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 6B: Levels of Involvement
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Do curso por Johns Hopkins University
Community Change in Public Health
98 classificações
Johns Hopkins University
98 classificações
Curso 5 de 6 em Specialization Foundations of Global 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 important thing during participation and in terms of community capacity
building is that the evaluation process enhances the community's commitment to
continue. It helps them to see where they've
succeeded, identify what went right, any problems they have.
It helps them, through feedback, to take on new projects and new challenges.
In fact, many of these programs, when they first come in appear to be and
actually are somewhat of a social policy approach because the donor agency has
decided that they want to promote filters, that they want to improve
maternal and child health, that they want to distribute Ivermectine to control
onchocerciasis. The issue is how they relate to the
community and what role the community plays.
And whether the project is a springboard toward community problem-solving and
community participation and program sustainability or it's just another
service being offered. To help understand this, we can look at
the next slide which identifies five different levels of community
involvement, other researchers have identified
different levels, but this gives an idea that participation occurs along a
continuum. And where one starts to work with a
community, may be at one evel, but one can encourage the community to progress
along this participation continuum. The lowest level would be simply to
avoid, ignore the program. But in terms of participation, the
minimum one can expect is acceptance, where people utilize a service provided.
Health providers are often heard to talk about mothers participating in the
immunization program by bringing their babies.
That is really acceptance. The next level looks at the concept of
mobilization that we have discussed before.
The idea for change comes from outside, but community members are encouraged not
just to accept or utilize the immunization program, but contribute
resources to make it more successful. The third level, which is here term
participation, again, is similar to some of the projects we start, we described.
They started off with the idea coming from outside with community members are
encouraged to implement the programs themselves, so they have a role in
carrying it out. But they didn't have a role in
prioritizing. At the involvement level, community
members are partners and help plan and evaluate as well as implement the action,
action. Finally, at the level of community
control, the community comes up with its own needs, priorities and directs how the
program goes. The community owns the program.
Outside agencies are still involved but in a different way.
The community requests them to come in because a community sees the certain
agencies have resources they need. So, it's not the agency coming and
telling the community what they need, but the community telling the agency what
they want. The next slide shows this graphically.
And as we noted, it may be possible to start a program with a defined agenda by
an agency. But after some time, the community may
develop skills, develop motivation and interest to take control and start
planning new things for itself as has been done with the village health
workers, who use the filter project as a stimulus and a source of revenue to get
them started on community water supply, which was their real felt need.
And they took over and manage that themselves.
Another term for the acceptance level is passive participation.
Sometimes, health workers say, we want the community to cooperate with us, to go
along with our program, to do what we want them to do.
At this stage, it's simply a matter of fulfilling targets and goals, getting
enough children immunized. In this case, health education is used
simply to encourage people to adopt the behavior that's been determined by the
agency. Mobilization attempts to go beyond this,
in part, because the programs involved often require a large number of people to
be successful, such as at the immunization programs.
Mobilization attempts a broad scale movement or involvement of different
groups, different sectors of the community in achieving the goal,
recognizing that the immunization program requires transportation, requires
information. And so, the effort is to get these
resources donated toward achieving the agency's goals.
And it's recognized by those who promote mobilization that it needs to be combined
with a higher level of community participation if it's going to be
sustained. Participation can be redefined as taking
part in something. But taking part in what?
In many cases, taking part in things that someone else has designed.
And active participation inputs are provided by both the government and the
local population. Community members are identified who can
take a lead in carrying out the program. What differentiates this from the level
of community control is that although the community may be contributing, the
community may be offering leadership, but the goal setting,
it may not have occurred in the community.
Involvement addresses the concept of ownership.
If the ideas come from outside, the question arises, will the community
internalize them? Will they take the ideas as their own? Will they accept the
different approaches? This issue of internalization, was one of
the change process models of Kalman that we talked about in the first module.
Involvement requires voluntary contributions.
It requires an understanding or matching of the program goals with community goals
to see a connection. Involvement can only occur if there is a
good dialogue between the health workers and the communities such that the idea
and the intervention can be seen as relevant to and belonging to the
community will actually meet needs that they perceive.
