Family Planning and Religion

HouseOne of the topics about which I will teach here is family planning. Before coming to site, I was concerned about the topic because of how polarizing it is in the US. I worried that there would be as much religious rhetoric against contraception and teaching sexual health in Paraguay as there is in the US. Paraguay is a Catholic country and I wondered if some of the same denial of basic health realities was present here as in the US. It is not.

Family planning and sexual health in Paraguay is not a subject cramped by religion. It is awkward and hard to talk about, just like in the US, but not because of religious beliefs. I find it awkward because of the power relationships between men and women here. And, well, because it’s just a hard subject to discuss eloquently.

In Paraguay, birth control pills and condom are free and offered at every public health clinic in the country. To get birth control pills a woman simply needs to go to the health clinic, request them, and present her ID. Sexual education is taught in many schools. I like to think Paraguay is transitioning to a family model that allows women to have the number of children they want when it makes sense for them. Paraguay isn’t there yet, but it’s on its way.

One thing I find particularly interesting about the relative ease of discussing family planning in Paraguay is that abortion is illegal. Period. Having one national set of laws in Paraguay that governs actions related to family planning makes it easier than in the US to know what can be said and can’t be said when teaching.

What Do You Do With Your Trash?

House at the edge of the fieldIf your community didn’t have trash collection services, what would you do with your trash? That’s a questions that most Paraguayans face. Few communities have any organized trash collection, so every family is on their own.

Let’s assume you’re already doing everything you can to produce as little trash as possible.

Would you burn your trash?

Burning your trash would get rid of it, which is a plus because it would keep your property neater. But, when you burned plastic it would create a terrible smell and release bad chemicals.

Would you throw out your trash, just on the ground at the edge of your property?

That would avoid releasing bad chemicals in the air like when you burn it. Tossing trash is easy. But, it would make the entire area where you throw your trash ugly, and you might have to clean up trash a lot when animals and wind bring trash into your living space. Depending on what kind of trash you have and where you decide to throw it, it could contaminate water or make animals sick.

Would you bury your trash?

Burying your trash would get it out of sight and avoid releasing bad chemicals into the air. But, you’d have to dig a hole and cover it, and then a dig another one when it got full. That’s more work than burning it or tossing it. Depending on where you decide to dig your trash pit, it might contaminate your water, and it would make that area bad for growing things if you wanted to put a garden there in the future.

Would you divide your trash and treat each type differently?

It would be a lot of work, but you could do something with each kind of trash.

You could burn your paper trash. That would get rid of a lot of it—in Paraguay you can’t flush toilet paper so you have to get rid of used toilet paper somehow.  Because it’s paper it wouldn’t release too many harmful chemicals into the air.

You could make a compost pile or feed your food scraps and other organic waste to animals.

You could collect and reuse glass, metal, and plastic bottles, jars, and containers. In some places in Paraguay you can get money for glass and plastic bottles you bring to recycling, but sometimes those centers are really far away. Sometimes there is someone who goes around buying glass and plastic bottles for recycling.

What about all other plastic waste? It could be buried. With things like plastic wrappers and bags you could use them for other things. You could make trash art or eco-bricks. Plastic is the trickiest.

In places where there are public trashcans and trash collection it’s easy to just toss your trash and never think about it again—especially in areas where litter doesn’t serve as a visual reminder. But, despite what you think, your trash does go somewhere. In Paraguay, often that somewhere is a lot closer to home than a dump at the edge of town.

Drinking: Underage and Driving

DawnDrinking is just as common in Paraguay as it is in the US. The difference? Paraguayan private and public organizations haven’t sunk as many millions of dollars into raising public awareness about alcohol safety. The result? People are getting harmed.

You’ll see 15-year-olds get drunk in front of their parents, with beer their mother bought. You’ll see drunks finish their drink and hop on their motorcycle or in their car. Few people talk about the fact that driving is impaired by alcohol consumption, and fewer wear seat belts (ever) or opt out of riding vehicles operated by people under the influence.

You know there’s a reason why you’re not supposed to start drinking too young: it can affect brain development. As for drunk driving—if you’ve ever been sober while riding in a vehicle operated by someone who’s been drinking you already know it’s terrifying. According to one report, Paraguay has one of the highest motorcycle-related mortality rates in the Americas, with a rate of 2.5 deaths per 100,000 from 1998-2010. And according to another report, one of the highest traffic injury-related mortality rates in the Americas.

