In bringing about behavior change in public health, we often focus on the individual mother, student, or farmer. We should not forget the community structure and norms constrain for encouraging individual health behaviors. This course examines the community context of the changes needed to promote the public’s health. We begin by examining the various definitions of ‘community’ and the processes by which we ‘diagnose’ or seek to understand the structure and characteristics of different types of communities. An appreciation of community similarities and differences is necessary lest we fall into the trap of designing one-size-fits-all interventions. We need to recognize that no matter that outsiders may view a community as poor or neglected, we can find strengths and capacities for improvement in each community. Identifying community capacities and resources is the first step in facilitating community change. Different practical and philosophical approaches to change and therefore, examined. Specific to the change process is our recognition of the need for communities to participate in the design, implementation and evaluation of any intervention. We examine the concept of participation in an effort to see how different levels of involvement may affect sustainability of community change efforts. Finally a case study of a community participatory approach to onchocerciasis control in Africa is presented. Community Directed Intervention has subsequently been successfully applied to providing other essential primary health care services by and in the community, such as insecticide treated bednets, malaria treatment, vitamin A distribution, deworming medicines, and pneumonia and diarrhea case management.
Lecture 6A: What Is Participation?
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Community Change in Public Health
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Module 3
Welcome to Module 3. This week, we'll take a look at the political economy framework as well as the concepts of community participation and involvement levels. You'll also complete your first peer review assignment this week by reading a case study and using what you've learned to describe community change.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
The community partnerships that we discussed in the last lecture are an
ideal example of community participation. We've noted that participation is one of
the key words underlying the philosophy of the Alma Ata Declaration for primary
health care. In the past 22 years, governments have
signed on, have used the word participation, although often times it's
merely the form of mobilization where people are expected to donate, to a
project. In this lecture we'll look at what
participation is about. And how it can be developed and
sustained, and what the benefits are, participation.
As noted, community participation is a centerpiece for primary health care.
The photograph shown is a stakeholder's meeting, where the issue of malaria
problem was introduced to the community and rural local government in Nigeria.
Women's groups, social clubs, local leaders, village chiefs, private
providers. Indigenous healers all came together to
share their views about the nature of malaria in the community, and what should
be done about it. In the ama the declaration, as we know
that there, are, several references, to participation.
The definition of primary health care as essential care, has the component of
social acceptability in that definition. Social acceptability is not simply a
passive issue, where people like or dislike a service, but also, social
acceptability evolves through participation,
where people feel a sense of ownership of a program.
Participation is enhanced when services are accessible.
Alma Ata clearly states that primary health care services should be provided
through the full participation of community members.
And such participation provides the context for determining the cost that the
community can afford. Participation leads to self-reliance and
self-determination. Primary health care requires and promotes
maximum community and individual self-reliance.
Participation in the planning, organization, operation, and control of
services. Participation itself means that there's
greater access to and fuller use of local, national and other available
resources. So we've mentioned in coalition-building,
different community groups have different access to different resources, through
participation bringing these resources together, enhance access of the
organizations and individuals to those resources.
And specifically as an intervention strategy to promote participation, the
Alma Ata Declaration recognizes the need for appropriate health education of
communities. In essence, health education is more than
providing information. In fact, it's enabling people to
participate, to identify and solve their own problems.
Participation is the active involvement of a population in decision making and
implementation. The word's involvement and participation
are often used interchangeably. The key issue here is taking part in
making decisions and carrying those out. That is the underlying essence of
participation. In community participation, the community
has a clear role in formulating health programs, enabling residents, members of
the community to understand and make choices.
And reconciling the objectives of outside programs with community priorities.
In other words, a dialogue is needed. Because in reality, agencies will be
continuing to practice social policy planning.
The issue is that they need at this point, in primary healthcare, to
recognize the community as a partner to engage in dialogue and discuss the
objectives and see how they really meet the priorities of the community.
Because in fact, the community itself is who determines the collective needs and
priorities. The community itself assumes
responsibility and decisions. The agencies need to be aware of these
and adapt to them as opposed to expect the community to swallow agency messages
and programs. Participation often is promoted before
lip service so that different countries and agencies can appear to be in tune
with alma ata, which is adopted as the strategy for achieving health for all by
the WHO. People want to appear as if they belong,
as if they are politically correct in terms of participation.
