Community empowerment to enhance mental and social aspects of health in a community after the tsunami in 2004 in Sri Lanka

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1 Community empowerment to enhance mental and social aspects of health in a community after the tsunami in 2004 in Sri Lanka Mahesh Rajasuriya, Department of Psychological Medicine, Faculty of Medicine, University of Colombo, Sri Lanka cmrajasuriya@yahoo.co.uk Abstract Introduction: There were many clusters of temporary shelter set up after the devastating tsunami on 26 December The concerned intervention, whose effectiveness is studied here, was carried out in one such cluster of shelters near a small coastal town called Panadura. A cooking facility run by hired workers prepared meals for the entire population lived there, which was around 650. The quality of cooked food was poor and people were lined up before serving food. Repeated requests to relevant officials to grant permission for families to cook on their own had been rejected. The components of the intervention were person-to-person communication, group discussions and other group activities, voicing their concerns to relevant authorities, modelling and direct advice/ education under the theme of improving their health and quality of life, which winning the right to cook on their own as they please was one major prerequisite. Method: In addition to the test group, another such settlement located about 3 km away, which was similar in many ways, except for the intervention, was selected as the control. Firstly, direct observations were made on apparent associated changes in the communities, namely realisation of their goals, degree of social cohesion, complaints/ satisfaction in relation to the services they received, and their sense of independence and empowerment. Secondly the intervention was compared against the principles laid down by World Health Organisation (WHO) in relation to mental and social aspects of health of populations exposed to extreme stressors. Results: Within two weeks the permission was obtained and all families were cooking on their own in the test group. The reporting of complaints regarding food was nil. The control group still did not cook on their own and had probably more complaints regarding food. The degree of social cohesion of the community was more in the test group compared to the control. The intervention appeared to be consistent with most of the principles of WHO. Conclusions: This intervention called 'community empowerment has been associated with positive health/ social changes in a community displaced by tsunami. It was culturally acceptable and was consistent with internationally prescribed guidelines. Keywords: community empowerment, social cohesion, tsunami, Sri Lanka, health

2 1. Introduction: The people, the tsunami, the resettlement and community empowerment 1.1 The People Panadura is a coastal town about 30 km to the south of Colombo. Panadura administrative division is 44 km 2 in area with a population of 163,492, making it one of the most densely populated areas (3,715.7 per square kilometre) in the country (Department of Census and Statistics, 2005). The population is mainly Sinhala Buddhist with a mix of fishing communities, public and private sector workers and farmers. Panadura was moderately affected by the tsunami (Department of Census and Statistics, 2005). Table 1 gives a comparison indicating the degree of impact. The actual numbers would be higher as these figures are from the census done after the tsunami on damaged housing units where only the residents of those units were considered. Table 1: Comparison of dead and missing persons in three divisions in Western, Southern and North Eastern coastal area. Source: Department of Census and Statistics, Sri Lanka. Division Impact Dead Missing Total affected Population (2001 data) Affected per 10,000 Panadura Western coast , Hikkaduwa Southern coast , Manmunai North Eastern coast , The tsunami A tsunami is a wave train, or series of waves, generated in a body of water by an impulsive disturbance that vertically displaces the water column (College of Environment, University of Washington, 2005). On December 26, 2004, the day known as the Boxing Day in the Western World, a tsunami hit many countries in the Indian Ocean following an earthquake off the coast of Sumatra, Indonesia. Sri Lanka was one of the countries affected most severely. The damage was unprecedented with a death toll over 31,000 and number of housing units destroyed was over 99,000. The worst hit areas were the north and east of the island (UN Office for the Coordination of Humanitarian Affairs, 2004).

