As is often the case in my trips to emerging nations, internet connectivity has been intermittent. It first failed at my hotel the Thursday evening before we left for the field. But, I am not here to connect with the rest of the world, but to connect with my partners here at the Save the Children in Mali – and the families and children. So, I will use the business center here at the hotel for the internet.
I have just returned from two days in the field. We traveled for a couple of hours to the villages of Klesokoro and Diambala in the Bougouni region, or known administratively as the Bougouni Aire Sante. After we left the capital city of Bamako. We traveled across a flat plain of scrub and trees. The roads were excellent with the occasional detour for road construction.
My French language speaking skills are slowly returning from my high schools days. They have increased in quality from listening to speaking, in that order. This area reminds me often of my travels in Haiti. I recall that a Save the Children friend once told me that Haiti is like West Africa transplanted, since many of the present day inhabitants of Haiti were forcibly moved from there. It is true, from what I have seen. I love it here.
Even though I have recovered from the effects of the jet lag, I felt some discomfort the first couple of days. I now believe, that it was the effects of the typhoid vaccine that I received just prior to my departure from the United States. Due to Save the Children’s generosity, I utilize the benefit of a traveler’s health service. Two years ago, I went to see the health doctor and to advise them of the countries I was about to visit. The doctor then advised me of what diseases were endemic in those locations and to administer appropriate vaccines. I was due for a typhoid update, so my travel health doctor suggested the newly approved oral typhoid vaccine which is good for five years. Instead of an inoculation from a needle, it is, as the name suggests, taken orally in the form of four capsules taken on alternating days. The instructions strongly urg keeping the unused capsules refrigerated at all times. They must be taken with food and even the water was to be cold and not warm. The instructions even said that the capsule should not be held in the mouth for too long before swallowing!
The vaccine itself, is termed attenuated, or a live form of the virus in a weakened state. By ingesting the virus, it then invokes an antigen response by the body’s immune system. Then, if the in-the-wild version is encountered, the body has the antigens already available to fight off the virus. Well, on my 2nd day here in Mali, I felt a slight distension of my upper abdomen and I felt chills in the evening. I recall that when I was inoculated with the Japanese encephalitis vaccine, I experienced the same effects. The abdominal distension is due to an enlargement of the spleen as it produces the antibodies. I watched this carefully and I had no apparent fever. If you think, “why would anyone subject their bodies to these foreign bodies”, then just do a Google search on the effects, and usually death, of the real non-attenuated, viruses! The vaccine contraindications are nothing compared to the real thing. Horrible stuff. You can watch a Hollywood version in the typhoid death of John Malkovich in Algeria in the movie Sheltering Sky. That is just too much screaming for me.
From Monday through Wednesday, my Monitoring and Evaluation partner, Modibo Bamadio and I reviewed a paper form questionnaire, called Zinkifura, which we wanted to test on the PDA’s. This questionnaire was in French and was used to interview mothers over their use of a zinc (hence, Zinkifura) supplement to offset the effects of diarrhea on their children less than five years of age. Diarrhea of course, is a response to the body to flush out harmful bacteria in the intestinal tract. In doing so, the body can overreact and lose too much water and become dangerously dehydrated. This is often the cause of death with cholera and other intestinal diseases.
We stayed overnight at a nice hotel in the city of Bougouni. The following morning we arrived at the Save the Children office nearby. Last names are used here in Mali for identifying persons. In Vietnam, it was middle names – all too confusing the first few days for this Westerner! We met Bamadio's M&E peer here in Bougouni, Zanna Daou (his name sound like Xanadu to my ears) to accompany us to the villages. The villages were not far away so we arrived by mid morning. The Bamako Country Office (CO) Information Technology (IT) person came with us. Adama Soro is a very friendly and capable IT person, having skills in Microsoft SL Server (the preferred database repository software located on a protected server), Visual Basic (a high level programming language and application development software).
In the early morning, I handed a PDA to Soro and two PDA’s to Bamadio, with the 2nd for Zanna. When Zanna arrived, I suggested that Bamadio provide some initial training to him in the use of the PDA. Bamadio did all of the right things. After turning the PDA on, Bamadio then came alongside Zanna so that Zanna could see the screen. Soon, Bamadio handed the PDA to Zanna to let him use it for himself. This might seem a small thing, but Bamadio not only transferred his technical knowledge to Zanna, but also enjoined trust with his partner with his subtle body language. This is vital during actual interviews. Paper forms on clipboard in the hands of interviewers often present a large physical barrier between interviewer and respondent. The interviewer will often shield themselves from the respondent using the clipboard.
The PDA’s smaller size allows a closer proximity to the respondent and is easier to show the respondent. Yet, since the screen is much smaller, the respondent often loses interest and then disengages from the data capture instrument and concentrates more fully on responding to the questions of the interviewer.