Although, in fact, participation may be antithetical to the political system in a
particular locality or country. In fact, participation does have positive
benefits for health. It increases the sense of, not just
acceptance of a program but ownership. Community members who make decisions,
help plan and implement. Then want to sustain a program because
they feel it is theirs. Participation ensures that programs meet
local needs. A one size fits all program may not
succeed in every area. Participation can reduce cost because
local resources are use. Participation can be efficient because
local familiar community organizations and problem solving mechanisms are use.
People find it easier to get involve if they understand what's going on because
their local organizations are running the program.
Some examples of the outcome, the benefits of community participation are
seen in the examples that follow. The idea of filtering water to prevent
Guinea Worm as we noted before. Does not necessarily appear to be a
behavior that many individuals would want to adopt.
Based on their beliefs about Guinea worm being inside the body,
based on perceptions that filtering may be a second rate intervention compared to
wells. But where the community had control over
planning a filter distribution program. The results were somewhat different.
Village health workers had been trained, in the small community of Idari.
In 1978, they had organized some guinea worm control activities and reduced the
prevalence in some of the the hamlet surrounding the town.
Additional training was provided and more people were involved in 1983.
The village house workers subsequently formed their own organization,
so that they could collectevely buy medications from a wholesaler at a lower
price, so that they could collectively organize
campaigns and be recognized in the community.
And so they took over the responsibility of organizing the filter program, to test
the social acceptability of the filters through a WHO project.
The association had members who were tailors and they organized the
production. The group itself debated the costs.
They decided that the filters would be sold at cost for the cloth plus a set
modest amount that the individual seller could keep.
The village health workers were located throughout the community and surrounding
hamlets. And so, they were able to ensure that the
product could get out to the place where it would be distributed.
And the village health workers again, were trained how to promote the filter
use. The pictures here show one of their
training sessions, where the importance of demonstration of the filter and
explanation to the villagers were shown. What occurred, since the village health
workers themselves, these volunteers, were actively involved in the design of
the program, the management of the program.
In those hamlets, where they sold the filter themselves.
Coverage was, was highest. Even in those hamlets where they lived,
but did not decide to sell, but only advised their co-villagers to buy from
the project staff the, the coverage, the number of people who bought was fairly
high. In contrast to those hamlets where there
was no village health worker, and only the project staff going around to sell.
So the effect of their being involved enhanced the ability of them to sell, to
promote. And they were much more successful than
an outside person selling the filter. They were trusted by co-villagers.
Here again, some of the concepts of social learning theory.
Some of the concepts of peer education. Some of the concepts of the adoption
diffusion model in terms of haemophilus communication were born out.
So if participation builds on these theories and ideas to enhance the
likelihood of people adopting health innovations.
Interestingly enough, the profits that were made from selling the filters.
The village health workers decided what to do with that.
And they plowed that into a fund to be used to dig community wells,
because again, people did say that they would prefer wells to filtering.
Wells would be a more long term source of water.
The ponds would dry up in the dry season, whereas wells, if sunk to a proper depth,
would not. And so the community themselves, through
their village health workers, planned the short-term, selling the filters, and the
long-term. And they raised money initially to dig
two wells. They supervised the wells, they actually
charge people a small amount for each bucket of water they collected, and used
that to maintain the wells and to dig more.
So the filters, although it was an outside idea was able, the filters were
able to provide a basis to start community fundraising and address the
longer term problem of community water supply.
Concerning water supply, research was done to look at what happened in two
countries, Indonesia and Togo, where, USA id water programs had been underway, and
other water supply programs. In some countries, the water supply had
been established through Participatory process, where people in the village were
involved in deciding where the water source, the well, would be located.
participated in providing resources, labor.
And it was interesting to see how this had an effect on the community in terms
it, its overall health competence. The community competency model implies
that individual health decision making is enhanced when the community as a whole is
actively participating in addressing and solving its own health and development
needs. The results from the study in Indonesia
and Togo, show that this is likely to be true.
In Indonesia is was possible to compare immunization coverage in villages that
participated in establishing their own community water supply, in villages where
water supply was provided by the government, without village
participation. And in villages where there was no water
supply project. And coverage was significantly higher in
the participatory villages. Whereas, the non-participatory villages,
there was no difference in their coverage with villages that even had no water
project, no new project at all. And the interpretation was that, by
community as a whole becoming actively involved in meeting a community need,
developing its own competence that members of the community also felt a
greater sense of efficacy in seeking health services.
Yeah, similar result was seen, with the data from Togo.
