WOMEN`S HEALTH AND HEALTH PROMOTION ... COMMUNITY OF OMBOGA AREA IN KENYA
WOMEN`S HEALTH AND HEALTH PROMOTION IN THE LUO COMMUNITY OF OMBOGA AREA IN KENYA Irene Veräjänkorva Thesis Autumn 2012 Diaconia University of Applied Sciences, Diak Etelä Helsinki Degree Programme in Health Services Bachelor in Public Health Terveydenhoitaja (AMK) ABSTRACT Veräjänkorva, Irene. Women`s Health and Health Promotion in the Luo Community of Omboga Area in Kenya. 61 p., 1 appendix. Language: English. Helsinki, Autumn 2012. Diaconia University of Applied Sciences. Degree Programme in Nursing, Option in Health Care. Degree: Public Health Nurse. Health promotion in developing countries is important especially among the women because they face numerous health risks daily. The objective of this study was to find out how the women of Omboga viewed their health and what health promotion measures have been carried out within the community to help promote the women`s general health. Omboga is a small village located in the Nyanza province of Kenya close to Lake Victoria. The community has a population of 1000 people. The participants were chosen based on gender, literacy rate, age and educational level. Other key members of the community were also interviewed. As for methods, a questionnaire was administered to the women. Other methods used in collecting the data included observation and unstructured interviews carried out in English and in the local language, Luo. Other documented material on the subject was used, including audiovisual material. This thesis is a qualitative ethnographic study. The data used was collected between February and May 2010 in the village of Omboga. The data obtained was analyzed by using content analysis with Leininger`s culture care theory as a theoretical background. The results were categorized by using Leininger`s sunrise model`s dimensions of holistic health. Results showed that women in Omboga face many physical, social, psychological, economic and environmental health risks. The results also showed that despite these health risks the women consider themselves healthy. Despite the hardships faced by the community, the research concludes that the community has taken simple measures aimed at promoting women`s health in the community. The research indicates that the women of Omboga actively develop their understanding of the benefits gained from taking preventive measures in order to sustain their health. In conclusion, the feedback from the participants was positive and encouraging. They appreciated the use of Luo language in the study. The women expressed their desire to know more about health promotion with the help of health promotion events and workshops. A topic for further studies would be the impact of cultural beliefs and practices on the women`s sexual and reproductive health. Key words: Health care, health promotion, health risks, ethnography TIIVISTELMÄ Veräjänkorva, Irene. Women`s Health and Health Promotion in the Luo Community of Omboga Area in Kenya. Helsinki, Syksy 2012, 61 s., 1 liite. Diakonia-ammattikorkeakoulu, Diak Etelä Helsinki. Hoitotyön koulutusohjelma, Terveydenhoitotyön suuntautumisvaihtoehto, terveydenhoitaja (AMK). Terveyden edistäminen kehitysmaissa on tärkeä koska kehitysmaan naiset kohtaavat terveysriskit päivittäin. Tutkimuksen ensimmäinen tavoite oli kartoittaa ja kuvata Luo heimon naisten terveyttä Ombogan alueella heidän elin olosuhteita huomioiden. Toinen tavoite oli kartoittaa mitä terveys riskejä naiset kokivat elämässään ja miten terveydenedistäminen näkyy kyseisessä yhteisössä. Omboga on pikku kylä Nyanza läänissä, Kenia. Kylä on Victoria järven lähellä. Ombogan väkiluku on noin 1000 ihmistä. Aineisto kerättiin haastattelemalla heimon naisia puolistrukturoidun kyselyn avulla. Haastateltavien valinta perusteena oli sukupuoli, ikä ja koulutus taso. Aineisto kerättiin Helmikuun ja Toukokuun 2010 välisenä aikana. Suullisia haastatteluja tehtiin myös heimon vanhemmille naisille ja avainhenkilöille sekä englanniksi että paikallisella kielellä. Osa aineistosta kerättiin sekä havainnoimalla että tuottamalla tutkimusta varten kuvallinen aineisto, esimerkiksi video materiaalia. Tutkimuksessa käytettiin laadullista tutkimusmenetelmää yhdistettynä etnografiaan. Analysoinnissa käytettiin induktiivista analyysimenetelmää. Aineisto pelkistettiin ja tyypitettiin käyttäen Leiningerin culture care theory:n sunrise modelia aineiston ryhmittelyssä. Tutkimus osoitti että vaikka Ombogan naisiin kohdistuu päivittäin lukuisia terveysriskejä, he kokevat terveytensä hyväksi. Yksinkertaisia terveydenedistämismenetelmiä on käytössä yhteisössä. Ombogan naiset ovat hyvin aktiivisia ja kiinnostuneita terveydestään ja ovat alkaneet toimimaan itsenäisesti terveyttä edistävällä tavalla. Tutkimus osoitti että nämä naiset ymmärtävät terveydenedistämisen edut ja hyödyt ja miten heidän toimintansa auttaa heidät ylläpitämään heidän terveyttään. Palaute oli hyvin positiivinen. Naiset olivat tyytyväisiä kun saivat ohjeita omalla äidinkielellään ja aihe oli heille hyvin tärkeä. He toivoivat jatkossa enemmän tietoa terveyden edistämisestä tapahtumien ja työpajojen kautta. Jatkotutkimusaiheena voisi olla kulttuurin vaikutus naisten seksuaalisen- ja lisääntymisterveydelle. Avainsanat: Naisten terveys, terveyden edistäminen, laadullinen tutkimus, etnografia, terveysriskit LIST OF CONTENTS 1 INTRODUCTION ............................................................................................. 6 2 THEORITICAL BACKGROUND....................................................................... 8 2.1 Leininger`s culture care theory and its application in this study ................. 8 2.2 Health promotion as reviewed in this study ............................................... 9 2.3 Previous research .................................................................................... 10 3 KENYA ........................................................................................................... 12 3.1 Kenya’s socio-economic status................................................................ 15 4 THE LUO COMMUNITY ................................................................................ 18 4.1 Historical background .............................................................................. 18 4.2 Culture and customs ................................................................................ 19 5 THE RESEARCH ENVIRONMENT ............................................................... 21 5.1 Health care facilities................................................................................. 22 5.2 Educational facilities ................................................................................ 24 5.3 Law and order .......................................................................................... 25 6 RESEARCH METHODS AND DATA COLLECTION ..................................... 26 6.1 Data collection and the research questions ............................................. 26 6.2 Data analysis ........................................................................................... 30 6.3 Research ethics ....................................................................................... 30 7 RESEARCH FINDINGS ................................................................................. 32 7.1 Technological factors and their influence on the women`s health ........... 32 7.2 Religious and philosophical factors influencing the women`s health ....... 34 7.3 Kinship and social factors and their influences to the women`s health .... 36 7.4 Cultural values and beliefs influencing the women`s health .................... 37 7.5 Political and legal factors affecting the women`s health .......................... 39 7.6 Economic factors and their impact on the women`s health...................... 39 7.7 Educational factors .................................................................................. 40 7.8 Environmental factors and how they influence the women`s health ........ 41 7.9 Health promotion in Omboga with regards to the research questions ..... 43 8 SUMMARY OF RESEARCH FINDINGS ........................................................ 48 9 CONCLUSIONS............................................................................................. 52 10 DISCUSSION............................................................................................... 54 REFERENCES ................................................................................................. 56 APPENDIX 1 QUESTIONNAIRE ...................................................................... 59 1 INTRODUCTION Children`s health in developing countries has been a matter of great interest, but very little is discussed concerning the health of women. It is very important to study the state of women’s health in these societies since women are the mothers of every community. Healthy women produce healthy offspring and therefore, it is in the basic interest of every community to safeguard the mental, psychological, social, political, financial and physical health and wellbeing of its women. Being an African woman and a member of the Luo community, this subject has been a matter of personal interest for a long time. I grew up in a close knit family and society where everybody seemed to have a particular task and place. From a young age, children are taught what their place in the society is, how the society dynamics work as well as what their roles are. The main aim of this study is to describe the lives and living conditions under which the women in Omboga live and find out how women from different social, financial and physical settings in the Luo society of Omboga view their state of health. Being a student and an aspiring health care official, my interest was intrigued mainly concerning health promotion measures carried out by the society to help prevent health risks. In order to carry out this research, I used Madeleine Leininger`s culture care theory and concepts of transcultural nursing. According to Leininger, to understand an individual, one needs to understand global human culture, societal and national cultures, regional and community cultures, institutional cultures, groups and family cultures as well as individual cultures. (Leininger 1995, 23.) 7 One of the reasons why I chose to conduct this specific study was to broaden not only my knowledge but other people`s knowledge as well on how health promotion is carried out in this particular environment. I studied women’s health from a health promotion point of view. In this study I considered the risks these women face in their daily lives and how their lives are affected by society. This research was carried out with the help and co-operation of Soroptimist International of Finland. 