Lessons Learnt from Implementation of Community Health Groups

LESSONS LEARNT FROM IMPLEMENTATION OF COMMUNITY HEALTH GROUPS: AN EXPEREINCE OF 2 DISTRICTS IN NORTH EASTERN PROVINCE, KENYA

ACTION AGAINST HUNGER, KENYA MISSION, PUBLIC HEALTH PROMOTION DEPARTMENT (JUNE 2009, DAISY NYAGA)

INTRODUCTION:

Child hood malnutrition remains one of the main public health concerns and a leading cause of mortality and morbidity among children. Around the world, 178 million children are suffering from acute malnutrition among which 90% are in the developing nations. In Kenya, the malnutrition rates vary across the districts, with highest rates being within the arid and semi arid areas such as Lodwar, Turkana, Isiolo districts and majority districts in North Eastern Province1. Within North Eastern province, where ACH2 has been implementing a Nutritional Program, acute malnutrition rates have remained above emergency levels for at least the past decade. The most recent reports from three International NGOs nutritional surveys in Greater Mandera districts revealed that Global Acute Malnutrition (GAM) stands at an average 30%, twice the World Health Organization’s (WHO) emergency threshold of 15%. Equally, the rate of Severe Acute Malnutrition (SAM) is at an average of 5%3, well above the WHO emergency level of 4%. The high rates of malnutrition in North Eastern Province are attributed to food insecurity, poor child care practices, poor hygiene and sanitation practices as well as the lack of proper social, economic and political systems. Sentinel site surveillance data from Garissa and Mandera show a strong correlation between children who had been ill in the past 2 weeks and those who were malnourished. Typical of Kenya, the most reported illnesses in all Mandera and Garissa ACH surveys are fever with chills (like malaria), coughing or trouble breathing (upper respiratory infection) and diarrhea. These are all preventable diseases, which speaks to the importance of strong public health interventions in fighting malnutrition. Improving health will have direct influence on malnutrition rates in the area4. ACH experience in Kenya also shows that compounds or households that were “neat and tidy” generally do not have children in nutritional treatment programs, which speaks to the importance of integrated preventive health programs providing a whole package, rather than addressing a single cause of malnutrition. According to WHO (2000), within every 15 seconds, a child dies from diseases largely due to poor water, sanitation and hygiene. On the same issue, it has been found that sanitation can lower the rate of diarrhea disease by 35%, and good home hygiene by 33% and that these two interventions alone are more effective in reducing diarrhea than improvements in water quantity(20%) of water quality (15%) (Esrey et al.,1991)5. No wonder the Millennium Development Goal 7, target 10’s objective is to half the 2.4

1 FEWS NET (2006) Understanding nutrition data and the causes of malnutrition in Kenya. A special report by the famine early warning systems network. 2 ACH- Action Contra El Hambre also known as ACF- Action contra La Faim or Action Against Hunger International Network 3 ACH,SCUK &Islamic Relief (2009) Nutritional Crises in North East Kenya as Acute Malnutrition doubles WHO Emergency Level. 4 Similar strong associations have also been observed in comparable context (Somalia) by FSAU - Somalia where the trend of the prevalence of diarrhea episodes was closely followed by correlated rates of Global acute malnutrition (Food Security Analysis Unit, July 2007. Somalia Nutrition Situation. FSAU- Somalia ).

1 billion of the people in the world without sanitation by 2015. This immense task, relies not only on scaling up of activities and funds related to this noble act, but also in using effective technologies as well as building the capacity of the populations to respond to this effort. Thus, to facilitate the adoption of disease prevention and improved child caring behaviors within communities with high malnutrition preference, ACH under took the community health groups approach as the methodology to implement the public health promotion sessions at the community level. The community health groups approach brings together a group of people into a “club” that meets regularly to learn about health subjects and apply this knowledge to their daily lives. This approach has brought forth outputs and eventual behavior change worth documenting. For example, ACH has realized the construction of 971 latrines within 12 months of project implementation, even in arid semi arid communities, some that did not have any latrines as a baseline This paper discusses community health groups approach as experienced from North East Kenya, a methodology that draws credit from social capital and the value of group think in realizing and sustaining behavior change among populations.