I get that people just want to have fun. But, do responsibility and fun have to be mutually exclusive? I think not.  My quandary: How can I help transmit this message in Paraguay? More difficult still: How can I help encourage behavior change to improve drinking safety?

Bad Habits

Paraguayan skyWhy is the knowledge that something is bad for you not enough to make you stop doing it?

I’ve been thinking about this question a lot recently. When I tell Paraguayans that I’m in Paraguay to teach about health they jump right in and tell me how bad the Paraguayan diet is. Paraguayans tell me their food “has a lot of fat” or that the food “is heavy.” They tell me that there are a lot of people who are overweight, have diabetes, or have high blood pressure.

Next, Paraguayans ask if I like their traditional foods like sopa paraguaya, tortillas, and mandioca. They tell me they want to lose weight, but then put three tablespoons of sugar in the milk they are going to drink with bread. They ask, already knowing the answer, if they should eat fewer carbohydrates if they want to lose weight. They explain how they don’t exercise or eat vegetables.

I don’t know if the people I talk to know that different foods have different nutrients or that balancing calorie intake and calorie burn is the center to weight control, but it’s clear they know what they are consuming isn’t the healthiest option.

If they know it’s bad for them, why aren’t they trying to change it?

  • Is it habit?
  • Is it that they don’t know how to cook different foods?
  • Is it taste preference?
  • Is it cost?
  • Is it cultural heritage?
  • Is it a lack of information or understanding about what makes food healthy or unhealthy?
  • Is it something I’m not seeing?

In the past, I wrote about developing public health programs that encourage change by focusing on the out-of-box-experience. But, as I work in Paraguay, it’s daunting. Clearly, a lack of knowledge isn’t the only thing at work here. But what can I do other than provide information?

Where Public Health Fits Into the Health Picture

ClimbingParaguay and Health Care

Every country has it’s own way of trying to protect its citizens’ right to health. In Paraguay, there is universal health care. This means that consults and medications are free. Well, at least that’s the idea. Most people have access to doctors and nurses trained in family medicine, but things get complicated when it comes to medications and access to specialists.

Every medical facility in Paraguay doesn’t always get all the medications it needs for its patients. (Paraguay is working to decentralize its medical system with the hope to reduce some of the bureaucracy that might be contributing to these shortages.) As for specialized care, it’s unsustainable for every health clinic to have specialist in all areas, so they are centralized regionally in hospitals and health centers.

These limitations sometimes mean individuals go without the medications or care they need. Public health has a role to play to help relieve strain on the health care system by helping people lead healthier lives in the first place.

Barriers to Medicines and Specialized Care When They Are Not Available in Local Clinics

The main barrier is access. When a local clinic doesn’t have a needed medication patients must either buy it or find a public health facility that has the medication.

For families where money is short or income is unreliable, it means individuals go without their medications—a scary thought in a land where hypertension and diabetes are leading conditions.

Traveling to another medical facility might also be out of the question. It costs money to travel—whether by bus, by dirt bike, or by car. What’s more, it takes time that individuals might not have. For those who work, they can’t be absent from their jobs. And, for those who are looking after a house, there’s food to cook, children to watch, and clothes to wash.

When patients have to travel to a regional facility for care they face the same challenges as accessing medications. It’s not uncommon for local health care providers to use their personal money and vehicles to help people see specialists. But, that is limited because it puts stress on health care providers beyond their normal work and their vehicles may not fit everyone who needs to see a specialist.

There’s no silver bullet for resolving barriers preventing people from the health care they need. But, one thing is for sure; the more we can do to help prevent illness the better off individuals will be. That’s why health education and providing individuals with advice on how to lead healthier lives makes a difference.

Turn On the Public Health

Palms and ParaguayMy latest quandary (excluding all the integration and assimilation challenges I face) is not whether I will have work but rather where to begin. The community clinic and school where I plan to start my work seem open to have me do everything I can do to share information about health. What’s more, my school expressed commitment to teaching life skills and sexual health, my dream topics, along with all the other PC community health focus areas (plus some, like drug prevention).

I can see the need for public health education—from five-year olds with rotting front teeth to pregnant teens. It’s exciting to transition from creating health education materials in an office far removed from those I was trying to help to working with my target audiences directly. It’s a wonderful puzzle trying to find resources and find methods to convey information in a way that each audience will find useful.

It’s not going to be easy. I still don’t know how to say everything I want to say in Spanish (or Guarani). I don’t yet have allies in the community I know will help me or know if anyone will show up to whatever activities I do plan. I’m not sure I know enough about all the topics about which I’m supposed to teach.

