) No useful purpose would be served, and perhaps harm might result, from attempts to standardize or ‘codify’ the techniques for collection of specific types of data.
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(iii) There is no need to test several different methods for their relative efficacy of data collection. (iv) Graduate students and other researchers can find out about the various alternative methods, or invent their own, without specific guidance or guidelines. In the applied community health research of the 1980s and 1990s this laissez faire attitude toward qualitative research techniques has become increasingly untenable. Applied programs need research techniques and guidelines that do not require great amounts of time, and which can be transmitted to non-anthropologist field workers. In programs such as the Ford Foundation sponsored work in India, the exchanging of data across several community-based research groups practically requires that they share some common data-gathering tools and language. Specific guidelines for ethnographic data-gathering are not wholly new in community health research. For example, at the beginning of the 1980s T. Marchione prepared a field manual with specific ethnographic research guidelines for a multi-nation study of infant feeding practices carried out under the auspices of the Population Council, Cornell University and Columbia University [9]. The field manual specified the numbers of informants to be interviewed and questions to be asked. Similarly, G. Pelto designed a field manual for ethnographic study of infant feeding practices in northern Cameroon [lo, 111. The RAP Manual [5] also presents guidelines for specific data-gathering, as well as models of data analysis, intended for ‘improving programme effectiveness’ in nutrition and primary health care. The appendix of the manual includes outlines for ‘exit interviews of patients’ (at community health centers), interview of staff of pharmacies, protocols for observing chnical encounters, and other specific data-gathering templates. The paper by Herman and Bentley in this volume also underscores the growing importance of data-gathering guidelines and manuals. Additional development of guidelines and protocols, as well as methodological studies of reliability and validity of specific data collection procedures, will be important future activities to further the development of applied medical anthropology in Third World countries. POST GRADUATE
TRAINING
NEEDS
Short term training workshops and research guidelines are tools directed to a larger issue, namely the matter of post graduate training for applied researchers. Almost no one today would deny that applied problems throughout the world-in health care and other sectors-are fraught with great complexity. Moreover, anthropologists have been among the social scientists most likely to point out those complexities. We wonder, then, why the field of anthropology has very little in the way of organized
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post-graduate ‘continuing education’. Many other professional sectors, notably in clinical sciences, require their practitioners to periodically upgrade their knowledge and technical skills. Why not in anthropology? Traditionally, anthropological training has been based on the image of the lone fieldworker who learned all he or she needed to know through direct immersion in the field work experience. Third World anthropologists, often trained initially in North American or European programs, have suffered from the basic shortcomings of graduate training programs that fail to provide students with adequate methodological tools. In addition, they face the further disadvantage of having much less recourse to newer learning through publications, frequent colloquium speakers, and all the other high-cost communications features of modern university systems. Most Third World programs suffer from severe shortages in publications, lack of travel funds, and other handicaps that seriously hinder any attempts to upgrade professional expertise. We suggest that medical anthropology, and in fact the entire anthropological enterprise, needs to have a coherent system of post-doctoral professional training. Mertens and Pelto [12] have discussed the needs for such advanced training programmes in connection with interdisciplinary nutritional science research. They call for upgrading the basic structure of graduate training for nutritional anthropologists, in addition to which they suggest short-term workshops and other modes of advanced training for persons already fully involved in professional work. Similar advanced training programs are needed in all areas of applied social sciences.