8 2 THEORITICAL BACKGROUND 2.1 Leininger`s culture care theory and its application in this study The culture care theory was developed by Leininger between the 1940`s and 1950`s. Its goal was to be a holistic way of viewing people compared to the fragmented way used in the health care sector that views people as cells, body parts of symptoms. The theory was meant to identify the assets and strengths of culture rather than its problems and diseases. This would be achieved by understanding people’s worldview, religious and spiritual beliefs, family relations, home remedies, social ties as well as cultural values and beliefs. (Leininger 1995, 98−99.) One of the anthropological concepts of transcultural nursing is enculturation. It is the learning of a culture that includes its specific values, beliefs and practices that allow individuals in that particular culture to live or function effectively. (Leininger 1995, 72.) Using the transcultural care theory, this study is aimed at enculturating the Luo people in order to understand how their society work and what their understanding of a healthy member of their society is. In order to achieve this goal, I will be examining and understanding shared meanings and life experiences in the community’s social, cultural and physical environment in relation to each other and how it influences their attitude, thinking and behavior. This is referred to as cultural context. (Leininger 1995, 78.) I have used the sunrise model to help envision a holistic picture of the culture being assessed. The sunrise model ensures that the researcher takes into account different factors that can influence an individual’s health. According to Leininger, these factors include cultural values, beliefs and practices, religious, 9 philosophical and spiritual beliefs, economic factors, political and legal factors, educational factors, technological views, kinship and social ties as well as environmental and ethno historical factors including language. (Leininger 1995, 121.) Research shows that the culture care theory along with the sunrise model can serve as an excellent guide to obtaining a holistic view of the individual’s, family`s or group’s health. It can also be used in assessing institutions. (Leininger 1995, 129.) 2.2 Health promotion as reviewed in this study WHO (World Health Organization) defines health as a state of complete physical, mental and social wellbeing and not just as the absence of disease. Health is therefore a diverse and complex concept that applies not only to an individual but a community as whole. The Ottawa charter document published by the WHO views health as a positive force that supports personal and communal wellbeing as well as an important component in maintaining physical functions. Health is viewed as a daily source of strength rather than a goal in life. (Ottawa charter, 1986.) According to the WHO as stated in the Ottawa charter, health promotion is an action intended to improve a person’s chances of controlling as well as improving his own health. The document states that in order to achieve a perfect balance between physical, spiritual and social wellbeing, one must be able to achieve his goals, satisfy his needs as well as change his environment or learn to thrive in it. Health promotion is divided into five categories: the development of healthy community politics, the creation of a healthier environment, the efficiency of the community’s actions, the development of personal skills and the redirection of health services. (Ottawa charter, 1986.) 10 This study concentrates on the division of health promotion that concerns the efficiency of the community’s actions towards improving health. This research studies the women’s understanding of health and how they perceive their health. Perceived health is important because it can be in many ways useful in prophesying future health. (Vertio 2003, 45.) In order to be able to promote health, one needs to understand the health risks involved. The risks can be either voluntary or one can be exposed to them involuntarily. The interviews established the health risks faced by the women as well as their coping skills. Taking these risks into consideration I examined the health promoting measures implemented in the community physically, socially, financially and spiritually. 2.3 Previous research UNICEF`s (United Nations Children`s Fund) research, The State of The World’s Children 2010, mentions that women’s health has a great impact on children. In a study to improve the health care outreach in villages carried out in the SouthEast Asia region by the World Health Organization, it was shown that after three years of teaching women about nutrition and maternal diet, there was a remarkable improvement in the mother’s knowledge of nutrition. As a result, there was a reduction in both maternal and infant mortalities. This shows that educating women is for the good of a whole community. The community should educate women in matters concerning health in order to achieve a longer sustainability of the community`s health. According to UNICEF, the solution to the growing rate of child and maternal mortality is improving health and nutrition of pregnant and young women. This can be achieved by providing quality reproductive health services to women. (UNICEF, 2009.) The African woman and girl child have a great disadvantage compared the women and girls in the western societies in matters concerning health. A re- 11 search carried out by Jonna Roos states that the average life expectancy of an African woman is fifty years at its best. This life expectancy continues to deteriorate due to diseases and high infant mortality rates. In the rural areas, the research showed that the low life expectancy is due to poor access to medicine and medical services as. Poverty also has a major impact on the low life expectancy. The research also showed that younger women have a higher risk of dying from complications during birth. The African woman’s, cultural and religious beliefs and practices as well as the women’s rights and position in the society also contribute to the high mortality rate. (Roos & Kekäläinen 2006, 11−13.) The World Health Organization’s fact sheet number 134 published in 2003 states that eighty percent of the population in Africa still uses traditional medicine either as a first choice or to support western medicine in treating diseases. Traditional medicine men treat the patients as a whole taking into account the person’s spiritual and social surroundings as well. The African women’s rights concerning their sexuality and sexual health are in most cases dependent on their level of education and the society in which they live. Research shows that about half of eighteen year old women in Africa are married and a third of them are in polygamous marriages. The same research also shows that twenty percent of the women’s health problems are related to poor sexual health. (WHO 2003.) One of the biggest gynecological problems faced by these women according to the World Health Organization is fistula. Fistula is a nerve damage suffered by women during childbirth that causes inability to retain urine and excrete. These women are then isolated from the society due to the foul smell which leads to psychological, social and financial problems. Statistics also show that over half of the HIV positive persons in Africa are women. The death rate from abortion among the African women is established as one in 150 (Roos & Kekäläinen 2006, 15−18.) 12 3 KENYA Kenya is situated in the eastern part of Africa with Nairobi city as its capital. It shares boarders with Ethiopia, Somalia, Sudan, Tanzania and Uganda. The country has 53 580,367 km2 in total surface area, of which 569,140km2 consists of land and 11,227km2 is water. The Great Rift Valley located in Central and Western Kenya contains three of Africa’s highest mountains, Mount Kenya, Mount Elgon and Kilimanjaro (Finlay, Fitzpatrick, Fletcher & Ray 2000, 123.) The equator divides the country almost in half the lowest point of the country being the Indian Ocean at sea level and the highest point is the Mount Kenya at 5,199 meters above sea level. Wildlife is a very important resource in the country and for that reason the country has numerous parks and wildlife reserve centers. (Finlay, Fitzpatrick, Fletcher & Ray 2000, 123−127.) Kenya is a republic that gained its independence on 12th December 1963 from the British colonialists. The governing organ consists of the President, the prime minister, the Cabinet and the Parliament, the Judiciary and Courts and the Judicial and Public Service Commission. Executive power is held by the President, prime minister and Cabinet (Briggs & Williams 2011, 18.) To be elected as a member of parliament, one must be a Kenya citizen above 18 years of age and must be registered as a voter. For administration purposes Kenya is divided into eight provinces which are further on divided into districts and sub-districts. Elections are held every five years and one must be 18 years of age to be able to vote. Although Kenya is a democracy, politics is still very much based on ethnicity meaning that people tend to vote for those with who 13 come from the same ethnic group as themselves. (Finlay, Fitzpatrick, Fletcher & Ray 2000, 127−128.) Kenya’s educational system is based on the 8-4-4 system that was introduced in 1985. Based on this system, primary education is completed in eight years. The government run primary schools are free but the country has a lot of private owned primary schools that charge school fees for their services (The Kenya ministry of education, 2011.) The government declared free primary education in 2003. However, this proved to be impossible to implement due to the great number of students (Wajibu n.d, issue 20.) Education is expensive in Kenya with boarding schools charging a recommended fee of Ksh.18, 627 per year at maximum of which the government provides Ksh. 10,265 per student. Despite this recommendation, some schools still charge ksh. 50,000 and top national and provincial schools charge as much as ksh. 73,600. These expenses exclude books and uniforms. (Ayodo & Too 2010.) Kenya’s health care system The ministry of health The Kenya ministry of health has two ministers. The ministry`s functions are among others the formation and implementation of health policies, sanitation policies, policies concerning the prevention of diseases and promotion of health. The ministry is also in charge of the registration of health care personnel (The Kenyan government, n.d.) 14 Kenya’s health care system consists of different health care facilities such as dispensaries, private clinics, health centers, sub-district hospitals, nursing homes, district hospitals, private hospitals, provincial hospitals and national hospitals. Dispensaries are basic health care facilities in the country. They are run by the government and managed by registered nurses who are supervised by nursing officers at health centers. They supply the very basic care like maternity care, immunization and family planning. They also give advice and education concerning child care and preventive health care. The more challenging ailments that require complex procedures are referred to health centers. There are also private clinics operating in the country. These are small self-owned and sometimes self-contained medical facilities which offer a wide range of services depending on the training of the staff. The requirement needed for one to establish a private clinic is usually ten years of medical experience. (The ministry of health n.d.) Health care centers are medium sized facilities that are meant to cater for the needs of a population of up to 80 000 though in reality the population covered is usually much higher due to lack of facilities. Most of them are government owned but a few are owned by mission hospitals. The typical staff includes at least one clinical officer who acts as the team leader and to whom the rest of the staff reports to except public health officers and technicians who report to the district public health officer. Health centers provide a wide range of services. Well-equipped health centers have an outpatient department, inpatient wing that includes admission wards, laboratory, a pharmacy and a minor theatre. Here the community gets a wide range of health care services including preventive care, maternal care, and primary care. Sub-district hospitals are very similar to health centers but they have an additional surgical unit and a wider range of surgical facilities. Nursing homes are very similar to these but are usually not 15 government owned but individually owned or owned by churches and other organizations. (The ministry of health n.d.) Each district has a district hospital. These are much bigger and have a wider range of facilities than the latter. They provide similar services as sub district hospitals but in a wider scale and to a bigger population thus the whole district. Kenya has eight provincial hospitals, one in each province, that are equipped with intensive care units and other life support capabilities. The provincial hospitals have experts and equipment to provide adequate health care to the members of its province. The most advanced health care facility in the country is the national hospital of which Kenya has two: Moi Teaching and Referral Hospital (MTRH) and Kenyatta National Hospital (KNH). These two hospitals serve the country as referral hospitals and provide the most advanced level of care to patients. Even though modern medicine is practiced widely in the country, traditional medicine is still very much present in the society. Local medicine men still provide home remedies to simple ailments and healing services to those who cannot afford medical expences. (the kenya government n.d). 