“Our voices matter”: A before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya

BMC Health Services Research, Volume 18, No. 1, Year 2018

Interpretation

Background: Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age. Methods: Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test. Results: Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1-3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = – 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = – 0.698, P = 0.03). Conclusions: A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes. Community units (CUs) are established as part of the Community Health Strategy of Kenya’s Ministry of Health (MoH). Each CU comprises of ~ 1000 households and is aligned to official administrative sub-units (sub-locations) comprising of several villages. Each CU is served by ~ 50 community health volunteers (CHVs) i.e. each CHV serves ~ 20 households and is supervised by a community health extension worker (CHEW) who is typically an HCW from the primary care facility to which the CU is linked. At the time of implementing the current study, the County Government of Kwale had adopted the MoH’s Community Health Strategy and prioritized setting up of CUs for high-volume facilities serving large catchment populations. The DM intervention was implemented between October 2013 and December 2015 nested within the framework of the MOMI project that was funded by the European Commission Seventh Framework Programme (Grant Agreement #265448). This project was implemented in 10/20 (50%) facilities in Matuga sub-county and their associated CUs (intervention facilities) and included interventions at multiple levels including the county health administration, health facility as well as community. The intervention facilities were selected purposively as they were the only ones that had active CUs at the time i.e. CUs with a clearly-mapped geographic scope and CHVs selected and trained as per the MoH’s guidelines. As a result of the Kenyan government’s policy of free maternity services enacted in early 2013, the bulk of rural dispensaries in Kenya established maternity delivery units [38, 39]. These units enabled pregnant mothers to access delivery services at primary care level. Complicated deliveries are typically referred to more specialized levels for advanced care. Delivery units at lower levels are typically manned by a nurse-midwife and consist of 1–2 delivery beds. Additionally, all pregnant women in Kenya receive ANC follow up at primary care level including any recommended prophylaxis and supplementation. The DM sessions followed a series of standardized steps as outlined in the study-specific procedures developed a priori to guide the organization and conduct of each session (Additional file 1). The procedures required that local CHVs mobilize participants from their communities to attend sessions disaggregated by age and gender. These CHVs also selected a date and venue for the session and informed the local administrator (chief/village elder) as well as an HCW from the local facility who would be present during the session to clarify any health-related issues. Since DM sessions were meant to be held at the convenience of community members, no specific number was planned from the onset. The CHVs were encouraged to convene sessions as regularly as practicable aiming to conduct at least one session per month in their community. During the session, a local community member, typically a CHV chosen to suit the age and gender of the session’s participants and who had prior training on effective conduct of a DM session, would act as session moderator. Prior training for moderators focused on encouraging use of open-ended and probing questions, conducting the session using techniques that affirmed each participant’s contribution and promoting reflective listening with paraphrasing of each participant’s contributions. Moderators were also trained to remain neutral and ensure that they maintained group control so that that some participants do not dominate while encouraging silent ones to engage in the discussion. Each DM session was initiated using a dialogue stimulator/starter, in our case, an informational picture booklet. The purpose of this starter was to stimulate initial discussions focusing on the issues targeted for deliberation. Specifically, the issues discussed during the sessions revolved around promoting uptake and utilization of FP, ANC and facility-based deliveries, including discussions around barriers and facilitators to uptake and how to effectively deal with these as a community and individuals. The informational picture booklet was simple, specific, culturally sensitive, posing a single problem without providing a solution and adapted to the audience’s age and gender. The session moderator then posed a series of questions that aimed to identify and define the issues and confirm relevance to session participants. For example, “What did you see in the pictures? Did you identify a health problem? What was the problem? Does this problem occur in this community?” Participants then proceeded to provide individual testimonies of actual experiences with the issues identified. This step was also meant to get session participants to start talking and enabled them to define the issues under consideration from their own perspective and to emotionally own the problem as well as begin to reflect on any needed improvement. The next step in the session was meant to identify current actions to addressing the issues identified and the extent to which they could achieve desired results. The question posed was “Why does the issue identified persist despite current efforts?” This step was meant to promote an analysis of the causes of the issue and develop consensus that the current situation could be improved. This step was also meant to identify new actions/options necessary to solve the issue from the perspective of the community. Through brainstorming, a list of actions was generated and appraised in terms of effectiveness and feasibility. The final step involved generating commitment by participants to consider and list the consequences of taking or not taking the recommended actions. The question posed was “What do you think will be the results of carrying out the recommended action?” Having confirmed the importance and urgency of actions to be taken, session participants then proceeded to prepare an action plan detailing what will be done, by whom, when and with what resources. For each session, a facilitator, typically another CHV, kept a record of issues that were discussed and the agreed upon action plan. They also completed a session event log and shared this with study investigators who provided regular supportive supervision in conjunction with county/sub-county health administrators. Community health volunteers were provided with training on how to effectively conduct a DM session. This was an adaptation of the CHV training curriculum offered by the Kenyan MoH and incorporated aspects of the standardized DM procedures. The CHVs did not receive any monetary payment for their services. Instead, they were reimbursed for travel and meals when they attended trainings. They were also trained on how to organize themselves into informal community self-help groups for income generation. The trainings lasted a week at a time and were meant to improve the capacity of CHVs to effectively conduct their roles as well as to promote an avenue for continued self-sustenance. The local CHEW supervised CHVs’ activities and each provided monthly written reports of their activities. The 12 CUs associated with the 10 intervention facilities where DM sessions were held were sampled purposively as they were the only ones in Matuga sub-county at the time of implementing the MOMI project that were active. Depending on geographic scope, each CU covered several villages. Villages where DM sessions were held were selected at the convenience of the CHVs organizing the meeting. Participants during the sessions were also sampled purposively according to the required age and gender. Separate sessions were held by age and gender to ensure cultural appropriateness and promote effective discussions. The total number of participants per DM session was restricted to 40 and each lasted up to 30 min. In order to obtain buy-in, a series of meetings was held with community gatekeepers (religious leaders and local administrators) in collaboration with county/sub-county health management teams and other stakeholders prior to and during intervention implementation. Ethical approval for the study was obtained from the Ethics Review Committee of the University of Nairobi and Kenyatta National Hospital (P151/03/2014). A research permit was also obtained from the National Commission for Science, Technology and Innovation (#4703). Participants in the DM sessions provided group, oral informed consent. Data on the number of DM sessions held per month was logged into a Microsoft Excel (2010) spreadsheet (Microsoft Inc. Seattle, WA, USA). Continuous data on the outcomes of interest were then abstracted per facility from the District Health Information System (DHIS)-2. Outcomes of interest included uptake of FP, ANC and facility-based deliveries with specific DHIS-2 indicators abstracted being: 1) number of women of reproductive age (WRA) receiving FP commodities, 2) number of new ANC attendees and 3) total number of deliveries. These were compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test. All statistical analyses were conducted in Microsoft Excel (Microsoft Inc. Seattle, WA, USA) and all statistical tests were evaluated using an α-value of 0.05.

