Practicum Report:A Public Health Experience with Africa 180° in Mozambique

January 2011 to May 2011

StudentLee M. Van IderstineMPH Candidate 2011leevani1@gmail.com

Academic AdvisorKatherine Andrinopoulos, PhDAssistant Professorkandrino@tulane.edu

PreceptorTracy Evans, PA-CDirectorAfrica 180°Mussunca, Manica Province, Mozambiquetracyinmoz@gmail.com

Dept. of International Health & DevelopmentSchool of Public Health & Tropical Medicine Tulane University New Orleans, LA, USA

Africa 180°Manica Province, Mozambique

Lee Van IderstineMPH Candidate 2011leevani1@gmail.com

Academic Advisor: Katherine Andrinopoulos, PhD

kandrino@tulane.edu

Preceptor: Tracy Evans, PA-CDirector of Africa 180°tracyinmoz@gmail.com

Tulane University, School of Public Health and Tropical MedicineNew Orleans, LA, USA

A personal blog of my practicum experience can be viewed online at http://leevani1.wordpress.com/.

Abstract: In 500 words or less, describe the goals of the project, activities, and results

Table of Contents

Acknowledgements ..........................................................................................................1

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AbstractIn the fulfillment of the practicum requirement for the Master of Public Health degree from Tulane University's School of Public Health & Tropical Medicine, I spent four months in Manica Province, Mozambique in south-eastern Africa volunteering with a small, Christian organization called Africa 180°. My main project to help the organization fulfill its mission was to initiate the Mavambo Upenyu Wakakwana (Foundations of Abundant Life) Hygiene & Health Education Program, which operates within the Makomborero Nutrition Program that provides support and care to vulnerable children of HIV+ mothers. A hygiene and health curriculum was assembled and a course was taught to at least 234 caregivers of the children enrolled in the nutrition program. A Mozambican woman was trained as the Supervisor of Health Education to sustain the program after my departure. Included in her responsibilities is the training of six Community Health Educators who teach the course to new audiences. In addition to a $3,000 scholarship awarded by Katie Memorial Foundation to cover the costs of my practicum experience, over $700 was raised to fund the continuation of the education program over the next year. Other major practicum activities include the formation of a women's empowerment group called Simba Madzimai (Powerful Mothers) that meets weekly to share skills and offer support and the assembly of a booklet describing the organization's programs and partnerships and its annual budget for use in fundraising.

I. The Host Organization: Africa 180° ...............................................................................2

II. Practicum Rationale .....................................................................................................3

III. Goals & Objectives ......................................................................................................5

IV. Activities & Outcomes .................................................................................................6

V. Discussion .................................................................................................................18

VI. Recommendations ....................................................................................................19

VII. Self-Assessment ......................................................................................................20

VIII. References .............................................................................................................21

IX. Appendices

Appendix 1: Africa 180°'s Programs and PartnershipsAppendix 2: Activity LogAppendix 3: Expense ReportAppendix 4: Education Program Administrative DocumentsAppendix 5: Hygiene and Health Curriculum

Acknowledgements ..........................................................................................................1

I. The Host Organization: Africa 180° ...............................................................................2

II. Practicum Rationale .....................................................................................................3

III. Goals & Objectives ......................................................................................................5

IV. Activities & Outcomes .................................................................................................6

V. Discussion .................................................................................................................18

VI. Recommendations ....................................................................................................19

VII. Self assessment ......................................................................................................20

VIII. References .............................................................................................................21

IX. Appendices

Appendix 1: Africa 180°'s Programs and PartnershipsAppendix 2: Activity LogAppendix 3: Expense ReportAppendix 4: Education Program Administrative DocumentsAppendix 5: Hygiene and Health Curriculum

Acknowledgements

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The success of this project is attributed to many people who supported me in this endeavor. I am so grateful for the love and encouragement given.

Thank you to my parents, Richard and Candee Van Iderstine, brother, Sky Van Iderstine, Aunt Robin, and Aunt Shirley for your excitement for my pursuits, strength to let me go, and help to get me there.

Thank you to Katherine Andrinopoulos, PhD, my academic advisor, for giving me the freedom to fulfill my heart's desire and the guidance to fulfill my academic requirements. Your enthusiasm for my ideas bolstered my confidence to be successful in the professional work of public health.

Thank you to the Katie Memorial Foundation for honoring me with the scholarship to fund this experience.

Thank you to the colleagues and friends who made generous donations to ensure the continuation of my practicum program: Carl Kendall, Cyril Adams, Kym Rohmann, Wendy Diaz, Elise Carpentier, and Bamidéle Ladipo.

Thank you to Tulane University School of Public Health & Tropical Medicine for allowing me to customize my degree requirements for a unique career preparation. I enjoyed the flexibility of the practicum guidelines that allowed me to fulfill my dreams.

I. The Host Organization: Africa 180°Africa 180° is a Christian non-profit organization located in Mussunza, Manica

Province, Mozambique, on the southeast coast of Africa. The organization was registered with Mozambique's Department of Religious Affairs in 2005, when an American physician assistant realized that registration would enable more missionaries to receive visas into Mozambique. The organization's mission is "reversing the cycles of poverty, disease and death in Mozambique.   In word and in deed, we proclaim the Gospel of Jesus Christ to those we live with and minister to." Africa 180° declares their goals to be focused in the categories of healthcare, education, and community development. According to the director, Tracy Evans, PA-C, it is necessary to keep the goals and objectives broad to ensure freedom in the organization's activities as visitors with different professions and talents stay visit and contribute transiently. Permanently residing in Mozambique and working with Africa 180° are 8 volunteers from around the world: USA, Germany, Ireland, South Africa, and Zimbabwe. Africa 180° employs 13 full-time and 6 part-time paid nationals with positions such as guards, gardeners, preschool teachers, teaching assistants, translators, kitchen staff, and clinic assistants. In addition, Africa 180° hosts temporary international volunteers, some for a week and others for up to 10 months of the year.

Africa 180° has many programs and projects, which are outlined in more detail in Appendix 1: Programs and Partnerships, a document that I created during my practicum. Under the goal category of education, Africa 180° has the Pre-Éscola de Mussunza, a school with 45 students in two pre-school classes and one kindergarten class. The children in pre-school are taught writing, letters, colors, and numbers, and many social and organizational skills such as listening, waiting in line, completing tasks, sharing, and participation. In kindergarten, the children are taught reading, writing, adding, and subtracting. The skills of critical thinking, creativity, individuality,

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organization, and social skills are also conveyed and practiced. The children are taught hygiene practices like brushing teeth, keeping nails trimmed, and washing hands after using the toilet and before eating. In addition, Africa 180° is partnering with two of their permanent resident missionaries to establish "Passo Por Passo" (Step by Step), a high-school offering a high standard of education, instilling Christian values, offering agricultural programs, and promoting physical well-being through sports activities.

Under the goal category of healthcare, Africa 180° has the Makomborero Nutrition Program. The nutrition program currently supports around 800 children of HIV+ mothers, and their caregivers who attend a clinic twice every month. During each visit, the clinic provides full-cream powdered milk, sugar, oil, crushed peanuts, corn meal, and/or beans, as appropriate, to improve the health of the children enrolled on the program. Each child's growth is monitored, and the child, siblings, and caregiver receive a health check-up. The clinic treats most health problems presented, providing the prescribed medications, and also refers patients to the hospital when necessary. Some caregivers are provided financial support for a season to allow him/her to focus their attention on improving the health of the child(ren) to prevent death due to acute malnutrition or illness. The clinic staff provides social support services, coordinating care of patients, making home visits, and sometimes providing homes after disasters or when the health of the caregiver is critical. Additionally, the clinic often provides support for particularly vulnerable children and orphans being cared for by a non-parent, regardless of their HIV status. The clinic has many new programs planned, such as equine therapy, a recovery center for critical patients, and farming skills training.