WHY COMMUNITY HEALTH GROUPS?

The community health groups approach is consistent with the school of development thinking that argues for long-term, broad development, rather than vertical programs that address particular problems and ignore the fundamental problems that have retarded development. The basic assumption of the ‘Community Development’ approach is that ‘communities’ are dysfunctional, and that until the ‘social capital’ within them is increased in terms of knowledge, organization and capacity, no amount of aid will produce sustainable improvement. Therefore, the promotion of self-efficacy is the key objective in the process of empowerment and is one of the basic assumptions of this strategy. It is for this reason that communities need to be assisted through capacity building interventions such as the facilitation of a health groups before and during implementation of projects so that they can succeed. The theory of community health group regards health promotion as the ideal entry point for community development because health is the basis of a strong society and family. The methodology will develop a common unity of understanding and a culture of health within a community. This thus translates to water and sanitation, as well as nutritional, programs that are effective, easier to implement and sustainable.

THE COMMUNITY HEALTH GROUPS METHODOLOGY AND PROCESS

This methodology is based on the premise that participants establish a sense of identity within the groups since a certain community does not exist until it is purposefully manufactured. Thus, a collection of people living together does not automatically imply that they are a community. Participants in the community health

5 Esrey S. A, Potash J.B, Roberts L, and Shiff C. (199) Effects of improved water supply and sanitation on ascariasis, diarrhea,dracunculiasis, hook worm infection, schistosomiasis and trachoma. Bulletin of the world Health Organization 69 (5) pages 609-621

2 groups participate in weekly interactive sessions on public health promotion and they progress to building water and sanitation structures to prevent disease at the household level. Finally, it is hopped that the participants can grow to introduce income generating activities. The key to this model is that the whole group endorses decisions, thus removing any individual fears or risks of ‘going at it alone’. In other words, it builds a support network for positive change. The beauty of this methodology is that it appeals to the whole village through the group, and once there is consensus, most individuals make an effort to conform. The community health groups targeted any willing mothers as participants, but were limited to 30 participants each in order to keep the groups small. Priority for participation was given to women with children in ACH nutritional treatment programs. Men were not typically participants, but they were open to join the sessions sometimes, which built support to women in their action plans from their husbands. The participants of the groups were taken through health related topics during regular weekly meetings of 2-4 hours over a period of 6-12 weeks. The subjects were outlined in a membership card (example below) and after every participant passed all subjects, the group graduated Simple household action plans were developed at the end of each session (relating to each topic). These were then followed up in the next session, challenges discussed and sharing of successes and ideas. Each session also began with a discussion of current health problems within the communities such that the program relates to the real, immediate problems of the women’s lives. Positive deviants within the group led sessions and as cohesion developed more timid members felt support to become more and more engaged. The SARAR6 methodology was employed within every aspect of the training as described below so as to bring about outputs within the groups, which through social cohesion result to behavior change. Table: Example Membership Card COMMUNITY HEALTH CLUB MEMBERSHIP CARD

NAME OF THE CARD HOLDER: COMMUNITY NAME: NAME OF THE HEALTH EDUCATION FACILITATOR: DATE TOPIC/ DISCUSSION THEME FACILITATORS REMARKS NAME ACF ACTIVITIES AND THE CONCEPTUAL FRAME WORK OF MALNUTRITON. MALARIA AND MALARIA PREVENTION COMMUNITY MOBILIZATION AND INDENTIFICATION OF A MALNOURISHED CHILD IMMUNIZATION AND IMMUNIZABLE

6 Self Esteem, Associative strength, Resourcefulness, Action planning and Responsibility: See Dr. Lyra Srinivasan 1970 – Humanistic Psychology, conceiticazion, Gadhi.

