Copyright Sociological Research Online, 2000

Marion Gibbon (2000) 'The Health Analysis and Action Cycle an Empowering Approach to Women's Health'
Sociological Research Online, vol. 4, no. 4, <http://www.socresonline.org.uk/4/4/gibbon.html>

Abstract

This paper analyses the health analysis cycle as an empowering approach to development. It discusses what the terms power and empowerment within the development discourse mean. It considers the factors that contribute to empowerment and those that hinder it. The study involved the use of a participatory action research approach in a community setting. The relationships between women's socio-economic circumstances, their ethnicity or caste and the process of empowerment are introduced through the use of case studies.The health analysis cycle is described in an annexe to this paper.

Keywords:

Community; Empowerment; Health Analysis and Action Cycle; Participatory Action Research; Power; Women's Health

Introduction

1.1

From 1995 to 1999 I lived in Eastern Nepal. In 1996 I started a doctorate and was working with women's groups from two different organisations: the Community Health Development Project (CHDP) of the Britain Nepal Medical Trust and the Women's Empowerment Support Team (WEST) (a local non-governmental organisation). At the same time I was also involved in the capacity enhancement of local NGOs in Dhankuta and helped form one of the first district based NGO networks in Nepal. One of my main concerns during my time in Nepal was to enable a process where local women could look at the health issues facing them and be able to make decisions and take control of projects to improve their well-being. I explored this possibility with two of the organisations that I was working with. This paper aims to describe this process and how the Health Analysis and Action Cycle (HAAC) was conceived as an empowering approach to working with women in rural Nepal. It sets out the context of the study and then outlines some of the terms used in the analysis. The first section considers the term power. The second section involves a discussion on the meaning of empowerment. Following this the factors that contribute to and obstruct empowerment are discussed. A model of empowerment is described in order to help analyse the effectiveness of the HAAC approach.

1.2

Case studies are used to consider the barriers and beneficiary factors that contribute to empowerment. Social networks are used to show how there has been a change in the capacity of the groups involved in the process. The final section links the findings with the theoretical underpinnings of the approach and suggests how the approach could be used in other settings.

Background

2.1

Nepal is a small country (140.797 sq km) that lies in the central Himalayas and is sandwiched between India and China. The population (19 143 000) (WHO, 1993) is very unevenly distributed with the most densely populated area being the lowland (Terai) along the border with India. The area is relatively fertile and has a tropical climate. Along the border with Tibet are the Himalayas. The mountainous terrain of this area is less densely populated, and large parts are uninhabited. In between is the hill region, where the availability of fertile land is limited. The land pressure in the hills is further increased by deforestation and soil erosion. The mountainous terrain and distinct geographic divisions isolate the rural areas from the city of Kathmandu and have hindered the development of the country's infrastructure.

2.2

The population comprises approximately 75 ethnic groups, and more than thirty languages are spoken in Nepal. Officially Nepal is a Hindu Kingdom, however the country is characterised by religious diversity, with substantial Buddhist and Muslim minorities in certain areas. It is in the eastern hills of two districts (Dhankuta and Sankhuwasabha) that this study took place. Along with the many different languages spoken is a complex social system. The predominant religion in Nepal is Hinduism and therefore there is a strong existence of the caste system. In the study area there are three main groupings: the first two, Brahmin and Chhetri are located within the Hindu system. The last group is Rai, which is an ethnic group outside the caste system. The religion of this group is animist. However, they are strongly influenced by the predominant Hindu religion. In the women's groups that I interacted with there were no Buddhists, the other main minority religion within Nepal.

2.3

This paper analyses an approach that enables women to review their health and environmental situation. The approach considers health in its socio-environmental context and does not only focus on the bio-medical dimension. The women are able to consider their own beliefs surrounding health and illness in a non-threatening way, and to plan and take action for themselves. It was developed within a participatory action research framework in order to consider process and outcomes.

2.4

The approach was first developed for use amongst literate women's groups of the Britain Nepal Medical Trust's CHDP in Sankhuwasabha district and later a more visual approach was adapted from this for non-literate groups of the WEST in Dhankuta district. The reason this second step was felt necessary is due to the high levels of illiteracy (75%) amongst women (UNICEF, 1996).

2.5

The people of the hills of Eastern Nepal face many hardships. Rural poverty is prevalent, with households depending on subsistence agriculture and many families not food secure throughout the year. Other difficulties faced include the lack of quality primary health care services. The health statistics of the country reflect the poor services offered. The maternal mortality rate is 515 deaths per 100 000 live births and the infant mortality rate is 165 deaths per 1000 live births (UNICEF, 1996). Most of the deaths are preventable; diarrhoeal disease is the biggest killer.

2.6

Several studies depict a scenario of under utilisation of the existing health care services (Sigdel 1998; Justice, 1986). Among the reasons suggested are paucity of medicines, the health posts not being situated conveniently and the rudeness of the medical personnel (Sigdel, 1998). Others comment on the lack of awareness surrounding health issues and health being a low priority for village people. It was with this in mind that staff from the CHDP and myself set about developing an alternative model: a health action approach with women's groups. We, called this the Health Analysis and Action Cycle (Appendix 1). For the approach to be 'empowering' it was also necessary to consider the terms power and empowerment to ensure that the approach was not reinforcing women's oppression within society.

