The Object of Rotary

The Object of Rotary is to encourage and foster the ideal of service as a basis of worthy enterprise and, in particular, to encourage and foster:

-the development of acquaintance as an opportunity for service

-high ethical standards in business and professions; the recognition of the worthiness of all useful occupations; and the dignifying of each Rotarian’s occupation as an opportunity to serve society

-the application of the ideal of service in each Rotarian’s personal, business and community life

-the advancement of international understanding, goodwill and peace through a world fellowship of business and professional persons united in the ideal of service

The 4-Way Test

Of the things Rotarians think, say and do:

1.       Is it the truth?

2.       Is it fair to all concerned?

3.      Will it build goodwill and better friendships?

4.      Will it be beneficial to all concerned?

The Object of Rotary and the 4 Way Test are said at every Rotary meeting.  Whether you are in Hong Kong, India, Swaziland, the US, Canada, Honduras, these doctrines guide your life as a Rotarian.  I enjoy this time at meetings.  It is unifying and reminds me that whatever we chose to do, whatever skills and connections we have, there is always an opportunity to use them to serve one another.  I am thankful for this weekly reminder.  It puts into perspective why I am in Swaziland and refreshes me for the work ahead.

Buyani’s Got Soul

Soul.  That’s what this 26 year old Rotaracter says is his favorite part of being a Swazi.  “You feel like you’ve known another Swazi forever…  there’s just a connection, even if you’ve never met before,” he says.

Buyani- you’ve said it best.  My first real introduction to the Rotaract club of Mbabane-Mbuluzi was on a three day retreat where I was the only non-African.  By the end of the three days, it really was like we had known each other forever.  The hospitality, warmth, and “soul” of the Swazi people are a main draw to the Kingdom.

Buyani Fakudza was one of the founders of the Rotaract club of Mbabane-Mbuluzi.  Rotaract is like Rotary, but for young adults.  Buyani’s first introduction to Rotaract was as a university student, where he majored in GEP (geography, environment, and planning).  From his first meeting, Buyani was hooked and after graduation, attended the Manzini Rotaract club where he was president.  Commuting to Manzini became taxing and Buyani saw the need to start a club where he lived, in Mbabane, so start a club he did! 

Currently, Buyani works as an Assistant Geologist for the Ministry of Natural Resources and Energy.  Recently a blaring headline in the Swazi Times stated the IMF recommended civil servants in Swaziland should not paid due to the extreme financial crisis gripping the country.  In fact, there is only enough in the natinal budget to pay civil servants for three more months.  Buyani seemed concerned about this, as a civil servant, but stated this is not a new issue.  Recommendations like this have happened in the past, but there always seemed to be a solution at the last minute, and civil servants were paid.  Will it work this time?  How can you run a country without civil servants?  Why work for the government at all, if this is a fairly common threat?

I sit across a calm, but firm Buyani, who argues that despite these issues, the government still has the best job security, good pay, and options for advancement and further education than a job in the private sector.  But he also holds his government responsible for the financial mismanagement and asks hard questions about priorities and budgets.  I wish I wasn’t the only one hearing his honest and intelligent assessment of the issues his country faces and areas where government needs to be more responsive.

You find that it’s in his nature to work hard and be concerned about the welfare of others.  From the choice of his major, to his work as a secondary school teacher and football coach, to his involvement in Rotaract and an NGO called REASWA (renewable energy association of Swaziland), Buyani embodies the Rotary commitment of service above self. 

As I quiz Buyani about his hobbies I realize that we have more in common than we are different.  He likes reading, sports (soccer), and traveling.  I ask, “Where do you want to travel?” 

            He replies, “All over Africa.”  Hmmmmmm.  Anyone else seeing where my mind is going?

            His favorite book is “I Read What I Like” by Steve Biko, the man known for developing Black Consciousness during apartheid.  His favorite food?  Emasi, which is sour milk which is usually eaten with stiff porridge.  O.K., now I’m starting to see some differences between us!  Emasi and ligusha are the two Swazi foods that I don’t do well with. 

