Engaging Stakeholders in Machakos with Theory of Change

There are a number of buzz words and trending ideas being used in public health at the moment.

Community ownership, stakeholder engagement, participatory processes, sustainability and empowerment are just a number that are floating around.

In this blog post I’m also going to be jumping on the bandwagon.  I’m going to explain why my field is currently fascinated with them and some of what I’ve been working on the past few weeks.

So what is a stakeholder? What is Theory of Change? And as my father says “What is a Machakos?”

Well for my Dad and everyone else who is interested, Machakos is a town in Kenya just southeast of Nairobi.  My first week on site a number of Africa Mental Health Foundation staff and I left Nairobi and drove to Machakos to run a Theory of Change workshop with a number of the stakeholders for both of AMHF’s Grand Challenges Canada projects (e-DATA K and KIDS).  It takes about an hour to get there depending on traffic. Why were we going there? Well Machakos and Makindu are the two rural districts that are the grounds for both e-DATA K and KIDS projects. We were going there to complete a process called Theory of Change with a number of the projects’ stakeholders (i.e. community and ministry leaders of the communities who will be affected by these projects).

Now before I explain Theory of Change I think it’s important to give you some context and go back to those trending ideas in public health.

The ideas of community ownership, stakeholder engagement, participatory processes, sustainability and empowerment are all wrapped up in a process called community based participatory research (CBPR).  CBPR is based on the ideas of Paulo Freire and the idea that traditionally there is a significant power imbalance and inequitable transfer of benefits in research between individuals doing the research and those being researched (especially in marginalized communities and populations).

In research, traditionally information is passed from those being researched to the researcher.  That information is then typically ‘owned’ and disseminated by the researcher from their perspective. Despite claims in background and justification sections of publications traditionally the results of that research typically only benefit the career of the researcher.  Sometimes this is due to the fact the project was designed for the sake of science and objectivity rather than action.  However, without input from the community the results cannot generally be integrated into any meaningful changes in the community. Traditionally, more often than not research information that could empower and strengthen communities is lost in academic journals accessible only by subscription to the academic elite and resource rich and/or communities are provided with summary copies of the information that are full of jargon and provides hypothetical solutions to problems they may not even think are important. Fortunately, these things are changing, research ethics are being updated and fields specializing in translating research into practice are emerging (Knowledge Translation). 

For clarification, I am not saying there is not a place for basic research and knowledge for knowledge sake (sorry for the double negative).  I have a background in philosophy.  I love asking absurd questions for the sake of the intellectual journey.  However, I think it’s hypocritical and a little egocentric for outside academics to claim their research is for the good of community and then fail to translate that research into any meaningful changes in that community, or strengthen that community with the information collected and/or tools that:

  1. Are made meaningful  and presented in a way that can be easily understood (i.e. accessible) and
  2. Can be used to tackle problems identified as important by that community.

A foundation to these ideas is the respect for a community’s autonomy and the idea that they are the experts of their own lives and problems and therefore any action looking for meaningful and effective solutions demands their participation and involvement. This idea runs parallel to ideas in counselling psychology, client focused perspectives in addictions and mental health recovery and is something that I strongly believe; people are experts in their own lives, experiences and problems.  It is not my place or anyone else’s to tell anyone else what is best for them. People often may not have all the information, resources or tools to make the ‘healthiest’ decisions or ‘best’ solution.  It is my belief that it is our jobs as health professionals to provide people with all the information and tools that we can. It is then up to the individual to make informed decisions on what they think will work best for their lives.

The line between advice and suggestion is tricky. However, there is a difference between asking “do you know about this resource/tool/strategy? Do you think this may work for you?” and “You should do this”. The difference is that advice is disempowering and can even be perceived as disrespectful. What I mean by this is that advice does not provide any ‘ownership’ or responsibility for a decision or course of action.  So if that decision/action results in success it is due to the advice giver and does nothing to strengthen the capacity of the advice taker.  Alternatively, if the decision/action fails then that too is due to the advice giver.  The people receiving the advice are less responsible for their own decisions/actions and often the only thing that can be learnt is, “maybe I shouldn’t take advice from that person.” You take something away from someone when giving advice. It is the opposite of supporting individuals in making their own decisions.