Power

3.1

To understand power, I this can be seen in two ways; "as a coercive power constituting and maintaining an oppressive structure, and as enabling power; helping those who wish to bring about change (Mingers, 1992: 8)". Hill Collins (1991:619) says that, "Traditional accounts assume that power as domination operates from the top down by forcing and controlling unwilling victims to bend to the will of more powerful superiors". However, as she also outlines this does not account for the willingness of someone to collude in his or her own victimisation. It also fails to account for resistance, even when chances for victory appear remote. Traditional accounts of power view it as domination that can be seen to operate not only as a structuring power from the top down but by simultaneously annexing the power and energy of those at the bottom for its own ends. In this view, power is seen as those at the top having all and those at the bottom having none. As Mingers (1992:8) relates "... Power is not all-or-nothing, but a complex continuum of actions which, to varying degrees, provides barriers or gateways to further actions". Power is where relationships are structured so that one person or group of people benefits at the expense of another person or group; the people who benefit have the greatest power and can also be viewed as oppressors. Power can manifest itself at individual, household, group, community or societal level and in material or emotional forms. This understanding results in a simple model of power, a single dimension of experience or oppression in being lower caste, female, or from a minority ethnic group.

3.2

The second dimension of power is the:

Recognition of further differentiation and complexity according to each individual's experience of oppression. This has entailed awareness of the diversities between people in the same oppressed group, recognition that 'none of us belongs to one social compartment' and that attempts to reduce the complexities of people's experience to neat little boxes ... result in simplistic responses (Bray and Preston-Shoot, 1995: 47).

3.3

So oppression is then viewed as multi-dimensional due to caste, gender and ethnicity. In this way Rai women are disadvantaged in terms of their gender and being part of a minority ethnic group. Even this conception is inadequate, as you cannot just add the different forms of oppression. The notion of simultaneous oppressions is more helpful as an individual has a distinct, separate experience and identity and marginalisation can come from different sources.

3.4

An alternative focus on power is power as it is actually exercised (Foucault, 1980) rather than power as a possession. The model that emerges is of a complex interacting network of individuals and agencies undertaking particular activities and using various resources to encourage or hinder potential outcomes.

3.5

Dominant groups can be said to aim to replace subjugated knowledge with their own specialised knowledge because they realise gaining control over this dimension of subordinate groups' lives simplifies control. Power in this context can therefore be said to involve rejecting the dimensions of knowledge, whether personal, cultural, political or institutional, that perpetuates subordination and dehumanisation.

3.6

I suggest power can be seen as a dynamic that allows the interplay of differing theoretical approaches with an interlocking nature rather than dichotomous one, allows us to view the world where the goal is not merely to fit, survive, or cope. Rather it is a place where we can feel accountable and have a sense of ownership. There is always a choice, a power to act, no matter the material circumstances. Viewing the world as 'one in the making' raises the issue of individual responsibility for bringing about change. It also shows that while individual empowerment is necessary, only changes in policy perhaps through collective action can effectively generate lasting social change of the political and economic institutions. This can be seen where groups form and bring about social change that is impossible on an individual basis.

Different Forms of Power

4.1

In summary there are four different types of power (Rowlands, 1997):

• Power over - a controlling power, where the response is one of compliance, resistance or manipulation
• Power to - a generative or productive power which can incorporate or manifest as forms of resistance or manipulation. This form of power creates new possibilities and actions without domination
• Power with - the social power that arises as the 'whole is greater than the sum of the parts'.
• Power from within - "the spiritual strength and uniqueness that resides in each one of us and makes us truly human. Its basis is self-acceptance and self-respect which extend, in turn, to respect for and acceptance of others as equals" (Williams, 1995).

4.2

Power is multi-dimensional not all or nothing. As Kabeer (1995: 229) states:

The multi-dimensional nature of power suggests that empowerment strategies for women must build on 'the power within' as a necessary adjunct to improving their ability to control resources, to determine agendas and make decisions.

Dimensions of Empowerment

5.1

What is lacking in Kabeer's work is that she confines her analysis to grassroots NGOs, and does not enter into the micro-level dimension of empowerment at the level of the individual. Her account therefore misses the interactions between personal, close and that within collective relationships.

5.2

Rowlands (1997:15) includes three dimensions to empowerment:

• Personal: developing a sense of self and individual confidence and capacity, and undoing the efforts of internalised oppression
• Relational: developing the ability to negotiate and influence the nature of a relationship and decisions made within it
• Collective: where individuals work together to achieve a more extensive impact than each other could have done alone

5.3

I have termed them psychological, social and political as shown in below.

Figure 1: Forms of empowerment

5.4

We each have access to these three forms of power to a greater or lesser extent. All three forms of empowerment are critical for a possibility of social change. Linking the individual triad with other individual triads results in a social network of empowering relations that are mutually reinforcing (Figure 2).

Figure 2: Empowering networks

5.5

Women that are working or learning with other women on projects, in non-formal education classes, in mutual support groups, income generation groups, political movements, can accomplish much more than a single women acting on her own. Such activities tend to reinforce the process of women's social, psychological and political empowerment. This is one of the lessons to be learnt from the social movements in Latin America (Fals-Borda and Rahman, 1991) and from the non-governmental organisations working at grass-root level in India (SEWA - rural team, 1996). This would also apply to men/women and men only actions.

5.6

Empowerment can therefore be seen as:

The process by which people, organisations or groups who are powerless a) become aware of the power dynamics at work in their life context, b) develop the skills and capacity for gaining some reasonable control over their lives and c) exercise this control without infringing on the rights of others and d) support the empowerment of others in the community (McWhirter, 1991).

5.7

There is a 'situation of empowerment' when all four are present and an 'empowering situation' when one or more of these conditions are in place or being developed but the full requirements are not present. Rowlands (1997) considers for each of the forms of empowerment there are:

• Encouraging factors
• Inhibiting factors and
• Changes that occur as a result of empowerment.