3.1 Kenya’s socio-economic status The population in Kenya at the moment is about 40 million which is an alarming growth compared to the 9 million people that inhabited the country when it gained independence in 1963. According to the National Census conducted in Kenya in August 2009, the population in Kenya grows by 1 million people every year meaning that for example by the year 2029, the population will be almost 70 million. This makes the alarming population growth one of Kenya’s biggest challenges. (Ulkoasianministeriön julkaisu, 2010.) 16 The census that was carried out by 130,000 people revealed that the average Kenyan woman has an average of 4.6 children apart from Nairobi where the count was an average of 2,8 children per woman. The average life expectancy is 54 years and birthrate is 39 children for every 1000 people. Another discovery made by the census is that an alarming 60% of the population consists of people 25 years of age or less. (Ulkoasianministeriön julkaisu, 2010.) The census also showed that Kenya has a total of 42 tribes or ethnic groups. The largest ethnic group is the Kikuyu with 6, 6 million, followed by Luhya with 5, 3 million then third comes the Kalenjin with 4, 9 million and fourth is Luo with 4 million people. 67% of Kenyans live in the rural areas and 33% in urban areas. 1 million more women than men live in the rural areas which conclude that men tend to migrate to the cities to look for work to be able to support their families while the wives stay behind to take care of the children. This is proven by Nairobi which has 100,000 more men than women. However, the country has 200,000 more women than men. (Ulkoasianministeriön julkaisu, 2010.) The census also showed a positive direction in the level of education in the country. The result showed that 14 million Kenyans are at the moment attending some form of education. About 6 million people have never attended any form of school and 2 million children between the age of 6 and 13 are not attending school at the moment. Of all the students in the country, 7, 3 million are male and 6, 8 million are female. (Ulkoasianministeriön julkaisu, 2010.) Kenya however still has a long way to go in matters of sanitation and clean water distribution in the country which is still very weak. A third of the population gets clean water from wells and springs and 25% from rivers and lakes. Only 30% of the population have clean tapped water reveals the census. This varies very much depending on the different areas. In Nairobi, 75% get tapped water 17 while in Western province and Nyanza province situated on the shores of Lake Victoria only 10% have tapped water. Only 7, 7% of the population has proper sanitation of which about 50% live in Nairobi. 0, 5% of people in North-Eastern province have sanitation facilities while in Nyanza and Western provinces the number is 1%. (Ulkoasianministeriön julkaisu, 2010.) It was discovered that in 75% of homes, people use latrines and 14% do not even have latrines and instead use “bushes” to dispose of their wastes. Of all diseases causing deaths in Kenya, 30% are caused by poor water and sanitation facilities. These are diseases such as diarrhea and cholera. Technology is also developing fast in Kenya. 74% of homes were shown to have radios, 28% television, 63% have cell phones (Ulkoasianministeriön julkaisu, 2010.) and 0, 5% have computers. 18 4 THE LUO COMMUNITY 4.1 Historical background The Luo community inhabits the Nyanza province of Kenya situated on the shores of the Lake Victoria with Kisumu town as its headquarters with a population of 400,000 people. The community has a population of 4 million people and is the fourth largest ethnic group in the country. The community leaders expressed their worries about the growth of the community after losing its status as the second largest ethnic group to Luhya and Kalenjin in the census. The Luo tribe is a big tribe consisting of 25 sub-groups not only found in Kenya but in the neighboring countries of Tanzania, Sudan and Uganda as well. These sub-groups are composed of several clans and sub clans. Because their home is located on the shores of Lake Victoria, their traditional occupation is fishing but they practice agriculture and pastoral herding as well. (Finlay, Fitzpatrick, Fletcher & Ray 2000, 38−39.) The Luo tribe descends from the pre-colonial communities of western Kenya. The people and the language is said to have ancestry from powerful families of chiefs whose clans married several wives and produced multitudes of heirs to the chieftains. Due to these intermarriages and as an outcome of wars, the Luos are a genetic mixture of consisting of modern East African ethnic groups, the Buganda, the Bunyoro, the Toro and the Nubians. They also settled and interacted with neighbors such as the Nandi, Luhya, Kipsigis and Kisii which resulted in a mixture of cultural practices and ideals. The Kenyan luos migrated into western Kenya through Uganda around 1500 AD in different waves, arriving at different times. By 1840, the Luo had formed a society led by regional chiefs called ruodhi. 19 In 1915 the colonial government sent the then Ruodh of Gem to Kampala in Uganda where he discovered the British settlement there and was impressed. He then decided on his return to adopt the western style of life among his people and thus begun the education of the community in the English way of life. They then used their education to advance the independence of Kenya. (Ogot, 1967.) 4.2 Culture and customs Among the religious culture of the Luo is the strong belief in an afterlife and a supreme being referred to as Nyasaye. The Luo also still maintain a strong ancestral cult despite the fact that most Luos are today of Christian religion. In the past, the lives of the society members revolved around a series of rituals. After birth and before the age of two, one had to go through a ritual called Juogi meaning a naming ceremony. However, unlike many communities in Kenya, the Luo did not practice circumcision. Instead, the initiation into adulthood meant the removal of children’s six lower teeth. Because of its brutality, this ritual is nowadays rarely practiced. (Obere, 2002.) Marriage customs and practices have evolved from bride stealing to matchmakers and in this day, marriage is very much westernized. However the giving of dowry referred to as Ayie is still commonly practiced in the society. Ayie involves giving money to the mother of the bride and herds of cattle to the father of the bride as a sign of appreciation. It is customary for the bride to then move out of her home and live with the groom and his family. One of the traditional marriage customs that is not so often practiced today due to HIV is wife inheritance. It was customary that if one’s husband died, the groom`s brother stepped up and took his place thus inherited his wife. Polygamy was also very 20 common in the Luo society derived from their ancestors. One was allowed to marry up to five wives provided he can take care of his wives and children. Though society has not disowned this practice, it seems to be slowly eradicating due to poverty and westernization. (Obere, 2002.) Music has always played a very important role in the Luo society. Music is still used in ceremonies. Music is performed in different ceremonies of political, religious or incidental importance. Ceremonial music is till today played in funerals to praise the departed, console the bereaved and to keep people awake while grieving with the family of the departed. During dance performances, the Luo dress in traditional costumes made from locally available materials. (Obere, 2002.) 21 5 THE RESEARCH ENVIRONMENT Omboga Jo-Karachuonyo (the people of Rachuonyo) was among the first tribes to migrate from Acholiland and settled along the Lake Victoria like the people of Omboga. While collecting data, I had the privilege of living among the Luo in Omboga for a period of three months. During this period, I made observations concerning the conditions under which they live and how they go about their daily lives in relation to each other. The population is estimated to be around one thousand people. The people of Omboga practiced fishing in the past. However, due to climate change farming is today their main economic activity. Crops grown in the area are mainly maize and groundnuts. Apart from farming, livestock keeping is also a major economic activity. Despite the fact that the village is situated close to the lake, Omboga experiences long spells of dry seasons which make it difficult for the local people to cultivate land and breed their livestock. They attribute this to climate change and lack of irrigation systems. The poor nutrition is also attributed to the low population of fish in the Lake Victoria due to over fishing and the presence of the hyacinth plant that covers the surface of the lake. Omboga is a small village that consists of a marketplace, a small dispensary, a secondary school, two primary schools, a nursery school, a church, the chief`s office and residential homes. The marketplace in Omboga has of a few shops that sell basic items, a few restaurants where one can buy something to eat and drink, a pharmacy where the locals can buy over the counter medicine, some few tailoring shops, a poshomill where they go to grind maize into flour for making porridge, a bar, a butchery where meat is sold once a week and small stalls where vegetables are sold. The nearest trade center to the community is a 22 small but fairly developing town called Oyugis. This is where the business men and women of Omboga go to sell and purchase goods and services. Oyugis is about 35 kilometers north of Omboga. The lack of proper roads makes transportation very difficult and unreliable. Public transportation to Oyugis is available during market days which are on Tuesdays and Fridays. To travel to Oyugis on other days, there are motorbikes or bicycles that can be boarded for a fee of 300ksh (2,50e) from the market center at Omboga. Omboga does not have electricity, running tap water or constructed roads. Another challenge facing Omboga is lack of drinking water. Women fetch water from boreholes and a nearby river only for domestic use because the water is not clean enough to drink. Water from the borehole is too salty and can only be used for cooking. During the dry seasons, water from the river is either boiled or treated to serve as drinking water. During rainy seasons, drinking water is obtained from rain. 5.1 Health care facilities The community can get access to other essential services like health care from Oyugis. Omboga has a dispensary, a small building in the outskirts of the market place, which is meant to provide basic health care however it does not function as desired. The dispensary opens only once a week due to lack of staff. There are no doctors available whatsoever at the dispensary. A nurse, the only medical personnel available, comes to give first aid and disperse medicine to those who need it urgently. 