Health Promoters

I was thinking today about lay health promoters. They go by various names - indigenous health worker, lay health workers, community health workers, etc. - however, all share the common role of serving communities that are underserved and that have populations that differ from the majority of professional providers - either in language/culture, race/ethnicity or SES. Having worked in those communities for many years I have been a strong proponent of those programs. However, I also realize that there are many requirements if such programs are to work. The promoter needs to be a member of the community he/she will serve, they need to be carefully selected and they need to be property trained, with continuing education required. And the programs need to be well funded and supported by the entity with which they are affiliated. 

This morning I was reading A Tzeltal Maya Community by Robert Harman. On page 219 I read:

 "The Indianist Institute has clinics which are well equipped and staffed by full-time salaried physicians or promoters. However, the Institute has no way to compel individuals to follow its recommendations on health related matters. This problem became clear when I spoke with members of the community about an Institute-sponsored puppet theatre in which characters act out humorous roles that delight the audience. The purpose of the puppet theater is to instruct viewers to employ Western medical practices and beliefs in order to promote better health. Beliefs in witchcraft and other 'superstitions' are ridiculed by the puppets, but, while the viewers recalled that they enjoyed the performance, they did not remember the import of the health topic messages. As a result of the puppet theater and other education many of the Indians have adopted the term microbios ('microbes') into their vocabulary, but none appear to associate with the word meanings that resemble those of the western world."

This account then goes on to describe the life of the promoter, who, it admits,  save lives and alleviate suffering. On page 220, the life of the promoter is described:

"The same promoter believes that people get sick frequently from winds and microbes, which have the effect of drying up the body. He uses his affluence to support three wives, polygamy being a traditional symbol of wealth and prestige in Maya society. He tells patients to avoid 'hot' foods on the day they receive an injection with the rationale that it would interact unfavorably with the 'hot' medicine. He speaks with conviction about the clairvoyances of a local shaman and about the peopling of Oxchuc by distant ancestors as recorded in the kawaltik, a sacred book which is actually a legal document written by a Spanish administrator in 1674."

The first example, of the puppet performances is interesting. The people in the audience reacted to the plays as if they were forms of entertainment, not as forms of education - in other words, the plays - which are enacted stories -did not "teach" them about health. Needless to say, they did not incorporate what they did not learn into their behavior. 

It is clear that storytelling - in puppet play format - doesn't necessarily educate - doesn't necessarily change behavior (the aim of education being to change behavior). It might be true that puppet theatre in the past has always been about entertainment and that is what members of the audience expected to see and responded to as such.  However, it is equally true - or seems to be true - that we are influenced even by plays, stories, movies, etc. that entertain us. If we are influenced we are more likely to change our behavior to the models presented. It would be interested to see if even if the members of the audience couldn't recite the message they were likely to change their behavior. The author didn't ask that question.

In the second example, one question  is - does his increased prestige - having three wives - help him influence people?  Is a hierarchy important in influencing others? A third question is whether the fact that the promoter is paid make him less likely to be seen as a member of the community. He was a member when he was poor - does he continue to be seen as one? 

I could go on, but this is long enough. Perhaps I will continue this theme on another day.