5.8

Collaborative research can be seen to be a way of opening up channels of communication so that you learn better ways of how to be understood and to understand. There is a possibility of developing relationships and group identity. Together you discover ways of sharing meanings and feelings, in the process there is a way of identifying progress and recording it for ourselves and others, so that the piece of research becomes a shared enterprise that acknowledges the complexities of the social world. As Daniel (1988:14-15) says:

The researcher should never ignore the obligation to those who give information and advice or who allow her into their own domain to watch the way they live their lives. The reciprocity implicit in this trust constitutes an obligation to be honoured by a sharing of knowledge and a promotion of understanding of the participants' actions and interests. It is good practice to seek out all sides of a conflict, so that, when the researcher becomes (inevitably) an advocate the advocacy will be more balanced and point in some way to just solutions.

5.9

Wherever there is the possibility for exploitation, what intervenes is recognition of the 'other'. Recognition allows negotiation to take place and with this the possibility of domination is disrupted. There has to be something to shape the direction of our political vision, otherwise we will be, "seduced, in one way or the other, into continued allegiance to systems of domination - imperialism, sexism, racism, classism (hooks, 1994: 243)". hooks (1994:243) goes on to declare that this something should be love, "Without love, our efforts to liberate ourselves and our world community from oppression and exploitation are doomed".

5.10

With respect to women's political claims, there is perhaps a need for external assistance in the process of collective self-empowerment. This requires a process approach to self-organisation, social mobilisation, and attention to social, psychological and political empowerment in culturally appropriate ways. This will need to enable women and men to be mobilised in partnerships at various levels and the search for more coherent and comprehensive approaches to social issues then becomes possible. As stated by the Commission of the European Communities (1993:11), "The setting-up of durable and effective networks and the achieving of Community added value are significant benefits".

5.11

Highlighting the practical aspects rather than the strategic ones is important because these dimensions need to be tackled at the local level. Strategic claims need changes in the institutional and legal aspects of women's status. Such changes are essential, but are less likely to involve poor women. Kranta (1990:57) in her discussion about Nepalese adolescent girls points out that, "In 1963 the National Code banned child marriage, during the International Women's Year, the sixth amendment raised the minimum age of marriage from 14 to 16 years for a girl with parental consent and to 18 years without consent". However, child marriage remains. Kranta (1990:57) goes on to say, "In an extensive survey in eight ethnically different villages, it was found that 22.5 percent of the girl children were married before they had reached their fourteenth year. 63.1 percent were married between the ages of 14 and 20. In another survey of mothers with children under 5 years of age, 8.2 percent had married between the ages of 4 and 9, 32.8 between ages of 10 and 14 and 48 percent between ages of 15 and 20. "

5.12

Enforcing compliance to legislation is not possible until there is widespread agreement as to their content. Democratisation of the household forms an essential part of rural social change; it is an extremely daunting task as it implies a vast transformation. The ultimate goal is clear, as women's rights are part of basic human rights and are therefore a critical issue at the heart of development. Women's rights will only be achieved through the empowerment of women. However, empowerment is not always positive.

5.13

Nira Yuval-Davies (1994) is openly critical of empowerment. She feels that empowerment for one group of people might easily represent another group's disempowerment. It is necessary to consider the power relationships within a group as well as between groups and others. There may well be conflicts of interest to overcome. Empowerment is problematic. I feel that the goal of 'empowerment of the oppressed' as a goal as a feminist within the context of Nepal is also problematic. In Nepal empowerment of the oppressed is leading to atrocities, brutality and violence between the state and the so-called 'subversive Maoist groups' as the government tries to contain the 'subversive' activities of the Maoist Movement that is not officially recognised as a political party.

5.14

Simplistic notions of power and empowerment also mask other aspects of the power and responsibility of the researcher. It is the researcher who has the time, resources and skills to conduct methodological work, to make sense of the experience and locate the research within a time and place. A further issue may arise when the understandings and interpretations in the account are not shared, or represent a challenge, to the group members own coping strategies. If researchers rely on simplistic models of 'empowerment' this disguises and denies the complexities involved. Some women hold anti-feminist viewpoints, such realities problematise the 'empathy' that shared gender is supposed to embody. Differences in cultural affinity - my own identity, history and political inclinations may also affect my reactions.

5.15

Kelly, Burton and Regan (1994: 39-40) phrase this aim succinctly:

If we accept that conducting and participating in research is an interactive process, what participants get or take from it should concern us. Whilst we are not claiming that researchers have the 'power' to change individuals' attitudes, behaviour and perceptions, we do have the power to construct research which involves questioning dominant/oppressive discourses; this can occur within the process of 'doing' research, and need not be limited to the analysis and writing-up stages.

5.16

I am therefore looking for a framework rather than a methodology that will enable local people (women in particular) to obtain, share and analyse knowledge of their life and conditions, in order to plan and act in harmony with that knowledge (White and Taket, 1997).

5.17

The analysis of power and empowerment contributes to my understanding of what it is to be a 'principled researcher' while at the same time acting as a 'passionate scholar' and thereby undertaking research as a strategy towards a society of justice, equality and well-being (Everitt, 1996). The discussion regarding the process of how research of this nature is carried out is important as without it the research would hinder empowerment rather than facilitate its development. Professionals can be seen as upholding a system of distribution of oppression that is profoundly unequal by focusing on individuals rather than on structures. We have to become more radical as Bray and Preston-Shoot (1995: 50) state:

In the radical value base it involves working alongside oppressed people to challenge the source of their oppression in the abuse of power by others. Borrowed by the traditional value base it is used to describe a process of enabling people to acquire the skills and self-confidence needed to bring improvements in the quality of their lives, or helping people to compete more effectively for scare resources.

Factors that Contribute to and Hinder Empowerment

6.1

What are the factors that contribute to empowerment and those that hinder it? Stein (1997: 257) provides a model for considering the factors that contribute to women's empowerment (Figure 3). The Women's Empowerment Model considers development to be a contextual factor that has specific impact on the circumstances within which women live and on their needs. Stein (1997) considers empowerment to grow out of groups organised in response to those needs and it leads to a wide variety of outcomes affecting the women, their situations and the groups in which they participate. She suggests there are changes in both group and individual characteristics. The group can undergo either positive or negative organisational change. The individual can either undergo positive or negative situational change. There can be changes in the values and attitudes of the group and the individuals within the group. Each of these changes can lead to changes in health producing knowledge and behaviour that will in turn help create improvements in health and well-being.