As a proud independent female (maybe too proud) with these beliefs, I often feel disrespected by unsolicited advice and especially if the person giving it does not know me well. Even though I know advice typically comes from a warm and caring place, I understand advice to be saying “I know more about your life and situation then you and here is a solution that I don’t think you could come up with.” This is something called ‘meta-communication’ or what is also communicated by what you do or do not say. Men who have responded with silence or too slowly to the question “Does this make me look fat?” know what I am talking about.  In conversations and interactions, there is more to what is being said than the words or phrases being said.  Different people and different cultures all respond and interpret things and advice differently.  In social interactions there is not one correct meaning or interception to a single phrase (I do think there are interpretations that are contextually ‘healthier’ than others); meaning is negotiated between those involved in that interaction and coloured by their perspective and world views. I believe that every response makes sense given that person’s culture and personal history, it might just not be apparent to an outsider or anyone else.  When this happens there is simply a need for more negotiation and open communication in order for both parties to get on the same page.

The idea of advice giving that I have just outlined refers to interactions that occur between single individuals.  Now re-frame this idea and think about how this disempowerment or empowerment can happen with communities and larger groups or populations of individuals. This is why these traditional approaches to research, social programming for marginalized populations and international aid can be seen as being paternalistic, disempowering and also can explain their ineffectiveness and inability to bring about positive meaningful change. For those of us from privileged backgrounds, can you imagine a complete stranger suddenly coming into to your life (without asking for your perspective) who then proceeds to outline what they think all your problems are and then what the best and only solutions are?  What is the meta-communication in this situation? Possibly:

  • “Your perspective, problems, solutions, and input have no value.”
  • “You are wrong. Those problems that you think are problem aren’t actually the problem.”
  • “Everything you’ve done before to make your life better, any decisions and problem solving you’ve done up to this point aren’t going to work.”

Now add that these messages are explained in words and a language that you cannot quite understand with an underlying expectation that you do understand. Then without providing you any tools to undertake these foreign “solutions” this stranger leaves (and is potentially replace with a new stranger who repeats this process).

To be first told that the knowledge and perspective you have is not valuable and won’t solve your problems and then  to be provided with nothing meaningful to change the situation is what I mean by disempowerment.  This sows hopelessness and the idea that people need experts and others to solve their problems. Empowerment is the opposite.  It is done by providing individuals and communities the information and tools they need to make informed decisions as well as strengthening their capacity to make meaningful change in their lives and situations. They are the owners of their problems and therefore are also responsible for any solutionsWhen this happens the solutions that are developed are generally more meaningful to the affected communities and individuals, which in turn makes them more effective as well as more sustainable and long lasting.

SOooo how does this all fit into what I was doing in Machakos? Theory of Change is a process which involves stakeholders (so those affected by the project) in creating a unique theory or story (specific to that community and project) about how to make the changes they want to see in the world happen.  After providing a workshop on how to create these Theories of Change, (ToC) our research team, with our stakeholders, created specific ToCs for both of our projects.  These ToCs will affect how the project is implemented, measured and hopefully be sustained by the communities once the research team leaves. Basically, by using ToC we hope to break out of those traditional disempowering patterns of research that I have been going on about. To use all those buzz words I listed in the begin of my post; this Theory of Change process hopes to increases community ownership and project sustainability through an empowering participatory process of stakeholder engagement.

I hope that all made sense. As always thanks for reading.

Until next time,



Global Mental Health 101


Mental Health protest – Image from: The Center for Global Mental Health

In writing my next blog post I realized that a good number of my readers may have not talked to me about my degree or may just need a crash course in order to understand my passion and what I am talking about.  So welcome to my version of Global Mental Health 101.

Let me break it down and start with some basic definitions and distinctions as well as my two cents.  Then I’m going to slip in slightly revised parts of my practicum plan (with references) for your information.

I am completing my master in public health.  No, I am not a nurse.  I am not a doctor.  I am not a clinician.  Public Health is a field that focuses, not on the health of specific individuals, but of the health of populations. This means that public health professionals work in the planning, evaluation and motoring of health programs and services as well as health policy and health system reform. Public health also has the tendency to focus on preventative services that prevent people from getting sick rather than curative services that treat people once they sick.  In looking at health from a preventative stand point more and more attention has begun to be paid to the social determinants of health. These social determinants of health recognize there is more to health than simple biology and anatomy.