I’m excited all the same. I have two years to give it my best shot. I hope by the end I’ve given at least a couple of people information they can use to improve their health and that of their loved ones.

I see a lot health presentations, lectures, games, and activities in my future. Don’t worry; I’ll let you know what works for me and what doesn’t.

Why Am I in Paraguay: Peace Corps Goals

A Paraguayan viewI know the Peace Corps and its work sounds abstract, being hard to explain is one of the many challenges of international development. Before leaving for Paraguay, many people asked what I would be doing and I couldn’t tell them. Here is my post-training attempt to define my work as a volunteer.

The Peace Corps Goals

  • To help the people of interested countries in meeting their need for trained men and women
  • To help promote a better understanding of Americans on the part of the peoples served
  • To help promote a better understanding of other peoples on the part of Americans

Cultural Exchange

The first job (and inevitable outcome of a job well done) of Peace Corps volunteer (PCV) is cultural exchange. Cultural exchange means learning about your host country’s culture and sharing about the culture of the US.

As a PCV, I’ve lived with a host family almost 3 months now and will live with one for almost 5 months when all is said and done. Living with a host family gives me the chance to learn what Paraguayan family life is like, eat tons of Paraguayan food, and ask endless questions about social events, pastimes, and beliefs. On the flip side, it also allows my host family to ask billions of questions and allows me to combat myths about the US, share my music, share American food, and offer a new perspective.

Of course, this exchange isn’t limited to my host family or the time I will live with them. Through all my interactions with community members, including people just seeing me do what I do, we are exchanging culture. Also, this blog, conversations with friends in the US, and all the stories I will tell when I get back to the States work toward the cultural exchange goals.

Health Education and Public Health

As a community health volunteer my work toward helping Paraguay develop skilled men and women involves raising awareness about health issues and working to improve health environments. The community health sector goals in Paraguay are:

Goal 1: Improve hygiene and environmental health practices

  • Dental health: I could teach why brushing your teen is important and how to brush properly. It is normal in Paraguay to see children with visible rotten teeth and for people to be missing some or many of their teeth.
  • Hand washing and parasite prevention: I may teach kids how to wash their hands correctly and parents how to recognize if their children have parasites. The main types of parasites found in Paraguay are giardia, roundworm, and hookworm.
  • Sanitation Practices (trash management and potable water): There isn’t trash collection in most places in Paraguay so most families burn or burry their trash. Water pollution can be a problem in some areas of Paraguay because of sewage management and livestock, among other things. Many people don’t think twice before throwing trash on ground.
  • Cook Stoves: Many families in Paraguay use open fires to cook. The Peace Corps has developed several wood cook stoves that when built can improve cooking efficiency, reduce the risk of burns, and reduce respiratory problems aggravated by breathing smoke.

Goal 2: Reduce the risk of non-communicable diseases (NCD)

  • Non-communicable diseases education: NCDs are diseases that can’t be passed from one person to another. Some of the most common NCDs in Paraguay are diabetes, hypertension, and obesity.  I could provide general information about these diseases and teach about nutrition and exercise as a way to control and prevent NCDs.
  • Gardens: I’m planning to have my own veggie garden, help my school have a school garden, and work with anyone who wants help making their own veggie garden. Gardens are a great opportunity to promote healthy eating and diversify the veggies available to families.

Goal 3: Reproductive Health:

  • Life Skills: I will work with youth to help them expand their decision-making and problem solving skills, critical and creative thinking abilities, communication and interpersonal relationship strategies, self-awareness and sense of empathy, and stress and emotional strain coping strategies.
  • Sexual and Reproductive Health: I may talk to youth about what sex is, STDs, and family planning strategies.
  • HIV/AIDS: As part of reproductive health, I could work to educate youth about what HIV is and how it is transmitted. Also, through this work I can hopefully help reduce discrimination against people who are living with HIV.

Carrying Health Messages Beyond Behavior Change

In October, I attended a George Washington University Communication & Marketing symposium titled “Frontiers of the New Social Marketing” presented by Dr. Craig Lefebvre a professor at the University of South Florida. Lefebvre discussed the complexity of public health problems, and how solutions to those problems are equally complex. He summarized the evolution of theories of change from the “Stages of Change” model to the “Social Networks” model. He argued that the social networks model should be the main framework for social marketing—and that social marketing is behind corporate marketing (by a lot).

What struck me most was what Lefebvre called the “OOBE” or the “out-of-box experience.” The OOBE is the experience you have after you’ve taken the desired action a marketing campaign (social or otherwise) was designed to convince you to take.

