[MUSIC] With lecture 10, we're starting on module four that looks at the community level of the ecological

model. Looks at community change processes, attempts to understand how the community is constructed, what kind of activities go on at the community, what we can learn about health from the community. First picture shows a view of downtown Ibadan in Nigeria. Ibadan an old city that was founded over 200 years ago by various warring camps during inter-tribal wars. And the city has now grown to over two million people. What is interesting is that the city itself has many different subcommunities. In the front, one can see large buildings that are three or four stories. This is in, what one would call a transitional area. Relatively, modern in construction, built since the 1950s, of people who come from all over, Nigeria. But farther in the distance to the left, we have a more indigenous section, of people who are descendants of those original, settlers from over 200 years ago. Houses are still made with mud, even if they're two stories tall. People trace themselves to a common ancestor. They still have indigenous chiefs and kings in that area. Very densely packed. Toward the middle and the back is the modern business district. Off to the far right in the back would be communities that are like, housing estates or housing developments. And so, there are different kinds of communities within a city and it's important for us to realize that these exist. They have different characteristics, different needs, and different subcultures and backgrounds. The question, therefore, arises, what is a community? And various definitions are presented here. One has community as being a group of people living in the same defined area, and sharing the same basic values, organization, and interests. Two clear components, the idea of

location, and the idea of social system and values that distinguish a community. This is particularly true, of places like Ibaden. These days of course, in places like US and Europe. Geography does not necessarily define communities completely because people have other ways through the internet as we're using now. And telephones to have contact with a wi, wider group of people that form their community or social networks. But still, for the most part, we're concerned about where people live and the relationships they have with the people around them. And, again as noted, if they share a common sense of identity values, organizational structure, leadership interests, concerns, they are then a community. Another definition looks at community as an informally organized social entity which is characterized by a sense of identity. This brings us back to our discussion in module one about units of identity. And, of course, after one develops from a concept of an individual to family to social groups, neighborhoods, then one identifies next as one matures with a community. And so, people within that community can identify, can explain who belongs, where the boundaries are. So, this sense of identity is very important in defining a community. Another definition says the community is a population which is geographically focused, but which also exists as a discrete social entity with a local collective identity and corporate purpose. Here again, the idea of common norms, common culture, and organizational structure, leadership etc., defines a community. So, from the foregoing, we can see that important components of community are locality. The fact that defined social group exists interdependent among it self. Different social networks combining to form this community. A community consists of relationships among it's members, and a community has a shared culture of values, norms, sense of belonging, identity.

We'll now talk about the concept of community diagnosis. During the review of precede model in module two, we talked about behavioral diagnosis, educational diagnosis. If we're going to work with the community, we do need to also diagnose the community to understand how it functions. Community diagnosis is used not only to identify problems and needs, but equally importantly to identify resources that can help solve community problems, community strengths. A community is comprised of systems. When a physician conducts an exam of a patient, the physician looks at systems such as the respiratory system, the gastro-intestinal system. Community also has a series of interrelated systems. And we look though those systems to help us identify how the community is structured, what the concerns and issues are, where the solutions and resources to problems may be. One of the five systems that we'll discuss is the social system. And if we think back, we're paralleling our discussion about the contribution of the social sciences to primary healthcare and that let's us see these five different systems within the community. The social system defines the basic units of identity, social groupings, institutions, families and it also defines the roles that people play in these units in the community. In the social system, we're concerned about a concept called social capital. And this in a way takes us beyond looking at the community as a source of problems that need to be solved to the community as a location of strengths and resources. We've talked about social networks in the previous module. And social networks, these groups, clubs, associations, connections, are social capital. They are the resources that help people accomplish their goals. They are the groups and organizations that the community can draw upon to help dig wells, build clinics, make contacts with the outside agencies. So, it's important as part of our community diagnosis to identify these groups, find out what their strengths are, what types of activities they're engaged in, and what their connections