AI Digest

Study Justification:

The study aimed to assess the effect of a community-participatory intervention, known as the Dialogue Model, on the uptake of maternal and child health services in Kwale, Kenya. This type of intervention is important for effective maternal and child health interventions, as it involves community members in decision-making and promotes their involvement in improving their own health outcomes.

Highlights:

– The study found that the implementation of the Dialogue Model resulted in significant increases in the uptake of family planning, antenatal care, and facility-based deliveries in the intervention facilities.
– Overall, there was a 15% increase in family planning uptake, a 2% increase in antenatal care uptake, and a 74% increase in facility-based deliveries.
– These findings demonstrate the effectiveness of a structured, community-participatory intervention in addressing demand-side factors and empowering communities to influence their health outcomes.

Recommendations:

Based on the study findings, the following recommendations can be made:

1. Scale up the implementation of the Dialogue Model in other health facilities and communities to promote the uptake of maternal and child health services.
2. Provide training and support to community health volunteers to effectively facilitate Dialogue Model sessions.
3. Strengthen collaboration between community health volunteers, health facility staff, and local administrators to ensure the success of the intervention.
4. Continue monitoring and evaluation of the intervention to assess its long-term impact and identify areas for improvement.

Key Role Players:

To address the recommendations, the following key role players are needed:

1. Community health volunteers: They play a crucial role in facilitating Dialogue Model sessions and mobilizing community members to participate.
2. Health facility staff: They provide support and guidance to community health volunteers and ensure the availability of maternal and child health services.
3. Local administrators: They collaborate with community health volunteers and health facility staff to create an enabling environment for the intervention.
4. County/sub-county health administrators: They provide supportive supervision and guidance to community health volunteers and health facility staff.