Figure 3: The Women's Empowerment Model

6.2

The formation of a group is the first step towards empowerment, as the group enables the development of a stronger sense of social identity. The group gives support to the individual and increases the sense of solidarity that women have towards each other. Mullender and Ward (1991) emphasise that:

• All people have skills, understanding and ability;
• People have rights to be heard, to participate, to choose, to define problems and action;
• People's problems are complex and social oppression is a contributory factor;
• People acting collectively are powerful;
• Methods of work must be non-elitist and non-oppressive.

Collective or Group Empowerment

7.1

Collective empowerment is closely related to the personal and builds on it. Group members by virtue of their membership of the group are concerned with certain elements of empowerment through its experiences. Furthermore, there is a need to consider the group as a separate entity distinct from its members. It is an imposed distinction but helpful in considering the processes involved. From this point I will consider the collective or group empowerment and individual or personal empowerment in relation to the findings from my own research in Nepal. The findings are summarised in Table 1.

7.2

The central values of collective or group empowerment are management, enhanced group identity and self-organisation or the ability for the groups to organise themselves independently from the supporting organisation.

Contributing Factors

8.1

The encouraging factors for collective empowerment were the development of group confidence, enhanced status and identity within the group and community, and support from key-individuals. One example was the support gained from the ward chairman of two Dhankuta groups.

Hindering Factors

9.1

The following factors were found to be inhibiting economic obstacles, time constraints, and a lack of social identity. The lack of social identity occurred if there was an imbalance between the caste and ethnic groups. The Rai women are perceived as poor, non-Hindu and usually illiterate. If there were only one or two within a group they then felt inhibited. The land they had at their disposal was rain-fed and not irrigated and of a poorer quality and this also led to impoverishment.

Individual or Personal Empowerment

10.1

Central to the process of personal empowerment there are fundamental psychological and psychosocial processes and changes that the group members separately recounted. Of these the development of self-confidence and self-esteem are particularly important. In the beginning the women group members were quiet and shy and behaved as though they were embarrassed. They were ashamed of their lack of literacy skills and considered themselves powerless and unable to achieve anything. They felt they were unable to make decisions, their planning skills were minimal, and they had never been involved in a group let alone implementing a project. The following quotation from an interview I carried out with my co-worker shows this more clearly:

MYSELF: What kinds of changes have you seen in the individual women?

CO-WORKER: They were shy to speak but these days the women who did not speak have more confidence. Their capacity to speak has increase they have more speaking power. Now they can speak freely. They can speak in front of others not only you and me but with outsiders too. The other day there were visitors from Kathmandu and they freely answered their questions and also made questions to them.

MYSELF: How do you think the group decision-making skills have changed?

CO-WORKER: Before any decision was made individually. When starting now they meet in a group and make decisions together when they do the meeting. I saw the minutes and I saw they say now their decisions are made and recorded. They are now minuting and recording their decisions. They are deciding many things in a group (Interview with co-worker September 1998).

10.2

The status of women in Nepal is low and yet this is changing. Each woman experiences personal change and development in a different way that relates to her own circumstances and actions. Some of the factors mentioned were an increased ability to interact outside the home, more choices and greater ability to choose. Some mentioned greater participation in activities and an ability to participate in a small group, they were now more able to express their own opinions and more things were possible as a result.

10.3

There are many stereotypes that these women are changing: women cannot plan; they cannot organise; and would never be able to carry out a project on their own. Women are also considered to have inferior mental capacities and have far less opportunities than Nepalese men do.

10.4

There have been some changes in the respect shown towards the women group members throughout the process. In some cases men are doing more to help their wives so a redistribution of power is occurring within the household. Chhetri men find this more difficult than among the Rai households where the power distribution is more equal. The women now feel more able to speak to their husbands about different issues:

MYSELF: Have you seen any changes in the status of the women who have been involved in groups?

CO-WORKER: How can I say? Exactly I cannot say. I can say they now feel confident that they can also do something for the community. It does not mean they always have to depend on others. There are now more empowered. These days they are able to discuss more with their husbands. (Interview with co-worker September 1998).

Contributing Factors

11.1

Learning health-related and literacy skills contributed to the development of their self-confidence. Other factors were the sharing and support from other women, the encouragement that my co-worker gave them, and working only with other women. Other encouraging factors mentioned were doing things outside the home, and the development of social skills, such as participating in meetings and discussions.

Hindering Factors

12.1

The main factors seen to inhibit the growth of individuals were based on components of the cultural, social and physical conditions in which women live, and the gender roles to which they are expected to conform. Some of these were; at the beginning husbands did not give them permission to participate, a lack of time due to their intense workloads, having to fetch wood, water and fodder for the animals.

12.2

Table 1 outlines the different factors within the empowerment process.

---

Table 1: Factors that contribute to and hinder empowerment

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Contributing factors	Hindering factors
Positive social identity within a group Increased membership Increased community support Improved leadership Respect Increased networks Self-help groups Health promoting activities Sanitation	Negative social identity within a group Different religion than majority Different caste than majority Different ethnicity than majority Geographical neighbourhood Marital status Poverty Illiterate when majority literate
Individual beneficial factors Confidence Self-esteem Sense of control Improved skills Ability to discuss and formulate ideas Sense of participation Sense of solidarity Increased initiative Sense of community	Individual hindering factors Amount of work Divorce/separation Exposure to repression Generation gap Loss of traditional support Unmet expectations

---

12.3

The next section considers the Health Analysis and Action Cycle approach and attempts to determine whether it is effective as an empowering approach.