3 DISEASES DIARRHEA DISEASES: CHOLERA AND TYPHOID, CAUSES AND PREVENTION BREASTFEEDING AND WEANING PRACTICES SOLID WASTE MANAGEMENT, COLLECTION, DISPOSAL AND RECYCLING BIO-SAND FILTER, SAFE WATER HANDLING AND OTHER WATER TREATMENT METHODS NUTRITION, MALNUTRITION: BALANCED DIET AND BENEFITS OF DIVERSIFIED DIET- ACCOMPANIED WITH COOKING SESSIONS. LATRINE USAGE AND MAINTENANCE PREVENTION OF RESPIRATORY INFECTIONS CONFLICT RESOLUTION DROUGHT RISK MANAGEMENT SUPERVISORS COMMENTS :

SUPERVISORS NAME: SUPERVISORS SIGNATURE: DATE:

RESULTS:

The experience in Mandera and Garissa areas of Northeastern Kenya showed the following positive results which led to high impact projects:

Self Esteem: After the formation of the groups, trainings were led using participatory methods by the ACH public health promoters assisted by community health volunteers, based within the target communities. Discussions were facilitated, focusing on the importance of adopting appropriate health measures and putting in place health enablers. Because the participants of the health groups had already implemented the positive behaviors and enablers, they were promoted as a positive example for the entire community, thus resulting in a high regard and admiration of the participants and their households by the general population.

Associative strength: Through discussions of what was possible and not possible within the communities, the participants of the groups depended on each other, to ensure attendance to the sessions as well as reduction of fears of risk of going at it alone. Many times, community members are afraid to embrace a new idea, because of fear of the risk. But with the associative strength, newly introduced ideas were easily

4 adopted through a patient process of stimulating a community unity of perception and shared values.

Resourcefulness: The participants of the groups were enabled with the capacity to visualize new solutions to the problems that they constantly faced, with discussions leading to the willingness to be challenged and the participants taking risks to come up with new ideas that were appropriate and important to their own lives. This was especially important to find sustainable ways to implement health enablers like hand washing stations.

Action Planning: Every topic was concluded through the drawing of an action plan in a participatory way. The action plan entailed improved hygiene practices through the construction and use of the related health enablers. The activities and time frame for action plan were elicited from the participating groups, which reinforced ownership. The contents of the follow up comprised of:

- the activity to be implemented - identification of important resources required - person responsible to under take activity - time line to implement activity - the person responsible for the follow up

Responsibility: To ensure that the participants of the groups took responsibility of the issues taught, the group participants followed each other within the households to assess for adoption of the action plan drawn from the previous sessions. Thus, it was viewed a group responsibility that members of the groups check on each other as well as personal a responsibility to their fellow group members to implement the action plan. To reinforce the follow up practice and add value to it, the community volunteers based within the communities supported the participants, as well as the ACH public health promoters who went from home to home assessing for the health related improvements.

After the cycle of these social processes, the group members begun to establish their own standards of hygiene in a sustainable demand led approach, which resulted to an increase of the seen health enablers’ e.g. household latrines first, as well as others like hand washing stations, dish racks and garbage pits.

The table below illustrates the phases of the process:

Phase 1: knowledge phase Phase 2: practical Phase Community mobilization Safe Sanitation using potties for children

Formation of the health clubs Household latrines construction

Creation of common unity among Hand washing practices and fixing hand the groups washing stations

Hygiene and health promotion Home Hygiene Improvements eg dish rack

5 construction Follow up the household level

Impact s arising from t he trainings in community health groups: 1. Household latrines constructed Below is a breakdown of the number of latrines that were constructed within the 12 months project.

Baseline Total Latrines Latrines Latrine Total Total total target under constructed replicated Additiona Latrines Latrines populatio progres with through l latrines end project March n s Slab from Household March 09 08 ACH effort 4344 198,661 1534 467 504 971 5315

Presence and use of latrines is a new concept among the pastoralist populations of North East Kenya, thus the idea of household latrine construction had to be approached innovatively. ACH supported the people with digging tools that were donated to communities and managed by a sanitation committee based in every community. A few of identified households were supported with 1/3 of the effort towards the latrine construction i.e. with slab material that comprised of 1 bag of cement, 20 ft long R6, 0.2 kg binding wire and 8 ft long (3X2) piece of wood and the household contributed to excavating the pit to required depth, construction of the slab as well as the super structure. This aim of the slab was to subsidize the cost of the latrine as well as to create the demand. Additional participants of the community health groups constructed latrines through a replication effort while additional latrines are still under construction.