23 The dispensary has a waiting room equipped with a few benches, a reception room where volunteers acquire basic information on the patients concerning their ailments and medical history as well as make the decisions on whether the patient needs to be examined by the nurse or not. The nurse`s office is equipped with a stethoscope, a draw of medicines that can be used to treat basic ailments like coughs, colds and painkillers, basic antibiotics, syringes and needles, some bandages and antiseptic to clean and dress wounds, and a draw for storing different documents. Alice Koima, the dispensary nurse, stated in an interview that all she can do is give the people some first aid and refer them to the nearby district hospital for a proper examination by a doctor. Some of the patients brought to the dispensary are sometimes however very ill thus are not able to take the trip to Oyugis on board a bicycle or motorcycle. She stated that the dispensary is visited by pregnant women who develop complications during their pregnancies. Most of them do not have the money to seek medical attention from the district hospital. According to the nurse, patients suffering from HIV and aids visit the dispensary as well. Some of them are going through the final phases of the disease and suffer from a wide range of ailments. She also gets visits from those who are infected and yet do not want to admit that they have the disease but rather blame it on witchcraft or an act of the devil. She expressed that her frustration concerning how little she can do for these people is overwhelming. (Alice, Koima, personal interview 12.4.2011.) Other medical representatives in the community include the local witchdoctors, medicine men and traditional midwives. Medicine men are self proclaimed healers who learn their skills in traditional medicine from their fore fathers. The traditional midwives are elderly women in the community who are believed to be experienced in childbirth and childcare but are not trained in the profession. 24 5.2 Educational facilities Omboga area has two primary schools, a private nursery school and a secondary school. Nyawino primary school is situated some 7km from the main market place and provides basic education for children from standard one to eight. Omboga primary school borders the market place and gives education from nursery school to class eight. Omboga primary school has the potential to cater for more students but due to the lack of classrooms and teaching staff, most parents prefer to send their children to Nyawino says the head teacher of Omboga, Jacob Odek. According to Odek, the school was once prosperous and plans of expanding the school and building permanent structures for the students to learn in had been made. Due to lack of funds the project was abandoned and the remaining structures pose a health hazard to the students due to their poor conditions. The students are however very committed to studying and sometimes classes are conducted under trees whenever the weather allows. (Jacob,Odek, personal interview 5.3.2011). Omboga secondary school is the only institution that provides education after primary school in the area. The school has few structures and lack in essential structures such as a library and laboratory according to the head teacher Dennish Ochieng. Due to the small capacity of students that the school can entertain, most children in Omboga do not get a chance at secondary school education. This has lead to a high number of primary school drop outs. With no professional schools available, the drop outs have to help out in the farms at home or start small businesses for example selling vegetables in stalls at the marketplace. Another challenge is the ability to keep students in school due to lack of funds. Most parents in the area cannot afford to pay school fees for their chil- 25 dren. This leads to students sometimes foregoing a semester or two before coming back to school. This contributes to the schools poor performance in the national examinations as well as the poor performance of the students individually (Dennish, Ochieng, personal interview 1.3.2011.) 5.3 Law and order About 500m from the market center stands the chief`s office. This is the only representative of law and order in the area. The chief rarely visits however it opens a few times a week. It is the place where villagers come to settle their quarrels as well as hold political gatherings such as rallies and elections. It acts as a courtroom for the villagers and almost all legal matters are settled here without needing proper legal procedures, says Mr. John Ounda, the chief of Omboga. (John,Ounda, personal interview 16.3.2011.) The villagers however rely on each other to keep law and order. Being such a close knit society, there is virtually no crime committed in the village except the occasional wife beating. The village however has a youth task force that deals with unruly youths in the village. They deliver swift justice in form of beatings and community service to youth who do not follow the community rules. (John, Ounda, personal interview 16.3.2011). 26 6 RESEARCH METHODS AND DATA COLLECTION 6.1 Data collection and the research questions The questions I set out to answer in this research are three: 1. To find out how the women in Omboga understand health and how they perceive their own health. 2. To find out what health risks the women face 3. To look into the implementation of health promotion measures in the community and how the community’s actions promote women’s health. In order to answer these questions, I carried out a qualitative research. The data I acquired and used was qualitative and not numerical and thus cannot be attached to any dependencies for example research patterns or nature. (Aaltola & Raine 2007, 159.) This research method is suitable for this particular research because the research aimed at studying these women’s personal observations and experiences concerning their well being as they viewed it. As well as being qualitative, this study is also an ethnographic research which means that the research aims at describing a community. Ethnography is a method of research that obtains data from observations conducted by observing the research subject’s social interactions in a natural environment. (Eskola & Suoranta 1998, 104.) While conducting the research, I lived with the Luo people in Omboga for a period of three months between February and May 2010 during which I observed 27 and documented the women’s daily activities. I achieved this by making observations, documenting events in the form of video material and photographs, participating in cultural events and gatherings as well as conversing with the women. The written material used in this research was collected through means like half structured questionnaires, interviews, observations, documents and statistics. The material is mainly qualitative thus reduced data in the form of written text. (Eskola & Suoranta 1998, 15.) Choosing of the interviewees Before conducting the interviews, I obtained permission to carry out the research from the local authorities. I achieved this by organizing a meeting with the area chief during which I requested his permission to carry out the research. I provided him with information concerning Finland as whole as well as the institution and the degree program of which I am a student. I also informed him on the purpose of the study, the methods I would be using to carry out the research and the time frame in which the study would be conducted. I also presented him with a copy of the research questions for his approval. We briefly discussed the current state of the community and challenges faced by the women in the community during which I had a chance to conduct a short informal interview concerning the research. After obtaining permission to conduct my research, I carried out a small scale test to find out whether the interview questions were clear and understandable to the interviewees and if the questions would satisfactorily answer the research questions. To do this I interviewed four randomly chosen women in the community using the questionnaires and analyzed their responses. I then made a few changes to the questionnaires and printed them out ready for the interviews. 28 I then approached the women after the church service and explained to them why and how I would carry out the research. I chose volunteers using various criteria the first of which was literacy. Since not all women in the community are educated, I selected those who could read and write in English. The other criterion was occupation because I needed women from different backgrounds, social standings and age groups. I selected thirty women to be interviewed based on these criteria and together we set a suitable date for the interview. The women I selected ranged in age between sixteen to fifty eight years of age. I also verbally interviewed two older women in the society who could not read or write. Occupation wise, they represented students, the unemployed, housewives, teachers, business women and a veterinary doctor. To make sure that the turn up would be satisfactory on the day of the interview, I organized food and drinks to the venue for participants. The interviews were carried out at the market place in a restaurant rented for this purpose. Twenty seven women out of the chosen thirty attended the occasion and were interviewed using the questioners. The interviews were conducted as individual interviews. Besides the questioners, short interviews were also carried out with some key figures in the society such as the dispensary nurse, primary- and secondary school head teachers, the area chief and two older women who could not read or write. The interview questions were based on Leninger`s culture care theory and the sunrise model. I used only the top half of the sunrise model in this study as a guide and a mind map. The figure below depicts the top half of Leininger`s culture care theory’s sunrise model. 29 DIAGRAM.1 The top half of Leininger`s sunrise model to depict the theory ofculture care diversity. (Leininger 1995, 108.) 