3 1.3 The resettlement Hours after the tsunami there was a large response from the unaffected nearby communities. Local groups of people organised themselves and collected clothes, food and other necessities to be given to the affected people. Buildings of schools and temples were immediately open to accommodate them. Within days the government officials, i.e. civil administrators with the help of local military personnel, organised temporary shelters, which were called camps. There were two major camps in Panadura area. Each had a large number of tents of varying sizes mostly supplied by the United Nations and their agencies. Camp A, where the intervention was carried out, was larger with over two hundred families living in overcrowded conditions. One tent, usually less than 100 m 2 in floor area, was generally shared by two or three families. The total population of this camp was around 650. Camp B, was similar except that it housed approximately half the number of people as in Camp A and smaller in land area The food The officials set up central kitchens to cook for the entire populations. Paid workers and volunteers residents of the camps worked in these facilities. Despite their enthusiasm and commitment, the food and the way it was served were way below acceptable standards, mainly because of the vast number of people that have to be served. The situation is graphically depicted in figure 1. Figure 1: Issues related to meals and their apparent negative effects As rice was cooked in very large pots they were essentially not boiled to the right temperature in an even manner. On personal inspection the author found that some grains were overcooked while others were undercooked. Rice cooked in such way is culturally as well as gustatory very unacceptable. Hence the overall quality of the meals was significantly low. Other contributors

4 to the low quality were the repetitive cooking of same convenient dishes and failure to add fine flavours with right combinations of various spices. The way the meals were served had significant problems, too. General meal times in Sri Lanka are 7 am for the breakfast, noon time for lunch and 7 pm for dinner. But in the camps meals were served one to two hours behind these times. For an example dinner was never served before 8 pm, as observed during each of daily visits by the author to Camp A at time of intervention. Once a meal was ready an alarm would be sounded and residents including children would line up at the kitchen. Waiting time in the line would be considerable and at noon the temperature would be very high and there would be no shelter from sunlight. One of the major complaints was that the children were very tired, hungry and had fallen asleep by the time dinner was served. Some parents reported that their children had lost weight during these few weeks. The other complaints the residents had were perceptions of being treated like prisoners, low quality inedible food and high dissatisfaction about food. Residents were critical of the rules against their cooking on their own, which effectively prevented having whatever they felt they needed. 1.4 Community empowerment A community may be conceptualised as heterogeneous individuals and groups who share common interests and needs, and who are able to mobilize and organize themselves toward social and political change (Laverack and Wallerstein, 2001). Community empowerment has been described in many ways, but in relation to this study, it may be relevant to identify that this process is closely linked to topics such as competencies and capacities of a community and developing them toward social and political change (Laverack and Wallerstein, 2001). It is also important to recognise that empowerment does not include, but actually excludes, charity. When agency X empowers community Y, Y becomes independent of X s charity by becoming self-reliant so they can sustain their own development without X s help. Some features of effective methods to empower communities have been recognised. Here is a list adapted from works of Bartle (2010): Presence/ initiation of motivation and willingness in community leaders to become more self-reliant. Availability of an experienced and/or trained agent to stimulate and guide the community on the path to self-reliance, but not to control or force it to change. Assistance, when offered, that promotes autonomy, not dependency.

5 2. Process: The intervention, its justification and practicalities. 2.1 The justification of intervention There was a general feeling among residents of the camps that the quality of life could be improved by a large margin, not by major interventions, but by little changes in the camp life. Many were lamenting about not being able to give their children some extra fish or chicken or give them a tasty meal when they are hungry. They also felt that the camp officials were happy for them to continue life as it was and were blocking any chance of increasing their independence. Some overtly stated that some officials pilfered the cooking and other provisions, and allowing residents to cook on their own would prevent such pilferage. Occasionally there would be heated arguments between residents and lower level officials. The main reasons the officials gave against granting permission to cook on own were fire hazards and possibility of creating a chaotic situation in the camps. The author and other workers felt that they needed to do something mainly because they were concerned of the negative impact on children. The initial requests drew such a negative response from camp officials that the author decided to initiate a more comprehensive and powerful intervention. It was also felt that overall health and social cohesion would be enhanced while alcohol and tobacco related problems would reduce with such an intervention. Hence community empowerment was initiated with primary emphasis on winning residents right to cook on their own. 2.2 The intervention The author together with few other volunteer workers, mainly his wife and toddler daughter, visited Camp A daily during the intervention. Infrequently they were accompanied by a volunteer worker of a local community organisation. The intervention could be conceptualised as a close supportive relationship with a group of the residents. Out of the 650 odd individuals in Camp A, about 200 were in close contact with the volunteer workers who carried out the intervention. The relationship with this group of residents was used as a base for carrying out various activities related to the intervention. Through these activities many massages were created and spread across the community. It was felt that the intervention was accepted well it readily complied with the features described under 1.4 Community empowerment. Figure 2 gives a comprehensive outline of the relationship created, activities carried out and the key messages expressed by participants. In addition it was also debated if obtaining permission to cook was needed at all since no law or regulation has actually banned cooking.