Lefebvre provided a simple example, the iPhone. When you buy a iPhone you take it home. The packaging is neat and when you open it the charger and directions are nicely place by the phone. In a matter of minutes, you are well on your way to setting up your phone. You are happy and you tell your friends about your great new phone. You use your phone a lot and love it. Compare that to an unnamed other phone. You buy an unnamed phone and bring it home. When you open the package you can’t find the instructions, and there isn’t a charger. An hour later, your phone still isn’t set up and you’re annoyed. You tell your friends how annoying it was to set up your phone. You use the phone and  maybe you like it, but you might buy a different phone next time.

In this example, the iPhone won the OOBE. Both companies got you to buy their phone, but by winning the OOBE Apple won not only a new customer, but also a loyal one who believes in their product. Why is this so important? There are two reasons.

  1. People don’t talk about the research they did to find the right phone or where they bought their phone. People talk about their experience with and enjoyment (or hate) of their phone.
  2. Creating a great OOBE helps sustain the action your original marketing campaign was trying to produce. You bought the iPhone and you love it. Next time you need a phone, or maybe another electronic device, you’ll look first at Apple products.

Right now, public health campaigns leave out the OOBE. Campaigns tell you to stop smoking, eat less, exercise more, avoid this, do that…but what happens if you actually do take the action the campaign asks you to take? Nothing. There are no rewards and no one says, “Great job, keep it up.” Those who take the desired action are checked off, forgotten.

You might say the reward for listening to a public health campaign is better health. That’s true, better health is an amazing thing. But, quitting smoking or eating less or exercising more doesn’t provide instant, tangible results and in most cases comes at a price. It’s hard to quit smoking because it’s addictive, and maybe your life is centered on the social aspect of smoking. It’s hard to eat less; food is so good and there are so many options. It’s hard to exercise, everyone’s busy and sometimes you just don’t want to get sweaty. Summary: Even after you make a healthy change there is a chance that you will revert to your old ways. You’re not necessarily sold on the new “product.”

So the question is, how can public health professionals create an OOBE experience? How can they sustain behavior change after initial action is taken?

Let me offer one example of a health program I think does create an OOBE: Alcoholics Anonymous (AA). I know some people find the AA philosophy controversial, but here I am not interested in the philosophy or method but more the structural model. AA is life-long. You are welcome at AA meetings when you are trying to stop drinking; when you are struggling to avoid relapse; and when you’ve been sober for one month, five years, or two decades. You are always welcome. People at the meetings are at varying stages of recovery and sobriety. The community is always there. There are coins that mark that you’ve made it to certain stages or lengths of time. You have a mentor. The OOBE is the sustained support and the opportunity to use your success to help others achieve the same thing.

Social marketing has a lot to do to catch up with marketing. But most important, especially with the rise of chronic diseases, is finding and creating the OOBE to help those who do take action, maintain their healthier choices.

Empathy – Critical and Elusive

Helping others is dependent on your ability to be empathetic, not just your knowledge and skill. In the world of health this may seem obvious, however empathy often gets lost in the complexity of the health care system.

I began pondering the sometimes dire absence of empathy in health care after watching Peter Attia’s TED Talk “Is the obesity crisis hiding a bigger problem?.” In his talk Attia discusses the practice of blaming obese patients for their health and questions the current way we think about obesity. He starts the talk with a story about a patient whom he treated. He explains that he provided exemplary medical treatment but failed as a person. He says he failed as a person because rather than being empathic he subconsciously blamed the patient for her condition.

In today’s U.S. culture it’s easy to blame people for health conditions like their weight; it’s easy to blame them for all their unhealthy choices. But, what does blaming achieve?

A large portion of my current work is in substance abuse prevention. Empathy is sometimes so hard. When I read the latest horror story about drug use, it’s hard to stop thoughts like “How can ANYONE start meth? There’s just no upside.” But, thoughts like that don’t help prevent anyone from using drugs and they certainly don’t help people trying to recover from addiction. Again, it’s so easy to blame people for using drugs. But if we want to help we must get beyond the finger pointing. We must acknowledge that we are trying to help individual humans, and that those individuals are struggling. Their struggle is their own, but we do not have to be another barrier, we can be a positive force.