2. Improved safe water handling practices at the household level House holds that Before After Despite this community’s demonstrate safe water trainings the dependence on rain run off handling at household training water, or raw water from the level s only seasonal river Daua, the Garissa 35.7% 78.5% water handling practices are very poor, marked by outbreaks Mandera East 33% 68.7% of Acute Watery Diarrhea Mandera West 21.8% 81.5% episodes, especially in Mandera East. MoH7 hospital records show that this seasonal peak did not happen in this project duration. An assessment of the water handing practices among the participants of the community health groups showed a significant improvements as indicated in the table above. Issues assessed on safe water handling included: water treatment and storage of treated drinking water in separate thin necked containers.

LESSONS LEARNT:

7 MoH records- Ministry of Health, Mandera District Hospital, Hospital Surveillance Data

6 - Timing of sessions and practicality: The timing of the group meetings is adaptable and must be acceptable to the participants. The mothers (participants) were willing and able to participate in sessions for up to 4 hours with a tea break after 2 hours. - Build on existing social capital: Health songs and hadiths from the holy Koran were produced with relation to the topics taught. The choice was so that to capitalize on the aspect of social capital and the influence of peer pressure from members who compete with each other in rural areas. - Focus: The sessions are held on a weekly basis, with 12 topics covered on different days, all relating to good hygiene and preventable diseases. This contravenes the common8 premise that semi-literate women can only be expected to focus on few key high risk practices for behavior change to occur. - Accountability: The trainings were held with consistent and dedicated group members who met regularly over a period of time, as well as follow up to their homes to assess for change. Home visits as well as the Hawthorne effect 9contributed to impressive shifts in practice.

REASONS FOR SUCCESS FOR THE COMMUNITY HEALTH GROUPS MODEL:

- The community health groups sought to influence people in a coordinated manner, such that changes were approved by a group decisions rather than individual decisions. Since individuals are few in a poor household, the margin of failure and the potential impact of loss is larger unlike in a group. In a group, individuals were prepared to undertake change without fear of failure as the risk was spread out. - Repetition of the health messages over a period of time, by peers showed a more thorough reinforcement than other vertical programs. - The North East Province is ranked lowest in literacy levels in Kenya, with 94% of the women classifies as illiterate. The health groups had the ability to feed the intellectual ability of both old and young mothers who previously did not have an opportunity to education or knowledge exchange. - The idea of checking on each other, where the group members visited each other also resulted to the success of the groups. - Unlike the health promotion carried out sporadically in groups commonly referred to in Barazas, follow up was easy and resulted to the observed change. - It was also easy to mobilize the mothers and the groups for the health sessions. They called each for the hygiene promotion sessions. If a participant was absent, it was out of an unavoidable reason which majority of the members reckoned with. - The availability of the member ship card, made the members realize the need for commitment to the noble task.

8 Curtis et al, (2001) Evidence of behavior change following a hygiene and promotion programme in Burkina Faso. Bulletin of World Health Organization 79 (6) 518-527 and Loevinsohn B (1990) Health education interventions in developing countries, A methodological review of published articles. International journal of epidemiology 19 (4) 788- 794 9 The Hawthorne effect refers to the psychological theory which argues that an individual will change behavior to meet the expectations of the observer …if they are aware that their behavior is being watched.

7 - In highly aid dependant communities, like north eastern Kenya, where communities have relied on relief food for over 40 years, the issue of social capital and group think in value of the groups was evident. The participants of the groups did not so much attach the trainings to tangible material gains. However, ACH linked its beneficiaries with Food Security and Livelihood (e.g. income generating activities) activities within the community, as the idea was to create sustainability while fighting malnutrition.

CHALLENGES OF THIS METHODOLOGY:

This strategy may take longer at the start of an intervention project as a lot of mobilization and planning is required, but it achieves far greater results in the end.