But finally, as we mentioned, community control is change that is directed by the
community. It may be through a locality development
approach where the community identifies the problem, and uses its own resources.
It may be a community action approach where community members identify the
problem, plan action, but realize that they don't have all the resources and
support they need. And therefore, reach out to lobby,
pressure agencies in government to provide them what they need to carry out
the program to meet their own needs. Community control is aimed at,
ultimately, in the program for community directed treatment with Ivermectin for
onchocerciasis control. Because it's recognized that during the
past 22 years, primary healthcare where village volunteers and village health
committees has taken over their health care has not succeeded in many places.
And as we'll discuss later, the CDTI program, even though it's based
on one issue, tries to get the community together in meetings, as seen in the
picture, in this slide, to discuss their own needs, their own
problems in terms of making Ivermectin available,
getting it to the village, but then using that as a springboard
where communities can experience some success with that program and decide on
other health issues that they want to, to tackle.
The key issue for the health worker is the role to play in the levels of
community involvement and community control.
It's important for the health worker to take the role of facilitator.
In facilitation, we ask open-ended questions.
We encourage the community to identify problems, address what they think causes
them. Come up with ideas about what they want
to do about it and then, articulate what help they think that they need, or they
want. The issue of ownership is more likely to
be addressed successfully, if community members, themselves, identified their own
problems, if the issues addressed by a program are perceived as important to the
community. A participation approach, as we noted, is
lower down the ladder than community control or involvement.
The issue is program specific. The health worker asks,
tells the community, we want to eliminate onchocerciasis.
We need your help. This is what you can do.
So, this would either be mobilization or participation, giving them a role.
The issue is perceived by the community to belong to the health workers.
The community thinks it's not helping itself, but it's helping the health
workers get their job done, depending on their relationship, they may
go along with it or they may not. But anything that, that happens with the
program, anything that succeeds or fails is ultimately considered to be the result
of, or the responsibility of the, the health workers themselves, not the
community. It's not easy to facilitate.
Health workers are often trained to be authority figures.
The health inspector visits homes, visits establishments in the market that sell
and cook food, and is expected to carry out the letter of the law in terms of
sanitation. The nurse is expected to encourage the
patient to comply with medication. And in these various situations, the idea
of being a facilitator, being, being a partner, does not occur.
If we're doing community organization, it's very important that this partnership
be established. If we're going to facilitate, we need to
be able to listen to the community when they express their needs, when they talk
about their limitations, when they talk about their hopes and desires.
We need to learn from local knowledge. How do people recognize conditions are
explanatory models? What local forms of organization exist?
We mentioned age, age grades before. They serve a valuable purpose in terms of
community mobilization. As health workers, can we adopt new
roles, not always being the, the expert, but
also being the learner? And within agencies, we're not just
concerned about facilitating the community, but also, are we able to allow
the front line health staff to make some decisions for themselves, to be involved
in programming, to take initiative, instead of waiting for directives from
above? Basic training for many health workers
does not include community organization, counseling skills, client-centered work.
So, the question arise, are health workers and are health organizations
ready for new roles and relationships, that would faster, higher levels of
community involvement and participation? Are health workers in a position to
respect community viewpoints? Or are they afraid of community beliefs
and views, as being unscientific or even dangerous?
Are we willing to let the community make decisions and stand by the community in
their decisions? And particularly, are we willing to help
the community link with outside resources?
Many times, communities express needs when they're encouraged to become
involved, that are not within the realm of the
health department to provide. The health department cannot provide new
roads, the health department cannot build new market stalls,
the health department cannot install electricity.
But these are important needs to the community and even, in fact, relate to
health. Better roads increase access.
An improved market will enhance the economic condition of the community.
Instead of ignoring such community needs as outside our realm,
we need to be able to help link the community with other agencies.
And this is why the Alma Ata Declaration talks about intersectoral collaboration
such that the health workers who may be in closer contact with the community can
help the community contact the Ministry of Works that's responsible for roads or
contact the Ministry of Education about locating a school in their village.
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