We continue our conversation, I learn that Buyani has never been on an airplane.  Really?  Hmmm, we just might have to fix that.  Buyani, my brother from another mother, I am so glad that I met you during that crazy weekend at Mlawula, and that you have continued to befriend me and share your Swazi soulful nature. Ngiyabonga kakhulu umngani wami.

Multi Purpose Vuvusela

You may remember the vuvusela from the World Cup.  At least I know my grandmother does- she watched the entire World Cup with the sound down, as these popular horns were too irritating for her to listen to. 

I’ve seen my share of crazy vuvusela’s in Swaziland.  I’ve seen beaded ones, giant ones, and ones used by companies as a marketing tools.

Before Christmas, I went to a Rotary sponsored Christmas Carol Night where Rotarians sang carols and had gifts for children at a local orphanage.  I nearly died when Santa emerged with, you guessed it, a vuvusela!  No one batted an eye, except for me, who was laughing hysterically at the back.  I suppose that sleigh bells aren’t really relevant in a place with no snow, so why not a vuvusela?  The South African flag was painted on it, so it was actually red and green- how perfect! 

            Christmas time was a bit challenging for me in Swaziland this year, as so many of our traditions in the US aren’t really celebrated here, and Swazis don’t have a lot of their own traditions.  But celebrating with Rotarians, singing carols, and meeting up with them for a lunch and afternoon of fun/crazy games helped me celebrate.  At first I thought, how can I celebrate without my family, with no stockings, and when it’s hot?  I guess the answer is, you bust out a vuvusela!  Kisimusi lomuhle- Merry Christmas!

How We Roll

        Some of you know that coming to Swaziland ended up being a stressful decision.  I had just found a rhythm in my life in Kansas City the last year before coming to Swaziland.  I felt I was in a very good place in my career and in my personal life.  I had also gone through some drama with my scholarship- getting a scholarship, then having it taken away, then applying for a different kind of scholarship and waiting anxiously to see if it was accepted. 

My first day of data collection made all of the stress, work, and anxiety of the last year totally worthwhile.  In fact, the whole month of data collection went off almost flawlessly and put a lot of things in perspective.  All the work I put into the research and moving to another continent seems incomparable to that experience.

        I was blessed with a charismatic and hard-working team of data collectors, and we went all over Swaziland together.  When I worked with the RHMs (the population I was surveying in my study) as a Peace Corps Volunteer, I had an impression of their work and their burden, which prompted the study.  But as the time neared when the study would actually take place, I started to worry.  Am I, as a foreigner missing the point?  Are my impressions off?  Am I doing this study for nothing?  Will there actually be a change coming out of the work I am doing? 

        All of those fears came to rest when I went to a preparation meeting where I asked the RHMs if anyone had ever asked how they were doing.  All 100 women responded loudly, “Kute!” which means that no one had.  Countless times when we were surveying the RHMs, they came up to me afterwards and thanked me for coming, for caring, for paying attention to their needs.  Participants called me “Sibusiso” meaning blessing, or gift from God. (Now, this could have been because all of the participants received an incentive of E25!)

        Apart from the satisfaction of doing something meaningful, it was extremely fun and an incredible learning experience  going out every day with my team to do the research.  I rented the University kombi (15 seater van) and met half of the team at the University.  Mary, one of the data collectors, insisted we pray before leaving.  The driver would even turn off the engine while we prayed for a safe journey and successful work.  If we forgot to pray, Mary would remind me, and the driver would pull over on the side of the road so we could pray.

        We would pick up two more data collectors along the road, and met the final group in Manzini, and then proceeded to wherever the destination was for the day.  It usually took us more than an hour to get to our destination, and in some cases it took 2.5 and up to 3 hours because we went to very remote places.  When the data collectors asked why we were going so far, I always remembered my experience of being a frustrated Peace Corps Volunteer in Mambane, which was so remote, most NGOs would not come to help me on projects.  I didn’t want to be like them! 