30 6.2 Data analysis Being that the material used in this research was of a wide variety, it required different methods of analysis in order to obtain the required research results. One of the data analysis methods used in this research is content analysis through which the data was reduced. (Eskola & Suoranta 1998, 182.) The goal of data analysis is to find the research’s basic dimensions that represent or describe the research subject and through which a reliable conclusion can be drawn. (Aaltola & Raine 2007, 80.) Being that some of the data was obtained by listening to conversations, another analysis method I used in this study was narrative analysis. Narrative analysis does not focus on the categorizing of data but rather configures a new point of view based on the data that brings forth the central themes of the data. This is basically focused on producing a cohesive “story” which is commonly found in ethnographies. These usually consist of among others the production of research text based on the interaction between the researcher and the subject. (Aaltola & Raine 2007, 148−150.) I found this method of analysis necessary because some of the research material is based on my own observations and interaction with the environment as well as the research subjects. 6.3 Research ethics When carrying out this research, I carefully examined and took into account my personal background and close ties to the community and how this may affect or manipulate the research. The first matter of concern was in regards to my 31 relationship to the research community. Being a member of the community in question, I examined my pre conceived notions and my ability to set them aside in order to carry out a well balanced and credible research. I also took into account my relationship with the interviewees. In order to ensure that the results would be as honest as possible, I avoided interviewing close family members and friends. Another ethical matter was the question of whether the information and knowledge I had acquired all through my childhood about the community would affect the research. All through the research process, I constantly examined the information acquired objectively and avoided making assumptions based on my personal knowledge. I also took into account the fact that the research process may bring fourth some unwanted truths about the community and mixed emotions concerning my own personal identity. I was concerned about portraying the community in a just and fair manner. Being a member of this community, I wondered whether I was portraying the community as the interviewees viewed it or as I myself viewed it. Was I in my work being too critical? While I recognized that to some extent my personal views in some issues completely differed from those of the interviewees, I however took steps to express their views rather than impose my own. The interviewees were treated with respect throughout the research process. The fact that I was able to answer their questions in a language they could fully understand gave the interviewees assurance and confidence. Based on the results of this study and the positive feedback I received from the interviewees, I conclude that the credibility of this research was not compromised at any point and therefore the results obtained are accurate. 32 7 RESEARCH FINDINGS 7.1 Technological factors and their influence on the women`s health The art of pottery, ceramic and the household ceramic industry has been practiced by the Luo for many generations. This has resulted into the development of unique and different styles of manufacturing ceramic for household use (Dietler & Herbich, 2010.) Technology has however advanced since then. Is there any technological advancement among the Luo community of Omboga and how do these technological advancements or lack of technological advancements affect the women`s everyday life? For example do they have access to media, books, libraries or computers to assist the women in obtaining current information concerning health promotion? Without electricity, roads and running water, how do these women go about their day to day lives? From observation, lack of technology in the area has had a great impact on the availability and implementation of health care services to the women of Omboga. The health center has no electricity therefore the only apparatus available is manual and outdated. This makes even the simple procedures that could be done in the health center almost impossible to carry out since there is no means of sterilization. The women therefore have to rely on the district hospitals for almost all basic care. The district hospitals are overcrowded and hard to reach due to the lack of a functional transportation system. Most of the women therefore neglect to seek medical attention on minor illnesses until these develop into life threatening medical problems. 33 Lack of technology affects the availability of preventive care in Omboga as well. The unpredictable public transport, difficult roads, the hot humid weather and lack of refrigeration at the health center makes it impossible to transport or store medicines and vaccines. On occasion vaccination campaigns are carried out and mass vaccination is conducted in the area. However, women and children have to travel to the district hospitals for vaccines. The research shows that because the area lacks in maternal services and gynecological health services, the women rely on each other for education on preventive health care. On occasion they contact the nurse at the health center on matters that they do not understand. The interviews conducted revealed that the participants consider technology very important not only in health care but also in obtaining information in matters concerning welfare. They attributed the lack of employment and awareness to lack of technology since without proper technology they are unable to access work opportunities in nearby towns. The participants find it hard to obtain information on current affairs. The students interviewed attributed their poor educational performances to lack of technology. The young generation expressed that they only have their school text books to rely on for information which does not give them an opportunity to criticize their sources. They argued that the information available to them is neither diverse nor argumentative. The least important role of technology according to the participants was considered to be entertainment. The participants agreed that technological advancement in the area is very minimal and that without technology, they cannot achieve their goals for better health. They feel that other nearby tribes are better developed mainly because they have access to electricity. The participants concluded that the most important advancement that the women need is electricity. This would grant them access to refrigeration systems which in turn would boost their economical well being, improve their communication and learning possibilities. 34 The interviewed students also believe that electricity would enable the schools to provide tuition to students after dark. They considered oil lamps that are currently used to be a poor source of light as well as an expensive option. They believe that the main reason why schools in the cities perform better than those in the village is because they have electricity and are able to study longer and access information better. Even though these women value technology, they do not depend upon modern technology to be able to function in the community. 7.2 Religious and philosophical factors influencing the women`s health Health and religion are closely linked in the Luo society. Religion is considered to be a way of life and not confined to worship. The African societies believe in God or a supreme being who is approached through ancestors, spirits or worship depending on one`s denomination. In illness or if one encounter`s problems, they pray or turn to their religion or spiritual beliefs. This is common in case an illness is not responding to modern treatments. (Leininger 1995, 593−594.) The important role of religion and spirituality in the lives of the participants was very clear. The village has one Christian church and a few different smaller denominations. Majority of the villagers are members of the Seventh Day Adventist Church and attend prayers in the church every Saturday. Saturday is also a day deemed for resting in the village. Most families prepare meals beforehand so that they do not have to make food on Saturday. After worship the villagers spend the rest of the day lazing around under trees or visiting with friends and family. 35 The participants have a strong belief in God, heaven and the afterlife. They believe that God protects them from evil and delivers them from suffering. A positive effect of religion is that it is seen as a unifying force in the community. It gives them a sense of belonging and hope in times of hardship. The weekly religious gatherings gives the villagers a chance to interact with each other, meet with the elderly members of the community as well as a platform to share their problems or triumphs with the rest of the village. Religion governs and controls the women’s decisions and actions. It also guides them women and the youth morally. The participants believe that a strong faith is the key to good health. In the past, the Luo people have had strong beliefs in ancestral spirits and witchcraft but today due to the presence of the Adventist church, these beliefs are slowly fading into the past. Even though they have a strong faith in God and the church, in the background there still is a silent belief in these ancestral spirits that can be noticed in conversations. Traditional practices that used to be carried out before the introduction of Christianity are very rarely carried out in the community by those who believe in Christianity according to the women. It became clear that immorality is not accepted by the participants and moral values are of great importance. Fornication, adultery, and sexual misconduct are considered to be very shameful acts not only to whoever commits them but to the village as a whole. This However, contradicts with certain traditional customs that one may consider immoral for instance wife inheritance. The participants` opinion was divided as to whether this practice is immoral or important. The participants also believe strongly in togetherness and assisting one another. Women believe that their strength lies in working together towards a common goal. The village women have formed several different small self-help groups. These women`s groups raise money and venture into different business ideas. On occasion the money is used to help group members who are experi- 36 encing financial difficulty in the form of loans to be returned at an agreed date with interest. 7.3 Kinship and social factors and their influences to the women`s health Kinship ties, relations and social structures play a very important role to the women of Omboga. The luo people have in the past practiced polygamy which resulted in the creation of large families. While conducting the research, I observed that family ties and kinship plays a very important role at the core of the Luo people’s values. During a conversation with one of the village’s elderly women in a polygamous marriage, she revealed that it has been difficult coexisting with the other wives. Being one of four wives and her being the second wife, she has had to set aside her emotions and to learn to pull together with the other wives in order to avoid quarrel. In the Luo polygamous families, homesteads are built close to each other to allow all the family members to participate in taking care of the elderly as well as the young. Division of labor is important in these families. The participants attributed the harmonious co-existence within these large family settings to mutual respect as well as respect for their elders. The youth believe that harmony is maintained by obedience to God and their parents. Polygamy is today rare in the community due to the fear of disease and imposed laws. However, the same practice of sharing labor and responsibility is still a great driving force the community. The participants considered their kin and social friends to be like a big family that collectively form a social safety network. The women rely on this safety network in times of hardship or illness. 