are. It's the social and economic resources of the community that are embedded in these networks. This is where we can find, as we said, the strengths of the community. And again, these strengths go beyond the individual community. Because these networks have contacts with external organizations and can bring in resources for the community. Another important system in the community is the political system. This is concerned with power relations, leadership structure, subgroups, and how power is shared among these groups. Some may be disenfranchised, some may be power elites. It also recognizes that the political system consists of both formal, for example, appointed, elected, designated leaders. And informal leadership are opinion leaders, people who are valued for their experience in the community. People that others go to for help and advice. Behind the scenes leadership. As we mentioned, the political system involves both informal and formal leaders. It helps us examine the decision making process. Are decisions reached by consensus, by voting, by strength and power? What is the level of participation and decision making? Are all groups involved? Men and women, younger people and older people, different ethnic groups, different religious groups. And, ultimately, in terms of our leadership issues, are the leader accountable? Who do they report to? Who holds them in check? Even in some of the traditional kingdoms in Nigeria, the king, all though his position was inherited, could be driven out of the town if the people were not satisfied with his performance. There was a traditional procedure that if people in the community were unsatisfied with the work of the king, or felt that he was being vindictive, or wasting their resources. If all the women paraded through the street naked, the king would leave the

town immediately. There was no recourse. So, the question of leaders, whether they're democratically or elected, or they come by their position through inheritance, they're accountable to the community. But to what extent, and how does that accountability work? A third system is the cultural system. The cultural system considers the basic beliefs and values of the people. It also describes their way of life, how they go about doing things, the technologies that they use. If it's a farming community, do they farm using hoes and cutlasses? Do they farm using tractors? What is the system by which land is allocated? So, this would be an example of a cultural system. A fourth system is the economic system. In the economic system, we examine the resource base. How do people earn a living? And, considering the resources that are available, how are these distributed within the community by section, by gender, by age group. The fifth system that we will consider is the geographic system, and this concerns how people use the space available in their community. Where are important resources actually located? How is movement facilitated? Communication among people? These are issues that one would look at in the geographic system. And related to the geographic system is the issue of mapping. Maps help us diagnose the community by showing us the location of resources, the distribution of the population, access of the population to important resources, and prevalence of health problems. Much more sophisticated mapping has developed in recent years using geographical information systems, satellite positioning, etc. But, at the local level, if someone is involved in public health and wants to work with the community, it's important to involve the community in mapping and understanding these relationships of resources and population. It's important to get the community involved in doing their own mapping of their community.

This may be done with simple sketches. It may involve bringing community members together in an open space using sticks, bottle caps, stones to draw roads, to symbolically represent houses of important people. The community can be involved in doing its own mapping, it can come to an understanding of some of its basic social, economic, political, and health problems. The next slide shows a rough sketch map of Apata village. And this will come up win your laboratory exercise. This is a prototype of some of the kinds of villages where we're working in Nigeria, where Guinea worm and other tropical diseases are common. If you look at the map carefully, you can start to get some ideas about what some of the health and social issues might be. You can formulate hypotheses based on your observations. Clearly, a health worker should not make these hypotheses and jump to conclusions in isolation. This is why, we say, it's important that the community actually provides and gives meaning to these observations. If one looks closely at the map and see, there are two different settlement patterns at the top. The little squares represent houses are tightly clustered but not in particular order. There are dotted lines that represent foot paths, there's only one paved road through the middle of that section. Whereas, in the bottom part of the map have a more laid out area with streets and houses along streets? One would want to consider why does that occur, are there differences in the two populations? Do these differences imply different economic status, different disease status? One could ask questions whether sanitation is different in the two areas, and the diseases that result from poor sanitation. If you look closely, you can see that wells are primarily located in small, blue circles. In the bottom half of the map, whereas these oval blue items are pawns, and they're more common. In the upper section, so people have different access to different kinds of