        The long journeys felt like a mini road trips, and afforded me the opportunity to have long discussions with the data collectors.  It was cool seeing them get into the research.  Some of them discovered they have a natural aptitude for research and community work.  Many of the data collectors were from urban areas, and it was interesting seeing how much they learned about the challenges in their own country, and as always it was a wonderful learning experience for me too. 

They were also incredibly patient with me, as it can be challenging to design and implement a project in another country and culture.  I never knew exactly where we were going, and relied heavily on our driver to get us places.  Misunderstandings occurred, including forgetting to tell the research team that we were headed to an umphakatsi (the chief’s place), where certain attire needs to be worn.  This made the women scramble at the last minute to find cloth to cover their pants and their heads with.  Opps!  They were yelling, “you didn’t tell us!” and answered, “I didn’t know!”  Afterwards we all had a good laugh.

        Surveying 930 participants in one month all over Swaziland was exhausting, and we often had to change our plan on the fly and be flexible.  I have learned a great deal about communication, flexibility, and perseverance.  Most of all, I learned to listen.  The data we collected was at times very sensitive information, including illnesses (many had HIV) and depression.  We asked about their sex life and other personal questions.  So I really wanted to make sure participants were surveyed in as confidential setting as possible.  I knew that most of the time the surveys would be done outside, under a tree, and you can’t always control if people walk past.  But I was determined to make the settings as confidential and consistent from place to place to make sure the data was valid.

         But I learned a remarkable thing about Swazi culture verses American and Western culture in this respect.  On the very first day, the data collectors started to interview 2 participants at once.  I quickly told them to stop and do them individually because I was afraid that participants would not feel comfortable being completely honest with another participant listening in.  A data collector pulled me aside and said that the participants had asked to go together.  Not only does it save time, but doing a survey was new to them, so they felt more comfortable doing it with a familiar person.  When I brought up confidentiality, the data collector stated that he asked the participants, and they said that they all know about each other anyway, and that they don’t have a problem.  I was skeptical.  Are they really going to be honest?  Will my data be valid?

         I could see that this was something the participants had asked for, so I allowed them to be surveyed in groups.  I asked the data collectors afterward, and they responded that many participants were open and reported HIV+ statuses, and that they found that they were more honest in the groups.  What they found was that the participants knew each other so well, that they would call each other out if they were lying!  How remarkable! 

         This example and many more taught me that while I had graduated from university and had experience in research, my data collectors were experienced in ways I was not.  I learned to listen and change my perspective based on their recommendations.  I felt there was a healthy give and take among us where we questioned and pushed each other to make the study better and more relevant. 

As is almost always the case, I learned much more from my Swazi counterparts than I taught them, even if I was the “boss” of the research.  I know I have been enriched by this experience and I hope they were too.  Who knew research could be this fun?

Data Collection

Data collection: November 2010

Nuts and Bolts:

-11 Swazi data collectors

-11 days of data collection

-900 participants surveyed

-13 sites: 11 Tinkundla, 3 clinics, all 4 regions of Swaziland

-sites included:

Hhohho region: Mbabane East and West Tinkundla, Mhlaganatane Inkundla, Mahwalala Red Cross clinic

Manzini region: Manzini North and South Tinkundla, Mafutseni Inkundla, Ludzeludze Inkundla, Sigombeni Red Cross clinic

Lubombo region: Siphofaneni Inkundla, Dvokodvweni Inkundla (met at the Malindza Umphakatsi)

Shiselweni region: Shiselweni II Inkundla, Sandleni Inkundla, Silele Red Cross clinic

Description:

Participants were Rural Health Motivators and Care Facilitators in Swaziland.  RHMs and CFs are community care-givers.  We surveyed them during their monthly meeting.  I randomly selected sites, choosing 2 per region for the RHMs.  For the Red Cross Care Facilitators, we went to the 3 Red Cross clinics in Swaziland, in the Hhohho, Manzini and Shiselweni regions.  The goal was to survey 100 RHMs during each meeting, totaling 800 RHMs.  There are 200 CFs in Swaziland, so our goal was to survey as many of them as possible.  The grand total being 1,000 participants.

