Medical Center Success – pairwise ranking session!

My Program Manager recently asked me to lead this summer’s training sessions on medical center work for the new health volunteers.  Thus, while the events of this post took place a couple of months ago now, it constitutes one of my bigger successes here in Moldova and is something I’m thinking about a lot while preparing to teach the new volunteers.

One of the hard parts of the Health Education program is that we straddle worlds – we must work in both the highly structured educational system, and the much more fluid world of community medical centers.  Work at the school begins very quickly after arriving at site, and similar to English Education (EE) volunteers, the fruits of our labors become quickly visible.

Facilitating a needs assessment session at the med center.

At the medical centers, however, our job is much closer to that of Community Organization and Development (COD) volunteers – work at the organization goes in fits and starts depending on how busy they are and how effective we are at identifying projects they are motivated to collaborate on.  These two cultures can often be hard to bridge, with the fast pace of the school making it harder to be patient with the incremental change at the medical centers.  This is one reason I think so few healthies work at their medical centers for the entire two years of service.

As a result of the less structured environment of medical centers, the needs assessment stage is a much longer process.  Facilitating good needs assessment, in fact, is not just necessary to choosing the best health education topics, but is in of itself a key skill we need to transfer.  Good needs assessment is also the first step of any long term planning process.

After coming up short for months in trying to get my medical center to write a one year health education plan, we’d had a number of needs assessment discussions that fizzled.  I finally decided it was time to try a different approach, and reached out to my COD friend Craig.  One of the downsides of bridging programs is it doubles the number of competencies a successful volunteer needs to possess; one of the upsides of Peace Corps is that we have colleagues like Craig who bring the perspective of a different program.

As part of its heavy emphasis on local sustainability, Peace Corps teaches the PACA  approach to needs assessment, (Participatory Analysis for Community Action).  More than a set of tools, PACA is a whole philosophy that calls for empowering community members instead of the development worker to set the agenda through participatory activities.  It also includes a toolkit of creative needs assessment activities.  The results are better needs assessments and thus an increase in the number of stakeholders, which lays a stronger foundation for resulting actions.  The analysis itself helps build consensus amongst participants by demonstrating that the agreed upon needs were not a foregone conclusion.

For my medical center, Craig recommended we try an approach known as Pairwise Group Ranking,

which is underpinned by psychology research that shows we humans are very good at choosing between two alternatives, but rapidly become much worse as the number of alternatives increases.  Pairwise Ranking consequently employs a technique where all participants have a chance to identify all possible needs.  Participants then consider needs one pair at a time, voting on which alternative is more important for every potential pairing.  For example, if we have issues 1, 2, 3, and 4, participants need to vote six times (between options 1 vs. 2, 1 vs. 3, 1 vs. 4, 2 vs. 3, 2 vs. 4, and 3 vs. 4).  Votes are then tallied, and issues are ranked from most to least important depending on how many votes each one has.

I ran the idea by my nurse partner Galena, who had never heard of the method before, but agreed to give it a try.  While she is my formal counterpart at the center, ideally I should be collaborating with the entire staff.  We have struggled, however, to get the other nurses involved in our health education work, though we have managed a couple of meetings.  Simply put, health education and I are extra work, and these medical workers already have a LOT of work to begin with.

Voting: a bloc affair.

Still, we got six or seven of the nurses to come to our needs assessment session, a pretty good turnout.  Like most conversations we initiate about health education, it started a little reluctantly.  We were quickly surprised, however, at how much the nurses all got into this activity.  Especially once we were voting, our session prompted a lot of discussion.  One interesting facet was the tendency of the nurses to vote together as a bloc – I somehow feel this would not be so common in the U.S.  Still, there were some revealing divergences as well, and the ensuing conversation provided me with some key insights while also helping the nurses better understand their colleagues’ reasoning.

This was the priority ranking we ended with after the activity (vote tallies in parentheses):

Listening: a key step in community change.

1. Hypertension (69)
2. Breast Cancer (69)
3. Smoking (51)
4. Drugs (48)
5. Mother and child nutrition (46)
6. Flu (46)
7. Tuberculosis (38)
8. Immunization (34)
9. Cancer (29)
10. Alcoholism (25)
11. HIV/AIDS (25)
12. Cancers of the digestive system (21)
13. Type II Diabetes (19)
14. STIs (5)

We agreed to concentrate on the top five during the next year.  More important than the issues themselves, however, was another positive result: the other nurses left the meeting much more enthusiastic about health education activities targeting these priorities.  The activity prompted a great discussion in which nurses for the first time started brainstorming about what we could do about these identified needs.  One nurse even asked me if we could collaborate on some anti-smoking posters for her sector of the village, which includes the big agricultural firm (where a lot of the men smoke).

In development jargon, we’d increased the number of stakeholders by including them in choosing topics.  The decision making process itself increased participant commitment to the issues identified and built consensus.  Even if the other nurses don’t actively participate in interventions targeting these topics, they are much stronger allies when we engage the community.  And that is exactly what Participatory Analysis is meant to do.