My interests lie in mental health and addictions. I like to think my view is captured by the following statement by the World Health Organization “there is no health without mental health” (WHO, 2005).  Within a public health framework, this means I do not plan on being a front line worker or a mental health clinician – a counsellor, psychiatrist, or psychologist.  Instead, I am interested in looking at and working on larger programs, systems and policies that relate to mental health and addictions.  For example:

  • Public awareness and education campaigns aimed at increasing awareness and decreasing the stigma of mental illness or
  • Advocating for policy regarding the implementation of publically funded evidence based treatment for mood disorders (depression and bipolar).
  • Developing and creating outreach,  life skills and employment programs

Furthermore, my interests in mental health and addictions are not limited to the North American or ‘Western’ contexts. Within public health is the field of Global Health.  Global health is not international health or the health of ‘developing’ countries. Global health refers to the public health activities that address health conditions that cross borders.  This means that global health professionals look at a wide range of issues from infectious diseases like HIV/AIDs issues, malaria and TB; chronic diseases like diabetes, heart disease and obesity, food security and nutrition, maternal and child health, genetic conditions,  traffic accidents, environmental and occupational health and of course my interest mental health and addictions.

It wasn’t until late in the 20th century that mental disorders (also known as mental illnesses or neuropsychiatric disorders which also includes addictions/substance use disorders) were recognized as things that were ‘real’ (Patel, 2012).  A Canadian estimate states that one in five people will personally experience a mental illness at some point in their lives (CMHA, 2013). Mental illnesses occur in individuals in all countries, all age groups, across gender, socioeconomic status (rich/poor) and urban and rural divides (WHO, 2009; WHO & Wonca 2008). Mental health concerns are just now starting to be recognized as a silent global epidemic. It is currently estimated that 450 million people worldwide suffer from a mental illness, accounting for an estimated 13-14% of the current global burden disease, with almost 75% of this burden falling in low- and middle- income countries (LMIC) (WHO, 2010).  This means that 13-14% of healthy years lost to early death and disability in the world are a result of mental illness.  90% of one million suicides that occur every year are linked with a mental disorder (WHO, 2009).

Furthermore, individuals suffering from mental illness are more at risk for suffering physical illness and more likely to participate in unhealthy and risky behaviours (WHO, 2009; WHO & Wonca 2008). Mental disorders are associated with social disadvantage, including poverty, violence, gender disadvantage, conflicts, and disaster (Patel, 2012;WHO 2010) as well as experiences of crippling stigma, discrimination, rampant abuse and human rights violations (Bass et al., 2012; Patel, 2012).

Mental illness has staggering economic cost in addition to its social costs (Bas et al., 2012; WHO, 2010; WHO, 2009). It is estimated that over the next 20 years the global economic cost of neuropsychiatric disorders alone will account for $US 16.1 trillion in loss productivity (not counting costs to quality of life) (Bass et al., 2012).  In low resource countries, as a result of the lack of publically funded supports and health care services the social and economic burden of these disorders fall on the shoulders of families (WHO, 2009).  When individuals fail to receive treatment they and their families often become marginalized and may descend into cycles of poverty and homelessness (Bass et al., 2012; WHO, 2009).

Despite the common place of mental illness and the huge costs associated with them, many countries fail to have adequate mental health systems and services (WHO, 2010; WHO, 2009; WHO & Wonca 2008). There are global shortages of trained mental health care workers and less than 28% of countries have budgets specifically for mental health (WHO, 2009). Moreover, when resources are earmarked for mental health, they often fail to go to services and care that are close to where people live (WHO & Wonca 2008). Thus, the majority of individuals affected by neuropsychological disorders globally do not have access to treatments that have evidence supporting their efficacy (Bass et al., 2012; Patel, 2012; WHO, 2010; WHO, 2009; WHO & Wonca 2008).  This is often referred to as the mental health “treatment gap.”  In Sub-Saharan Africa this gap is estimated to exceed 90%; meaning that 90% of individuals affected by mental illness (including those who suffer from most severe and debilitating mental disorders like Schizophrenia and bipolar disorders) do not receive the treatment they need (Patel, 2012).

A primary goal of Africa Mental Health Foundation and a number of organizations and projects around the world is to increase access to psychological treatments to those who need it, but ultimately to improve the lives of those who suffer from mental illness and addictions by decreasing levels of stigma and discrimination and advocating for comprehensive mental health legislation, policies and national mental health plans. My aim of this practicum and my degree in general is to learn how local people and ideas can mobilize and lead to the fulfillment of these goals.

Thanks for reading



Bass JK, Bornemann TH, Burkey M, Chehil S, Chen L, et al. (2012) A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come. PLoS Med.v9(1)

Patel, V. (2012) Global Mental Health: From Science to Action. Harv Rev Psychiatry.v20(1), p.1-12.