I was struck by the power of empathy after watching Eleanor Longden’s TED Talk, “The voices in my head.” She talks about her struggle with schizophrenia. When she was first diagnosed it seemed her world would end. However in her fight for peace she got help from someone who told her she could work with the voices in her head. He believed in her and her ability to lead a safe and happy life. He was right. She was able to master the voices in her head. By simply offering support and understanding he changed the course of her recovery.

Health is charged. Health is mysterious. Empathy is simple. But in its simplicity it is easy to overlook. Don’t.

Empower People to Take Ownership of Their Health

Public Health

The heated debate about U.S. health care focuses largely on health insurance and health care access. Of course, these two aspects are appropriate for the policy debate—there are few who would say our current system is optimal with regard to either, and many who say it’s not acceptable. But from a public health prospective, I can’t help but think of a slightly more humble part of the future of health in the U.S. –mainly the everyday tools everyday people can use to take ownership of their health. Two tools are of particular interest to me: the Internet and health tracking.

It’s not to say that Internet information or personal health tracking can replace medical professionals and their care, but it is to say that the health of the individual goes beyond medical visits and consultations with health care professionals. Many of us who do visit the doctor and the dentist may already know this—the forceful suggestions to exercise at least 4 times a week and to floss everyday remind us that maintaining our health is not just the responsibility of medical professionals.

It’s true that individual people can take ownership of their health on a daily basis. There are tons of health education initiatives trying to help people do that by providing them with information and specific steps they can take. What makes these initiatives both strong and weak is that they focus on one specific aspect of life that can improve health, like quitting smoking or exercising.

But, what if health education in the U.S. taught people how to find out about health conditions and healthy actions instead of focusing on disseminating the facts about conditions and healthy actions?

The Internet: A First Source of Health Information

According to a 2013 Pew Internet report, 35% of U.S. adults reported going online to try to diagnose a medical condition they or someone else had. Of these, 46% said their findings made them think they needed help from a medical professional and 38% said the condition was something they could take care of at home. In addition, 41% of the adults who used the Internet to form a diagnosis said that a medical professional confirmed their diagnosis.

What I find fascinating is that of adults who looked for health information online, 77% started their search on a search engine and only 13% said they started on a site that specializes in health information.

This leads to several questions:

  • How can we make the Internet, as a whole, a better source of health information?
  • How can we help individuals develop good online searching skills that will lead them to accurate health information online?
  • How can we make online health information easier to weed through?
  • How can we ensure that the most helpful, accurate, and credible sources of online health information come up when people search for health information?

Many health organizations are already putting health information online—not just research organizations but also doctor’s offices that allow you to view your medical records online.  But, putting information online is not enough. Empowering individuals to find health information on their own is going to also require helping people learn how to navigate the sea of information and creating tools that organize and sort that information.

Tracking Health: Health Empowerment

According to a 2013 Pew Internet report, 69% of U.S. adults track one or more health indicators (e.g. weight, exercise, or diet). Adults are more likely to track health indicators if they have one or more chronic health conditions. People have different ways of tracking these conditions—49% of adults reported tracking their health mentally, 34% reported tracking their health on paper, and 21% reported using technology to track their health.

What’s more, 63% of those who reported tracking their health also agreed with at least one statement of impact including: their tracking changed their approach to maintaining their (or someone else’s) health, caused them to ask their doctor questions or get a second opinion, and impacted a decision about treatment for a illness or condition.

Much like with Internet health information, personal tracking can provide individuals with knowledge about their health before they visit a health professional. The prevalence and impact of health tracking indicated in this report lead to several questions:

  • How can we help people become better at tracking their own health?
  • How can we develop tools to help people keep better track of their health?
  • How can we develop tools that not only track health but also provide analysis of the tracking results?

Access to technology can help individuals track their health, according to the same Pew Internet report one in five smartphone owners has a health app, but it’s not the only important piece to effective health monitoring. Providing people with the knowledge of what aspects of their health are most important to track and the skills to track those aspects with consistency is another key piece to the puzzle.

Health Ownership

Tools like the Internet allow individuals to find health information on their own and tools like health trackers empower individuals to monitor their own health. While online information and health trackers abound, the challenge with these tools is their usability and accessibility. The usability of these tools not only depends on the tools themselves but on individual’s skills and confidence in using the tools. The accessibility of the tools is about how an individual is going to find the tools when there is so much information online and so many different ways of tracking health.

As we look forward to improving public health, it may be worth shifting our focus from pushing information about specific conditions and actions to teaching skills that help individuals effectively find health information on any condition and track their health on their own.  It’s not enough to just push the facts, we need to empower individuals with health knowledge and skills so they can take ownership of their health.