37 7.4 Cultural values and beliefs influencing the women`s health Cultural values are peoples’ acceptable way of life. The African lifestyle consists of ceremonies, customs and rituals for every step of the human life. There are cultural beliefs, practices and taboos that are closely observed by African communities. Some have been abandoned as superstition and failure to observe these taboos could affect the whole person physically, psychologically and relationship wise. (Leininger 1995, 593−594.) The Luo have a very rich culture and are very proud of their cultural background. Cultural values are usually embedded in song, poetry and myths passed down from generation to generation. Due to the rich cultural background of the Luo, many cultural beliefs and practices emerged in the interviews that were considered important because of their roots in the community. However all the participants considered some of these practices old fashioned. One of these cultural practices is considered to be nagi which is equivalent to male circumcision. While most of the tribes in Kenya practice circumcision of either sex, the Luo`s male passage to adulthood requires the removal of either four or six lower teeth. (Finlay, Fitzpatrick, Fletcher & Ray 2000, 38−39.) The participants agreed that the practice of nagi is brutal and should not be allowed to take place in the community. Other cultural practices opposed by the participants due to the health risks they impose included the practice of dowry payment, widow cleansing and wife inheritance. Dowry or ayie is the bride price paid to a woman`s parents by her suitor as a token for raisin the bride to be. This is usually in the form of livestock or money. The participants expressed that this practice gives men the right to exercise domestic abuse either physically or psychologically. Despite the fact 38 that the participants recognized the health risk imposed by this practice, they considered it to be of great cultural importance. The practice of widow cleansing is slowly being eradicated in the Luo society. Widow cleansing meant that a widow would have unprotected sex with either a member of the society or a hired cleanser in order to release her dead husband’s spirit to roam into the afterlife. The hired cleansers are men who are hired to go from village to village having sex with newly widowed women for a set price usually given in form of cows (Robson, 2009.) The participants were convinced that this practice was no longer carried out in this village because of the fear of AIDS. Wife inheritance or tero however is still present in the community. When one`s husband dies, the deceased man’s wife is passed on to his brother as an inheritance. The participants recognized the health risks involved in this practice especially considering that the diseased might have had HIV or AIDS. When asked if they themselves would consider getting involved in these practices, the participants responded that they would not consider because they now know the dangers involved. In an attempt to find out more about the effects that these practices have had on the women`s health, the subject of conversation was quickly diverted to other practices. Taboo poses a great health risk according to the youth interviewed. Matters such as sex and sexuality are not to be discussed openly. Because of this, the youth learn about sex from each other or school textbooks which sometimes lead to them obtaining misguided information. Traditional medicine and medicine men still has a great impact to the community. Despite the belief in God, the women expressed that there are some diseases that modern medicine cannot cure and for these they rely on traditional medicine men for remedies. 39 7.5 Political and legal factors affecting the women`s health The participants expressed their pride in the Luo community’s political achievements. Many leaders have emerged from the Luo community and many continue to emerge. The women consider their role in community politics to be in the background organizing elections, counting votes or preparing meals at political gatherings. Despite this, they believe that women are better suited to run the community since they are the community mothers and therefore, they know what is best. They however agreed that women are not taken seriously by men within the community. The participants believe that they are content by exercising their voting rights and advising their men on matters concerning politics. Maintaining law and order is also a task for the men in the community. The participants pointed out that most of the law breakers in the community tend to be young men and so they require their fellow men to give them good examples and straighten them out. They feel that their role as mothers is to teach their children the difference between right and wrong not only concerning morals and values but also concerning law and order. 7.6 Economic factors and their impact on the women`s health The participants came from a wide range of different financial backgrounds. Their professions ranged from primary school teachers to veterinary doctors, kiosk owners and fruit and vegetable vendors. Most of them however grew foodstuff like maize, beans, peanuts and vegetables for their own consumption. This reduces the cost of living. They believe that money means a better health for the women and so they rely on themselves rather than the men to obtain money for their own use. They achieve this through the women groups. 40 In the interviews, health care and education emerged as one of the most important needs for money. Without money, one cannot get proper healthcare or education. The participants expressed their concern that most families are not able to send their children to school due to lack of money. Food and clothing were also considered by the women to be important to health. Even though the women grow most of the foodstuff, milk, sugar, salt and many other necessities require money. They expressed their concern that climate change has greatly affected food production. Today, long spells of draught and floods from heavy rainfall destroy their crops and render them helpless. The participants stated that men control the family finances and decide on how family revenue is spent. They however, have a fair say in the decisions made concerning the family’s well being. According to the women, the largest area in which family funds are spent is considered to be education followed by health care. They stated that nowadays women contribute just as much as men and therefore, they also get to participate in making the decisions on how money is spent in the household. Because of poverty and the fact that men make the final decisions, women`s health and health promotion is not made into a priority according to the women. 7.7 Educational factors The Luo people take pride in being one of the most intelligent tribes in Africa and attribute this intelligence to their genes. (Grigorenko, Wenzel, Geissler, Prince, Okatcha, Nokes, Kenny, Bundy & Sternberg 2010, 367−378.) The educational structure of Omboga area is very limiting in that the area does not provide for further education after secondary education. While the Luo people pride themselves in being the most educated clan in Kenya, education does not come 41 cheap. However, the importance of education is very much emphasized in the community. The average level of education of the participants was secondary education. Despite the introduction of western education, traditional education is also still practiced in the village. Young women are educated by the elderly on how to be good wives and mothers. Young women are taught the importance of moral values, obedience as well as survival skills. The participants expressed their desire to further their education in order to achieve their goals. The students interviewed attributed the poor educational level to lack of proper facilities and poverty. Lack of electricity, computers, libraries, school text books, laboratories and qualified teaching personnel has contributed to the high illiteracy level of the area. Numerous chores and responsibility makes it difficult for the students to study outside of the classrooms according to the students interviewed. It became clear that the level of education has had a big impact on the women’s understanding of health care especially sexual health. Even though sex is kind of a taboo topic in the community, the younger generation are well informed and more willing to discuss the topic compared to the older women who cannot read or write. 7.8 Environmental factors and how they influence the women`s health The Luo of Omboga live in a very close and tightly knit environment in regards to family and kin. The homes are very modest usually made from mud and 42 grass. The prosperous families however have more permanent housing. The living conditions in the village are harsh. The area lacks proper sanitation facilities, food, water and contact with the outside world. However, the women are dedicated to working hard to improve their living conditions. They make the best use of what they have and improvise on what they don’t have. The village is situated close to Lake Victoria which in itself poses a health hazard. The presence of malaria has contributed to the increase in the mortality rate of the area. Despite the devastating effects of malaria, the dsease is still perceived as a mild everyday illness that is easily treatable using over-the counter drugs. Anti-malarial medicine is rarely used by the local people as a preventive measure and severe malarial symptoms such as convulsions are not linked to malaria by the locals (Mwenesi, Harpham &Snow 2009, 1271−1277.) The Kenya Red Cross Society has however made an effort in helping the community combat this problem. In the past, malaria campaigns have been organized in Omboga aimed at educating the community on ways to prevent malaria, signs and symptoms of malaria as well as early treatment and first aid. The community has been educated on the dangers and causes malaria as well as preventive measures. Mosquito nets have been provided and the community has been instructed on their proper use in order to prevent the onset of the disease. The participants believe that climate change has had a devastating effect on the area. The area experiences exceptionally long spells of draught as well as heavy downfalls of rain during the rainy seasons. This sudden change of climate has rendered the women helpless. Spells of draught destroy their crops and make it difficult to find water for domestic use. On the other hand, the heavy downfalls sweep away their crops as well as their houses sometimes rendering them homeless. 