No Toothpaste, Just Water With Salt

Twins and brushes!

I’ve had the opportunity to conduct two focus groups in Santa Ana and Manchon. There were mostly mothers in both focus groups. Both focus groups lasted about 45 minutes, and I was able to gain a deeper understanding of the community and their habits because of the open ended format of the focus group. In contrast with the individual interviews, I was able to diverge from the pre-formed questions when something interesting was said and able to learn more about the problem that is affecting the community. Many answers were similar in both communities. They all believed they were susceptible to the problem, thought the problem was serious, knew brushing could prevent cavities, believed it was socially acceptable to brush and did not think it was god’s will that people got cavities. The answers differed when we talked about the actual habits though. In Santa Ana, all the participants said they brushed their teeth three times a day and so did their children. They also said their children knew how to brush teeth properly and brushed for a long enough time. It gave the impression that everything was fine (I do not have data of the number of children with cavities in the specific community to confirm this.) In Manchon, on the other hand, the parents admitted that they and their kids only brushed their teeth twice a day and often brushed too quickly, hurriedly and not properly. They also said the children sometimes don’t know that cavities are serious because parents are busy with other problems to teach them. They also admitted that many of their children had cavities. With consideration to the sample size, this still raises the question of why two communities so close together, about 2 km, gave such different answers?

Kids in Santa Ana with a brigidista

At first glance at all the results from my focus groups and individual interviews, I think the problem with cavities stems from 4 reasons: inadequate technique in brushing teeth, insufficient amount of time spent brushing teeth, acquisition of cavities at a young age and using an ineffective alternative to the use of toothpaste. First, I believe the technique of brushing could be inadequate in the nearby communities. In both the focus groups I conducted, people recalled and demonstrated a completely different technique for brushing their teeth. Second, as people in Manchon mentioned, people could be spending very little time brushing their teeth even if they brushed their teeth atleast twice a day. Third, children could have acquired cavities at a young age, since parents do not think cavities are serious at a young age and dental hygiene is not enforced. Neglected cavities at a young age could affect the growing permanent teeth underneath. Fourth, people often do not have paste, so they brush their teeth with water and salt. I was not aware of this until I came here, but it is often difficult for community members to buy paste on a consistent basis. Either they cannot afford it or do not allocate funds to it because they believe water with salt is a equally effective alternative. With no fluoridated water, the use of water and salt means that the community members do not acquire fluoride to enforce their teeth at all. Although the water with salt has been enforced in talks and presentations as an effective alternative by all kinds of non profit and ngo organizations in Nicaragua, I'm not sure if it is effective. Even if it is effective, I'm not sure if they use the right kind (sea salt is the most effective I think) or the right amount. More research needs to be done on this.

After interviews, kids in Casa de Piedra.

"Nica Time"

Over the past two weeks, I have accomplished quite a bit. I’ve conducted about 20 more interviews, received permission from more parents and conducted two focus groups. I believe I have yet to describe what my daily schedule is like so here it is. On an average day, I wake up at 7 and start my daily routine, and I leave my house at around 7:30. After a 10 minute walk to the bus stop, 40 minute bus ride to Nandaime and 10 minute ride to Manchon, I finally arrive at the Children’s Wellness Fund clinic, which I suppose is my headquarters, from which I branch to nearby communities in Nandaime. After finishing my work, I usually have very few options to return to Granada. I have to wait for the one clock bus, but if I miss that, I have to wait until 4 o' clock. The bus can come anywhere from 15 minutes before or half an hour after. So an average day includes a lot of waiting.

Made a new friend on my bus ride to work.

When I’m in the community itself, I usually need to wait for one of the brigidistas. There are about 13 brigidistas that work in the Children's Wellness Fund clinic. These brigidistas are scholarship students who received financial aid from Children’s Wellness Fund to pay their tuition for University in return for their work at the clinic and nearby communities. These brigidistas are often my key to networking into schools and setting up interviews and focus groups. It has been especially frustrating when they are consistently late, building my frustration in the teeming tropical sun of Nicaragua. This kind of habitual lateness is so common here that many foreigners refer to as “Nica time” where being late by an hour or more is normal. This kind of habitual stems from its own culture. In contrast with Nicaragua, America has a different concept of time. While Nicaragua has a polychronic view of time, America has a monochronic view of time. To put it simply, in Nicaragua, people are WAY more relaxed with time. Thus, it has been especially hard for me to persist among this frustration, but I have been able to achieve my goals to a certain degree.

Brigidistas giving "charlas" at the clinic.