The Health Analysis and Action Cycle as an Empowering Approach

13.1

The women's group members were able to undertake many of the steps of the Health Analysis and Action Cycle (HAAC) themselves. The group knows their own environment and can map their own tole^[1] better than anyone from outside.

Photograph 1: The women's group makes their own community health map

13.2

They are able to show the factors that contribute to good and bad health in their community better than the facilitator could. (The facilitator for the Dhankuta groups was my co-worker, who lives, in the adjacent hamlet to them; the facilitators for the Sankhuwasabha groups were employees of the Community Health Development Project).

13.3

The facilitator starts from the viewpoint that she has little knowledge about their environment and their hamlet. The facilitator therefore seeks to learn from the group members. Each member of the group marks on the map where they live and if they have a latrine or a vegetable garden. Together they discuss the minutiae of the village, draw in the paths, fields and forests. The mapping process generates lots of discussion and draws in some of the other family members. Debates occur over where a house is to be drawn where the streams are located and where the local 'healer'^[2] lives.

13.4

The group also discusses the criteria for prioritising their health concerns. The criteria they choose are not imposed but are of their own choice. They then use the criteria for prioritisation within a health matrix. In this way they are working together and making decisions jointly thereby developing skills and capacity to gain control over their own lives. Working together in a group also helps provide support to each other and they then gain confidence to support the empowerment of others in the community.

Photograph 2: The women's group makes their own health matrix

13.5

The health matrix provides a visual tool for the women to discuss their health concerns. On one side of the matrix they list the different health concerns or problems in their community and on the other axis they list the criteria they have chosen to consider importance. Stones, seeds or other locally available materials are used to rank the importance of each criterion and the totals are then added to determine the most important issue. In this way the matrix provides a focus for discussion and helps the group prioritise which issue to focus their efforts on.

13.6

The action planning stage allows the groups to consider how to implement a small project. They discuss what they need to do, what resources are required, how they are going to carry out the different activities involved, when the activities will be carried out, and who will make sure everything gets done. This step gives the group a format to help improve planning and decision making that they can use in other settings.

The HAAC in Action

14.1

In this next section I am going to use three case studies to illustrate the HAAC 'in action'. Initially drawing up an action plan requires a lot of external facilitation but gradually the groups become more independent and are able to make their own action plans (Case study 1).

Case study 1 In Dhankuta two women's groups have made their own action plans and have joined forces to run a community health initiative. The groups identified that many families did not know how to make oral rehydration solution (ORS). They decided to organise a programme before the onset of the diarrhoea season. They obtained oral rehydration solution packets and set about teaching the women in their communities how to make packet ORS, to use rice water and other locally available solutions as ORS and, to administer ORS to someone with diarrhoea. They also decided that two of the members would stock ORS packets and they advertised this to everyone in the community. In this way the ORS packets would be readily available when required. The promotion of nun-chini-pani (sugar-salt solution) was not encouraged after discussions with UNICEF suggested that their research had found it to be more harmful than beneficial within the Rai community as many of them did not use sugar and it was therefore not easily available to them.

14.2

The second case study (Case study 2) highlights two barriers to empowerment. The first is poverty and the second is ethnicity. Families who are economically disadvantaged have far less resources available to them than those who are wealthier. Poorer families are also under greater time constraints. They are far more inclined to activities that bring them a financial benefit rather than those that require time, resources and efforts with only a vague possibility of an improvement to their well-being.

Case study 2 Nineteen households now have latrines as a result of the HAAC process in Pangsing, Dhankuta district. There are differences in the latrines built as the photographs show (See Photograph 3 and Photograph 4). Socio-economic circumstances influence the outcomes of the approach. The Chhetri household is a wealthy one. They could raise the 3,000 Nepalese rupees required by the municipality as evidence to their commitment to building a latrine. The municipality then provided a further 12,000 Nepalese rupees to enable the family to build a permanent latrine. On the other hand the Rai family are economically deprived. To have three thousand Nepalese rupees is beyond their wildest dreams. However, they still endeavoured to build a latrine using the materials they had available to them. The latrine does at least have a concrete slab obtained by a donation from the community.

Photograph 3: The Chhetri latrine

Photograph 4: The Rai latrine

14.3

Associated with low socio-economic status is a further hindering factor, that of ethnicity (See Case study 3). The Rai ethnic groups are outside the predominant Hindu caste system and are considered to have marginal status. Many have been unable to attend school, and literacy rates are therefore very low amongst this group. A factor in their favour is the enhanced status of women in their community (Bista, 1996). Rai men and women have far more equal workloads and men help in productive tasks rather than leaving them all to women. The Chhetri are higher up the social scale, they are second only to the high caste Brahmins and in this community are socio-economically advantaged.

Case study 3 Two literacy circles were formed after the HAAC workshops were completed. One group was predominantly Chhetri and the other group was mainly Rai. The Rai group completed six months of classes that were run daily from six o'clock to eight o'clock. The women were all assiduous in their attendance and enjoyed the classes. The Chhetri group completed four months of classes. The women were far more erratic in their attendance. They stopped the classes when their daily workloads started to increase due to the agricultural season. The Chhetri women although more economically advantaged had far less support from their families. The allocation of household tasks is biased against them. They have very little help from their husbands in tasks that are regarded as women's work.

14.4

Material well-being is insufficient in considering the constraining factors to attendance. The social mobility of the Rai women is greater than that of the Chhetri women. The Chhetri women are considered inferior to their men-folk and have to follow their wishes. Men are becoming more involved in the discussions as the confidence of the women's groups improves. My co-worker is trying to raise questions that allow the status of women and the gender roles outlined for them by society to be discussed more openly. The caste system is inhibiting change within women's lives and although the law has now banned its use, it is still pervasive and changes are slow within Nepalese society. There are changes afoot that the following quotation shows. It is from a sharing workshop held in Dhankuta in October 1998. It outlines some of the hindering factors to empowerment amongst women in rural Nepal. Several women forest user group members shared their experiences of being involved in a group process. After their presentation one participant from the sharing workshop asked a question.