Since not all of the participants are literate, I hired data collectors to read the questions to each participant and assist them in filling in the answers.  I held a training for the 11 data collectors before going out to do the surveys.  A good part of the training was held in siSwati!  

An Upgrade

I didn’t really know what to expect when I designed this research project at home in Kansas City.  How many participants is it realistic for me to survey?  How will I travel to each site?  How will I convince each clinic to work with me?  Who will help me do the surveys???

I had the basic research design mapped out, but all of these details spun around inside my head for a year as I prepared to leave, knowing that they would only be solved once I was actually in Swaziland.  Since my prior experience in Swaziland was as a Peace Corps Volunteer , I was resigned to do this the hard way- using my contacts in 3 of the regions I had experience with, taking the bus to the research site, staying overnight with host families and sleeping on the floor,  and figured I would spend a considerable amount of time trying to find local Swazi’s to partner with.

As a Peace Corps Volunteer, I walked for more than 2 hours a day to meet with active community members and worked extremely hard to “prove” myself to the leadership and community members.  It took a long time to integrate into my community and for projects to start gaining momentum.  So, I didn’t know what to expect this time around.  I hoped that my previous experience would speed up the process some, but I had no idea what was in store for me.

Two weeks ago I sat across from the National Coordinator for RHMs at the Ministry of Health and had a meeting on how we would work together.  We drafted a letter to each of the four regional clinic directors calling a meeting to discuss the research and ways they can support the project.  We also discussed my ideas for helping mitigate stress for RHMs, which the coordinator liked and stated she would incorporate in the national plan, which rolls out in January.  As I sat there, I started to pinch myself to make sure this was really happening!

During a previous meeting with my University of Swaziland supervisor, she encouraged me to increase my target number of participants from 200 to 1,000.  She is also helping to recruit my research assistants, and the Dean of the Health Science department at the University has agreed to organize transportation so we can all ride to the research sites together.  Every time we finish a meeting, my supervisor says, “this research will be very interesting!” 

I’ve finally scraped my jaw off the floor and am on cloud nine.  I certainly have gotten a research “upgrade.”  Yebo!

FAQ

I have been asked often what I’m doing in Swaziland and have found it difficult to formulate a quick answer.  Here is a better idea of what I’m doing here and why. 

Q:  What are you doing in Swaziland?

A:  I am working on a research project titled, “Emotional Effects of Caregiving: Depression and Quality of Life in Rural Health Motivators and Care Facilitators in Swaziland.  I am also taking siSwati classes and speaking at Rotary clubs in district 9400 and participating in Rotary events.

Q: What are Rural Health Motivators (RHMs) and Care Facilitators (CFs) and why are you researching them?

A:  RHMs are community members who are chosen by their community to receive training in first aid and caregiving.  They provide care, support, and health education to community members.  CFs have a similar role but are affiliated with the Red Cross, whereas RHMs are affiliated with government. 

I am researching the emotional toll their work has on their life because:

-There is a need to care for caregivers in Swaziland as it has the highest rate of HIV in the world, and caring for someone with a chronic illness is extremely taxing.

-I worked with RHMs when I was in Swaziland as a Peace Corps Volunteer and saw how draining their work was.

-There is a low level of mental health understanding in the general public in Swaziland, so many of the RHMs may not know the symptoms for depression, burnout, and compassion fatigue, making it difficult for them to seek treatment.

-There was a similar study done on depression rates and community health workers in South Africa (done by the South African Depression and Anxiety Group) which found that 89% of their sample had depression, and I believe there is also a high rate of depression existing among community workers in Swaziland.

-I believe that a lot can be done within the current system and for little or no cost.  Therefore, shedding light on the issue will go a long way towards developing interventions to lessen the emotional burden of caring, and subsequently making a real difference in the lives of caregivers.