During times of waiting and when my appointments have been cancelled, I have learned to take advantage of this time to help the community. It took me a while, but I've finally been able to understand that my project goals are only sub-goals of my greater goal of the helping the community in general. Thus, during my free/waiting time, I have also started helping the community through other projects. Working with another student in Manchon, I helped build “fosas” for the community. These fosas are built to reduce the amount of standing water in the Manchon community. In the community, all households wash their clothes and dishes outside. This soapy water does not absorb into the ground and remains stagnant above ground. In order to alleviate this, “fosas” or pits with gravel and sand are built underground, so the soapy water can be absorbed by the ground. Even with this though, soapy water will soon begin to accumulate again, so the conservative estimate of the fosas' lifetime is about an year. I’ve worked with another student to procure the gravel and transfer it to four households to build the fosas. This has involved a lot of physical labor, but it has already started working in two households. This experience has been very rewarding. I’ve also gone around the community to give SODIS, solar water disinfection, workshops and given talks to help the the brigidistas improve their presentation skills.

View at Corn Islands.

During the weekends, I’ve also had the opportunity to travel and experience other parts of Nicaragua. Last weekend, I went to the Corn Islands which is off the Atlantic Coast of Nicaragua. It is almost an another world there since it is so secluded from the mainland of Nicaragua. People speak English, Creole and Miskito. It was quite an adventure to figure what language to speak to them since I couldn’t really understand their accented English or creole. In English, they would say things that sounded like “do you have your bat suit?” I was quite confused of what they were referring to and as my friend said, I was quite tempted to respond and say I left it in my bat mobile. In actuality, what they were referring to was a bathing suit and calling it a bathsuit which sounded like bat suit. Overall, the corn island was a good experience though as I was able to experience a different culture. The coconut bread is also delicious which you cannot miss out on if you get a chance to travel there. While there, I was also able to fish and acquire my scuba diving license. Quite an epic trip.

But I brush my teeth three times a day....

I have conducted over 40 interviews now in Casa de Piedra, Santa Ana and Manchon. These interviews were usually done in a separate classroom where is there was no class held. After discussing with the teacher, we decided that the best way would be to send students one by one to the classroom so I could interview them. While most of the questions were basic, some children had difficulty understanding my accent (this is when working with another organization could have been a tremendous help!). But, most children, more or less understood me and I could get answers from them. After an hour or so though, I would usually get back spasms because I had to use the chair that the children used which was about one foot off the ground.

The road to Cordeza, a community similar to Santa Ana. It´s almost impossible to use any transportation with wheels, especially after rain.

While I still have to analyze the data, I´ve found some interesting responses to my interviews already. My original goal was to identify at least 60 children who brushed their teeth at least twice a day and at least 60 children who didn’t brush their teeth twice a day. I admit that this goal was quite ambitious. The problem I encountered wasn´t the number of interviews, but rather the type of interviews. Right now, almost 90% of the children I have interviewed have said they brushed their teeth at least twice a day though. Actually, most of the children were confused why I asked them if they brush their teeth twice a day, so they responded, ¨No, I brush my teeth three times a day after each meal (Unfortunately, I don´t even do that). I have two plausible hypotheses of what´s happening

1. The kids could be lying because I’m interviewing them, and since they know they need to brush their teeth three times a day, they repeat what have been told repeatedly to please me. If this is right, the good news is that health education has been somewhat effective and at least the children know they need to do it.

2. They really are brushing their teeth three times a day. Then, although I do not have the data for number children that have cavities, why do many children still get cavities? Maybe there’s a reason that I haven’t covered that´s affecting them. Maybe, they’re not brushing properly or for enough duration. Or is there some other reason?

In order to answer some of these questions, I might have to add some questions to my interview and get IRB approval first. Hopefully, focus groups will also help me comprehend the situation better.

Children at the Santa Ana community with brushes donated by Global Grins.

In my free time, I’ve also been helping out a clinic called Hijos de Maiz in San Blas. A dental brigade had come to give free dental checkups, cleanings and extractions in the clinic. They brought all the equipment and efficiently, treated over 40 patients every day. I believe this kind of work is necessary especially because dental checkups are only needed once or twice a year, if they are taking care of their teeth on a regular basis. Two physicians had also accompanied the dentists to help out the clinic. I worked as the translator since the doctors did not speak any Spanish. He would speak to me in English and I would translate it to Spanish to the patients and so forth. In contrast with shadowing or observing, in this kind of work, I was a crucial step and mediator between the patient and the doctor, and I learned a tremendous amount. At times, I did get into trouble because I would not know medical terminology or other crucial vocabulary words. Once, I had to ask a female patient about her menstruation, and without knowledge of the correct word for it, I had to continue to explain the process of menstruation to get the idea across-compound that with the fact that girl was 16 years old and there were 5 other patients and two other doctors in the room. Imagine how uncomfortable that must have been! Either way, it was a good learning experience, and it was interesting to see the myriad of problems that the clinic on an average day.