43 Language plays an important role in this society. Despite their rich language, the women interviewed felt that their ability to communicate and interact with the outside world is limited because of illiteracy and minimal knowledge of other languages. They believe that with the knowledge of common languages such as English and Kiswahili, they would be better equipped to carry out trade with other communities. The participants also thought that their ethno historical background has contributed a great deal to their ability to prosper despite the hardships they face. Because of the honesty, wit, and coping abilities believed to be possessed by the Luo, they are able to sustain themselves and bring development to the clan given the necessary resources. 7.9 Health promotion in Omboga with regards to the research questions How the women perceive their health The women of Omboga describe the status of their health as satisfactory. Through the numerous conversations I carried out with the women, it became apparent that the women considered the relevance of health to be limited to the physical aspect of health. The general view on health is that the absence of disease means good health. The women that were free from disease described themselves as having good health while those who had some form of illness described themselves as having poor health. Most of the women viewed sexual health as not being an essential part of health since the general understanding of sexual health is that it is only relevant to those with multiple partners. Young women are taught that good sexual health means complete abstinence from sex until marriage. 44 The women linked financial health to holistic health in that without money they could not get health services. Those who are financially stable do not however consider themselves healthier than those without money but rather lucky to be able to receive medical attention. Social health however was not considered by the women as being a component of health but rather as the normal life in general at the village. Spiritual health however is considered to be the most important component of health. The participants explained that without a strong faith, one may not be able to overcome even the mildest of ailments. This is proven by the fact that some illnesses such as mental problems are viewed in the society as being caused by spirits, curses or demons. The cure for mental problems is therefore the breaking of the curse or getting rid of the demons. In sickness, the women turn to spirituality for guidance and help alongside modern medicine. The people believe in spiritual healing and miracles that cannot be understood or explained by modern medicine. It`s a common belief that modern medicine cures but only God has the power to heal. Health risks faced by the women The women living in Omboga face many health risks daily. Some of these risks are voluntary while others are involuntary. Some of the risks are necessary risks meaning that their advantages to the women are greater than the risks that they impose to their health. Involuntary risks are risks that are impossible for an individual to eliminate (Vertio 2003, 57.) One such risk is the risk imposed by the environment in which the women live. The ever changing climate of the area exposes the women to long spells of draught during which water is scares. During these dry spells women travel long distances to fetch water for domestic use several times a day since this is regarded as a woman`s job. Besides the dry seasons, the rainy seasons impose health risks as well. Improper roofing in most homesteads allows water into houses. The wet living environment in turn causes the outbreak of pneumonia and respiratory problems to both the children and their mothers. Water also clogs in pads near houses which serve as 45 ideal breeding place for mosquitoes. These in turn causes diseases like malaria and diarrhea. For the less prosperous, their houses are sometimes swept off by the rains rendering them homeless. The climate change has also weakened the economic health of the women. Food is limited and the environment makes it difficult for the women to grow their own. The community`s beliefs and practices pose a great risk to the women`s sexual health. Practices such wife inheritance, widow cleansing and polygamy contribute to the spread of sexually transmitted diseases. According to the participants, today most widows choose not to re-marry unless a woman desires to continue bearing children. The Luo widow`s status and security in old age is very much dependent on the number of son`s one has which causes pressure on widows to re-marry and produce offspring (Potash 1986, 11.) Ayie or the payment of dowry subjects the women to domestic abuse which can damage the woman`s physical and mental health. Lack of information and education has lead to the women being inadequately educated in issues concerning health. This imposes a health risk as well. This is as an outcome of inadequate health care facilities and personnel in the area. A necessary risk encountered by the women is the use of public transport. The roads are extremely poor and safety is not a priority in public transport. The matatus are usually overcrowded and poorly maintained leading to an increase in the number of road accidents. Those who travel by motorcycles or bicycles do not use helmets or protection gear of any kind. However, in order to obtain food supplies or medical attention, the women have to travel to the nearby town of Oyugis despite the risk of fatal accidents. Pregnancy also poses a health risk to the women. Pregnant women are vulnerable to miscarriages, premature births, medical complications during childbirth and even death due to their living conditions and improper medical attention. Most pregnant women do hard labor in the fields for long hours all through their pregnancy period which increases the chances of maternal and infant mortality. 46 Health promotion in the community Health promotion is an important part of health that needs to be practiced in every community. In the western communities, health promotion is easily practiced and enforced. This is made easy by literacy and availability of necessary material and personnel. In the rural communities of third world countries, promotion of health poses a great challenge. Despite the challenges, the women in Omboga are committed to promoting their health and the community gives them as much support as possible. Other organizations like the Red Cross Society, has played a big role in promoting the health of the women in Omboga. At the community level, the women rely on one another for advice on matters concerning health. The available resources are limited; however, the dispensary nurse gives information and education on health promotion as much as she can. The church also plays a big role in promoting the spiritual health in the community as well as general health. The church summons held every Saturday in the church usually concentrate on taking about taking care of one`s self spiritually, physically and socially as well. The teachings are based on their religious beliefs rather than science. On occasion, the church organizes activities such as fund raisings to help improve the living conditions of some of the poorest members of the community. The Kenya Red Cross Society in association with the government has also arranged health promotion campaigns in the past. The KRCS arranges for immunization campaigns that are aimed at not only vaccinating the children but giving mothers education concerning the importance of vaccination. These campaigns educate women on the dangers of common childhood diseases. 47 Malaria campaigns are conducted depending on availability of funds. During the campaigns the women are educated on the dangers, origin, symptoms, treatment and prevention of malaria. Women are instructed on the correct use and care of mosquito nets as a preventive measure. The campaigns also give general information on health especially HIV which is a common problem. The women are informed on the dangers of the stigmatization of those with the disease as well. The youth also receive information concerning sexual health. KRCS clubs are set up in schools as a forum for young people to discuss and learn about sexuality since the topic is somehow a taboo in the community. Other practical ways that the community has put in place to promote health includes the setting up of boreholes for access to water with the help of well wishers. However, there are only two boreholes in the area which makes it difficult for everyone to be able to access water. The mineral water obtained from these boreholes is also too salty for drinking and too hard for washing so it can only be used for cooking. 48 8 SUMMARY OF RESEARCH FINDINGS Factors that influence the women`s health negatively Technological factors - The health center has out dated and non functional health care apparatus. There is no maternal or gynecological services or proper personnel and therefore the health center cannot adequately care for the women`s health care needs. - The lack of electricity in the area makes it difficult to store medicine and vaccines making it difficult to promote health in the area. - Without electricity the storage of foodstuff and produce is not possible which contributes to poverty and the outbreak of diarrheal diseases. - The lack of technological advances has also lead to ignorance and unawareness of health risks - The lack of proper transportation makes it difficult to access health care services which in turn lead to the inadequate use of health care services. Religion - When it comes to religion, in some cases the belief in God has lead to the one not seeking medical help for their ailments but rather only praying. Treatable diseases therefore go untreated or worsen which may lead to greater health problems or even death. Kinship and social ties 49 - Kinship and social ties also negatively affect the women`s health in that Omboga. Being a small village where everyone is acquainted, the women tend to feel embarrassed about seeking help for sexuality related diseases. - HIV stigmatization is also very present in the society and so the problem is largely ignored. Cultural beliefs and practices - Culture seems to have the most negative consequences on the women`s health. Practices like wife inheritance, widow cleansing and polygamy pose a great threat to the women`s sexual health in terms of the spread of disease. - The fact that it is taboo to talk about one`s sexuality hinders the spread of awareness on this matter. - The payment of dowry also objectifies women which make them vulnerable to domestic violence. - The belief in traditional medicine and medicine men sometimes mean that treatable diseases go untreated due to the primitive nature of traditional medicinal practices. Politics, law and order - The fact that the women are comfortable staying in the background politically leaves the decision making to the men which means that women`s sexual health is not made into a priority for example when assigning the use of family funds. Economic factors - Economical climate change makes it difficult for the women to obtain sufficient food for their families which leads to malnutrition and disease. 