Q:  Who are you partnering with?

A: I have two supervisors at the University of Swaziland as well as help from the psychology department at William Jewell College.  Also, I am partnered with the Baphalali Red Cross, the National Coordinator for RHMs at the Ministry of Health, and the Mbabane Mental Health Support Group. 

Q: What is this for?

A:  This project is not for a masters or PhD program.  It is simply because I saw a need and personally wanted to be back in Swaziland. 

While serving at Mother Teresa’s Home for the Dying and Destitute in Calcutta, India in 2004, I became very aware of the need to support helping professionals and anyone in a caregiving role.  In high school I chose to enter the mental health profession after deciding that I wanted to be a physician in order to help people heal.  After experiencing clinical depression as a teenager, I decided I wanted to focus on mental health because the stigma creates an additional barrier to care.  Since then, I have had a particular interest in underserved populations.  This has lead me back to Swaziland to work on access to care for caregivers, with the hope that this research will highlight the need to pay attention to caregivers’ needs and provide supportive structures for them.  Through this, I also hope to draw attention for the need for more comprehensive mental health support for all Swazis.  Currently there is one psychiatric facility that employs two psychiatrists for the entire country.  This is equivalent to a ratio of one psychiatrist to half a million people. 

Q: Tell me more about the research design.

A:  Research participants will include 800 RHMs, 200 from each of the 4 regions, and 200 CFs, totaling 1,000 participants.  They will be surveyed during their monthly meeting.  Data will be collected at 10 sites, with 100 participants surveyed in each site.  I have hired 10 research assistants to assist with data collection.  Participants will answer 3 questionnaires: a demographic questionnaire, Zung Depression Scale, and WHO Quality of Life survey. 

Q:  What are you looking for in the data analysis?

A:  The first thing that I am looking for is the overall rate of depression.  I am also interested to see where caregiving is beneficial to the caregiver and enhances quality of life, and also where it is stressful and diminishes quality of life.  Finally, I will be looking at differences in the data, for example, what makes one person prone to depression and another person not?  What is different about those who do have depression?  Is it because they have a higher burden of care, less resources and are more socially isolated?  Is it because they also have an illness, or are caring for a family member in addition to their work in the community?  Is it because of age, education, or length of time working as community health worker?  If we can answer some of these questions, then we can better know how to mitigate the negative aspects of caregiving while enhancing the positives.   

Q:  How do you possibly make a difference in a country with a human resource crisis and the highest HIV rate in the world?  Isn’t it inevitable that caregivers will be stressed, no matter what you do?

A:  A big complex problem does not require one giant complicated answer.  It requires lots of small, simple changes.  It requires attention.  It requires lots of hands in the pot.  I have decided to put my hands in this pot because I feel I have a lot to offer and because I think there are some small, simple changes I can help with; the biggest being that I can draw attention to them.  The literature suggests that even while it is typical for nurses working with HIV+ patients to have a high depression rate, their rates of burnout and job dissatisfaction remain low in those who expressed having adequate support and a high feeling of personal satisfaction from caregiving.  Therefore, by increasing levels of support, a lot can be done to mitigate the stress of caring. 

My two main ideas are to increase social support and technical knowledge and to provide mental health education to help community health workers identify the symptoms of depression in themselves, and to identify positive coping mechanisms.  The best way I can think of to increase social support is to structure the monthly meetings, which currently serve the purpose of handing out the monthly stipend, into a support group.  Here, RHMs and CFs would discuss challenges and triumphs of their work and be able to draw from the experiences of other RHMs in their area.  This time can also be used for continuing education, so the workers can gain more knowledge on health issues and feel more prepared when visiting the sick in their community.  A training manual can be created and given to the nurse or lead RHM in each community, so they can facilitate the lesson easily.  When I return to each research site, I will conduct a health talk on depression and mitigating stress.  I will also develop a mental health referral list which will be distributed along with information on depression and other mental health disorders.