Karen W. Lapping Transcultural fund recipient
Summer 1999, Pakistan

Project Background: Since 1990, the number of refugees and internally displaced persons worldwide has grown by 40%, from approximately 30 million to 43 million people (Toole, 1993). In 1987, Afghans were the world's largest single refugee population, with 2.5 million living in exile in neighboring Pakistan, primarily in the Northwest Frontier Province (NWFP) (Boss et al., 1987). In 1980, Afghan refugee camps were established in district Haripur, NWFP, Pakistan. In 1991 Save the Children (USA) assumed the responsibility for the provision of health services. Since SC/US took over the responsibility of the Health project, the focus has shifted from curative treatment services to preventive health services. The major components of the current PHC program are: Child Health Care (E PI, GM, nutrition management and prevention of ARI and CDD), TB and Malaria control, Primary Eye Care, Matenial Care (antenatal, safe delivery and postnatal care), Basic Medical Services and provision of health education to the refugee community. 

The population of the refugee camps in and around Haripur is estimated at 115,102. The current political, security and economic situation inside Afghanistan has not inspired many Afghans to return 
home. In fact, since the Taliban capture of the country's capital in 1996, there has been a small but steady flow of new refugees. Very few people have any formal education, women live in strict purdah (isolation), and family incomes are small. There is little published data about this fairly unique refugee population. 

Project Objectives:

Objective I: Become familiarized and gather contextual data about the Afghan Refugee experience in Haripur and factors impacting their lives in Pakistan and possible plans for repatriation 

Methodology:

• Conduct preliminary research in Islamabad to gather data and understand Save the Children's role in Haripur and programming objectives. 
• Attend meetings with Dr. Marsh to further understand health situation in Haripur. 
• Visit all BHU'S, attend a NFE class session and talk with key health personnel. 
• Conduct Focus Group Discussions to understand key issues that impact scope of work and analysis. 
• Conduct research at ACBAR library in Peshawar 
• Discuss with various NGO personnel state of Afghan refugees in Pakistan and factors impacting their repatriation plans. 

Methodology:

• Attend training session with Dr. David Marsh and BHU staff 
• Collaborate with Dr. Marsh, Dr. Ihsan and Dr. Zahir to create a feasible plan for the creation, testing and implementation of the Positive Deviance Inquiry. 
• Create Positive Deviance Inquiry (PDI) team. 
• Train team members in interviewing and observation skills. 
• Role-play and pilot test to further train, and refine instrument. 
• Execute actual PDI. 
• Translate and compile data, create matrixes of home visits and case studies. 
• Analyze data with PDI team and create PD profile. 

Methodology: 

• Calculate sample size given time, resource and logistic constraints 
• Create questionnaire and locate cases and controls
• Train Case Control team in field techniques 
• Pilot test Case Control questionnaire and refine instrument 
• Conduct actual Case Control
• Translate and compile data 
• Analyze data using Epi Info software 

Finding: The role of the FHS (female health supervisor) is critical as she is the person who has the most frequent and consistent contact with the family. The presence of severe malnutrition and poor health seeking behaviors despite frequent FHS encounters suggest that this critical "frontline" position in the PHC program is not being utilized to its optimum level. The range of expertise and knowledge among the FHS's needs to be examined as the FHS is the primary liaison between the Afghan Refugee Health program and the families. 

Suggestion: A thorough evaluation of the FHS's examining selection, training, responsibility, evaluation and monitoring should be carried out. The range of expertise and knowledge among the FHS's needs to be examined. Training programs are a constant in Haripur but the content and appropriateness of the training needs to be reexamined. Supervisor evaluations should be compiled and acted upon. Having a "training heavy program" without proper monitoring, evaluation and support is not beneficial, a fundamental shift needs to be made from quantity of training to quality of training and adequate follow up. 

Finding: Breast-feeding was found to be protective against malnutrition (P value .009) as was breast feeding during diarrhea and increasing feeding during illness (P value .001, P value .0006 more analysis will be done on these variables). While the Afghan Refugee Health Program PDI did identify "special foods" to promote, the most significant differences between PD and NPD families was the presence of active feeding and positive health seeking behaviors. 

