Hesperian Health Guides

Working for Change

When Juanita had taken the medicine and was feeling better, it was tempting to think that her health problem had been solved. But she knew this was not true. When her husband returned from the coast, she would get infected again if he did not take the medicine and use condoms. She discussed the problem with Suyapa and other women whose husbands work at the coast, and together they decided to ask Valeria for advice.

Looking for the Root Causes of Health Problems

Valeria agreed that Juanita’s health problem was not yet solved, because many of the conditions that created the problem still existed. She suggested playing a game called "But why . . . ?" to help everyone identify all the conditions that created the problem.

Valeria gathered the women in a circle, and asked them to try and answer her questions:

health worker Valeria asking questions that a group of women answer
Q:  Why did Juanita get sick?
A:  From gonorrhea and chlamydia.
Q:  BUT WHY did she get gonorrhea and chlamydia?
A:  Because she was infected by her husband.
Q:  BUT WHY did her husband have gonorrhea and chlamydia?
A:  Because he had sex with other people.
Q:  BUT WHY did he have sex with other people?
A:  Because men are taught that they do not need to control their desire, and he was away from his wife for a long time.
Q:  BUT WHY was he away from his wife for so long?
A:  Because he does not have enough land to feed his family and must work on the coast for months at a time.
Q:  BUT WHY does he have so little land?
A:  Because most of the land is owned by big landowners. (A long discussion follows from this answer.)
Q:  Why else did Juanita get infected?
A:  Because her husband won't use condoms.
Q:  BUT WHY won't Juanita's husband use condoms?
A:  Because he doesn't know how STIs are spread.
And so on.

When the women had named a long list of causes, Valeria suggested putting the causes in groups. This way it is easier to see the different kinds of conditions that cause health problems:

Physical causes: germs or parasites, or something that goes wrong in the body or that the body lacks

Environmental causes: conditions in the physical surroundings that harm the body, such as cooking smoke, lack of clean water, or crowded living conditions

Social causes: the way people relate to or treat each other, including their attitudes, customs, and beliefs

Political and economic causes: causes having to do with power—who has control and how—and money, land, and resources—who has them and who does not

When the women put the causes of Juanita’s problem into these groups, they came up with the following list:

women looking at their list of causes
This is a nice list, but what can we do about these things?
  • gonorrhea germs
  • drug-resistant germs
  • women's bodies are more susceptible to STIs than men's bodies especially when weakened by many pregnancies.
  • town is isolated so men must go away to work
  • foreign soldiers at the coast spreading drug resistant germs
  • no medicines for drug- resistant gonorrhea or laboratory for testing in the town
  • town is isolated, far away from the city
  • road is in poor condition
  • men often have other sex partners
  • men won't use condoms because, "it's not manly"
  • lack of education about STIs
  • condoms are not easily available

Organizing to Solve Community Health Problems

The next step, Valeria told the women, is to look at the different causes and decide which ones you and others in the community can change. Then think about what actions must be done to make the changes happen.

After a lot of discussion, the women decided they would probably not be able to change the fact that the men had to go away for work—or even keep them from having sex with other women. But they thought they might get their husbands to use condoms if the men knew more about STIs, and if condoms were not so expensive. The actions they decided to take were:

three women discussing actions to take
Let's ask Don Pedro to talk with the men about STI's since they respect him and listen to him.
Let's all meet together to practice talking with our husbands about using condoms.

I'll see if the health center can give out free condoms.

Other members of the group suggested these actions:

  • Organize a community group to talk about health problems, and include STIs in the topics discussed.
  • While women are washing clothes at the river, talk to them about STIs and how to prevent them.
  • Talk to their sons about STIs before they leave the village to go to the coast.

The last step, said Valeria, is to make a plan to carry out each of these ideas for action. The plan, she said, should answer each of these questions:

  • What are we going to do? What steps will we take?
  • When are we going to do these things?
  • Who will we do them with?
  • Who is responsible for making sure that the plan is carried out?
  • How will we know if the plan is working?
three women looking at their plan for action
Cause: Men do not use condoms.
Action: Help men learn about how STIs are spread.
What/Who: Don Pedro will talk to the men about STIs and how condoms prevent the spread of STIs.
When: When the men return from the coast.
What materials do we need? Condoms.
Who is responsible? Juanita will ask Don Pedro.
How will we evaluate? If men begin to use condoms.

To help you use this method of solving health problems yourself, here is a chart with a list of all of the steps. On the left are the steps and on the right are the parts of Juanita’s story that go with each step. Any time you have a health problem you can use this chart to help you remember this method for thinking about and taking action to solve the problem.

The Steps Juanita's Story
1. Start with doubt. 1. Don Pedro did not know what caused the problem. He needed more information.
2. Find out as much as possible about the problem. Ask questions. 2. Don Pedro asked Juanita questions to find out what could have caused the problem.
3. Think about all the different illnesses that could be causing the signs. 3. Don Pedro thought about all the illnesses with these signs: an STI, another kind of vaginal infection, or cancer.
4. Look for clues that can tell you which answer is most likely. 4. Don Pedro tried to find out if an STI could have caused Juanita’s illness.
5. Decide which answer is probably the right one. 5. Don Pedro decided Juanita probably had an STI.
6. Decide on the best treatment. 6. Don Pedro did not know which germs caused Juanita’s infection, so he chose a treatment that works for several STIs.
7. If there are no results, start over again. 7. Juanita took the pills but did not improve and developed new signs. So Don Pedro asked Valeria for help.
8. Look for the root causes of the problem. 8. Juanita and her friends thought about the reasons why there was this kind of sickness in their community, such as poverty, unequal land ownership, the ways that men and women were expected to act, and lack of information.
9. Put the causes into groups to think about what can be done. 9. The women put the causes into physical, environmental, social, political, and economic groups.
10. Decide which causes you and your community can change. 10. They decided to work on the “social” causes. They think they can get their partners to use condoms.
11. Decide what actions can make those changes happen. 11. The women decided to practice how to talk to their partners about using condoms, to see if the health center will give out free condoms, and to ask Don Pedro to talk with their partners about STIs.
12. Make a plan for carrying out the actions. 12. They made a plan for each action they decided to take.

This page was updated:17 Apr 2019