Under the goal category of community development, Africa 180° has many programs and partnerships. Programs include: Kids Club, a weekly children's meeting with games and Bible stories; prison ministry offering social support to inmates in the local prison facilities; leadership training targeting government officials; church planting, pastoral training, and discipleship to create community and social support structures; and seed-corn distribution to help vulnerable families in preparation for hunger season. Africa 180° also partners with other organizations, providing a women's Bible study to strengthen social support and a women's skills training that shares the craft of crocheting and knitting.

Initially, my role with Africa 180° was to gain an understanding of their programs and partnerships and offer insights and suggestions to improve the efficiency of their service delivery. In the first 3 weeks, I gained the knowledge above and compiled the Programs and Partnerships booklet (Appendix 1) summarizing the scope and operations of Africa 180°'s scope and operations. Subsequently, I was able to identify a gap in services, and develop and implement a new program in accordance with the organization's stated mission and goals. I volunteered with Africa 180° from January 22, 2011 to May 5, 2011, working on average 30 hours each week. I kept a detailed log of activities, included in Appendix 2: Activity Log

Trip expenses were paid out of pocket using accumulated unused living expense funds borrowed in loans for previous semesters. While in Mozambique, I applied to and was awarded the Katie Evans Memorial Scholarship by the Katie Memorial Foundation in the amount of $3,000. This scholarship covered the cost of the roundtrip flight, rent, most of the food expenses, some program expenses, and local transportation. In addition, I sent an update email to colleagues, friends, and family that included

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information about the public health program that I was working on. Thereafter, an additional $768.37 was donated for the program expenses. Detailed financial records are in Appendix 3: Expense Report.

II. Practicum RationaleMozambique was colonized by the Portuguese but gained independence in

1975. The country was at civil war until 1992 when a new multi-party system of democracy was adopted (USAID, 2005). During the time of the war, the country's government, infrastructure, systems, and previous strides toward development were ruined by the fighting, fires, and bombs of warfare. Further devastating the populations was the growing HIV/AIDS epidemic, which thrived in these conditions of traveling troops, movement of resources from the coasts inland, and deteriorated ideals of family. For the last 19 years, Mozambique has been rebuilding its government and infrastructure from the rubble. Mozambique's impoverished, post-war living conditions are characterized by limited access to clean water, poor sanitation, high prevalence of HIV, high illiteracy, and a generation lost to war and AIDS. In 2004, the country finally declared HIV/AIDS as a national emergency. Today, the population of Mozambique is nearly 23 million people, and 11.5% of them are infected with HIV. Sixty two percent of them live in rural areas where only 29% of them drink from improved water sources and only 4% of them use improved sanitation facilities. Table 1 contains relevant health and development indicators for Mozambique.

Table 1. Health and Development Indicators for MozambiqueIndicator Statistic YearPopulation urbanized 38% 2009Adult literacy rate, age 15+ 54% 2007Drinking from improved sources: urban 77% 2008Drinking from improved sources: rural 29% 2008Using improved sanitation facilities: urban 38% 2008Using improved sanitation facilities: rural 4% 2008Infant Mortality Rate (IMR) (per 1,000) 96 2009Under-5 mortality rate (per 1,000) 142 2009Maternal Mortality Rate (MMR) (per 100,000 live births) 550 2008Life Expectancy at birth (years) 48 2009Under-5 moderate to severe underweight 18% 2003-9*Women in union aged 15-49 years using contraceptives 16% 2005-9**Data is from the most recent year available in the range.Source: WHO, 2010

Africa 180° is located in Manica Province along a highway called the Beira Corridor, which connects Zimbabwe to the coastal city of Beira, a major harbor of exchange. This corridor serves as the main shipping route of resources inland through Mozambique to Zimbabwe, so it is a heavy-traffic trucking route. It previously served as a military route for troops and supplies movement. Because of this, the people living in the towns and villages along this corridor have a lower health status than indicated by the national statistics. Manica Province's HIV prevalence of 15.3% is higher than the national prevalence and ranks fifth out of the eleven provinces, whose prevalences

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range from 3.7% to 25.1%. Women are at higher risk for infection with HIV at a younger age than men. HIV prevalence is highest among women who are divorced, separated, or widowed. Table 2 contains relevant HIV/AIDS indicators for Mozambique and Manica Province.

Table 2. HIV/AIDS Indicators for Mozambique in 2009Region Indicator Statistic Source

CountryAdult HIV prevalence (ages 15-49) 11.5% INSIDA, 2010Children ages 0-14 years living with HIV 130,000 WHO, 2010Children ages 0-17 years orphaned by AIDS 670,000 WHO, 2010

Manica Province

Adult HIV prevalence 15.3% INSIDA, 2010Adult HIV prevalence: men 9.2% INSIDA, 2010Adult HIV prevalence: women 15.6% INSIDA, 2010Adult HIV prevalence: urban 15.9% INSIDA, 2010Adult HIV prevalence: rural 9.2% INSIDA, 2010Women ages 15-49 with comprehensive knowledge of AIDS 28.5% INSIDA, 2010

Women with knowledge of MTCT by breastfeeding and risk reduction by ARVs 44% INSIDA, 2010

HIV/AIDS causes disruptions in livelihoods due to reduced labor ability. This causes malnourishment, which further reduces immune function, making them more susceptible to wound infection, colds, scabies, fungal infections, diarrheal illness, parasites, and many other infectious diseases. Basic hygiene practices are not well known or widely practiced. This can be partially attributed to the war, which caused the loss of traditions, practices, and habits, and made it difficult for the older generation to pass on knowledge to the younger generation. The loss of a generation to war and AIDS has created too many orphans for communities to care for and keep healthy. Many orphans are taken in by relatives or neighbors. The Mozambicans have a strong sense of community, fully utilizing social capital to fulfill needs. However, the combined community resources within the social networks are often inadequate.

The Makomborero Nutrition Program supports around 800 children of HIV+ mothers every two weeks, keeping the caregiver healthy and providing food for the child. Many of the children are orphans, malnourished, and HIV+. The caregiver's skills and care are informal and often inadequate. Because of the poor living conditions, illness is frequent, each time threatening the life of the child. Counseling and hygiene and health education are given on an individual basis by the nurses in the clinic, but this takes time and often comes too late. It was apparent that preventative hygiene and health education for these caregivers could reduce the number of life-threatening acute presentations in the clinic and improve the overall health of the families represented at the clinic.

III. Goals & Objectives1. Become familiar with the organization's current programs and projects.

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A. Observe and inquire about day to day operations of Africa 180°, documenting each program's goals, objectives, activities, target population, targeting methods, coverage, intensity, and budget.B. Compile information into a booklet to inform stakeholders, donors, and potential funding sources of the scope of the organization.

2. Identify underlying causes and risks for poverty, disease, and death to inform potential new programs/projects and current activities.

A. Gather information using various informal qualitative methods.

3. Design a program/project to address the gaps in the contexts of culture and national and international policy using local, national, academic, and international resources.

A. Promote health and prevent illness by sharing and spreading life-saving knowledge of hygiene and health practices by teaching a health and hygiene curriculum to the caregivers of the patients of the nutrition program. Topics include: Introduction to Germs, The Disease Pathway, Blocking the Disease Pathway, Water Collection, Water Purification Methods, Water Storage and Use, Good/Bad Hygiene, Home Treatment of Diarrhea, Childhood Nutrition, Healthy Diets and Anemia, Family Planning, and HIV/AIDS.

1. Teach hygiene and health principles to at least 360 caregivers of the children of HIV+ mothers who are enrolled on the nutrition program.

2. Train a clinic assistant to teach the curriculum continually and to new audiences in the future

3. Write new health lessons, test and modify them, and submit them to the creators of the hygiene curriculum for expansion of their own curriculum and training.

4. Inform temporary American visitors to Africa 180° about the field of Public Health.A. Conduct a 1 hour information session describing the breadth of the field of public health, modes of entry into the field, and careers.

5. Provide tools and materials for clinic staff about health behavior as applied to the PLWHA served by the clinic's nutrition program.

6. Provide the organization with a Grant Proposal template to equip them to apply for grants to fund its various programs and projects from appropriate donors and funders.