Suggestion: Key messages need to be reiterated at every possible opportunity. Both the PDI and Case Control study illuminated the fact that the following key messages are not being acted upon and are thus, having a deleterious effect on health status. Key messages to reinforce include: 

• Increase Breast-feeding during episodes of diarrhea 
• Increasing feeding during and after illnesses 
• Reinforcing the message of exclusive breast-feeding for the first four months of life is critical (other than water and herbs)
• Stress the importance of more meals per day with healthful snacks
• Demonstrate active feeding techniques to mothers and secondary caregivers. 

Finding: Mothers who stated they did not want any more children were 3 times more likely to have a malnourished child than those who want more children (P-value .04, OR 3.27). This finding coincides with the PDI finding that the demeanor of the mother, which is very much related to her level of support from the family, has a substantial affect of the health and well being of the entire family. 

Suggestion: Efforts to try to strengthen positive male participation in family life would be very useful. Short of this admittedly "lofty goal" having the men not be a barrier to the use of modem contraceptives for birth spacing and potential prevention of STD's is critical to the health status of the community as a whole. The difficulty of this task is acknowledged however, this extremely important issued needs to be addressed. Both studies showed that the primary reason why women aren't using birth control is because their husbands don't want them to. Perhaps having male staff members talk with men in chai shops or on village paths or other locations where men feel comfortable and secure in discussing sensitive issues should be initiated. Despite conservative and traditional family values, the Afghan refugee community is not immune to the devastating impact of HIV/AIDS. Incorporating messages about family planning and STD's and targeting high-risk groups, such as men who work away from Haripur would be a solid step to potentially curtailing the inevitable impact of HIV/AIDS on the community. 

Finding: Secondary caretakers are primarily daughters and Mother-in-Laws. 

Suggestion: Target these groups for supplemental health education and highlight their importance in the health of the family as a whole. This is certainly a difficult task given cultural constraints but as SC endeavors upon new programming keeping this finding in mind would no doubt be beneficial. 

Finding: Fully vaccinated children were 9 times more likely to be well-nourished than those who are not fully vaccinated (P-value, 02, OR 9.33). 

Suggestion: In addition to stressing the import of vaccinations try to integrate the EPI program with the GM program in terms of identifying risk factors that may indicate other health issues. Cross reference registers to capture "At Risk Children" and when a child is in the BHU for a vaccination or GM visit do not miss the opportunity to provide assistance and counseling regarding nutritional status and education. 

Finding: The BHU's have a good system of recording "At Risk" Children but follow up needs to be made a priority. 

Suggestion: Reinforce the importance of proper follow-up. The "At Risk" children would be an ideal group to pilot a PDI intervention. 

Findinig: The Primary reason why women were not attending NFE classes was because they were not offered in their area. 

Suggestion: Locate these areas and examine the feasibility in terms of resources and personnel to facilitate NFE classes. NFE provides an ideal setting to transfer health education information. More collaboration and cooperation between NFE and Health programs is highly encouraged. 

Beyond these programmatic suggestions which the sponsoring agency was primarily interested in, the summers work also yielded critical information regarding the process of the Positive Deviance Inquiry. These findings are especially important as the Positive Deviance team in Haripur is planning on conducting a positive deviance inquiry in Mazar-I-Sharif in Northern Afghanistan later in the year.
 

• The PDI can be done in an "abbreviated manner", without the intention of introducing NERP (Nutrition Education Rehabilitation Program). The methodology and approach is still very worthwhile in terms of formative research even if Positive Deviance is not intended to be its own autonomous project. The information garnered can be used to refine current programming, as is the case in the Afghan Refugee Health project 
• A PDI can be accomplished with little baseline data regarding malnutrition. In our experience, we utilized the "At Risk Registers" in the BHU's to identify potential NPD families in addition to working closely with FHS's to identify families that would meet the criteria. Because of the lack of a baseline, the identification of fanfflies took much longer than anticipated, as the student researcher had to visit all potential study participants prior to their inclusion to ensure the criteria was in fact adequately met.