The idea of community involvement with the village health workers is again seen
in the slide on community management of essential drugs.
As we mentioned, one of the main reasons for the village health workers in this
small town of Edari forming their own association was so that they could get
low cost supplies of their essential drugs for their village drug kits.
During subsequent years, the local government health department also trained
village health workers. They received some federal funds to do
that, and they were also suppose to provide with that money drug boxes and
drug supplies to start off their village health workers, who would then sell those
and come back and get new supplies. And the village health workers in Edari,
during their association meetings. Would contribute a small amount of dues
every two weeks that they met. They used that money to make drug boxes.
And buy the first stock to start their revolving drug fund.
The local health department trained village health workers simply were given
the boxes. And the, and the first round of drugs by
the local government. Some of our students a couple years later
went out to find out what the situation was with the two different groups of
village health workers. They found that nearly twice as many of
the village health workers from the association would set up their own
revolving drug fund, had purchased drug stock.
Nearly twice as many as those village health workers trained by the local
government and supervised by them. Likewise, they found that the village
health workers who were managing their own fund were more likely to buy or
bought more drugs more often during the year than those in the local government
controlled program. So participation, in the program
guaranteed, that, basic drugs for, problems like malaria, were available in
the village, when the villagers themselves, through their, through their
selected village health worker, participated in designing and carrying
out their own program. The, African program, for onchocerciacis
control that was set up in 1995 by WHO and collaborating agencies, adopted as
its, main strategy, for getting the drug ivermectin, which was donated by the
manufacturers, out to communities. They, selected as their, key, strategy a
community-directed approach, basically community participation.
The idea was that villagers, through community meetings, would be informed of
the availability of the drug, that they would be asked to take
responsibility for collecting the drug from the nearest health center, selecting
some people who could be trained in the village on how to measure people and
administer the dosage, manage simple side effects.
So the community had, had the responsibility for the actual
distribution of the drug. The local government health department
had the responsibility for making sure that the drug was available in the
district. And that villagers who were selected were
trained. And then, of course, we said the donor
agencies made sure that, money was available for training.
And that the drug got from the manufacturers out to the different
countries. The initial research that was done
through the WHO/UNDP World Bank Tropical Disease Research Program.
Convinced the African Program for Onchocerciasis Control, APOC, that this
Community-Directed Treatment with Ivermectin, the CDTI, was the way to go.
The initial research took place in several countries.
And the results of four of them are shown here on the graph.
Two approaches were taken. One set of villages was organized so that
they could take responsibility themselves.
They planned how they would get the drug, who would be trained, when they would
distribute it. Would it be house to house?
Would it be at a central place? What day, etcetera.
Who will be their distributors, how they would do it.
And then another set of villages received the Ivermectin through outreach. The
health staff would simply come out to the village and provide them with the drug
when the health staff were ready. So we had a program directed versus a
community directed approach to distribution.
Overall we see that, the, community-directed approach achieved a
higher, level of coverage, and this is why, the APOC adopted, this approach,
such that any country that receives a grant, to set up, onchocerciasis control
using ivermectin, is expected to, adopt this approach, and subsequently
guidelines have been developed to help them.
Another example at participation is the Save the Children Project in Bolivia on
Maternal and Child Health. The project was based on strategies of
community organization. Community groups of women determine their
own priorities to improve the health of women and children.
These community groups did their own planning, including how they would get
resources they needed and how they would get them.
They administered and coordinated their own local efforts, and education, and
service provision. The planning cycle included problem
identification and prioritization, planning together.
The women's groups and coalitions planned together.
They carried out the projects, and outreached to their members, ensuring
that everyone got services. And they actually sat down and evaluated
what the outcome was. Was it acceptable?
Was it successful to them? This particular project evaluation did
not include a control group, but had before and after measures that were,
inlarge part, collected and analyzed by the women in the community themselves
with the assistance of the staff. And at the end, they could see that there
was change. Perinatal mortality was much lower at
follow-up. Other indicators in terms of health
behaviors, the program coverage increased.
The second pair of bars on the graph refer to contraceptive use and this
increased quite markedly after intervention.
Tetanus toxoid immunization during pregnancy rose after the program was
started. The fourth set of bars look at the number
of women who made an antenatal or prenatal care visit during their
pregnancy. That increased.
The number of women who gave birth under the supervision of a trained attendant,
either a formal health staff, or community birth attendant who had
received training, increased, and the number of women who initiated
breast feeding the first day also increased.
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