IV. Activities & OutcomesA detailed log of practicum activities was recorded and is presented in Appendix

3: Activity Log. The log includes all activities related to the practicum goals and objectives and includes time spent volunteering in the clinic during times of understaffing due to illness and childbirth. This was necessary to achieve my practicum goals because the education program had to fit within the activities of the nutrition clinic, which took priority. Table 3 is a weekly summary of practicum activities and hours. In addition to the activities documented, I often spent my time volunteering with Africa

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180°'s other programs, in the classroom of the pre-school, meeting with pre-school graduates, and accompanying the pre-school director on home visits. The total time logged is 453 hours and 45 minutes.

During my stay with Africa 180°, I did several things to help Africa 180° achieve its goals and enhance its current programs. For the first 2 weeks, I volunteered with all of the organizations' programs, interviewed the leader of each to ask about the name of the program, the time of initiation, goal(s), objectives, activities, target population, people involved, intensity, and coverage, and eventually compiled the information into a booklet titled, "Africa 180° Programs and Partnerships - May 2011", included in Appendix 1 (Goal 1). The booklet summarizes all of Africa 180°'s current endeavors. This gave me an excellent overview of the organization. The director plans to use it to inform current and potential stakeholders about the organization and to procure funding. I expect that it will help the organization to develop the content of a website, which is planned for Fall 2011.

After discussing many ideas for potential projects with the nutrition program manager and then meeting with the director of the organization (my preceptor), we decided that I would begin teaching a preventative hygiene curriculum to the caregivers waiting to be seen on the porch of the clinic in order to reduce the number of acute presentations in the clinic and improve the overall health of the population attending the clinic (Goal 3). One of the clinic assistants, named Dorca, who speaks English, would be offered to me for translation services during clinic hours, and would be trained to teach the curriculum. I spent the third week planning the teaching and training schedules, assembling teaching and demonstration materials, preparing Doca to translate and be trained to teach, and preparing the curriculum posters.Table 3. Weekly Hours and ActivitiesWeek Start Date End Date Hours Main Activities

0 Dec. 20 Jan. 12 6:30 Completing forms, researching language and culture

1 Jan. 22 Jan. 30 39:00 Participating in various programs, gathering information for Goal 1

2 Jan. 31 Feb. 4 19:00 Participating in various programs, gathering information for Goal 1

3 Feb. 7 Feb. 13 38:00 Designing hygiene and health education program, preparing curriculum

4 Feb. 14 Feb. 20 31:30 Preparing training handbook, facilitating Block 1 with pretest, revising program design

5 Feb. 21 Feb. 27 30:40Preparing training handbook, supervising Dorca facilitating Block 1, review of relevant course material and literature

6 Feb. 28 Mar. 4 11:40 Sick, preparing curriculum, "Overview of PH" presentation, and community organizing exercise

7 Mar. 7 Mar. 11 32:00 Facilitate Block 2, preparing training handbook, volunteering as clinic assistant

8 Mar. 14 Mar. 19 22:05"Overview of PH" presentation, supervise Dorca facilitating Block 2, begin interviewing CHE candidates, home visits

9 Mar. 21 Mar. 27 34:45 preparing Block 3 lessons, volunteering as clinic assistant, helping with various tasks at A180°

10 Mar. 28 Apr. 2 26:55 Facilitating Block 3, planning for program sustainability

11 Apr. 4 Apr. 10 25:30 Supervise Dorca facilitating Block 3, training Dorca to be

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SHE, preparing for program continuation

12 Apr. 11 Apr. 15 39:35Preparing Block 4, facilitating Block 4 and concluding, assist with Dorca facilitating and training at a local church

13 Apr. 18 Apr. 22 35:10Assist with Dorca facilitating course with parents at pre-school, supervise Dorca facilitating Block 4 and concluding

14 Apr. 25 Apr. 29 30:10 Practicum wrap-up, writing program protocol, facilitating Lessons 1-3 to A180° local staff

15 May 2 May 5 31:15 Preparation of additional training handbooks for CHEs, practicum wrap-up

Average Hours/Week (abroad) 29:49

TOTAL PRACTICUM HOURS 453:45

Table 3. Weekly Hours and ActivitiesWeek Start Date End Date Hours Main Activities

0 Dec. 20 Jan. 12 6:30 Completing forms, researching language and culture

1 Jan. 22 Jan. 30 39:00 Participating in various programs, gathering information for Goal 1

2 Jan. 31 Feb. 4 19:00 Participating in various programs, gathering information for Goal 1

3 Feb. 7 Feb. 13 38:00 Designing hygiene and health education program, preparing curriculum

4 Feb. 14 Feb. 20 31:30 Preparing training handbook, facilitating Block 1 with pretest, revising program design

5 Feb. 21 Feb. 27 30:40Preparing training handbook, supervising Dorca facilitating Block 1, review of relevant course material and literature

6 Feb. 28 Mar. 4 11:40 Sick, preparing curriculum, "Overview of PH" presentation, and community organizing exercise

7 Mar. 7 Mar. 11 32:00 Facilitate Block 2, preparing training handbook, volunteering as clinic assistant

8 Mar. 14 Mar. 19 22:05"Overview of PH" presentation, supervise Dorca facilitating Block 2, begin interviewing CHE candidates, home visits

9 Mar. 21 Mar. 27 34:45 preparing Block 3 lessons, volunteering as clinic assistant, helping with various tasks at A180°

10 Mar. 28 Apr. 2 26:55 Facilitating Block 3, planning for program sustainability

11 Apr. 4 Apr. 10 25:30 Supervise Dorca facilitating Block 3, training Dorca to be SHE, preparing for program continuation

12 Apr. 11 Apr. 15 39:35Preparing Block 4, facilitating Block 4 and concluding, assist with Dorca facilitating and training at a local church

13 Apr. 18 Apr. 22 35:10Assist with Dorca facilitating course with parents at pre-school, supervise Dorca facilitating Block 4 and concluding

14 Apr. 25 Apr. 29 30:10 Practicum wrap-up, writing program protocol, facilitating Lessons 1-3 to A180° local staff

15 May 2 May 5 31:15 Preparation of additional training handbooks for CHEs, practicum wrap-up

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Average Hours/Week (abroad) 29:49

TOTAL PRACTICUM HOURS 453:45

The training handbook development was a three month process. The hygiene

portion of the curriculum was written by Hydrating Humanity, formerly known as Grace-Connection. The curriculum is available on their website, so I downloaded and printed the pages, colored the teaching posters, and assembled them into page protectors in a binder for use during the teaching sessions. I wrote five additional lessons and drew corresponding teaching posters on health topics specifically relevant to the nutrition clinic patients, including "Home Treatment of Diarrhea", "Healthy Diets and Anemia", "Childhood Nutrition" for children of HIV+ mothers, "Family Planning", and "HIV/AIDS". In addition to various course lectures and notes, materials referenced in writing these lessons include: "Integrated Management of Childhood Illness" (WHO/UNICEF, 2002), "Helping Health Workers Learn" (Werner & Bower, 1991), "Where Women Have No Doctor" (Burns, et al, 1997), "Women and HIV/AIDS" (Berer & Ray, 1993) , "Nutrition Handbook for Community Workers in the Tropics" (CFNI, 1986), and "The Family Planning Clinic in Africa" (Brown & Brown, 1998). The lessons are all accompanied by a series of pictorial posters which serve two purposes: 1. to help the teacher recall the dialogue of the lessons, and 2. to help the verbal information make sense to the course participants. Most of the caregivers participating in the course at the clinic are female and illiterate with very little, if any, formal education. The health lessons follow the same format and guiding principle of participatory learning as the hygiene lessons as much as possible, and have subsequently been submitted to Hydrating Humanity for use in their programs, should they choose to do so. In fact, upon return to the states, I met with the Executive and International Directors of Hydrating Humanity to give them the health lessons that I wrote, exchange experiences, and share lessons learned. The entire curriculum is included in Appendix 5: Hygiene and Health Curriculum.