RELATIONSHIP!3
OF METHODOLOGY
COMMUNITY
HEALTH
AND THEORY
IN
TRAINING
The workshops in Antwerp and India, and similar workshops elsewhere, typically include very little discussion of theoretical models and frameworks. There are several reasons for this: Many of the people involved in community health programs, are suspicious of academic ‘theorizing’, and feel that any research should be pragmatic, focused on ‘just the facts’, so discussions about theory would be a waste of time. Also, it can be argued that most of the basic research tools-key informant interviewing, direct observation, structured surveys, and focus group discussions-are data-gathering techniques that can be considered ‘theory-neutral’. That is, they are useful techniques regardless of the theoretical perspectives that are used in data analysis and interpretation. In reality, however, every instance of research, no matter how applied, involves some theoretical assumptions. The growth of interest in cultural belief systems, ‘explanatory models’, and other ideational materials is based on theoretical assumptions con-
Developing applied medical anthropology cerning the importance of cultural factors in explaining health seeking decisions and other behaviors. Similarly, most community researchers collect information on differences in occupations, material goods, and other indicators of ‘socioeconomic status’, because of assumptions about the significance of material factors in affecting health behaviors. Statements by community health researchers are often laced with assumptions and statements that represent (often unrecognized) theoretical models. The paper in this collection by Stanton, Black, Engle and Pelto [13] examines some of the different theoretical perspectives that may be useful in various aspects of applied research in community health. There is clearly a growing need for theory-building in this sector of community health programs. On the other hand, the experiences in recent methodology workshops suggest that training in specific datagathering techniques can be carried out with only minimal reference to theoretical frameworks and models. SOME DIRECIXONS
FOR THE FUTURE
We will conclude this brief overview with a list of suggested skill- and knowledge-development components for facilitating effective social science research in community health programs:
(i) Basic training in research design, with particular (ii)
(iii)
(iv)
(v)
(vi)
attention to the need to integrate designs with contemporary thinking in epidemiology. Skill development workshops in up-to-date methods of systematic qualitative assessment of cultural belief systems and related behaviors. Skill development workshops in quantitative, field-based data gathering, including both structured interviews and structured direct observations of behavior. Basic training in statistics, with particular attention to the needs of researchers who work with relatively small samples, multiple variables, and nominal/ordinal levels of measurement. Skill development in the use of microcomputers for both qualitative and quantitative data analysis. Workshops on recent developments in key areas of medicine and health care, including diarrhea/ ORT, acute respiratory infections, AIDS, tropical fevers (malaria, dengue, etc.) and latest concepts in the nutritional sciences.
It should be apparent to the initial training,
that these components apply as well as the continuing
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education of, medical anthropologists and other social scientists in the arena of community health (primary health care). Moreover, with the exception of the specific contents in the last item, these suggestions apply as well to the training and professional upgrading that should take place in all graduate programs in the social sciences.
REFERENCES
1. Trostle
2.
J. Anthropology and epidemiology in the twentieth century: a selective history of collaborative projects and theoretical affinities, 1920-1970. In Anthropology and Epidemiology (Edited by Janes C. R., Stall R. and Gifford S. M.), pp. 59-96. Reidel, Dortrecht, 1986. Trotter R. T. Research methods training requirements
in anthropology (commentary). Anthropol. Newsleft. 29, (7), 28, 1988. Programme of 3. Lewis J. and Peters R. The Triangle Health Social Science Research & Training. Proposal funded by ABOS (Belgian aid organization), VLIR (Flemish Inter-University Council) and the EEC. Denartment of Communitv Medicine, University of Connecticut, Farmington, CT 06032, 1990. J. Building Social Science 4. Bentlev M. and Gittelsohn Resea&h for Women’s Reproductive Health in India. Proposal to Ford Foundation/New Delhi, India, 1990. S. C. M. and Hurtado E. Rapid Assessment 5. Scrimshaw Procedures: For Nutrition and Primary Health Care. United Nations University and UCLA Latin American Center, Tokyo, 1987. 6 Dean A. G., Dean J. A., Burton A. H. and Dicker R. C. EPI INFO, Version 5: A Word Processing, Database, and Statistics Program for Epidemiology on Microcomputers. USD, Inc. Stone Mountain, GA, 1990. S. ANTHROPAC. (Software program for I Borgatti management and analysis of structured qualitative data). University of South Carolina, 1989, 1990. A. Patients and Healers in the Context of 8. Kleinman Culrure. University of California Press, Berkeley, 1986. T. Ethnoaraohic studv: Phase I. Field 9. Marchione _ . manual. Infant feeding practices -study. Population Council/Columbia University/Cornell University. Unpublished Technical Paper, 198 I. 10. Pelto G. H. Consultant Report for Cameroon. Project on Effect of Food Availability and Infant Feeding Practices on Nutritional Status of Children O-23 months. Report one. Newton, Mass: Educational Development Center. (Dept of Nutritional Sciences; University of Connecticut, Storrs, CT 06269) 1983. Studies of the Effects of Food 11. Pelto G. H. Ethnographic Availabilitv and Feedina Practices. Food Nurr. Bull. 6, (1) 3343: 1984. 12. Mertens M. L. and Pelto G. H. Training and personnel issues in the introduction of social and behavioral components into nutrition programmes and research. Food Nutr. Bull. 10. (4). 16-19, 1989. B., Black R.; ‘Engle P. and Pelto G. Theory13. Stanton driven behavioral intervention research for the control of diarrhea1 research. Sot. Sci. Med. 35, 1405-1420, 1992.