50 Educational factors - Poor educational facilities and poverty has contributed to the low level of education in the area. This has lead to lack of information in regards to important health issues such as malaria and HIV. Environmental factors - Environmental challenges such as climate change, poor housing facilities, lack of proper sanitation and water, the presence of diseases and inadequate facilities has also imposed a great deal of health risks to the women. These include malaria and HIV, diarrheal diseases, respiratory diseases and poverty. Factors influencing the women`s health positively Technological factors - One of technology`s greatest positive influence in the women`s lives is the provision of safe drinking water. The area has two bore holes where the women can fetch clean water during the dry seasons. Religion - Religion has acted as moral compass to the young which in turn has had a positive influence in their sexual conduct. - Religion also acts a unifying factor in times of hardship easing the women`s burdens during these times and thus enhancing their psychological and mental health. - The church gives meaningful life sustaining and health promoting summons which enhance health promotion. 51 Kinship and social ties - Togetherness brought on by kinship ties provides a safety network for women to share their concerns as well as share labor and responsibility. Cultural beliefs and practices - While the traditional medicine men pose a negative threat to health, it also is a source of positive influence. Due to poverty, not everyone can afford to seek medical help for minor ailments and therefore they benefit from the traditional remedies that have been used for centuries in the community. Economical factors - When it comes to economical factors, these grow their own foodstuff whenever possible and thus ensure sufficient nutrition for their families. Educational factors - The Luo`s educational strong points include the wit of the Luo people and the women`s interest in learning and evolving. 52 9 CONCLUSIONS Even though gender inequality is an obstacle that they are yet to overcome, they have risen to the same level as the men in that they are equally responsible for developing their society. The women have organized themselves into women`s groups that work together to ensure that the development opportunities available are utilized by all equally and that everybody has a chance to help their families financially as well. They have accepted their place behind the men in matters such as politics and yet they have not left all the decision making to the men but rather act like advisers and in that way get their voices heard. The women have also achieved a great deal in developing themselves and each other. The women of Omboga have come together through these women`s groups and started businesses and other useful projects to help in times of hardship. Their determination to achieve a better life is admirable and a sign of real strength as well as a good example to the future generation of women. Despite their limited resources, they have continued to pursue collective dreams such as proper schools for their children and good maternal health care. They have also achieved peace within their own community. Most of the widows in the community choose not to remarry in order to avoid going head to head with some members of the society in matters such as widow cleansing and wife inheritance. However, the issue of gender inequality in regards to family planning issues is still a great problem. A research conducted among the Luo in South Nyanza concluded that the male partner`s fertility intentions has more effect compared to the female partner`s on whether there is a communication between the spouse in regards to family planning. (Reyner 2000.) 53 Violence towards women is still practiced by some men but the women have not surrendered to their fate. They have found ways to cope and keep peace within the community. They are able to work and live together like one big family. According to western standards, these women`s health is however in a poor state. Intervention and development is needed in order to raise their health standards. Organized campaigns and education sessions facilitated by the KRCS have helped women become aware of their rights in society and get education in ways to improve their health. Education is provided to the women in their own mother tongue using simple language as well as other forms of art including drama and song. The campaigns also bring to the women necessary tools needed to prevent diseases without any cost, for example immunizations and mosquito nets. The impact of westernization has had a positive effect on the women in regards to health promotion. Sex and sexuality is slowly evolving from a taboo topic into an important part of women`s health that can be discussed openly and freely without embarrassment. The youth are being encouraged to ask and discuss sex and sexuality with their peers and medical personnel whenever needed. This is a significant step towards producing healthier and educated future generation in Omboga. The government is also making an effort in promoting health. The harmful practice of polygamy has been made illegal which in turn helps the women combat HIV and abuse by men. The women also actively promote their own health and status in the community by organizing themselves into women`s groups and tackling the difficulties that they face together as women. These groups also provide them with an open male free forum where they can freely discuss intimate issues confidentially with each other. 54 10 DISCUSSION The International women’s conference held in Nairobi in 1985 gave women worldwide a hope for the future. After the women’s rights agreement of 1980, the world was made aware of women’s rights and was urged to improve women’s lives in all aspects. The Nairobi conference of 1985 was based on improving the status of women in regards to equality, development and peace. The conference defined equality as not just equality based on law or gender, but as the right, responsibility and opportunity to participate in women’s development so that women are the engineering force behind these developments as well as the beneficiaries. Development was defined as consisting of political, financial, social, cultural as well as individual and communal development. Peace was not only constricted to war and violence but financial and social justice, equality and the ability to exercise one’s basic rights. (Ulkoasiainministeriön julkaisu 1994, 8−9.) The United Nation’s strategy for women’s empowerment for the year 2000 provided recommendations on what needs to be done in order to achieve these goals. (Ulkoaiainministeriön julkaisu 1994, 115−129.) Even though the recommendations were suggested to be based on laws, years have passed but the situation still appears to be the same in most parts of the world especially in regards to the women interviewed in this research. Despite the fact that women’s rights are discussed and exercised, the women in Omboga are disadvantaged and unable to benefit from these rights because some of the women are not necessarily aware of their rights. Illiteracy and lack 55 of proper technology has limited the information flow and so most of the women are unaware of what is currently going on in other parts of the world. In conclusion, as a woman and a member of the society presented in this study, I feel very proud of the women in the community in general for not surrendering to their foreseen fate but rather working hard to improve it. The feedback collected verbally from the participants and other members of the society was very positive and encouraging. As a student in the public health sector, I learned a lot of important lessons during this journey. The most important form of health promotion is in my opinion mostly about making the right choices in regards to our own health. It does not matter how much information we are exposed to but rather how we improvise and use that information to improve our health and that of our community. We tend to take for granted the health advantages of everyday necessities such as food and clean drinking water instead of appreciating their health promoting qualities. In Omboga, the best way to promote these women`s health would be to provide them with clean drinking water and food since this is the best way to help them to prevent diseases and sustain good health. A topic for further research on this subject and in regards to the health of the women in Omboga would be to find out how cultural beliefs and practices have affected the sexual and reproductive health of the women. 56 REFERENCES Ayodo, Harold & Too, Titus 2010. The cost of education in Kenya rising beyond reach. Out of Africa news 13.6.2010. Referred 13.4.2010. http://outofafrika.org.uk/news/?p=347 Briggs, Phillip & Williams, Lizzie 2011. Eyewitness travel Kenya. China: L.Rex printing company limited. Dietler, Michael & Herbich, Ingrid 2010. 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What part does technology (i.e television, radio, e.t.c) play in your life? - Do you think you are greatly dependent on technology in your daily life? - In what ways do you think technological factors help or hinder your well being? - Do you think you are dependent on modern technology to remain healthy or get access to health care? - In your opinion is there any technological advancement in the community at Omboga? - How do this technological advancements or lack of technological advancements affect your everyday life? 8. What are your beliefs either traditionally, culturally or spiritually? - How do these beliefs and practices affect your daily life? - What specific beliefs do you find most important and why? 60 - What are some of the traditional practices and beliefs that you think affect women`s life in general either constructively or destructively? 9. What is your social life like in terms of relating, living and surviving around one another in the community? - What does your family and close social friends mean to you? - How have they influenced your life? - What are the key responsibilities of family and friends in regards to your well being? 10. What role do you think women play in the community`s legal and political decisions? - What are some of your views about politics and how you maintain your well being? - What political or legal problems influence your well being? - How does these political practices govern women`s everyday lives? 11. Do you think the educational structure of the area allows for sufficient opportunities to acquire knowledge? - In what ways do you believe education contributes to your well being? - What educational information, values or practices do you believe are important? - How has your education influenced your general life? - Do you value education and health instruction? 12. How do you think the environment in which the community lives affects the lives of women in the community? e.g access to health care facilities, clean water, food e.t.c. - How has the environment contributed into shaping your life? 61 - What would you like to change about the environment you live in? 13. What does money mean to you? - Where do you get money from? - In what ways do you believe money influences your health? - Do you find money necessary to keep well? 14. How does language and ethnic history facilitate or hinder the progress of women in this society in your opinion? - What languages do you speak? - In what ways do you think your ethnic history has contributed to your well being? 15. What would you like to change in your life? 16. What are your hopes and dreams for the future?