The schedule for teaching these lessons changed several times due to unforeseen circumstances, such as illness, understaffing, inclement weather, patient death, and overextended organizational capacity. Table 4 is the final and actual

Table 4. Teaching ScheduleDates (Tue-Fri) Lessons

Block 1Feb. 15-25

Pre-test1: Intro to Bacteria2: Discovering Disease Pathway3: Blocking the Disease Pathway

(Skip 1 week when I was sick)

Block 2Mar. 8-18

Review Block 14: Water Collection5: Water Purification Methods6: Water Storage & Use7: Good/Bad Hygiene

(Skip 1 week for understaffing)

Block 3Mar. 29-Apr. 8

Review Block 28: Treatment of Diarrhea9: Anemia Prevention10: Childhood Nutrition

Block 4Apr. 12-22

Review Block 311: Family Planning12: HIV/AIDSPost-test

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schedule. The 12 lessons were divided up into "sections" of "Hygiene", "Water", "Nutrition", and "Family Health". Each group of lessons was taught in the mornings that the clinic was open, Tuesday through Friday, over a two week block. Caregivers attend the clinic with their vulnerable, malnourished child every two weeks, so in these 2 weeks, most of the caregivers attended the clinic at least once. However, some caregivers come in the morning where they participated in the lessons, and some came in the afternoon, missing the teaching. In this way, each caregiver participated in a new block of lessons each time they attended the clinic for four sessions of teaching over 8 weeks. Notice that the schedule notes two weeks during which teaching sessions were not offered at the clinic due to illness and understaffing.

Attendance data were collected in two ways: attendance cards and daily headcounts. Each participant received an attendance card at their first session, on which was marked the number of the lessons in which they participated at the end of the teaching session each day. During Block 4, at the conclusion of the teaching sessions, the attendance cards were collected. During collection, the number of lessons the caregiver attended was reviewed by Dorca and I. Each caregiver who attended five or more of the twelve lessons received a bar of soap in reward. Each caregiver who attended all twelve lessons received two bars of soap in reward. Upon my return to the states, I entered the data of the attendance cards into Microsoft Excel and SPSS for analysis. The summary of the data is presented in Table 5. According to the attendance cards, 91% of the caregivers whose card was collected participated in five or more of the lessons, but only 15% of them attended all twelve. At the conclusion of each day's session, the number of caregivers present was recorded. This data is included in the last column of Table 5 for comparison, and the detailed data is presented in Table 6. Average daily attendance was 28 caregivers and average block attendance (all sessions over 2 weeks) was 234 caregivers.

Table 5. Attendance by Lesson Record Cards

Block Lesson Lesson Title Frequency % Headcount Attendance

1: Hygiene 1 Intro. to Germs 92 51.1 2682 Discovering Disease 92 51.1

Table 4. Teaching ScheduleDates (Tue-Fri) Lessons

Block 1Feb. 15-25

Pre-test1: Intro to Bacteria2: Discovering Disease Pathway3: Blocking the Disease Pathway

(Skip 1 week when I was sick)

Block 2Mar. 8-18

Review Block 14: Water Collection5: Water Purification Methods6: Water Storage & Use7: Good/Bad Hygiene

(Skip 1 week for understaffing)

Block 3Mar. 29-Apr. 8

Review Block 28: Treatment of Diarrhea9: Anemia Prevention10: Childhood Nutrition

Block 4Apr. 12-22

Review Block 311: Family Planning12: HIV/AIDSPost-test

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Pathways3 Blocking Disease Pathways 88 48.9

2: Water

4 Water Collection 98 54.4

2335 Water Purification Methods 98 54.46 Water Storage & Use 98 54.47 Good/Bad Hygiene 98 54.4

3: Nutrition8 Home Treatment of Diarrhea 110 61.1

2159 Healthy Diets and Anemia 109 60.610 Childhood Nutrition 107 59.4

4: Family Health 11 Family Planning 177 98.3 22112 HIV/AIDS 178 98.9Total Cards Collected 180 100

Total Cards w/ 5+ lessons 164 91.1Total Cards w/ 12 lessons 28.00 15.6

According to the headcounts, an average of 234 caregivers attended each block

of lessons. During the fourth block, the headcount revealed 221 caregivers in attendance, but, only 180 attendance cards were collected during this block. The headcount does not account for the proportion of caregivers who did not attend previous sessions. Therefore, it is not completely accurate to assume from the average block attendance of 234 caregivers, that this is the total number of caregivers who attended any session of the course. It is only an indication of the number of caregivers who participated in each block of lessons. The last column in Table 5 shows the per block attendance by headcount, which are all much higher than shown by the attendance cards collected. This is important because it indicates that about 50 attendance cards are missing (the difference between the number of cards collected, 180, and the average number of people who attended during each block). By teaching the course in two week blocks once, at least 234 or more caregivers received some part of the teaching. There are around 800 children enrolled in the nutrition program, so assuming that each one or two children have one caregiver, there are probably about 600 to 700 caregivers who attend the clinic every two weeks. This means that roughly 30 to 40% of the caregivers that attend the clinic were actually reached by the education program.

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Overall, I am very disappointed in the way that the attendance card method of data collection turned out.  I advised the caregivers to keep their attendance card with their child's hospital health chart, but I noticed that many caregivers kept the attendance card in their purse instead.  Some of the caregivers actually did keep the attendance cards with the health chart, but then put the health chart in the queue of health charts representing the patients present and waiting to be seen by a nurse, without first removing the attendance card, making it difficult to access. Many caregivers lost their cards, some caregivers received more than one card, and some caregivers attended but did not come forward to receive a card or to have their card marked. The caregivers who lost their cards were included in the daily headcount, but may have received another card without the previous lessons recorded, or they may have received another card with an inaccurate recording of previous lessons. Dorca and I asked them to recall something that they learned during each session they had previously attended in order to verify which lessons were recorded on the lost card. This did not allow for verification of individual lessons, so all lessons in the Block the caregiver recalled were recorded. The caregivers who attended the sessions but did not bring their card to be marked

Table 6. Attendance by Daily HeadcountBlock Date # Block Date #

1: Hygiene Lessons 1-3

Feb. 15 49

3: Nutrition Lessons 8-10

Mar. 23 18Feb. 16 23 Mar. 29 25Feb. 17 28 Mar. 30 37Feb. 18 29 Mar. 31 16Feb. 22 51 Apr. 1 15Feb. 23 32 Apr. 6 29Feb. 24 32 Apr. 19 32Feb. 25 24 Apr. 21 23

Block 1 Total 268 Apr. 22 20

2: Water Lessons 4-7

Mar.3 21 Block 3 Total 215Mar. 8 27

4: Family Health Lessons

11 & 12

Apr. 12 20Mar. 9 31 Apr. 13 21

Mar. 10 20 Apr. 14 20Mar. 11 12 Apr. 15 29Mar. 15 41 Apr. 20 42Mar. 16 22 May 3 32Mar. 17 33 May 5 21Mar. 18 26 May 6 36

Block 2 Total 233 Block 4 Total 221

Average Daily Attendance 28Average Block Attendance 234

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were counted in the daily headcount, but not included in the data compiled from the attendance cards. These inefficiencies caused error in the attendance card data. In addition, I was only able to collect cards from caregivers who attended Block 4 teaching sessions, so nearly all the cards collected are from caregivers who attended lessons 11 and 12, but almost none of the cards from caregivers who attended during other sessions, but not during Block 4.  I asked the nurses in the clinic to continue collecting any attendance cards that they see with the child's yellow health chart, but no additional data has been shared with me.  As you can see in Table 3, attendance to Block 4 lessons is 98% while the attendance to other lessons averages at 55% (meaning that each lessons was attended by about 55% of the caregivers whose cards were collected). The discrepancy is due to this circumstance. I speculate that had all cards been collected, attendance rates in the first three blocks would be around 65%, and attendance in Block 4 would be around the same.