water sources. What does this imply in terms of health and disease? But in terms of the systems, why? Are there different ethnic or social groupings? Do people in one section have different occupations, different income levels? Other, quote, modern or Western facilities that are amenities that are available in the community are more likely to be found in the lower portion of the map. There's a court, a high school, a postal agency, primary school, and the cosmopolitan religions have their major buildings in the lower part of the town, too. In contrast, in the upper part of the town we see shrines with, for indigenous religion located on the rocks surrounding the town. There is a King's Palace, the market there is not drawn with. Right angles, straight line the, the market spreads into the surrounding neighborhood. So, these could represent different populations or the same populations but different economic strata within that population. You wouldn't want to investigate and ask people why these services are located in one place. What are the differences? We've done simple studies in communities like this and found that for example, the health center being closer to one section of town influences whether women will deliver their babies in the health center or not. It's less likely in the. Upper section. The farther section of town for women to come down to the health center and use it. In terms of community diagnosis, looking at a map like this, one would want to find out something about Guinea worm. We can clearly see that there is a geographical influence. The people in the upper section of town do not have easy access to safe water supplies so they can get Guinea worm by drinking water from those ponds. There's probably an economic issue involved to dig and build sanitary wells. Money is needed. A proper well may cost $500. People in the south side of the town, the

lower side, may be able to mobilize resources and construct these things. Whereas, in the upper section of the town, they don't. There may be cultural differences. People in the southern or the lower side of the village have more access to education and they may have imbibed scientific beliefs about guinea worm, whereas people in the more congested. And possibly more indigenous area of the community probably hold on to the beliefs about getting warm, being in someone's body. And you can see they may have these shrines here. And consider an outbreak of Guinea worm being caused by the anger of one of the local divinities. So, this is the way that one can use maps, but also looking at maps and getting ideas about what is happening in the community, confirming those with the community, and reviewing the different systems, the geographical, the cultural, the economic, to find out why problems exist. And identify where the resources are to solve the problems. Where the political leadership is who could mobilize people. Where staff may be that have knowledge skills to, to share with the people to help them solve problems, like in the health centers and the schools. So, maps are important adjunct to our community diagnosis to help us learn more about the communities. In the next slide, we'll talk about some of the characteristics that differentiate different types of communities. As mentioned in a couple of the definitions, the issue of identity is very important. How strongly do people feel that they belong to a particular community? How much aware are they of their local values? How strongly do they feel that they share a common destiny with the other people, their neighbors? Is there a consciousness of where their community is spatially politically and they point out the boundaries and they differentiate their land from other people's land? A question arises. How do we know if there is a strong sense of identity or not? And some of the questions we may ask

people in the community, or we may observe if we walk around the community, is that people are generally getting along with each other. They're friendly, they talk in the streets, we can ask people what their interest and concerns and values are. And if you talk to enough people, you'll see that they share these values and interests. There's feeling of comfort with their neighbors. People feel free to leave their children with their neighbors if they go to the market or go on errands. Also, in terms of identity there's a strong sense of place, of their location, of their neighborhood and as seen in the next slide, a strong sense of community history. They know where they're coming from and hopefully they will be able to plan together for where they're going in the future. Another important community characteristic is integration. How often and to what extent do people get together, visit, interact, have festivals, do things in common? What does bring them together? Do they socialize together? Is this evident in former community projects, activities? Have they engaged in self-help? Have they built a primary school? Did they dig a well? What have they done together? A good place to start our diagnosis to observe interaction is in the market. The market brings people together from the community. Are they going from shop to shop talking to people? Do they gather in a small eating or drinking place and share news about community happenings? Are community leaders present in the market and people are bringing their concerns and complaints? In addition to observing interaction, integration, one can also again, observe certain important things about the health and the structure of the community. The economic status is important. Can people afford to buy goods? We observed in a small community like Apata that even though the town is 10,000 people, the butchers do not even slaughter one cow to be selling the meat in one day.