Dental brigade at the San Blas community.

You Still Have A Choice!

At 7 am, it´s rush hour in Granada, but

the mode of transportation is walking to a bus rather than cars.

I have held ¨reunions¨ in three communities now: Santa Ana, Casa de Piedra and Manchon. In these reunions, I have presented my project and the goal of my project as I gave the parents who attended the permission slip. The permission slip I created for the parents contains all the information for my project and their rights as well. There still seemed be in disbelief about what was going on. I don’t think they completely understood they could refuse to participate in the study and never really probed me about the study. By recruiting with the details about my study and giving the community a period of time before having the meeting to sign the permission, I attempted to give them a clear option to participate and tell them you still have a choice! In contrast, if I had let the Children´s Wellness Fund arrange a reunion and explained my study and signed permission forms on the same day, the community members might have felt obligated to sign the forms. This step was also supposed to mitigate the problem with "perceived authority." For example, when these community members go to the doctor, they listen to their judgment, their advice and conclusions because a doctor has achieved a position of authority through his knowledge and expertise in medicine. We experience submission to authority in many instances in our lives as well. In regards to my project, the ¨perceived authority that community members feel could stem from the fact that I’m associated with the Children´s Wellness Fund or the fact that I’m from the U.S on a service project to help them. Thus, they believe I know what´s best for them, so they agree with whatever I say. Women and mothers, the people who usually attend these reunion since most are stay at home mothers, are especially susceptible to this because of the "machismo culture" prevalent in Nicaragua. Machismo is an extreme form of male chauvinism that restricts women to certain and roles and deems the "weak gender". This instills in them the feeling that they always need to be saved and take a subservient role. While not true of all women, it affects many women, especially in the farms. I’m afraid these women, even though I separated the step of recruitment and the signing of permission forms, are affected by "perceived authority" so don´t really think they have an option or it would be best for them to not participate.

The three wheeler, mototaxi, is often used for

transportation in many places

where buses don´t run, especially in rural communities.

The reunions took place in the school in either the “comedor” or in a classroom. The schools that I’m working with all have “comedors”. These “comedors” are cafeterias where food is cooked by mothers in the community who take turns to cook for all the children in the school. The comedor and the school are jointly funded by the Children’s Wellness Fund. Children’s Wellness Fund, in turn, is funded by donors in Miami. These donors fled during the Contra War when many fled from Nicaragua to avoid being drafted into the army. The Contra War was a series of rebellions against the Sandinista government that had overthrown the Somoza dictatorship in 1979, the result of the Revolutionary War. After a long revolutionary war, many Nicaraguans would have rather fled and left everything behind than fight again. The donors in Miami started Children’s Wellness Fund as a way of giving back and helping their country. The purpose of the “comedor” is to feed the children adequately because many have anemia from a lack of iron in their diet. The “comedor” focuses on providing rice the beans, the staple diet in Nicaragua, since many families cannot afford beans, the main source of protein and iron in the diet.

Due to a initiative called Hambre Cero by the Sandinistas, part of the ALBA program, many families were given cows, pigs and chickens. The goal of the program is to raise families from absolute poverty by giving them opportunity to start businesses with these animals, but many families, unfortunately eat the animals as soon as they get them. Pictured above is a pig that was provided by Hambre Cero.

The reunion to receive permissions went smoothly, but only 12 to 15 mothers attended each meeting. These parents attend charlas consistently and are dedicated to improving the lives of their family and genuinely interested in discovering new knowledge. Often times though, it’s the parents who don’t come that need the information conveyed in charlas the most. With my project, receiving the permission of parents who don’t come to charlas will be the most difficult. In order to obtain the permission of these parents, I’ll probably send the permission forms home with the children. I’m not sure how effective this method will be, but it’s the only other option since going house to house is nearly impossible as inhabitants live miles apart.

The reunion at the comedor in Santa Ana. People of all ages came, and I gave them brushes donated by Global Grins. As seen above, children also attend with mothers at times which severly affects the attention of mothers at charlas.

Also, coincidentally, Children’s Wellness Fund was also creating a project similar to mine which was aimed at identifying why children didn’t brush their teeth, albeit with different methods which I’m not familiar with. They are excited about seeing my results. I had also wanted to work with Children’s Wellness Fund during the interviews and focus groups, but this would have required them to take the human research ethics training according to the IRB. This could’ve taken weeks, so unfortunately, I had to make the decision to exclude them from the project. I’ll still share the final results with them and hopefully, receive regular feedback from them as well.