I chose not to mark the attendance cards with the caregivers' names and then pull the cards each day to mark them because it would've been too time consuming.  As it was, Dorca's time and duties were divided between the education program and the clinic.  Each day, I helped her to complete her clinic duties to make time for teaching; time was valuable and difficult to gain each day.  I could have keep the named cards with their child's clinic records, but again, this would have taken a lot of time to match them all up, and it would have disturbed the clinic queue, kept in order by the child's paired health chart and clinic records.  Even with this method, the caregiver for that particular child may have been a different person over the weeks, still causing error.

Attendance rates were much lower than desired and anticipated. Attendance to the sessions largely depended on attendance to the clinic. Each caregiver expects to be able to receive food items from the clinic for their child every two weeks. Patients come from within 100 km of the nutrition clinic on foot, or sometimes by local transport vans, often taking many hours. Because the sessions were taught in the mornings, usually from about 9am to 11:30am, it is possible that a majority of the caregivers in attendance lived comparatively close to the clinic. The clinic itself is located in a very rural area, so the lower-educated villagers in the surrounding area can choose to come at any time in the day, perhaps inconsistently. The nearest town to the clinic is about 10km away, and the nearest city (Chimoio, the fourth largest in the country) is about 35km away. Therefore, the time of the sessions may have inadvertently favored caregivers who lived nearer to the clinic. However, some caregivers walk all day, spend the night somewhere along the way, and continue on to the clinic, arriving in the morning. The morning sessions would have favored these caregivers who live in the outermost parts of the catchment area of the clinic. Attendance to the clinic relies on referral to, or knowledge of the clinic. The nutrition program does not advertise its services, but is widely known among government officials, hospitals, and local private primary care facilities. Therefore, the caregivers who attend may be more connected to healthcare services and more knowledgeable about healthcare systems. Although caregivers were advised to attend the clinic every two weeks, some caregivers were unable to do so due to agricultural livelihood obligations, such as working in the fields. This would have reduced attendance for certain days, or weeks, depending on the weather and other agricultural circumstances. Attendance to the sessions was not dependent upon the topic because the topics were not routinely revealed ahead of time.

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The sessions of each block took place every day that the clinic was open for two weeks. Therefore, the day of clinic attendance was not a determinant of attendance to the sessions.

Major obstacles to the collection of accurate attendance data were limited human resources, limited time, and illiteracy of the audience. If this were to be done again, I would suggest that attendance cards be kept with the child's clinic records. These records were retrieved from record binders each day as the caregivers put their health chart into a pile that acted as a queue of the patients to be seen by a nurse. If attendance cards were kept with these records, it would be easier to retrieve when compiling data and it would give an indication of the proportion of children enrolled on the program whose caregiver had received the teaching. Unfortunately, finding each caregiver's child's chart while it is in the queue, and then marking it with the appropriate lessons would still be difficult and time consuming.

In an attempt to evaluate the effectiveness of the hygiene and health course, I designed a pre/post-test comprised of 15 questions about the information presented in all twelve lessons. Because most of the audience was illiterate, the test was administered verbally to the collective audience. I successfully gathered the "pre" data, but in the last block of teaching, I was unable to gather the "post" data during the last block. This was because of the other time-consuming obligations of teaching the two lengthy and discussion-evoking lessons of family planning and HIV/AIDS, collecting all attendance cards, and awarding participants with bars of soap. This was further complicated by the fact that Dorca's clinic duties were increased significantly when the only other literate clinic assistant gave birth and took maternal leave, leaving Dorca to retrieve all of the patient records. This significantly limited the time that Dorca had for the education program. ThereforeAs a result, there was insufficient time for us to ask the post test questions each day of the last block.  We were only able to do so on one day, but on that day, very few of the caregivers present had actually taken any of the lessons (for unknown reasons). Consequently, I have no way of truly knowing how much and what was learned as a result of the teaching.  It is clear to me, however, that much of the material was new, and many caregivers sincerely enjoyed the course.  Two or three of them even brought large sacs of food from their fields as a thank you gift to for Dorca and me! One of them said, “Thank you so much for teaching these things to us! They are very important and many of the younger women don’t know about these things.” Another caregiver who participated in the course said,

"I feel like I have been given opportunity to learn some things. When I had questions they responded without doubt. For example in the hygiene lesson we learned that feces has bacteria. Another thing about diarrhea the ladies didn't know how to prepare re-hydration fluid at home, and we didn't know that if someone has diarrhea they need to drink a lot of water to replace the fluid that the body has lost. Many times we thought that if someone has diarrhea you must not give water because it will make it worse. Now we know that we have to give water. About breastfeeding babies, we were wrong. We thought the first milk that comes out yellow is bad milk and would harm the baby. In this the lesson taught us to understand that the first, yellow milk helps prevent illnesses and the white milk helps the baby to grow. About water, we didn't know how to treat

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water so that it is drinkable. How to use a cloth to filter or put it in the sun, 3 containers for 3 days. With the lessons I know many things and I like this program and it is my desire to teach these lessons to other ladies, I am available. It is my last week of learning and next week I will start to teach too." (translated from Portuguese by the program manager)

In order for the education arm of the nutrition program to be sustained, the program needed a name, a replacement leader, protocol, and funding. The nutrition clinic's mantra is a Bible scripture, John 10:10 "Jesus said, 'I have come to give life, and to give it in abundance.'" The Portuguese phrase, "fundação da vida" or "foundations of life" is used to refer to good hygiene practices. From these phrases, the program's name was formed: "Mavambo Upenyu Wakakwana". This means, "Foundations of Abundant Life" in the local dialect of Shona. The name of the program is therefore, "Mavambo Upenyu Wakakwana Hygiene and Health Education Program". A Supervisor of Health Education was trained to be the leader in my absence. Dorca was the perfect candidate for this position because she speaks English, Portuguese, and the local dialect of Shona and she's intelligent, strong-willed, innovative, and speaks her mind. The relationship was mutually beneficial, as she offered cultural insights, ideas, and translation, while she was trained with new knowledge and skills in hygiene and health, which empowered her. She was also given a pay raise from part-time pay to full-time pay with benefits. For the first week of each block, I facilitated the lessons while Dorca translated. She then facilitated the lessons for the second week, while I provided guidance and feedback as needed. By the end of the four two week blocks of teaching all 12 lessons, Dorca had facilitated each lesson herself 4 times. She was awarded a certificate of training in hygiene and health. Dorca, being a local national, offered poignant insight into the effectiveness of the curriculum's suggested dialogue, including the health lessons that I wrote. The Supervisor of Health Education (SHE) is responsible for recruiting, interviewing, training, orienting, and deploying six new Community Health Educators (CHEs), scheduling new venues at which to teach, providing the CHEs with all of the materials they need to conduct a course, and reporting the activities of the program. The SHE position description is included in Appendix 4: Education Program Administrative Documents.

Once the SHE identifies a candidate for CHE training through recruitment at a course and an interview, she explains the education program, what is expected of the CHE, and what the program will provide to the CHE. The CHE position description is included in Appendix 4. Then, they both sign an agreement to follow through with the expectations. The SHE then teaches a course to a new audience with the CHE accompanying her to translate so that the course sessions are offered in Shona and Portuguese. This helps with memorization of the lesson dialogue, since many of the CHE candidates are only partially literate. At this point, the CHE has earned her certificate of training for participating in the course and assisting with teaching a course. She is then deployed to teach the course at a new venue on her own. Each CHE is expected to teach two courses to new audiences after their training. For each course taught, the CHE receives an incentive gift commiserate with four half-day wages. Thus far, Dorca has trained five CHEs. Two of them chose not to fulfill their contract at this time, but plan to teach to new audiences in the future. Three of them are teaching

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courses to new audiences. Dorca has been visiting these courses to assist and guide the CHEs, and to ensure accuracy and quality.