They may bring over a portion of a cow from a neighboring town and sell that meat so people do not buy much meat. Maybe there's only one or two people selling cloth, whereas in the next town, there maybe six, seven, or ten shops selling cloth. So, one can get some idea about what is available, what people are buying, how much money one can find out about prices. Nutritional options are important. What crops are being sold? Is it primarily carbohydrate? Do people have variety? As mentioned, we can look at social systems. The market itself may comprise social systems, different sellers associations. But also, an opportunity for family members who may be living in dispersed villages to come together and have meetings implies that the market is a good communication network and we can learn more about the community by visiting the market. Another word for integration of a community is also cohesion. The next two slides show examples of a cohesive community, when people come together to enjoy festivals. One festival that happens every year in southwestern Nigeria is the Gelede Festival. It's partly a fertility festival. And interestingly enough, the women take a major role in this festival. As you can see in the slide, we have a masquerade, or a statue that's paraded around the town. There are various parades, events like that, people come together and cook and eat together. And so, this is an opportunity for people to show their membership in the community. In the next slide we see picture from the Sierra Club magazine showing an American Indian festival. One of the concerns that was expressed in the article that accompanied this picture was that such ceremonies are declining and there's concern that. General environmental conditions that may reduce the presence of salmon, would make it difficult for communities to hold their salmon festivals. And so, environmental impact on the social structure and the cohesion of the community, is a concern we should be

aware of, in terms of social change. Another important community characteristic is group orientation. How important is the welfare of the community or social group compared to the needs or rights of individuals. Are decisions made for the benefit of individual members or for the benefit of the community as a whole. To strengthen and hold the community together. How strong are social norms. To what extent is there social control? We talked about perception of social norms and people's desires to comply with what other people think they should do. How strong is that pressure to comply? Another characteristic is linkage. After we looked at the map, after we talked to people, we realize that very few communities have all the resources they need to, to solve their problems. What linkage do they have with outside resources, with a larger. Community. For example, the old intersection of the city of Ibadan, to the residents there have connections with the local government, with the university. With various ministries, so that they can obtain information and resources to help them. What channels did they have to make contact with outside groups and resources? This may come, simply by membership, for example if someone is employed outside in the larger community. Or if someone is member, a member of a group, social institution, a religious group that also has branches in other parts of the community, outside. Do people interact with these outside groups? Do they bring back news and ideas to their own community? The next four slides shows some examples of what the concept of community linkage is, is all about. First we see a community that is dedicating a new well. The people in the community were able to donate money to hire people to dig, to buy the cement, to hire the laborers that would actually do the construction. But they lacked. The technical skills to know where to site the well, what is the best construction design. And so when members of the community who

worked at the district headquarters in the district hospital were consulted, they were saying okay when we go to work, we'll talk to our colleagues, we'll find other agencies that can provide this technical skill. So here is an example of linkage to the outside community. In the next slide, we can see the doors and windows of a rural clinic, they're fallen off because termites ate through the wood. Such a community has little linkage, little influence over government. They probably don't have the an elected official in the state legislature. They may not even know anybody who is on the county or district council. At their clinic, drug supplies are irregular, no one knows who to complain to, very few linkages. These linkages again may be through, our concept of social capital. We can see in the next slide that people may belong to associations. In this case, the National Union of Road Transport Workers, and they have connections throughout the state and the country. And in the process of their traveling around, they can learn about important resources, programs, political events that they can come back and share with their community, so they can keep up to date and take advantage of new programs. Finally, another important aspect of linkage, particularly in Africa, is the concept of the hometown association. Rural to urban migration is, in some senses, a problem. But what happens when people reach the urban areas is that they join together and form clubs and associations of people from their own hometown or home district. They meet once a month, they discuss issues and problems back home, and they're in a position. Because they're working in an urban area and earning salary, or in business, making some money, to collect funds that they can send back home to help make improvements at home. So, here is another example of linkages. Based on these different characteristics, one can hypothesize that there are different types of community. One can think about neighborhoods in your own work area where you live at, at home, places you've visited, they're not all alike.