6 Figure 2: The structure of the intervention called Community Empowerment 2.3 The practicalities of intervention In real life the intervention mainly took the form of author and other workers frequently (almost daily) visiting the Camp A. The relationship was strenghted as the workers sat with residents, share their feelings and discussed matters important to them. It was usual practice that the author s toddler daughter would mingle with residents, play with their children and be fed by them when appropriate. The author always tried to make contact with as many opinion leaders as possible on every visit. From time to time he invited a larger group of people (10-20) to gather and have a discussion on a relevant topic like which TV channel is more health promoting, how can we earn the right to watch the TV channel of our choice on the common television set at the

7 meeting hall etc. Sometimes the discussions directly addressed low quality food and what could be done about it. Tobacco and alcohol use, how they and frequent conflicts affect happiness were also focused on. 3. Methodology: The objective, the measurement, and data collection 3.1 The objective The objective of the study was to assess the effectiveness of the intervention called community empowerment in bringing about positive health changes in this community. It was also desired to check the compatibility of the intervention with international principles in relation to mental and social aspects of health of populations exposed to extreme stressors (Department of Mental Health and Substance Dependence, WHO, 2003). 3.2 The measurement Parameters that were measured were number of families cooking on their own, number of verbal complaints from residents on food, and the level of social cohesion seen among the community members Number of families cooking At the beginning this was not really zero. Some people covertly would light a hearth and cook a dish for their family occasionally evading the eyes of the officials. If there would be a significant rise in this number that would indicate that more people are cooking on their own without relying on the central kitchen. Thus it would be a measure of self-reliance as well Number of complaints on food From the time of entry into the camp, the author would receive 5 to 10 verbal comments on food from residents. He has frequently attempted to eat this food and thus personally has checked the accuracy of those comments. It was felt that a reduction in the number of such comments/ complaints would indicate increased satisfaction with food. It might also be conceptualised that it would be an indication of general level of satisfaction and happiness among the members of the community Level of social cohesion This would be an indirect measurement of the level of community empowerment (Speer P W, 2001). Although no instrument was used, author attempted to observe following documented

8 parameters of cohesion (MacCoun R J et al, 2006) to gauge his judgment about observed social cohesion: Degree members of the community visibly liked each other, amount of social time spent together by members, author's inner feelings about emotional closeness to the members of the community as an indirect measure of emotional closeness among them. 3.3 The data collection Initially in both camps, Camp A (the test group) and Camp B (the control group), the above measurements were made. Then the process of community empowerment was initiated in Camp A. The empowerment process was continued until the desired socio-political change, in this case the permission to cook on own, was achieved. This time period was around two weeks in this study. Then the measurements were repeated in both camps. This process is summarised in figure 3. Figure 3: The process of data collection It is also important to mention that the initial steps of empowerment, the step of building a relationship, has already been initiated before this time period, though without a specific objective. If that time period is also considered, it would be around four weeks of community empowerment. During this process the author also observed the compatibility of the intervention with the principles laid down by Department of Mental Health and Substance Dependence, WHO (2003) of World Health Organisation (WHO) in relation to mental and social aspects of health of populations exposed to extreme stressors. These principles are given in table 2.