Cost Items:

While the actual costs are not provided, the following budget items should be considered in planning the recommendations:

1. Training and capacity building for community health volunteers.
2. Materials and resources for conducting Dialogue Model sessions, such as informational picture booklets.
3. Monitoring and evaluation activities to assess the impact of the intervention.
4. Supportive supervision and guidance from county/sub-county health administrators.
5. Travel and meal reimbursements for community health volunteers attending trainings.
Please note that the actual costs will depend on the specific context and implementation strategy.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides specific data on the number of Dialogue Model sessions held, the increase in uptake of family planning, antenatal care, and facility-based deliveries, and the statistical significance of these changes. However, the abstract does not provide information on the sample size, the characteristics of the participants, or any potential limitations of the study. To improve the evidence, the abstract could include these missing details and provide a more comprehensive discussion of the study’s findings and implications.

Abstract

Community units (CUs) are established as part of the Community Health Strategy of Kenya’s Ministry of Health (MoH). Each CU comprises of ~ 1000 households and is aligned to official administrative sub-units (sub-locations) comprising of several villages. Each CU is served by ~ 50 community health volunteers (CHVs) i.e. each CHV serves ~ 20 households and is supervised by a community health extension worker (CHEW) who is typically an HCW from the primary care facility to which the CU is linked. At the time of implementing the current study, the County Government of Kwale had adopted the MoH’s Community Health Strategy and prioritized setting up of CUs for high-volume facilities serving large catchment populations. The DM intervention was implemented between October 2013 and December 2015 nested within the framework of the MOMI project that was funded by the European Commission Seventh Framework Programme (Grant Agreement #265448). This project was implemented in 10/20 (50%) facilities in Matuga sub-county and their associated CUs (intervention facilities) and included interventions at multiple levels including the county health administration, health facility as well as community. The intervention facilities were selected purposively as they were the only ones that had active CUs at the time i.e. CUs with a clearly-mapped geographic scope and CHVs selected and trained as per the MoH’s guidelines. As a result of the Kenyan government’s policy of free maternity services enacted in early 2013, the bulk of rural dispensaries in Kenya established maternity delivery units [38, 39]. These units enabled pregnant mothers to access delivery services at primary care level. Complicated deliveries are typically referred to more specialized levels for advanced care. Delivery units at lower levels are typically manned by a nurse-midwife and consist of 1–2 delivery beds. Additionally, all pregnant women in Kenya receive ANC follow up at primary care level including any recommended prophylaxis and supplementation. The DM sessions followed a series of standardized steps as outlined in the study-specific procedures developed a priori to guide the organization and conduct of each session (Additional file 1). The procedures required that local CHVs mobilize participants from their communities to attend sessions disaggregated by age and gender. These CHVs also selected a date and venue for the session and informed the local administrator (chief/village elder) as well as an HCW from the local facility who would be present during the session to clarify any health-related issues. Since DM sessions were meant to be held at the convenience of community members, no specific number was planned from the onset. The CHVs were encouraged to convene sessions as regularly as practicable aiming to conduct at least one session per month in their community. During the session, a local community member, typically a CHV chosen to suit the age and gender of the session’s participants and who had prior training on effective conduct of a DM session, would act as session moderator. Prior training for moderators focused on encouraging use of open-ended and probing questions, conducting the session using techniques that affirmed each participant’s contribution and promoting reflective listening with paraphrasing of each participant’s contributions. Moderators were also trained to remain neutral and ensure that they maintained group control so that that some participants do not dominate while encouraging silent ones to engage in the discussion. Each DM session was initiated using a dialogue stimulator/starter, in our case, an informational picture booklet. The purpose of this starter was to stimulate initial discussions focusing on the issues targeted for deliberation. Specifically, the issues discussed during the sessions revolved around promoting uptake and utilization of FP, ANC and facility-based deliveries, including discussions around barriers and facilitators to uptake and how to effectively deal with these as a community and individuals. The informational picture booklet was simple, specific, culturally sensitive, posing a single problem without providing a solution and adapted to the audience’s age and gender. The session moderator then posed a series of questions that aimed to identify and define the issues and confirm relevance to session participants. For example, “What did you see in the pictures? Did you identify a health problem? What was the problem? Does this problem occur in this community?” Participants then proceeded to provide