Non-Governmental Organisation participant: Do your husbands help in your housework when you are out? Kamala Ghimre: This is the first time in my life that I have got the chance to say something in front of a large audience. So, I may make a mistake and I hope you do not mind. Yes, it is true that the PRA concept has changed our village. Our men used to scold us when we wanted to take part in meetings and many other useful programmes. They had the belief that women are only made for cooking and doing housework but nothing more. But nowadays we get the chance to participate in village meetings, development programmes and much more. But, still men do not help us in the work that they feel is only made for women. Such as when we come out to participate in programmes like this we have to go back and feed our children, cook rice, feed our animals and do all the work which we have been doing over the years.

14.5

What Kamala relates is not wholly negative. She also mentions some changes have occurred and how she has benefited from the process. She is now far more confident and self-assured. She has a greater awareness of other broader issues and is no longer confined to the house. There are opportunities to attend meetings and gain support from others. Her network of social support has increased from her involvement in the research.

Social Network Analysis

15.1

Social network analysis was used at two different stages in the research process to find out more about the types of networks and hence social capital (Butler Flora, 1997) prevalent in the neighbourhood. Social network analysis involves asking the group about the places they visit and why they visit them. The first social network analysis was carried out in a pilot before the health analysis workshops and group formation took place. The second was carried out in an evaluation carried out by the groups.

15.2

Prior to the Women's Empowerment Strengthening Team (WEST - a locally based non-governmental organisation that works with women's groups) starting to work in ward 3 of Dhankuta municipality there were no women's groups in existence in the neighbourhood. During the HAAC workshops the women started two participatory health groups that meet on a monthly basis to discuss progress and plan new activities (Khalde participatory health group and Pangsing participatory health group). At a later stage a further group formed when they showed an interest in starting a literacy class (Tallo Pangsing participatory health group). The groups have also initiated a savings and credit scheme within their groups. Each group has decided how much each member should contribute on a monthly basis and the money is then banked and used according to group decisions.

15.3

During group interaction women mapped where they go to seek different forms of support: financial, social and health advice (Figure 4). The findings showed women were visiting each other for social support, the Dhami Jankri^[3] for health advice and key households for financial support (Gibbon, 1998). The networks are all within the village and none of the women venture out of their village to seek advice from other sources. House 21 is that of the local Dhami Jankri' (local healer) all the women mentioned her as their source of health advice. No linkages with any external agencies were mentioned.

15.4

During September 1998 a follow-up meeting including a group self-evaluation took place with the three Dhankuta groups looked again at the social networks now prevailing in the community; Khalde, Pangsing and Tallo Pangsing (Figure 5). The Khalde group shown in Figure 4 is one part of Figure 5 (the follow-up map of social networks) and is contained within the circle depicted as Khalde group with only the Dhami Jankri' (DJ) being outside that group although she is still within the circle representing the 'community'.

Figure 4: Map to show Khalde women's social networks

Figure 5: Social networks of WEST's women's groups

15.5

The social networks within the neighbourhood are now much more complex. Linkages with external agencies as well as links with the ward chairman, the forest user group and different NGO (SOLVE and PATRON) committees are now indicated. The Dhami Jankri' (local healer) continues to be a focal point within the neighbourhood (Figure 5), however, she is no longer the sole source for health related advice. The groups have strong links with each other, the ward chairman and WEST who sometimes acts as intermediary with other organisations. The groups were able to get support from the Nepal United Kingdom Community Forestry Programme (NUKCFP) for their literacy initiative in the form of stationery. They have also sought advice from the Institute of Health Science and District Public Health Office about running a clinic in their community.

15.6

Through increased unity they have gained more influence over development in their 'community'. Discussions with the ward chairman have led to the municipality giving cement for their latrine building programme. In next year's development budget finance for six latrines has been incorporated for their community.

15.7

The following quotations are indicative of the changes that have occurred in ward 3:

Before no one ever heard us, now we get together and discuss our plans, talk to the ward chairman and our community is changing, we now have a voice (Community member, September 1998).
Things have changed in our community, before we had no latrines and our environment was dirty, now we can cut our fodder close to our houses as people now use latrines (Community member, September 1998).

15.8

The increased number of linkages in their network within the neighbourhood has increased the capacity of the community. The increased number of linkages also means that there are more opportunities for the 'community'. They are able to draw on more resources to benefit themselves on an individual basis and their community. A mutually reinforcing network has arisen that will possibly be sustained once the research is completed. The groups are now able to carry out small projects using resources from within and external to the 'community' thereby increasing social and human capital (Bebbington, 1999). Their environment has improved through the latrine building activity, community members have mentioned a decrease in faeces along the paths and making fodder collection easier. Finally, their financial resources have increased through the initiation of savings and credit groups.

15.9

Involvement in a group can also lead to individual negative situational change. Women already burdened by their domestic and productive tasks may feel under too much pressure to take on further tasks like the political ones involved in a group's dynamics and may bring unexpected consequences. Stein (1997) speaks of the 'triple' day that arises due to a woman taking on further commitments due to her involvement in a group's activities. This can lead to further detrimental situations such as divorce or separation. A woman may become exposed to repression from family members; her husband may become aggressive or her mother-in-law angry at what she sees is neglect of the family. She therefore may lose traditional forms of support even though she gains in other ways through her group involvement.