It is the responsibility of the SHE to partner with local churches and other community centers at which to teach the course. To each new venue, the program goals, curriculum topics, and teaching schedule are presented to the venue's representative, and a request is made to partner in sharing the hygiene and health information and skills. The dates and times are scheduled for a CHE to teach the course at the venue. The protocol for presenting the education program to the venue contact and the information sheet that is given to the venue contact are included in Appendix 4. Dorca and I secured the first venue together by presenting the program to the wife of the pastor of a local church. This was the first venue where Dorca taught a course without me, while training a new CHE. This was done while I was still in Mozambique, and it gave Dorca confidence that she could fulfill her duties as SHE in my absence. While I was still present, Dorca also taught the course to the parents of the preschoolers enrolled at Africa 180°'s preschool.

All CHEs report their progress to the SHE, and she reports to the nutrition program manager. The training scheme diagram is included in Appendix 4. The SHE has the master copy of the hygiene and health curriculum (in English and Portuguese), as well as an administration notebook containing protocol, forms, and reporting documents. I wrote these documents to ensure that all tasks related to the education program were continued and performed properly. All programmatic documents, including the lessons, forms, and protocol, have been translated into Portuguese. These documents, along with samples of written records that Dorca keeps, are included in Appendix 4. The SHE also maintains two sets of four bags containing the demonstration materials necessary for each block of lessons. Though great potential was apparent in Dorca, the leadership skills of planning, organization, record-keeping, making partnerships, and decision-making were cultivated and refined. Her diligent help with planning, record keeping, teaching, translating, and administration were invaluable to the program. In reflection of our partnership in initiating the education program, Dorca said,

"I will remember all those times together. Actually, you teach me a lot. There's a lot of things which I didn't know, but through you, so, some of things I know, I know now…Thank you for those times of sharing deep things to me. So I really appreciate that. Even my English is not very good but you also teach me, correct me. Through you, actually, I'm much better than I was. I really appreciate that."

The program manager of the nutrition program, a South African nurse missionary, oversees the education program. All documents produced have been given to her in digital form, including a certificate template, forms, the curriculum, and protocol. Nearly $700 was procured for the continuation of the education program. The program manager is responsible for these funds, which pay for transport costs for the SHE and CHEs to travel to each course venue, incentive gifts, and printing of certificates and forms. During the initiation of the education program, the nutrition program manager served as my advisor on maternal and child health and nutrition for the planning and implementation of this education program, and she now makes all necessary decisions regarding the education program operations.

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In my absence, this project continues to have a great impact on the people of Manica Province in Mozambique, and has brought Africa 180° one step closer to achieving its mission. The program is giving many caregivers and communities the knowledge and skills necessary to prevent infectious illness and an understanding of very basic science information such as the digestive system, pathology of bacterial infections and HIV/AIDS, and the reproductive system. The courses also serve as a safe forum by which to discuss cultural beliefs that hinder health, frustrations with keeping the family healthy, and problems with the local healthcare system. For the CHEs, the education program is providing job training, skills, and certification to empower them and enhance their employability and self-esteem. The education program has continuing goals, materials and protocol, ample funds, and committed staff and volunteers, which reinforce and expand the reach of this valuable information.

In addition to teaching the hygiene and health course to caregivers at the clinic, I taught the hygiene lessons (1-3) to the gardeners, guards, and construction workers of Africa 180°.  The director asked me to do this because it was apparent that the male employees were not practicing good hygiene habits. To make these lessons more entertaining and interactive, I created a "hygiene jeopardy"; the prizes were flashlights. The three lessons were taught after lunch over three days. In total, a conservative estimate of the number of people who participated in the courses taught during my four month stay was at least 274. This is much less than the anticipated 360 at only the clinic, but the attendance of the course at the clinic was underreported. The small army of 6 CHEs and their SHE leader continue to teach courses to new audiences.

My relationship with Africa 180° will continue as their Advisor on Public Health on the Board of Advisors. I plan to return to Mozambique in December 2011 or January 2012 to follow up on the education program, make necessary changes, assess the program's progress, and create a plan for 2012.

Additional ActivitiesWhile volunteering my time with Africa 180°, there were many small things that I

did to improve the health of the environment. One problem was that there were two pit latrines with brick enclosures on the property, which were shared between the preschool staff and students, the clinic staff, caregivers, and children, construction workers, guards, and gardeners. The latrine cleaning was the responsibility of the clinic assistants. However, there was misuse of the latrines making them unsanitary. At the same time, the preschool hired a cook to make beans for lunch for the students. I requested that she sprinkle the white ash from the cooking fires in the latrines to deodorize and disinfect the concrete base.

Another problem that I noticed was that many of the caregivers bite their own and their children's nails to trim them, putting them at high risk for diarrheal disease. In response, I secured a pair of nail clippers to the clinic security gate for their use each time they attend the clinic (every two weeks). The clinic assistants will put them out in the morning and clean them and put them away when the clinic closes each day. I also incorporated safe nail trimming habits into the hygiene portion of the hygiene and health curriculum.

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When a church team of 15 was scheduled to visit Africa 180°, the director asked me to share information about the field of public health with them. Many of the team members are in their early 20s, so it was the perfect opportunity to inspire interest in pursuing a career in public health and promote Tulane's SPHTM. I prepared a one-hour "Overview of Public Health" lecture and presented it to them. The lecture included a definition of public health, examples of public health programs and initiatives with which they may be familiar, a description of the ten greatest public health achievements in the 20th century, a comparison of public health to the fields of development and medicine, the basic determinants of health, disciplines within the field, diversity of public health careers, and routes to enter the field. At least two of them expressed interest in the field.

The nutrition program manager requested that I conduct an in-house training for the clinic staff, particularly about health behavior (Goal 5). She is interested in the theories and models of behavior as applied to the population served by the nutrition clinic. In my time at Africa 180°, I was unable to adequately prepare and schedule an in-service training. However, I did compile all relevant course material from powerpoints and literature and left it with the program manager to review and share.

The director of Africa 180° shared that the organization had never received any grants, nor had written any grant proposals, but she is very interested in doing so. The tool of a grant proposal template will streamline the process of applying for grants for several different programs under the Africa 180° umbrella. Because I had taken a grant writing course, I offered to prepare a grant proposal template (Goal 6). Unfortunately, due to time constraints and other obligations for myself and the director, I was unable to complete this goal thus far. , but iIn my continuing relationship with Africa 180°, I would like toplan to pursue completion of a grant proposal template.

After taking a community organization course that included a practice component with a local neighborhood organization in New Orleans, I was eager to use my new skills! The parents of the preschool children was were the perfect group because they all live in the vicinity of Africa 180° in a loosely knit community. At a parent's meeting at the preschool, I invited the parents to meet together one afternoon to discuss their community. Although I was sick the week of the first meeting, I still attended with a hired translator. Twenty women were in attendance. Using the course materials, I created a community organizing exercise comprised of a series of activities, questions, and discussion points. The goal of the exercise was to help the group to identify assets within the group and issues that affect the community, and then formulate a plan to do something about the issue. In doing so, I hoped to improve social cohesion and widen support networks in the

Table 7. Simba Madzimai Activities and AttendanceDate Activity #March 3 Community organization exercise 20March 10 Community organization exercise 16March 17 Community organization exercise 11March 24 Community organization exercise 13March 31 Sharing songs and dances 17April 7 National Women's Day; home visits 5April 14 Sharing crochet skills 10April 21 Sharing clay pot making skills 15

April 28 Sharing about Earth's seasons, days, and nights, geography, and cultures 17

Average Attendance 14

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community. It was my hope that I would facilitate a discussion to evoke them to action to solve the issue that they identified. After the first meeting, we hadn't finished the exercise, so we planned to meet the next week. On the fourth week, we finished the exercise. None of the issues identified and the solutions presented seemed achievable to the group, but they were interested in continuing to meet. We decided to meet weekly to share our personal skills, which had been identified over the weeks through the exercise. In the formalization of the group on the fourth meeting, a name for the group was chosen and a president and vice president were selected by nomination and voting. The name of the group is "Simba Madzimai", Shona for "Powerful Mothers".