individual testimonies of actual experiences with the issues identified. This step was also meant to get session participants to start talking and enabled them to define the issues under consideration from their own perspective and to emotionally own the problem as well as begin to reflect on any needed improvement. The next step in the session was meant to identify current actions to addressing the issues identified and the extent to which they could achieve desired results. The question posed was “Why does the issue identified persist despite current efforts?” This step was meant to promote an analysis of the causes of the issue and develop consensus that the current situation could be improved. This step was also meant to identify new actions/options necessary to solve the issue from the perspective of the community. Through brainstorming, a list of actions was generated and appraised in terms of effectiveness and feasibility. The final step involved generating commitment by participants to consider and list the consequences of taking or not taking the recommended actions. The question posed was “What do you think will be the results of carrying out the recommended action?” Having confirmed the importance and urgency of actions to be taken, session participants then proceeded to prepare an action plan detailing what will be done, by whom, when and with what resources. For each session, a facilitator, typically another CHV, kept a record of issues that were discussed and the agreed upon action plan. They also completed a session event log and shared this with study investigators who provided regular supportive supervision in conjunction with county/sub-county health administrators. Community health volunteers were provided with training on how to effectively conduct a DM session. This was an adaptation of the CHV training curriculum offered by the Kenyan MoH and incorporated aspects of the standardized DM procedures. The CHVs did not receive any monetary payment for their services. Instead, they were reimbursed for travel and meals when they attended trainings. They were also trained on how to organize themselves into informal community self-help groups for income generation. The trainings lasted a week at a time and were meant to improve the capacity of CHVs to effectively conduct their roles as well as to promote an avenue for continued self-sustenance. The local CHEW supervised CHVs’ activities and each provided monthly written reports of their activities. The 12 CUs associated with the 10 intervention facilities where DM sessions were held were sampled purposively as they were the only ones in Matuga sub-county at the time of implementing the MOMI project that were active. Depending on geographic scope, each CU covered several villages. Villages where DM sessions were held were selected at the convenience of the CHVs organizing the meeting. Participants during the sessions were also sampled purposively according to the required age and gender. Separate sessions were held by age and gender to ensure cultural appropriateness and promote effective discussions. The total number of participants per DM session was restricted to 40 and each lasted up to 30 min. In order to obtain buy-in, a series of meetings was held with community gatekeepers (religious leaders and local administrators) in collaboration with county/sub-county health management teams and other stakeholders prior to and during intervention implementation. Ethical approval for the study was obtained from the Ethics Review Committee of the University of Nairobi and Kenyatta National Hospital (P151/03/2014). A research permit was also obtained from the National Commission for Science, Technology and Innovation (#4703). Participants in the DM sessions provided group, oral informed consent. Data on the number of DM sessions held per month was logged into a Microsoft Excel (2010) spreadsheet (Microsoft Inc. Seattle, WA, USA). Continuous data on the outcomes of interest were then abstracted per facility from the District Health Information System (DHIS)-2. Outcomes of interest included uptake of FP, ANC and facility-based deliveries with specific DHIS-2 indicators abstracted being: 1) number of women of reproductive age (WRA) receiving FP commodities, 2) number of new ANC attendees and 3) total number of deliveries. These were compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test. All statistical analyses were conducted in Microsoft Excel (Microsoft Inc. Seattle, WA, USA) and all statistical tests were evaluated using an α-value of 0.05.

Materials

https://efashare.b-cdn.net/materials/47f3b212b6f511f69c88749b62e7f7fe87949e1d476268e94a8358e69f4adeb4/12913_2018_3739_MOESM1_ESM.docx

Innovations

The recommendation described in the publication is to implement a community-participatory intervention called the Dialogue Model in Kwale County, Kenya. This intervention aims to enhance the uptake of maternal and child health services among women of reproductive age.

The Dialogue Model involves training community volunteers to facilitate sessions in community units associated with intervention health facilities. These sessions focus on promoting the uptake and utilization of family planning, antenatal care, and facility-based deliveries. The sessions follow a structured process, including the use of dialogue stimulators, open-ended questions, and brainstorming to identify barriers and develop action plans.

The study found that the implementation of the Dialogue Model resulted in significant increases in the uptake of family planning services and facility-based deliveries in the intervention facilities. The median number of sessions per month per facility was 2, and overall, there was a 15% increase in family planning uptake and a 74% increase in facility-based deliveries.

