1. Office of Global Health and HIV (OGHH) Office of Overseas Programming & Training Support (OPATS) Maternal and Newborn Health Training Package Session 9: Engaging Influential Actors

2. Two Dimensions of Culture  Development programs (MNH) are more appropriate and effective when they consider a community’s cultural realities.  One way to understand culture is to look at two, inter-related dimensions: – social structure (roles of family members, household decision-making dynamics, and communication patterns) – community and social norms (rules of conduct and behavior that guide interactions with others; rooted in customs, traditions, and value systems )

3. Discussion  Please share one thing you’ve observed in your community/host family around household decision-making that affects some aspect of maternal and newborn care – either positively or negatively.  Please share an example of a cultural value in your community that affects some aspect of maternal and newborn health.

4. Two Types of Cultural Systems: Individualist and Collectivist In many developing countries, a collectivist cultural system underpins social structures and community and social norms

5. Key Features of a Collectivist System with Implications for MNH  Group identity more important than individual identity  Interdependence valued more than independence  Collective, often hierarchical decision-making predominates; younger mothers in particular, rarely make independent decisions regarding health-related practices  Multi-generational and extended families influence attitudes of individual family members  Respect for elders as age and experience confer responsibility and authority. Elders play a key role in passing on learning to younger people

6. Key Features of a Collectivist System with Implications for MNH  Gender-specific roles and responsibilities for MNH – Senior women (grandmothers, aunts, etc.) often have primary responsibility for advice and management of health matters concerning mothers and newborns (breastfeeding, infant feeding, care of sick infants, bathing infants, infant care while mothers do other tasks, etc.) – Men provide financial and logistical resources for prenatal, delivery and postpartum care, drugs, health center visits on a routine and emergency basis; they are key decision-makers for child spacing and family planning

7. Discussion  Volunteers and many development workers come from individualist societies that stress and/or value self-reliance, personal achievement, individual independence, and youth  What happens when they work in communities anchored in a collectivist system?

8. Social Influence  Social influence comes from the field of social psychology. Defined as: – changes in an individual’s thoughts, feelings, attitudes or behaviors that result from interaction with another individual or group  The level or power of influence by others depends on their immediacy to the individual, their number, their perceived expertise, their perceived authority, and other factors.

9. The Buffalo Food Story  This story is a simple way to explain social influence. Please listen.  How would you tell this story in this country? Who influences whom?

10. Religious Leaders and MNH  As the Buffalo Story illustrates, religious leaders are often very influential. Their statements and actions can make a difference. For example: – Pope Francis and breastfeeding in Europe – The Emir of Kano and polio immunization in Nigeria

11. Post Adaptation  Share any country-specific information on religious leaders and their involvement and influence on maternal and newborn health issues.

12. Examples of MNH Practices Rooted in Culture  Postpartum and postnatal care of newborns in Uzbekistan: period of seclusion; intensive coaching of mother by senior women  Healthy timing and spacing of pregnancy in Cambodia: notable influence of husband but also peers and mother-in-law  Family planning in Mali: trusted source of information are family members and peers

13. Implications for SBC in MNH  Grandmothers often viewed as “barriers and obstacles”  Family planning programs focus on women, assume “nuclear” families with optimal couple communication

14. But…  The guardians of tradition are not averse to change!  It depends on the approach…

15. Wrap-Up  Consider the maternal and newborn health activities and services that you support along with your counterpart. – Regarding all we’ve discussed, what strikes you? – What are you doing now that is effective in bringing about desired changes in maternal and newborn practices? – In light of what we’ve learned, what do you think you should stop doing or start doing to be more effective and why?

16. 16 Individual: Those who practice the desired behavior, e.g., mother, father, and/or maternal or newborn caregiver Household: Members who have an influence on this individual’s behavior, e.g., grandmothers, husbands, aunts, etc. Individuals, groups, or institutions with an influence on individual and household members for this behavior, e.g., community leaders, religious leaders, opinion leaders, traditional birth attendants, etc. Community and outreach: Individuals, groups, or institutions with an influence on individual and household members for this behavior, e.g., community leaders, religious leaders, opinion leaders, traditional birth attendants, etc. Health Facility: Health service providers (government, private, NGO) that have an influence on individual, household, communities practice, and behavior

17. An Example  In Niger, a social influence analysis identified the following people who influence the mother’s care of a baby with diarrhea  Older women and grandmothers, fathers of young children, bokas (traditional healers), and marabouts (religious leaders) (From The Grandmother Project) 17