Transcript Community Based Reproductive Health

Community-Based Reproductive
Health: the only way to go
Mary Beth Powers
Senior Reproductive Health Advisor
Save the Children/US
Today’s Agenda
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Background on community based RH
Save the Children’s approach to CBRH
Results Framework for Health
Community level interventions to address
barriers to good RH (behavior and care)
Practicing community interventions
Community participation will be requested…
Community-Based Reproductive Health
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Who owns your reproductive health?
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What is a community?
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What do we mean by community based?
A SC working definition
Community based reproductive health
 Suggests that health information and services are not
merely located within the community, but are “owned
by the community”
 Recognizes that much of health itself is “owned” by
the individual through their own behavioral choices
and may not require any interaction with the health
system
 and that community members understand their
responsibility and contribution to good health and
good health care.
How SC works…
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Four modes of operation:
– Direct service delivery (especially in emergencies)
and in partnership with MOHs & NGOs to:
– Expand service delivery points
– Improve the quality of services available through
strengthening existing providers
– Mobilize communities to utilize and/or improve
existing or expanded services
focusing typically on underserved/marginalized/
disenfranchised populations.
Results Framework for Health Program
Design, Monitoring and Evaluation
Strategic Objective: Improved Health Status
Improved practice of key behaviors/use of appropriate services that
protect/promote health status
Access/Availability
of information &
health services
High quality health
services/counseling
Demand for health
services/intention to
practice healthy behaviors
Some examples of access/availability concerns
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Adolescents
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Pregnant women/women in labor
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Family Planning clients
Expanding service delivery points to
increase ACCESS to care
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Identification of community depot holders
(contraceptive supplies, drug boxes)
Adding new service to local health post
Training local health workers/community
volunteers to deliver some services
Partnering with private sector to sell needed
health care supplies
Improving hours of operation
Addressing cost concerns
Making services more culturally acceptable
Quality challenges
Provider communications skills
 Provider technical knowledge/skills
 Patient understanding/compliance
 Infrastructure problems
 Drug availability/method mix
 Patient flow
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Improved Quality of Health Services
Standards/protocols in place/used
 Diagnosis/Counseling skills
 Infrastructure improved
 Patient flow improved
 Interpersonal communications
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Demand/Behavior Challenges
Knowledge of illness/wellness and of
services available
 Perceptions of services/service
providers
 Risk/symptoms assessment
 Cultural “prescriptions”
 Social barriers/social pathways to care
 Etc…
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Increased Demand for Services/
Intention to practice healthy behaviors
Knowledge (of services, symptoms,
behaviors)
 Positive attitudes/Acceptance
 Community norms supportive
 Intention to practice
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Internal Determinants of Behavior
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Self-efficacy: an individual’s belief that he or she can do a
particular behavior
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Perceived Social Norms: perception that people important to
an individual think that’s/he should do the behavior; norms have two
parts: who matters most to the person on an particular issue, and what
s/he perceives those people think s/he should do
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Perceived Consequences: what a person thinks will happen,
either positive or negative, as a result of performing a behavior
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Knowledge: basic factual knowledge
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Attitudes/associations: a wide-ranging category for what an
individual thinks or feels about a variety of issues
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Perceived Risk: a person’s perception of how vulnerable they
feel
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Intentions: what an individual plans or projects s/he will do in
the future; commitment to a future act. Future intention to perform a
behavior is highly associated with actually performing that behavior
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External Determinants of Behavior
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Skills: the sets of abilities necessary to perform a
particular behavior.
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Access: encompasses the existence of services and
products, their availability to an audience and the audience’s
comfort in accessing desire types of products or using a service
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Policy: laws and regulations that affect behaviors and
access to products and services
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Culture: the set of history, customs, lifestyles, values,
and practices within a self-defined group. May be associated
with ethnicity or with lifestyle
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Actual Consequences: what actually happens after
performing a particular behavior
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Relationship Status: type of relationship, i.e., shortterm/long-term, casual/serious, monogamous/multiple partners
Let’s turn to some examples of
community-based methodologies…
SC responses/methodologies to address
community level barriers
Community Mobilization
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a process by which individuals, groups and
institutions at different levels of society engage in
sustained and concerted action around a common
objective.
SC identifies, organizes and works with key groups
and individuals to engage and mobilize them through
participatory adult education techniques to plan
sustained action on a mutually defined problem
through a cyclical process.
Why Community Mobilization for
behavior change?