World Health Organization (2010) mhGAP Intervention Guide for mental, neurological and substance use disorders. WHO press. Geneva, Switzerland.

World Health Organization (2009) Improving health systems and services for mental health. WHO press. Geneva, Switzerland

World Health Organization (2005) Facing the challenges, Building Solutions. Ministerial Conference on Mental Health. EUR/04/5047810/6. Helsinki/London: World Health Organization.

World Health Organization and World Organization of Family Doctors (Wonca)(2008).Integrating mental health into primary health care. WHO press. Geneva, Switzerland


My New Nemesis

Mosquito is the new name of my phone, because it is the new bane of my existence. Nairobi seems to be a special case in East Africa and due to its elevation is actually low risk for Malaria… therefore I have to worry less about the little buggers here. Therefore, the energy that I would have given to hating them, has now given to hating my phone. He, the little white devil, is my new Nemesis.

Before I continue, let me just name and recognize the “First World Problem” nature of this issue. I’d like to think the fact that I am a student of global health makes me aware of the fact I am incredibly lucky that this is the bane of my existence at the moment. Regardless of the fact that I am in Kenya, I don’t officially start my practicum until tomorrow and Nairobi is not the safest city so as result the vast vast majority of my hours have be spent in the compound of my hostel. Thus, my Kenyan experience so far has been colored most by the evilness of Mosquito (I have to say he ranks up there with the Evil Tofini – the monster that is desert tofu) and I have spent hours trying to circumvent his behavior. Thus, I also feel the need to warn you that this blog may not be the exciting African adventures you may have been hoping for but simply ridiculous rants and thoughts by yours truly (but who knows – I will try to keep you posted either way). 

Anyways, back to Mosquito (also you should know that you have to pronounce it “Most-quee-toe” you want to stay true to my naming system). From what I’ve gathered (read imagined) Mosquito’s origin story is as follows:

Once upon a time in a factory not so far away, lay the equipment used to make happy little cell phones that generally bring joy and connectedness to all the people. On one fateful eve after the factory had shut down for the day, a vent in the darkest corner of the lowest level was pushed open. The cover, now bent from the immense force, crashed to the floor and out of the shadows emerged a small figure dripping with sweet. Witching hour was upon the land and silence once again consumed the factory.  Shadows were the creature’s only company. The small creature’s movements rippled through it as it crept through the darkness along side the equipment.

The creature spotted its target and let out a gleeful giggle. It approached a conveyor belt with the innards of number of Samsung cell phones laid out with a the regularity of the factory’s machines. Climbing up the support metal buttress, the Evil Tofini smiled to himself. His plan was soon to be in motion. He reached the top of his climb. He counted on his tiny gooey fingers as he made his diabolical calculations with his freakish brain made of creepy protein infused jello. He hopped and skipped over to a single phone and whispered to it evil sweet nothings. He knew this phone would end up in the hands of his target, where it would preform evil deeds in a land out of his reach, where he and his people had yet to infect the populace. He placed his microscopic soy-chip into the phone and let out a high pitched squeal that echoed throughout the emptiness. He jumped off the conveyor belt,  rebounded once into the air and scampered off into the darkness.The butterfly had flapped it wings and Mosquito had been born.

Mosquito was fitted with his fancy white shell and his touch screen face, was boxed and shipped over seas and across the globe. He was opened, put to use and for all intensive purposes was a regular North American cellphone. He obeyed his masters’ every desires, all while the Evil Tofini’s soy-based program lie dormant just under the surface.

Time passed and Mosquito changed hands. All his users were none-the-wiser as he got closer and closer to to his unsuspecting victim. Until at last he was past on to me; a nemesis in disguise. Every time I think I have the upper hand his soy-based programming activates. The simple act of buying a sim card and activating Mosquito to make and take phone calls became a 2 day affair. He refused to activate upon registering a foreign sim card, something that takes other cell phones mere minutes demanded a second trip into central Nairobi to safaricom for in-person customer service. 

His next act of subterfuge occurred shortly after my “success” of finally being able to send and receive calls and text messages. During my first few calls home, I discovered his overly sensitive touch screen and how easy is to hang up on my loved ones with my face. In order to maintain any call, Mosquito demands to be in a very specific position or else the call will end. Thankfully, I am able-bodied and able-minded and have been able to adapt to Mosquito’s demands. Yes, I am not proud to say it but I have given in to a tiny touch-screened terrorist (Loved ones… that is how much I love you).