Why is that? And the presence or absence of some of these characteristics may explain. For example, in community typology, an integral community would have a strong sense of identity. Would have be well integrated with a lot of interaction and group activities, community activities, with projects planned. And they would also have strong linkages to the outside so they can get resources and support that they need to carry out their projects. This would be a cosmopolitan community, individuals are in close contact. They have concerns about their own community but they also have interest in the larger city, state surrounding them. A parochial community, perhaps a more indigenous local community would have a strong sense of identity. As we noted in the example of Eu Baden, they traced themselves back to a certain ancestor. they did have festivals and ceremonies together. But, being more working and lower class people, they don't have as much interaction with the cosmopolitan larger community. They don't have as much connection with the local government. They don't have much connection with educational institutions. And so, in a way, they are cut off. They have a strong sense of ethnic or class identity. They are more homogeneous in nature, self contained. Somewhat independent. In fact, this independence may intentionally be preserved. People do not want outside influences to come into their area and they may be able to screen these out if they don't conform with the values and beliefs of the local people. This may explain in part why some of the amenities and resources seen in Apata village such as the high school, a church, a health center, are located outside of the main, indigenous town. In fact, when either the government or missionaries, or the people came to the village and talked about these resources, people were polite enough not to refuse them and were willing to consider that there may be some future benefit. But they didn't necessarily want these things right in their midst in case there

were any problems. So, it was better to give them land farther away from the center of the community. A diffuse community may be exemplified by some of our housing estates, subdivisions outside of cities. There's a strong sense of identity of where I live, what kind of community wanting to preserve that. Often homogenous middle class people, similar background. They have things in common. Char, their personal characteristics, their economic background, their educational level, maybe even religion. But oftentimes, there is no internal life. People live somewhat isolated, not as much involvement with the neighbors. I don't know who lives next to me. Their connections maybe more with the outside, they may identify more with their place of work. Other examples are given in the subsequent slides, and in your notes. And you may want to think about these and how they apply to communities where you have actually lived to see if they make sense. Are there other kinds of communities that you've lived in with different characteristics? A stepping stone community where people are active in the neighborhood in order to gain social status and move along, move on. Transitory population is changing. Some of the peri-urban slums in, in many developing countries exemplify this. People come and go. There's really no sense of ownership of the land. And so, people are not secure. They may come from all different parts of the country we may have some inner city neighborhoods that are very weak in all of the characteristics. Economic communities were there's not much cohesion, identity, interaction. So, one needs to think about this. It's not that these typologies represent every single possibility, but it's important to think of these characteristics as the strengths that lead to a competent community that we'll talk about. And the basis if we work with communities that do have serious problems. They can tell us where we might need to intervene to help strengthen communities.

Can see in the slide of a small isolated rural settlement in the northern part of Nigeria, a group of maybe ten or fifteen huts. They may belong to a larger clan with another village a mile, half a mile away. There may be strong identity within, but they have poor access to external resources. In the next slide, we can see a village setting southwestern Uganda. A village may cover several square kilometers, but only have a few hundred people. Because of the nature of the land and their farming activities, they're spread quite wide. In contrast, we can see an urban community. People living in buildings three or four stories, all different kinds of ethnic groups gathered together. No clear king, or chief, or leader. People's main contacts may be with members of their own ethnic group in other parts of the city. So, there may be a weak sense of identity within that neighborhood. In some urban neighborhoods, there's a strong street life. People interact. There may be some cohesion. People come together to set up vigilante groups to protect themselves against thieves. So, there are different kinds of communities and it's important to recognize that whether it's in a rural or an urban area. We need to talk to the people in that community, find out their own sense of identity, their own definitions of their boundaries, their own sense of leadership and social groups. And again, when we decide to work in an area, it's the people themselves that will tell us their units of identity which will become our units of practice.