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Belief that behavior change at the individual
level is in part conditioned by community
norms
 Greater likelihood of sustainable change
 Diffusion of innovation – moving the tipping
point
 Community action in “spreading the word”
allows for greater relevant dialogue
SC methods for Community
Mobilization (under documentation for
behavior change outcomes)
Positive Deviance Inquiry/Hearth
 Appreciative Community Mobilization
 SECI
 WARMI
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Positive Deviance Defined
“Positive Deviance is a departure, a
difference, or deviation from the norm
resulting in a positive outcome”
 Identifying the positive deviants – and their
beliefs and practices – can reveal hidden
resources from which it is possible to devise
solutions that are cost effective, sustainable,
and internally owned and managed
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Criteria for use of Positive
Deviance
The objective is social/behavioral
change in a prevalent practice
 The problem to be addressed is
widespread or the norm
 There are some individuals (a minority
of the population) in the community who
already exhibit the desired (positive
deviant) behavior
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Who are the Positive Deviants?
Outcome
Good
Status or
Behavior
Higher
Risk
Lower
PD
Not Good
Status or
Behavior
What are we trying to understand
through PDI?
Policy environment
Peer pressure
Norms
Attitudes
Knowledge
Skills
Desired
Health
Promotive/
Protective
Behavior
PDI subject
Desired Health
Outcome or
Health Status
PDI subject
Illustrative Uses Of Positive Deviance
ISSUE
“COMMUNITY”
PD BEHAVIOR/STATUS
HIV/AIDS
 Brothel Clients
 Commercial Sex Worker
 Adolescents
 Exclusive condom use
 Exclusive condom use
 Exc. condom
use/Abstinence
GOOD NUTRITION STATUS
 Poor Villages with high
incidence of
malnutrition
 Poor well nourished
child
TRAFFICKING OF GIRLS
 Communities with high
incidence of trafficking
 Families with no girls
trafficked
EXCLUSIVE BF
 Mothers of infants
<6mos.
 Mothers exclusively BF
 Pregnant women
 Husbands of Pregnant
women
 Resting last mo.
pregnancy
 Doing work for wives
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 Not circumcised
 Against FGM
 Married uncircumcised
women
 Openly opposed
HEALTHY PREGNANCY
FGC
Girls 8-13 years old
Parents/grandparents
Husbands
Religious leaders
PD applied to Malnutrition
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Defined community norms that affect
the nutritional status of children
Identify well nourished children from
poor families in the community
Conduct home visits to look for what
they are doing differently
Analyze findings and design
intervention
PDI/Hearth Model
Hearth components usually include:
1. Positive Deviance Inquiry
2. Nutritional assessment of children
3. Training volunteers and staff
4. Two week nutrition and rehabilitation
sessions: mothers prepare meals based
upon PD foods/practices (including active
feeding) and adult learning on other health
practices
Results: Assessment Indicators
Increments in Weight-for-age: the
indicator child and the siblings
 Increments in Knowledge, Skills, and
Attitudes of Mothers/Caretakers
 Creation of well-functioning and
sustainable volunteer community
structures
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Vietnam: Longitudinal Impact on Weight-forAge: All Children < Age 3 (n=1893)
1200
1000
800
#
Baseline
Endline
600
400
200
0
Normal
Moderate
Severe
Tinh Gia District, Thanh Hoa Province, 1993-1995
V Severe
SC Egypt - Minia
Reduction in malnutrition (-2 SD
wt./age) among children 6 mo. to 3
years of age from 47 percent to 13%
over a period of 6 months
 In control village malnutrition level did
not change (48.1% to 46.4%)
 PD foods: cheese and salad
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SC Haiti – Central Plateau
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Reduction in 3rd degree malnutrition (wt/age)
from 26 to 6 percent, three years after foyer
participation (Dubuisson, 1993)
 Weight for Age Z-score gain between entry in
hearth and follow-up between 2-6 mo. was
0.34 (1997, Wand evaluation)
 PD behavior: frequency and variety of
feeding
A quick PDI exercise…
Policy environment
Peer pressure
Norms
Attitudes
Knowledge
Skills
Desired
Health
Promotive/
Protective
Behavior
PDI subject
Desired Health
Outcome or
Health Status
PDI subject
What about community involvement
in access and quality improvement?
Moving beyond the demand
mobilization piece of the framework
 Can communities themselves intervene
to improve the access and quality of
health services?
 What responsibility do communities
have for their own health?
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Community Defined Quality:
a partnership approach to
Quality Improvement
Changing the hypothesis
If you build it, they will come.
 If you improve it, they will come.
 If THEY build and improve it, they will
come.
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SC’s role is BUILDING community
capacity to participate in decision
making process.
What is CDQ?
A methodology to improve quality and
accessibility and utilization of services
with greater involvement of the
community in
defining,
implementing and
monitoring
the quality improvement process.
Why CDQ?
Quality improvement efforts often…
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2.
3.
4.
5.
begin with external definitions and standards that
may not address community concerns,
definitions and perspectives about quality of
care.
do not reach the most peripheral services, or do
not reach them in a timely way.
look for answers only inside the health system.
talk with clients, but not with non-clients.
don’t necessarily empower health workers, nor
the communities they serve.
