Community-Based Reproductive Health: the only way to go

1. Community-Based Reproductive Health: the only way to go Mary Beth Powers Senior Reproductive Health Advisor Save the Children/US

2. Today’s Agenda • 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…

3. Community-Based Reproductive Health • Who owns your reproductive health? • What is a community? • What do we mean by community based?

4. 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.

5. How SC works… • 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.

6. 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

7. Some examples of access/availability concerns • Adolescents • Pregnant women/women in labor • Family Planning clients

8. Expanding service delivery points to increase ACCESS to care • 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

9. Quality challenges • Provider communications skills • Provider technical knowledge/skills • Patient understanding/compliance • Infrastructure problems • Drug availability/method mix • Patient flow

10. Improved Quality of Health Services • Standards/protocols in place/used • Diagnosis/Counseling skills • Infrastructure improved • Patient flow improved • Interpersonal communications

11. 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…

12. Increased Demand for Services/Intention to practice healthy behaviors • Knowledge (of services, symptoms, behaviors) • Positive attitudes/Acceptance • Community norms supportive • Intention to practice

13. Internal Determinants of Behavior • ·Self-efficacy: an individual’s belief that he or she can do a particular behavior • ·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 • ·Perceived Consequences: what a person thinks will happen, either positive or negative, as a result of performing a behavior • ·Knowledge: basic factual knowledge • ·Attitudes/associations: a wide-ranging category for what an individual thinks or feels about a variety of issues • ·Perceived Risk: a person’s perception of how vulnerable they feel • ·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

14. External Determinants of Behavior • ·Skills: the sets of abilities necessary to perform a particular behavior. • ·Access: encompasses the existence of services and products, their availabilityto an audience and the audience’s comfort in accessing desire types of products or using a service • ·Policy: laws and regulations that affect behaviors and access to products and services • ·Culture: the set of history, customs, lifestyles, values, and practices within a self-defined group. May be associated with ethnicity or with lifestyle • ·Actual Consequences: what actually happens after performing a particular behavior • ·Relationship Status: type of relationship, i.e., short-term/long-term, casual/serious, monogamous/multiple partners

15. Let’s turn to some examples of community-based methodologies…

16. SC responses/methodologies to address community level barriers Community Mobilization • 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.

17. Why Community Mobilization for behavior change? • 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

18. SC methods for Community Mobilization (under documentation for behavior change outcomes) • Positive Deviance Inquiry/Hearth • Appreciative Community Mobilization • SECI • WARMI

19. 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

20. 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

21. Who are the Positive Deviants? Outcome Risk

22. What are we trying to understand through PDI? Policy environment Peer pressure Norms Desired Health Promotive/Protective Behavior Attitudes Knowledge Skills Desired Health Outcome or Health Status PDI subject PDI subject

23. Illustrative Uses Of Positive Deviance

24. PD applied to Malnutrition • 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

25. PDI/Hearth Model Hearth components usually include: • Positive Deviance Inquiry • Nutritional assessment of children • Training volunteers and staff • Two week nutrition and rehabilitation sessions: mothers prepare meals based upon PD foods/practices (including active feeding) and adult learning on other health practices

26. 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

27. Vietnam: Longitudinal Impact on Weight-for-Age: All Children < Age 3 (n=1893) # Tinh Gia District, Thanh Hoa Province, 1993-1995

28. 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

29. SC Haiti – Central Plateau • 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

30. A quick PDI exercise… Policy environment Peer pressure Norms Desired Health Promotive/Protective Behavior Attitudes Knowledge Skills Desired Health Outcome or Health Status PDI subject PDI subject

31. 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?

32. Community Defined Quality:a partnership approach to Quality Improvement

33. 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. SC’s role is BUILDING community capacity to participate in decision making process.

34. 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.

35. Why CDQ? Quality improvement efforts often… • 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.

36. 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.

37. Key features of CDQ • Creation of a quality improvement partnership between the community and health workers • Exploration and sharing of both community and health worker perceptions of quality • Emphasis on mutual responsibility for problem identification and problem solving - not blame • Operationalizes a rights based approach

38. CDQ PROCESS Getting Started Introduce Concept Build support (MOH, HW, Community) Step 1 Explore Quality Health Worker View Explore Quality Community View Step 2 Workshop Bridging the Gap: Problem & Solutions Step 3 Quality Improvement Team Working for Change: Mobilization/Advocacy/Monitoring Step 4 Health Workers “System” Community

39. Results from Haiti FGDsCommunity and Health Worker Definitions of Quality CDQ HWDQ • Welcome • Access/Distance • Waiting time • Consultation Style • Information/Counseling • CHOICE • Referral System • Confidentiality • Order • Acceptance of traditional meds • Follow up • Integration • Environment • Cost • Equal relationship

40. Early Experience in Nepal • 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.

41. Problems frequently cited in Community Discussion Groups / Siraha, Nepal • 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.

42. Some solutions proposed during CDQ workshop (health worker & community): • Lack of access to emergency services: • Health worker should be accessible 24 hours / day, but clients would pay for services during non-working hours. • Lack of water and sanitation at health facility: • Mobilize community members to help build latrine and water pump. Seek material support from VDC. • Lack of medicines: • Approach VDC and HMG to provide initial support for a revolving drug fund (CDP). • Communication problems: • Training of staff, monitoring by CDQ QI team.

43. 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

44. Levels for Evaluating CDQ (and CBRH)

45. Evaluating CDQ • 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

46. Some Preliminary Results • PDQ is breaking new ground - reported to be first-ever 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.

47. Preliminary Lessons Learned • 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. • While community members may not have the knowledge to recognize problems, they can still be involved in demanding change. • 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. • Has not required a huge investment of additional resources.