This community-participatory intervention is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes. It empowers community members to identify and address barriers to accessing maternal health services, ultimately improving access and utilization.

The publication provides detailed information on the implementation of the intervention, including the training of community health volunteers, the organization and conduct of the sessions, and the monitoring and supervision of the intervention. It also includes the statistical analysis of the outcomes using data from the District Health Information System.

Overall, the recommendation is to implement a community-participatory intervention like the Dialogue Model to improve access to maternal health services. This approach can be adapted and implemented in other settings to address demand-side factors and empower communities to take ownership of their health outcomes.

AI Innovations Description

The recommendation described in the publication is the implementation of a community-participatory intervention called the Dialogue Model. This intervention aims to enhance the uptake of maternal and child health services among women of reproductive age in Kwale County, Kenya.

The Dialogue Model involves training community volunteers to facilitate sessions in community units associated with intervention health facilities. These sessions focus on promoting the uptake and utilization of family planning, antenatal care, and facility-based deliveries. The sessions follow a structured process, including the use of dialogue stimulators, open-ended questions, and brainstorming to identify barriers and develop action plans.

The study found that the implementation of the Dialogue Model resulted in significant increases in the uptake of family planning services and facility-based deliveries in the intervention facilities. The median number of sessions per month per facility was 2, and overall, there was a 15% increase in family planning uptake and a 74% increase in facility-based deliveries.

This community-participatory intervention is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes. It empowers community members to identify and address barriers to accessing maternal health services, ultimately improving access and utilization.

The publication provides detailed information on the implementation of the intervention, including the training of community health volunteers, the organization and conduct of the sessions, and the monitoring and supervision of the intervention. It also includes the statistical analysis of the outcomes using data from the District Health Information System.

Overall, the recommendation is to implement a community-participatory intervention like the Dialogue Model to improve access to maternal health services. This approach can be adapted and implemented in other settings to address demand-side factors and empower communities to take ownership of their health outcomes.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, you can follow these steps:

1. Identify the target population: Determine the population you want to focus on for the simulation. This could be women of reproductive age in a specific region or community.

2. Define the intervention: Clearly outline the components of the community-participatory intervention, such as the training of community volunteers, the organization and conduct of the sessions, and the use of dialogue stimulators and open-ended questions.

3. Collect baseline data: Gather data on the current uptake of maternal health services in the target population. This can include information on family planning, antenatal care, and facility-based deliveries. Use data sources like the District Health Information System or other relevant databases.

4. Implement the intervention: Simulate the implementation of the Dialogue Model intervention by training community volunteers and conducting sessions in the community units associated with the intervention health facilities. Follow the structured process outlined in the publication, including the use of dialogue stimulators, open-ended questions, and brainstorming.

5. Monitor and collect data: Track the implementation of the intervention and collect data on the uptake of maternal health services. This can be done through regular monitoring and supervision of the intervention, as well as data collection from the District Health Information System or other relevant sources.

6. Analyze the data: Compare the pre- and post-intervention data on the uptake of maternal health services using statistical analysis. Use a paired sample t-test or other appropriate statistical tests to determine if there are significant differences in the outcomes.

7. Evaluate the impact: Assess the impact of the intervention by analyzing the changes in the uptake of family planning, antenatal care, and facility-based deliveries. Calculate the percentage increase or decrease in each outcome and determine if the changes are statistically significant.

8. Interpret the results: Interpret the findings of the simulation to understand the impact of the community-participatory intervention on improving access to maternal health services. Consider the limitations of the simulation and any potential confounding factors.

9. Make recommendations: Based on the simulation results, make recommendations for implementing similar community-participatory interventions in other settings to improve access to maternal health services. Consider the feasibility, scalability, and sustainability of the intervention.

10. Communicate the findings: Present the simulation results and recommendations in a clear and concise manner. Share the information with relevant stakeholders, such as policymakers, healthcare providers, and community leaders, to promote the adoption of community-participatory interventions for improving access to maternal health services.

Authors & Co-Authors

Statistics:

Citations: 5

Authors: 5

Identifiers:

DOI: 10.1186/s12913-018-3739-9

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Kenya

Study Design:

randomised-control-trial

Participants Gender:

Female