On the fifth week, we gathered to share songs and dances. Unfortunately, this caused some division among the group members, because the Muslim women were afraid of the consequences of being seen with a group singing Christian songs. When I noticed the president and vice president were no longer present, I inquired if the women knew where they went. At this point, it was explained to me what was happening, so I did my best to fix the situation, reminding the women that the mutually determined goal of Simba Madzimai was to share skills and knowledge with each other, in support of each other, not to cause division among community members. The group was reconciled later that day. On the sixth week, the meeting day happened to be National Women's Day, so only a few of the women gathered together. We simply spent time together, doing laundry and hanging it, shucking corn, and chatting. In a previous meeting, the women expressed interest in crocheting, but complained that they didn't have crochet hooks. I challenged the group members, including myself, to make a crochet hook with available resources. On the seventh week, I demonstrated how to carve a crochet hook from a local wood. A group member helped the other woment to practice crocheting with hooks and yarn that I borrowed from Africa 180°. On the eighth week, we all contributed 2 mets (~6¢) to a woman who taught us how to make clay pots. She brought clay from the riverbed, we pounded, wetted, softened, and kneaeded it, and then she taught us how to form the pots using our hands, a dried mango seed, and a corn husk as tools. The next day, we added a base to each pot, and then the next week, they were fired. Unfortunately, only one pot didn't break during the firing process. The ninth meeting was the final meeting I attended before I returned to the states. During this meeting, I taught the women about world geography, the orbit and rotation of the earth to make seasons and days, and about the many cultures and people-groups around the world. Then, I presented each group member with the gift of a capulana (a stretch of fabric used for a skirt or to carry various items). They expressed their desire to all have the same patterned capulana to identify them as a group during its formalization.

Table 7. Simba Madzimai Activities and AttendanceDate Activity #March 3 Community organization exercise 20March 10 Community organization exercise 16March 17 Community organization exercise 11March 24 Community organization exercise 13March 31 Sharing songs and dances 17April 7 National Women's Day; home visits 5April 14 Sharing crochet skills 10April 21 Sharing clay pot making skills 15

April 28 Sharing about Earth's seasons, days, and nights, geography, and cultures 17

Average Attendance 14

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Simba Madzimai continues to meet. This is also the group that to whomDorca taught the hygiene and health course to. The preschool director used this group of women to begin a local literacy class taught by a Mozambican, and has about 50 students in total enrolled. I hope that this helps the Simba Madzimai to grow and that they continue to meet after the literacy classes have finished.

V. Discussion: Provide a discussion based on the work accomplished. Was the need for the project addressed satisfactorily? Indicate positive and negative aspects of the experience. What lessons did you learn about public health practice from your experience? Would you recommend this agency as a placement site for future students? Why or why not? Include your feedback on the preceptor as well as the agency.

The nutrition program provides primary health care, assistance, and support to many families. The need for preventative education among the population it serves was quite obvious by the overwhelming presence of preventable illness. The constant fight for life is stressful and difficult for the children, their caregivers, and their families. The education program equipped this population with the knowledge and skills to prevent illness, provide proper nutrition for their families, maintain a healthy home environment, and promote health in order to improve survival and quality of life. The education program addresses many of the issues threatening these outcomes through teaching, demonstration, and participatory learning. While I was present, the education program reached only about 30-40% of the caregivers of children served by the nutrition program by the conservative attendance records, and not all of them participated in all of the curriculum's lessons. However, because a Supervisor of Health Education was trained to continue the education program and train six more Community Health Educators, the program's coverage will continually increase. Therefore, the need for a sustainable and effective education program was addressed satisfactorily. In addition to this main goal, I accomplished several other things to assist Africa 180° in achieving its mission to reverse "the cycles of poverty, disease and death in Mozambique" and "proclaim the Gospel of Jesus Christ to those we live with and minister to". Africa 180° benefitted from my volunteered time with them. However, my work was not without mistakes and lessons. Describe the curriculum through the lens of social and behavioral aspects of PH, using the models and their terms

৹ Social Capital: the clinic encourages orphaned children to be cared for by a relative or friend of the family, utilizing the social capital of the child and/or its mother to ensure adequate care.

৹ Self efficacy: Built through learning and seeing demonstrations during the lessons

৹ Collective efficacy: Built on their own in communities. Difficult to influence in the context of the clinic patients because they all come from villages within 100km

৹ Health Belief Model: The curriculum targets increasing the individual perceptions of susceptibility to infectious diseases, particularly those transmitted through infected feces. I also added to the curriculum information about conjunctivitis.

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The individual perception of severity of such infectious diseases largely depends on their own experiences with infectious diseases, and those that they've witnessed around them. For this population, the severity of diarrhea can be fatal for the malnourished, HIV+ children. Therefore, perceived threat should be fairly high. Modifying this, are intrapersonal factors and cues to action. The intrapersonal factors vary greatly, and cannot be easily influenced by this program. The cues to action can also vary greatly. For example, if a caregiver's child becomes sick with diarrhea after they have recently learned about bacteria and disease pathways, this may act as a cue to action to prevent the other children from getting sick. If the caregiver recently participated in the lesson about home treatment of diarrhea, the onset of the child's diarrhea may be a cue to action to provide oral rehydration. The barriers to action may be the cost of soap, coal to boil water, sugar, and salt, or previous contrary/different advice. If the expected benefit of health (and possibly prevention of the perceived threat of death) outweighs the barriers, then the caregivers should change their behavior.

৹ Community participation৹ Sustainability৹ Capacity building৹ Qualitative Methods employed: conversations, informal interviewing,

observation,

Perhaps analyze through lens of HIV psychology, social impacts, etc.

Elements 1-4 of PMTCT from M&E lectures!!!Focus of clinic is Element 3: Prevention of HIV Transmission from Women Infected with HIV to their infants and Element 4: Provision of Treatmes, Care and Support to Women Infected with HIV and their families. Interventions of Element 3 include: HIV testing and counseling, antiretrovirals, safer delivery practices, safer infant feeding practices. The clinic encourages testing and ARV use. Clinic focuses on safer infant feeding practices. Interventions of Element 4 include: prevention and treatment of opportunistic infectsion, ARV treatment, palliative and non-ARV care, nutritional support, reproductive healthcare, and psychosocial and community support. Clinic focuses on treatment of opportunistic infections (and prevention through this new education program), nutritional support, and psychosocial and community support. The clinic will soon begin palliative care with the recovery center.

How did your Project build capacity or increase knowledge? What new skills and knowledge have been acquired by your organization? The target community? Other project stakeholders? (please be specific)This project increased the knowledge of the caregivers about hygiene and health and gave them the ability to prevent infectious diseases, provide proper nutrition for their children, and maintain a healthy home environment for their family. The organization now has a fully operational education program with a supervisor continuing to teach courses to new audiences while training new Community Health Educators (CHEs). The program has the capacity to train 6 additional CHEs who are expected to reach 12

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new audiences with the hygiene and health curriculum by December 2011. These CHEs earn certification for hygiene and health teaching, which improves their employability and instills self-esteem, thus empowering them to become leaders in their community and provide better care for their families.