I always appreciate the IT person’s involvement on my visits. I emphasize from the first day, that we are not placing paper forms onto PDA's, we are building portable databases. The IT person is often pre-occupied with keeping the computers and servers up and running, but their skills are crucial to a centralized data management strategy Often CO’s have data contained in scattered, disparate spreadsheets, multiple Microsoft Access databases and even Microsoft Word documents (see, I have them in Word tables!). I always take the IT person aside and discuss a more centralized data management strategy and include it in my assessment report in order to provide knowledge and support to the managers.
We had loaded the test form onto 3 PDA’s. The form had a total of 70 questions, but we only used about 30 of those questions for field testing. Many of the questions were what are commonly termed skip questions. Skip questioning is, for example, when a mother answers Yes to the question, have you ever administered a zinc supplement to your baby? Then the PDA form screen automatically advances to the next series of questions asking the effects of the zinc dose on the child. If the mother answers No, then the questions pertaining to the effects of zinc administration are hidden automatically (through use of underlying scripts) and the PDA interviewer is then skipped to only the questions relevant for a respondent who has not administered zinc to their child, hence the term skip questioning.
I am finding that the skip questioning capability of PDA forms is a marked improvement over the functionality of paper survey forms. With a paper form, the interviewer must follow the logic of the answers and then shuffle through papers to the correct questions. This slows the interviews and distracts both respondent and interviewer, and at the worst, results in incorrect answers. It is pretty hard to sort through the answers while hand-typing in the data back at the office trying to determine the correct answer. If the mother answered yes, that she administered zinc to the child, why are the zinc administration answers blank! You can not easily return and rectify this problem easily.
As usual, at this point I am mostly observing the PDA users during the interviews. I am also entertaining the children with their photographs in order to make friends with them. Upon entering the village of Klekosoro, we approached unawares a mother and her 3 children in front of their house. When the children and saw the tall, light-skinned person approaching, they ran screaming into the house. I hate when that happens. I had been lagging behind taking pictures. I usually try to stay contained physically within the group so that I do not stand out so much. I blew it.
I spent my time principally with Zanna, while Bamadio and Soro went off to their interviews. Bamadio thoughtfully assigned a local young man to accompany us so that we could be re-directed to a common meeting point post-interview. Zanna began his interviews with a couple of mothers after about two minutes of turning on the PDA. I am finding that everyone takes to the PDA method of data collection quite easily everywhere that I travel.
The Pendragon software that we use for the PDA form design is easy to use, and it has a simple, intuitive interface on the PDA. At the same time Pendragon can be extended with the use of a scripting language such as we used for the skip questioning. Using the zinc administration question logic above, if question Z301 (just a question abbreviation code) is Yes, then skip to question Z306. If the mother answers No, then hide all following questions and advance the PDA screen to question Z310. The script that we used follows:
if answer == Y then
goto [Z306] {zinc administration question series}
else {meaning the answer to question Z301 is “No”}
goto [Z310] {“are you unaware of the zinc supplement available to your baby from the health worker?”}
endif
The following PDA screen imqges show how this works:
If answer is Yes
Then the PDA screen advances to:
On the other hand, if the answer is No:
Then the PDA screen automatically advances to the Title screen of the next section:
If the mother can answer a certain question in more than two ways, then we use a common script form called Switch Case. This allows for multiple answers to a question controlling the PDA user to the relevant screen.
SWITCH answer
CASE "1" {“yes, I give my baby the zinc supplement”}
goto [FS801]
CASE "2" {“no, I have received the zinc supplement, but have never given it to my baby”}
goto [FS504]
CASE "8" {“I am not sure, I have never heard of the zinc supplement”}
goto [FS504]
ENDSWITCH
After the interviews, we assembled where I asked Zanna, Bamadio and Soro how it went. I noted that all heads nodded up and down in the affirmative, then changed to shaking side to side when I asked if there were any problems. For them, they mostly were reporting to me on the technological aspect of using the PDA’s. For my part, I am most interested at this point in the usability by the interviewer and acceptability by the mother. The latter, can often be overwhelmed by the gaze of the interviewer on the small device, and not the usual clipboard and shuffling of paper forms. Here, I noted that the mothers would turn their head away from the interviewer in a disaffected gaze, listen to the question, and then answer with the head still turned. But, after the answer was given, often the mother then would look towards the interviewer to watch the entering of the answer on the PDA.
We then traveled a short distance to the village of Diambala. Here, Bamadio let me know that we needed to first visit the village chief to inform him of the reason of our visit and to obtain permission. I believe that my CTO had to do the same thing and observe correct protocol on his recent visit with Princess Anne in Great Britain. It is the same at any level…
The chief received us graciously, directing chairs to be provided as we reclined on a platform outside of his house. I listened to speeches being traded, then, with obvious permission of the chief, we arose to conduct our interviews. I was happy that I did not need to give a speech, which, from my experience, is often the case with a foreign visitor.
After our return to the Save the Children office in Bougouni, we downloaded the data in about three seconds (the rule is, type it once, and never type it again!). We found all records, with each person interviewing 2 to 3 mothers in each of the two villages. We really did not need to spend more time. Yes, that is me with a sweet potato that was given as a gift to me by a villager.
After the intervening weekend, we will travel to neighboring Guinea to conduct PDA tests at the Save the Children office there.
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