9 Table 2: WHO recommended principles to be observed in planning interventions in communities exposed to extreme stressors Principle 1. Preparation before the emergency. 2. Assessment of local context. 3. Collaboration with other agencies 4. Integration into primary health care. 5. Access to services for all. 6. Training and supervision. 7. Long-term perspective. 8. Monitoring indicators. 4. Results: Outcome and process 4.1 Outcome After the intervention all families in Camp A were cooking for themselves but none were doing so in Camp B. There were no comments/ complaints heard by author in Camp A but apparently more such complaints were heard from Camp B compared to previous. Level of social cohesion was observed to be higher in Camp A compared to Camp B. The results are summarised in table 3. Table 3: Observed parameters before and after the intervention Parameter Camp A Camp B 1. Number of families cooking on their own 2. Number of food related complaints 3. Level of social cohesion Before After Before After Nil Frequent Similar to Camp B All Almost nil Increased Nil Frequent Similar to Camp A Nil Increased Decreased 4.2 Process It was also observed that in carrying out the intervention, namely the components of relationship, activities and messages (figure 2), majority of the WHO principles were adhered to. The details are given in table 4.

10 Table 4: Compatibility of community intervention with WHO principles Principle 1. Preparation before the emergency. 2. Assessment of local context. 3. Collaboration with other agencies 4. Integration into primary health care. 5. Access to services for all. 6. Training and supervision. 7. Long-term perspective. 8. Monitoring indicators. Compatibility of intervention with principle Not compatible. Compatible. Compatible. Questionable.. Compatible. Not compatible. Compatible. Compatible. 5. Conclusions 5.1 Primary inferences The empowering intervention applied in this community was associated with significant healthy socio-political changes in the concerned community. The community was able to start cooking on their own without any of the feared negative outcomes. This indicates an improvement in self-reliance and autonomy. In addition the community now seems to be healthier and more cohesive than before setting the platform for further improvement. 5.2 Limitations Camp B is not the ideal control since it is significantly smaller than Camp A. It may be argued that covert cooking before permission was granted in Camp A was a major precursor of widespread overt cooking. This might have not been possible in Camp B since the smaller number of residents as well as smaller land area probably made it more convenient to be observed by officials. Therefore the change in Camp A is partially due to its bigger size. Despite social cohesion being a measurement in this study, as well as suitable instruments being available, the methods used to asses it were crude and subjective. Due to the nature of the intervention, statistical methods were not used and there is no indicator to the degree of significance of the findings.

11 5.3 Secondary inferences It is interesting to note that permission to cook was never actually given in any official way in Camp A after the intervention. Towards the end of the two weeks of application of the intervention, there was a sudden increase in the number of families cooking on their own and the number of times they did so per day. It was becoming clear that the officials were increasingly becoming aware of this development but were not expressing any serious disapproval. Then everybody was saying that the approval has been given to cook but actually no such statement was made by an official in a formal manner. It also highlights that most such restrictions imposed upon communities, like no cooking allowed, are arbitrary decisions but not real laws or regulations. And it seems they could be overcome rapidly and easily if the community affected is empowered. This is an intervention carried out with minimal man power and resources. In real life it did not cost anything financially. The relationship was mainly with around 200 individuals, which is about 30% of total population. It may be reasonable to hypothesis that at least 30% of a community has to be approached if empowerment is to be successful. But probably community leaders were over represented in these 200 individuals. 5.4 Recommendations Community empowerment may be recommended in attempts to bring about positive health changes in communities. More research with better methodology is required urgently. References Department of Mental Health and Subtance Dependence, WHO (2003), Mental Health in Emergencies: Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors, World Health Organization, Geneva. Speer P W (2001) The Relationship between Social Cohesion and Empowerment: Support and New Implications for Theory, Health Educ Behav 6: MacCoun R J et al (2006) Does Social Cohesion Determine Motivation in Combat? An Old Question with an Old Answer, Armed Forces & Society 4: Bartle P (2010) Empowerment Methodology, Community Empowerment Collective [Internet]

12 Laverack G, Wallerstein N (2001) Measuring community empowerment: a fresh look at organizational domains, Health Promot. Int. 16 (2): College of Environment, University of Washington (2005) The Physics of Tsunamis: The mechanisms of tsunami generation and propagation, Earth & Space Sciences [Internet] UN Office for the Coordination of Humanitarian Affairs (2004) Tsunami disaster -- Sri Lanka Summary situation report, UNDP relief web [Internet] disred/documents/tsunami/srilanka/reports/preliminary_assess_adb_0105.pdf. Department of Census and Statistics (2005) Impact of Tsunami 2004 on Sri Lanka, Website of Department of Census and Statistics, Sri Lanka [Internet]

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