What do you believe were the most important “lessons learned” (positive and negative) through this project? How has or will your organization use these lessons learned to enhance your work in this or other areas?The most frustrating lesson learned was that dData collection for monitoring and evaluation was extremely difficult and time-consuming. For the organization, records are important, but only for internal use, not for deep analysis to prove the effects of the program and . For the organization, qualitative data seems sufficient to inform changes and decisions. Qualitative Quantitative data is time-consuming and cumbersome, and seen as not worth the time or effort of the volunteer staff. My inability to maintain accurate and complete records of which lessons were attended by each (illiterate) course participantcourse attendance only confirmed the organization's disposition on monitoring and evaluation in the context of an illiterate population and valuable time.. Another valuable lesson learned was to trust the opinion and advice of Dorca, the clinic assistant assigned to aid with the education program. When Dorca was teaching the lessons under my guidance, there were many times that she purposefully changed phrases in order to make it more understandable and acceptable to the course participants. I learned to trust and honor her as she taught because I could see that the participants understood and grasped the information better than when she translated literally for me while I was teaching the same lesson. I also learned about women's empowerment through the profound transformation that I saw in Dorca through the initiation phase of the program. The program gave her new purpose: to share the valuable, life-saving information that had been entrusted to her. This gave her confidence in her abilities and excitement about her work and her life. The organization already operates under this principle of trusting the locals and empowering them to help their fellow country-men. Before my practicum, I knew of and believed in the value of community participation and ownership, and now that I have experienced it, it is ingrained in my work ethic. I was also able to develop the skills of flexibility, resourcefulness, and leadership. There were many opportunities for me to exercise these skills. I had to be flexible in my time and plans because of many unforeseen circumstances and events, and the fact that time is very differently managed in the Mozambican culture. There were also many instances when certain resources were unavailable; this required creativity and "thinking outside the box". As a mentor to Dorca and a leader of the education program, I gained experience with these skills. I would highly recommend Africa 180° to a very certain type of person. Africa 180° is a Christian organization with a Christ-centered mission comprised of Christian volunteers. Therefore, this agency is recommended for a Christian student, whose work is motivated by his/her faith. Having a successful and enjoyable practicum experience

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with this organization would require a student who can effectively work largely independently, set his/her own goals to aid the organization's mission, work well across cultures and humbly with less educated populations, and is deeply passionate and compassionate. This individual should also be spiritually and emotionally stable without an expectation for intense mentorship. This is not because the organization's staff members are not supportive, but that their focus of attention and emotional capacity is for the populations that they serve.

My preceptor was the director of the organization, Tracy Evans. She was very informative, helpful, and encouraging through the entire process. She allowed me ample freedom to be creative in accomplishing my academic requirements and personal goals. She provided logistical support to help me to extend my stay by an additional month. She provided encouragement to me for my career and my future. Tracy is an incredible woman who inspires many through her life's triumphs and accomplishments. It is a privilege to know her and to have a continuing relationship with such a great woman. I can hardly express how wonderful my practicum experience was.  For many years, I've been anticipating the fulfillment of the personal and academic formation process, when I would fit perfectly into a mold called my destiny. For those four months of my practicum, I felt incredibly fulfilled.

VI. Recommendations: Provide recommendations based on the project. How can/will the agency benefit from your project?

I was very impressed by Africa 180°, its volunteer staff, and its programs. I have no recommendations for the organization, as a whole. I learned a great deal about maternal and child health and nutrition from the organization and its Makomborero Nutrition Program. I perceived that the nutrition program wasn't very integrated into the local health care system, including public hospitals, private clinics, and other agencies focused on HIV/AIDS prevention, treatment, and care. The only recommendation that I have is to integrate the program into this network to strengthen referral systems and offer the people of Manica Province affected by HIV/AIDS more adequate and comprehensive care. I do understand, however, the apprehension of the organization to do so is potentially the result of their already maximized capacity.

What do you see as the next steps your organization can take to build on the successes of this project and leverage opportunities that the project has created?

To build on the successes of the initiation of the education program as an extension of the nutrition program, the nutrition program manager can continue to allow Dorcaa, the clinic assistant who also serves as the SHE, to divide her time adequately, giving her a full day and a half each week to devote to the education program activities. Dorca should also be encouraged to teach the curriculum to the caregivers of clinic patients again to reach the remaining 60-70% who did not participate in the first course offered. The nutrition program manager could also offer employment opportunities in the new recovery center (to begin operating later this year) to the volunteer CHEs.

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They are have already been trained in hygiene and health practices, which will help them to employ safe clinic technique and offer individual counseling to caregivers. This will help to sustain their own household and their family's health by providing a skilled livelihood.

The organization may want benefit from to ffostering partnerships with the the venues at which the hygiene and health courses are taught in order partnerships, especially with churches, to create a broader Christian communitynetwork by which to garner resources and support for community-wide events and initiatives., like the Worship Competition held in March 2011.

VII. Self-AssessmentI am very proud of the work that I accomplished during my practicum experience.

There are very very few things that I could have done better. As a public health professional, I gained much from this experience. My confidence in my ability to identify a public health need, develop a program with sustainability, and implement it using available resources and partnerships was strengthened. My skills in program development, human and resource management, mentorship, and leadership were improved. I gained experience with effecting behavior change through participatory teaching, and became more familiar with public speaking, teaching, and training. My skills as a community organizer were exercised, and though I learned a lot in this area, I know that I have a lot more to learn, too. The language barriers and cultural differences allowed me to find creative solutions, understanding, and tolerance in deep cross-cultural situations. I was also successful in procuring funds to enable program development and sustainability. Through all interactions, I made an effort to remain culturally humble by seeking opportunities to try new things, learn new methods, and gain a deeper understanding of the people, valuing their ways.

Unfortunately, in hindsight, I now see that I was unsuccessful with one particular cultural practice. The Mozambican people are very humble, respectful people. To show respect and honor, it is customary to kneel when receiving something from the one who is honored, and avert one's eyes, avoiding eye contact. Even though I recognized this cultural practice, I failed to do the same. It is only now that I can identify many instances when I did not show honor and respect in the same way. I know that I did show honor and respect in my own way, and I can only hope that it was recognized as such.

I was able to successfully accomplish most of the goals that I set for myself. Goals 5 and 6, teaching an in-service about health behavior and writing a grant proposal template, were not accomplished due to time constraints on my own time and that of the director and nutrition program manager. I even extended my stay for one month longer to ensure that the education program's foundations were firm. It was very important to me to finish what I had started, and to finish it exceedingly well, and I believe I did.

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VIII. References:Berer, M. & Ray, S. (1993). Women and HIV/AIDS: An International Resource Book:

Information, Action and Resources on Women and HIV/AIDS, Reproductive Health and Sexual Relations. Pandora, London, UK.

Brown, R. & Brown, J. (1998). The Family Planning Clinic in Africa: A Practical Guide for Workers in Contraception Clinics. Macmillan, London, UK.

Burns, A. A., Lovich, R., Maxwell, J., & Shapiro, K. (1997). Where Women have No Doctor: A Health Guide for Women. Ed. Niemann S. Hesperian Foundation, Berkeley, CA, USA.

CFNI. (1986). Nutrition Handbook for Community Workers in the Tropics. CFNI (Caribbean Food and Nutrition Institute) and Macmillan, London, UK.

INSIDA. (2010). National Survey on Prevalence, Behavioral Risks and Facts about HIV and AIDS in Mozambique – INSIDA 2009. Mozambique Ministry of Health, National Institute of Health, Maputo, Mozambique; ICF Macro, Calverton, MD, USA.

USAID. (2005). Mozambique: The Development Challenge. USAID, Retrieved online on July 7, 2011 from http://www.usaid.gov/mz/development_challenge.htm.

Werner, D, Thuman, C., & Maxwell, J. (1992). Where There is No Doctor: A village health care handbook. Herperian Foundation, Berkeley, CA, USA.

Werner, D. & Bower, B. (1991). Helping Health Workers Learn: A book of methods, aids, and ideas for instructors at the village level. Hesperian Foundation, Berkeley, CA, USA.

WHO. (2010). Mozambique Statistics. World Health Organization, Retrieved online on July 30, 2011 from http://www.unicef.org/infobycountry/mozambique _statistics.html.

WHO/UNICEF. (2002). Integrated Management of Childhood Illness chart booklet, South Africa Department of Health. Pretoria, South Africa.

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IX. Appendices

Appendix 1: Africa 180°'s Programs and Partnerships

Appendix 2: Activity Log

Appendix 3: Expense Report

Appendix 4: Education Program Administrative Documents1. Program Description2. Teaching Scheme Diagram 3. Training Scheme Diagram4. SHE Position Description5. CHE Interview Form6. CHE Position Description7. Protocol

a. Maintenance of Teaching Handbookb. Maintenance of Materials Bagsc. Protocol for the Orientation of a New Community Health Educatord. Protocol for the Presentation of the Education Program to a Venue

Contact8. Program Information Sheet for Venue Contact 9. Written Records Samples

Appendix 5: Hygiene and & Health Curriculum

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