Mosquito’s next blow to my psyche was developed slowly. Seeds of an empty promise were sown early. I was told, “It’s a smart phone and can even get internet and Facebook if you want. I just never had the desire or put the effort into it.” WRONG!!! Mosquito is smart, but not in that way. Not for me in this place or time. I sorted out his general activation on Friday afternoon. For the rest of that evening, I toyed with his menus, safaricom’s website, sms self-help system, and activation codes in attempts to activate his internet connection.

Saturday morning I learned that inputting a different code with airtime credits would produce data bundles. “AH HA!!” I thought I had finally bested the little beast. WRONG!!! I successfully inputted and received data bundles but Mosquito in stubbornness (besting that of my mother) continued to refuse to access it. By Saturday afternoon, I had discovered a customer service line, that promised to activate internet services on mobile phone. Unfortunately, these were more false promises. My first call lasted  about 15 minutes.  It consisted of a loop of music and advertisements while I was on hold until Mosquito simply ended the call (it wasn’t my face I swear). I tried a second time which lasted for 53 minutes and a third time lasting 10 minutes until the blaring loop of hold-advert-music simply stopped. Mosquito went silent and dropped the call. Horribly vexed, I gave up for the night. But, I still had hope that I would prevail and would be able to show Mosquito who was boss.

Today, Mosquito was cunning and a new kind of sly. The Evil Tofini would be proud of his minion. Today, my first call lasted one minute and 45 seconds and was characterized by the loop of hold-advert-music then suddenly a “Hi my name is Henry, how can I……” Now, what do you think Mosquito did? He dropped the call. 😐

This set back gave me more hope and suddenly I was thinking that I was master of the universe.  I must have been the most brilliant mind in all of history to consider calling Sunday morning while so many Kenyan were at church. I would beat Mosquito and make him bend to my will, embrace his intelligence and accept my data offerings. So, I tried again in hopes Henry or another agent would pick up within minutes. NOPE!!!  I ended up hanging up after being on hold for an hour, eleven minutes and eight seconds.  This new failure lead me to decide that once again a trip into town (to see in-person customer service) was necessary.

SOOOOooo after walking into Nairobi City Centre I learned two things.

  1. Mosquito is not an African smart phone and he never will be. He will never be able to access the data bundle I so kindly offered him (He most certainly won that round).
  2. Although my travel into town was virtually uneventful and my belongings and I both returned safely home, I learned that there are not enough people out on Sundays (except around churches) for me to feel comfortable enough to walk about. 

So currently, Mosquito and I are at a standstill. He outsmarted me and has remained just a dumb phone. However, he is still somewhat useful and I am cheap so we will continue our relationship (for now anyways).

So I will sign off for now. I am tired and my procrastination is complete. I congratulate you if you got the entire way through my ridiculousness. I apologize for any all all grammar/spelling mistakes in this and any future posts.  My brain doesn’t always work that way. Anyways, until next time,



My First Few Days

I arrived safely in Nairobi late two nights ago. After three never ending flights,  I find myself in a place which is very familiar but also unfamiliar, Cars drive on the right side of the road travelling either at break neck speeds or not at all in traffic jams that consume hours of the day. Green toilet paper and toilets that you need to pump to flush. Incredibly well dressed and polite people. Long skirts and conservative tops. Skeleton keys that you need to turn twice to lock and unlock. Shillings and airtime. A hot sun and sunscreen that always seems to find my eyes.

Thankfully I have found myself in a safe place that feeds me three meals a day.  I am surrounded by welcoming colleagues, who all appear to be as passionate about mental health as I am and are committed to helping me get settled. I am grateful that my current problems include wanting fruit for breakfast, but not knowing how much produce is at the local stands and not wanting to get fleeced, that with help I have sorted out my internet, paid my rent but my phone still isn’t working because I’m waiting for sarfaricom to register my sim,  that I find myself actually getting up at a reasonable time, but that I don’t start work officially until Monday and as a result I need to plan and fill the next 3 day with things (oh the horror!),  that I want to drink so much fanta orange all the time (but haven’t had any because it’s bad for me), that the sun is making it hard to read the words on my laptop screen,  I’m living with nuns(who are very kind), but there are rumors of incredibly strict rules that have yet to be explained to me, and that I have an amazing partner in crime who I love dearly but that I left at home.

I’m a lucky girl.  I am homesick but I am excited for what is to come. Anyways,  I’m off to have lunch, explore a bit, write an abstract and possibly stop off at the office for more Kenyan tech support.