15.10

Being involved in a group can lead to expectations that there will be improvements in wellbeing and socio-economic status. If such changes do not occur feelings of frustration over unmet expectations may occur. However, what a woman's empowerment model allows is a way of:

Linking together development and women's situation, empowerment, and health; placing them in a context that includes historical, political, economic, cultural, social and local circumstances; and adopting a non-reductionist, non-linear, dialectical approach to understanding complex issues, provides a framework to reorient our thinking about health from pathogenic to salutogenic (Stein, 1997: 255-256).

15.11

The move from pathogenesis to salutogenesis is an important one. The road to improved health is not clear but there are indications that a focus on development and empowerment, on social capital and social justice, will have a greater impact on women's health than just concentrating on factors thought to be more directly related to health. Rather than looking at single stranded interventions multiple stranded ones could provide a stronger fabric and suggest a potential way forward. The HAAC approach has led the groups to focus on ways of improving their neighbourhood rather than dwell on the problems of community development, a form of appreciative inquiry (Cooperider and Srivasta, 1997) rather than seeing their environment only in terms of the problematic.

Conclusion

16.1

Stein's (1996) model of empowerment together with Rowland's (1996) inhibiting and contributing factors to empowerment have been useful in assessing the effectiveness of the HAAC as an empowering approach to improve wellbeing in rural Nepal. The forms of power that have been most useful during the analysis are productive power, social power and the power from 'within'. The women group members have found that being part of a group gives them new possibilities. The social power they gain is far greater than what they would achieve as individuals. Group membership has also led to a greater feeling of respect and acceptance of each other as unique individuals on an equal basis. It would be interesting to see if the approach could be used in other developing countries and also if it could be adapted for use in a developed country setting. The HAAC shows there is a potential for the use of interactive approaches to promote health in the community. It is not static and changes to suit the needs of the women involved.

16.2

However, empowerment cannot be seen as a 'magic bullet'. It can only occur where it is willingly adopted and for as long as it serves those in need. There may be a greater resistance to women's empowerment as more women become involved and the network becomes more organised and devoted to wider issues. Men need to be brought on board to share the benefits and increase the programme's effectiveness. The question that remains is how can this occur without subordination and domination?

16.3

The approach used in this research was defined as an empowering process and therefore it is difficult to describe an end product. It is dynamic and changing and varies according to the local context. I have used a definition of power that is generative and productive. The analysis has shown that the process depends on the particular cultural, ethnic, economic, geographic and social location of the group and their environment and specific life-experiences interacting with the gender relations that prevail in their society. The central values of the process common to all the case studies consist of increases in self-confidence, self-esteem and capacity to make plans and implement them.

16.4

Having more self-confidence does not always lead to changes in how power is exercised or experienced. Action is significant. Empowerment processes are dynamic, the dimensions of empowerment put forward are closely linked: positive changes in one area can encourage growth in either the same dimension or another.

16.5

Factors that encourage empowerment can be reinforced; inhibiting factors need to be mitigated, and overcome. The strength in the approach is that it has started to develop scenarios that allow for the negotiation of power relationships within the household. However, the criticism of the approach as I see it is that power relationships within society are not challenged. The Rai households in Dhankuta remain unable to build latrines due to their economic situation and the ward chairman continues to show preference to his own caste in distribution of resources. The approach needs to allow a greater space to discuss inequity and social exclusion otherwise it will fail to help provide a more just development within society.

16.6

Throughout the research process I was aware of my power, I tried to scrutinise my own actions and intentions and often found this difficult. I completed the writing up in London far away from Nepal and in doing so I am concerned that the women I worked with are again represented as powerless, pathologized and having no sense of agency. However, the women I worked with were not exploited, they challenged and resisted when they saw no benefits and rewards to their lives. They enjoyed their involvement and it provided resources for developing their sense of self-worth. More importantly their involvement provided a framework which they were able to use to consider other issues that impinged on their lives.

Appendix: The Health Analysis and Action Cycle as a Process Leading to Action

The major dimension to the Health Analysis and Action Cycle (Figure 6) is the approach it takes to working in the community. Tones and Tilford (1994) outline two approaches; the first derives from the view that the community is a setting in which to deliver health education; while in contrast the second approach is based on the conviction that the facilitators should work with the community and seek to facilitate the achievement of the health goals that the community itself has identified.

It is the second of these approaches that CHDP takes, using a broader, 'holistic' perspective on health and concerned with people's empowerment. Tones and Tilford (1994) use a model known as the health action model to explain this further. Efficient decision making requires conscious calculations of the costs and benefits of actions. Decisions are influenced by beliefs, motives and social pressures, which enable action to occur if and when the appropriate circumstances arise. The Health Analysis and Action Cycle aims to enhance efficient decision making and conscious analysis.

If the approach we are investigating is to be an empowering approach the provision of support to facilitate genuine decision making is a necessary component. It is therefore essential to take into account the constraints and facilitating factors interposed between intention and action. The facilitating factors are a necessary prerequisite for effective health promotion.

All the Health Analysis and Action Cycle steps allows the groups to discuss and visualise several aspects of health:

• the effects of good health and bad health in their daily lives
• the relationships between their environment and its effects on health
• the mechanisms within their body through their own interpretation
• the possible preventive measures to the health issues discussed
• the attitude to adopt for each discussed health issues

The input of external knowledge is limited as much as possible (although not entirely excluded) and the emphasis is put upon facilitating the discussion and the exchange of knowledge between the participants. The external knowledge that is introduced is discussed and not imposed on the group members and allows them to make decisions about incorporating it into their worldview. The closeness to the problem created by the use of participatory tools seems to increase the participants' ownership of the action to be taken. In the piloting phase we observed that most of the time the decisions taken by the groups were followed by actions.