Why CDQ?
Other advantages...
 Accountability rests in the community rather
than with distant supervisors with limited
interest in the actual quality of services.
 Beyond educating clients about their rights,
encourages dialogue and action about the
right to quality care and suggests the
responsibility of the client in getting quality
care.
 Begins to establish a concept of consumerism
for health services.
Key features of CDQ
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Creation of a quality improvement partnership
between the community and health workers
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Exploration and sharing of both community and
health worker perceptions of quality
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Emphasis on mutual responsibility for problem
identification and problem solving - not blame
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Operationalizes a rights based approach
CDQ PROCESS
Getting Started
Step 1
Introduce Concept
Build support (MOH, HW, Community)
Step 2
Explore Quality
Explore Quality
Health Worker View
Community View
Workshop
Step 3
Bridging the Gap: Problem & Solutions
Quality Improvement Team
Working for Change:
Step 4
Mobilization/Advocacy/Monitoring
Community
Health Workers
“System”
Results from Haiti FGDs
Community and Health Worker Definitions of Quality
CDQ
•Cost
•Equal
relationship
HWDQ
•Welcome
•Access/Distance
•Waiting time
•Consultation Style
•Information/Counseling
•CHOICE
•Referral System
•Confidentiality
•Order
•Acceptance of
traditional
meds
•Follow up
•Integration
•Environment
Early Experience in Nepal
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Through partnership, seeking to:
 Make services more accessible and friendly to
disadvantaged/marginalized people.
 Establish a quality concept, and then create demand, while
fostering shared responsibility for, and ownership of,
services among community members.
 Mobilize advocates for health services among the
community that can assist health workers to find solutions
to problems in delivering quality care.
Problems frequently cited in Community
Discussion Groups / Siraha, Nepal
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Poor treatment – based on caste, wealth, gender, age, and type of
health problem (discrimination).
Lack of information – about prevention, medicines, illness, and
about services in general.
Interpersonal relations
 -wide range of problems associated with provider attitude
(rather than “communication skills”)
 -poor listening skills
 -rudeness
Problems associated with medicines
 -health care frequently equated with medicines
 -lack of sufficient medicines, range of medicines, information
Lack of awareness of preventive services. Health services viewed
mainly as curative.
Some solutions proposed during CDQ workshop
(health worker & community):
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Lack of access to emergency services:
 Health worker should be accessible 24 hours / day, but clients
would pay for services during non-working hours.
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Lack of water and sanitation at health facility:
 Mobilize community members to help build latrine and water
pump. Seek material support from VDC.
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Lack of medicines:
 Approach VDC and HMG to provide initial support for a
revolving drug fund (CDP).
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Communication problems:
 Training of staff, monitoring by CDQ QI team.
Priority problems identified for follow-up
by QI team:
Lack of information on available services
Provider behavior (communication with
clients)
Discrimination by gender, age, status
Need for physical examination
Medicines
Levels for Evaluating CDQ (and CBRH)
Meets Established
Quality Standards
 Consistent
Supplies
 Technical
Competence
(Standards
followed)
 Managerial
competence
 Infrastructure
improved
Meets
Consumer
Standards
 Client
Satisfaction
(CDQ
Improved)
Changes
Service
Utilization
Patterns
Changes in
Community
Accountability and
Involvement/
Empowerment for
Health
 Awareness/advocac
y re: the right to
quality
 CPR
 Discontinuation rate
 Increased feedback
from health service
 new users
users.
 appropriate
 QI plans
levels of
implemented
EOC sought  Increased civic
participation
 Coverage of
TT, PNC,
 Continued
EPI
community
participation in
CDQI process
 Improved health
status.
Evaluating CDQ
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Established quality standards met
Consumer standards met (as articulated and
monitored by community members)
Utilization patterns changed, coverage improved
Community capacity increased
Analysis of actions taken and results
Some Preliminary Results
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PDQ is breaking new ground - reported to be firstever dialogue between providers and community
members on quality of care.
Feedback provided reported affecting quality of
C-PI.
Early data suggest significant increase in use of
some services (TT and measles immunization).
Innovative tools developed and used to monitor
quality (e.g. pictorial exit survey for non-literates).
High level of participation by community
members, especially women, and health workers.
Preliminary Lessons Learned
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Problems of technical competence and safety may not be
mentioned or prioritized by the community. Standards and health
worker perspective must enter into the prioritization process.
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While community members may not have the knowledge to
recognize problems, they can still be involved in demanding
change.
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The process can be locally driven. While it is complementary to
more centralized ‘trickle-down’ quality improvement initiatives, it
does not depend on a period of waiting for capacity and resources
to reach rural areas.
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Has not required a huge investment of additional resources.