The Steps in the Health Analysis and Action Cycle

The Health Analysis and Action Cycle allows the women's group members to reflect on their perceptions and understanding of health. The Cycle uses a process through which there is an opportunity to exchange knowledge. All the steps should be facilitated in a way to trigger discussions between the group members and probing questions are very important. Checklists can be used as a means to ensure all the issues are covered. All the points raised during the discussions should be linked to each other and followed through to be included in the action plan. All the discussions need to be related to the local context. The participants' beliefs should be respected at all times. The facilitators may well have a completely different worldview and they should not impose their way of thinking on the group members. Differences in cultural group and level of education all have an effect on the way individuals view the world.

As health is being considered in a 'holistic' way there are many influencing factors that need to be considered. The focus will be on health preventive measures that the participants can realise themselves as well as on action that needs to be taken to address health problems once they have occurred.

This section will illustrate the use several tools that come from participatory rural appraisal. The tools include health mapping, seasonal calendar, body map, and cause tree. Some of the health problems mentioned by the groups are seasonal. For this reason we decided to include a seasonal calendar to consider seasonal illnesses, in relation to seasonal attributes and to examine if any of the causes defined in the discussion around the health map have a seasonal dimension.

The following steps were used with seven groups of women. Of these the findings of six were analysed in depth. Each group had a maximum of twenty (more usually between ten and fifteen) as more than this meant everyone was not able to contribute and participate in a meaningful way. The steps were facilitated by someone outside the group.

Note: The dotted line shows how in the second cycle it is not necessary to re-list and identify problems.

Figure 1: The Health Analysis and Action Cycle

The historical background to RRA, PRA and PLA

Rapid Rural Appraisal (RRA) was developed in the attempt to bring participation into development planning. It derives from the methods of participatory research, applied anthropology, and a farming systems research. Both RRA and its derivative Participatory Rural Appraisal (PRA) are concerned with; learning from the people, offsetting biases, optimising trade-offs, triangulating and seeking diversity. Its genesis occurred as a result of the disillusionment with baseline studies and their dependence on large scale questionnaires that arose due to the donors wanting subsequent comparable surveys that could 'prove' that their intervention had achieved its stated objectives. These surveys were found to be very costly and didn't justify their expense based on successful monitoring and evaluating projects. Consequently, more cost-effective methods of learning were sought. Chambers was the major proponent of RRA and he described it as a semi-structured was of learning rapidly from the people about essential problems and ways of alleviating them (Chambers, 1983). RRA has come under attack for its extractive nature and that it is mainly for the benefit of outsiders. In response to this, Chambers suggested a modification, which he calls PRA. PRA sees the outsiders as facilitators who work together with the people and that the resulting knowledge is owned and shared by local people. The major problem of PRA is then in the behaviour and attitude of the outsiders. They have to learn to give responsibility to the groups they are working with, there has to be an exchange of domination for facilitation.

PRA is not a methodology but a framework that links a family of approaches that were developed to enable local people to obtain, share and analyse their knowledge of life and conditions. From this information they can then plan and act according to that knowledge. PRA flows from and in fact owes a lot to RRA (White, 1994) which was developed from participatory research (Freire, 1972). Where PRA needs to develop is to aggregate local knowledge to influence policy, to take local knowledge and apply it to decision making at a central level.

White and Taket (1997) outline the principles of PRA as the following:

• Learning rapidly and progressively: with conscious exploration, flexible use of methods, improvisation, iteration and cross-checking, not following a blueprint programme but being adaptable in a learning process.
• Offsetting biases: especially those of the 'rural development tourist', by being relaxed and not rushing, listening and not lecturing, probing instead of passing on to the next topic, being unimposing instead of important, and seeking out the marginalised and disempowered groups, and learning their concerns and priorities.
• Optimising trade-offs: that is, relating the costs of learning to the perceived value of information, with trade-offs between quantity, quality, relevance, accuracy and timeliness. This includes the principles of optimal ignorance, knowing what is not worth knowing, and of appropriate imprecision - and not measuring more than needed, i.e. 'better to be approximately right than precisely wrong'.
• Triangulation: meaning using a range of methods of analysis, informants, types of information, investigators and/or disciplines too crosscheck.
• Seeking diversity: that is, maximising the diversity and richness of information. Chambers describes this as deliberately looking for, noticing and investigating contradictions, anomalies and 'differentness'.
• Facilitating - they do it: facilitating investigation, analysis, presentation and learning by rural people themselves, so that they present and own the outcomes, and also learn. This often entails the outsiders starting the process and then sitting back and not interrupting.
• Critical self-awareness: meaning that facilitators are continuously examining their behaviour, and trying to do it better.

PRA has been criticised, as it does not go beyond appraisal, and is therefore hailed not to incorporate analysis, planning, prioritisation of possible solutions, and finally a commitment to act. It may be a good set of tools for data collection but it does not explore the issues and assess different options and choices for action. It simplifies and overlooks the inherent problems in developing a plan of action. What do you do when there are conflicts of opinions, or different parties pursuing their own interests? It is apparent that there is a need for a further step. Participatory Appraisal of Needs and Development of Action (PANDA) takes on these tensions by incorporating tools from management sciences and operational research. PANDA sometimes but not imperatively uses a set of planning tools that was developed in the 1970s called the 'strategic choice approach' which incorporates ideas on participative decision making (White, 1994). These methods have been seen to be useful in Belize where the participatory and transparent nature of the techniques and the process facilitated learning.

The project aimed at helping the participants to visualise and structure the issues in terms of how they saw then, and ensuring that their main concerns were being aired. During the project, the incorporation of participative aids for decision-making helped the participants to consolidate what they learnt about their problems with what feasible options they could explore (White, 1994: 461).

Participatory Learning and Action is a further development that has incurred to incorporate the idea that action is inherently important and that the approach goes beyond being a method of appraisal (Chambers, 1997).

Notes

¹A tole is equivalent to a hamlet

²Healers or Dhami Jankri' in Nepal use shamanistic practices to heal their clients.

³A Dhami Jankri' is a traditional healer

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