Menu
Menu
Menu
Menu
Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.
Our work is situated in rural eastern Uganda, with a total estimated population of 1,045,100, consisting of Kamuli district (population 500,800), Pallisa district (362,600), and Kibuku district (181,700). Kibuku was carved out of Pallisa in 2010 and the two districts share similar economic activities, mainly crop farming and animal husbandry. Kamuli has more diverse economic activities, which include crop farming, animal husbandry, ranching, fishing, fish farming, bee keeping, quarrying and retail trading. The participatory action research approach was facilitated by a project called MANIFEST (Maternal and Neonatal Implementation for Equitable Systems), which aimed at improving maternal and neonatal health. It was implemented from 2013 to 2015, following a 9 month design phase in 2012 and based on prior working relationships between key partners starting in 2009. The main goal of the project was to improve maternal and newborn health by increasing community awareness, action and access to maternal and neonatal health (MNH) services. MANIFEST was implemented by district stakeholders with technical support provided by a Makerere University School of Public Health (MAKSPH) research team. District stakeholders involved actors at the community, parish, sub-county, and district levels. These stakeholders included leaders from the political system (local council leaders), administrative and technical system, community/religious system (priests and imams), and the district health system (from village level community health volunteers to district health teams) (Table 1). The MAKSPH team comprised of a multidisciplinary group of researchers and specialists including health systems experts, obstetricians, paediatricians, statisticians, sociologists and micro finance specialists. MANIFEST stakeholders from community to district levels PAR involves diagnosing a problem, planning action to address the problem, taking action and learning from this action in a cyclical manner. These stages are detailed in the sections that follow. It is important to include all stakeholders (especially the end users, i.e. households) in the design stage, to ensure that the solutions developed align with stakeholder needs and contexts. We conducted a series of consultation workshops and focus group discussions with community members to identify problems that women face when seeking maternal health services and to identify feasible solutions to these problems. These discussions were held along three main themes: quality of maternal health services, birth preparedness and transport for maternal health. The findings from these consultations were used to develop key components of the interventions implemented. Following the design stage, implementation manuals and training materials were developed by MAKSPH and district based staff. These manuals and training materials were designed to be used by different implementing actors while conducting community dialogues, home visits and radio talk shows and while managing saving groups. The project strengthened the capability of community stakeholders through community mobilization and supportive mechanisms (Fig. 1). Project framework mapping community capability to improved maternal and newborn health Community mobilization involved improving awareness about maternal and newborn health and improving maternal and newborn health practices in the home, specifically promoting birth preparedness; appropriate home care for pregnant women and newborns, and supportive male involvement. Awareness was raised through VHT home visits, community dialogues, talk shows, and radio spots. The radio sports covered a wide range of topics including: the importance of attending antenatal care, delivering in a facility, and receiving postnatal care; encouraging male involvement in maternal health; birth preparedness; the benefits of saving money to enable healthcare spending during pregnancy, childbirth and the neonatal period; and newborn danger signs, referral and caring for newborns. The radio spots and messages, developed in conjunction with the district health educator based on feedback from the design phase, were aired on local radio stations in respective local languages. The spots were run daily and the talk shows were conducted on a monthly basis. The talk shows were delivered by the district health officials and political leaders. Concurrently, support was provided for community development officers (public servants responsible for community development work including providing support to saving groups) and VHTs (community health workers). This support consisted of skills based training on how to assist saving groups in improving their management, their abilities to generate income and their link with local transport providers. A refresher training was conducted at the beginning of the project followed by quarterly meetings that were used to reinforce knowledge (Table 2). Types of review meetings In addition, quarterly supportive supervision of VHTs and quarterly review meetings at both sub county and district levels were supported to both build capacity and strengthen local accountability. As shown in Table Table2,2, during these meetings government actors (VHTs, community development officers, health assistants, sub county and district managers) were asked by local stakeholders (politicians, religious representatives, development partners, and local council leaders) to explain cases of poor service delivery in their respective areas. The government actors were informed about these cases through their community activities such as home visits and community dialogues. Solutions to these problems were then discussed and agreed upon. The MAKSPH research team and the district teams documented these meetings, noting issues discussed, achievements and challenges. General findings and learning events from the project were identified and documented on an ongoing basis. This included how planned activities were carried out, challenges experienced, how these challenges were resolved, and whether the objectives of the meetings or activities were met. The implementation of the program was undertaken in a phased manner to ensure learning from the roll out of the program. There was engagement with stakeholders at all levels to share experiences and lessons learned during the action cycle. The review meetings (Table 2) allowed all those involved in implementation as well as recipients to explore their subjective experiences about the programme, actions taken, as well as mechanisms and reasons for these actions. This continuous assessment helped to inform decisions to improve outcomes of the programme and to increase chances for sustaining the initiatives. Stakeholders identified problems and suggested solutions; the program was then adjusted based on these suggestions. Table 3 provides a summary of key changes that were made and reasons for these changes. Key changes made to the programme and reasons for the changes Alongside the PAR intervention, MaKSPH undertook a series of research activities designed to evaluate and inform the project. All study procedures were documented, as well as any deviations or changes that were made, in addition to any intended and unintended positive and negative consequences and steps taken to mitigate negative consequences. In addition, data for this paper has been drawn from key informant interviews (KIIs) and focus group discussions (FGDs). Twenty KIIs were carried out across the three districts with members of the sub county implementation committee who were involved in the implementation of the project at the beginning of the study and at the end of it, e.g. sub county chiefs, chairpersons, religious leaders, health assistants and facility in-charges. KIIs were also conducted with community leaders who were mainly involved in community mobilisation, such as local council chairmen and VHTs. In addition, KIIs were done with members of the district health team who took the lead in overseeing implementation. Written informed consent was sought from the key informants before conducting the interviews. Furthermore, 12 FGDs across the three districts were carried out at the beginning and end of the project. The FGDs were homogenous in composition and were with women (6 FGDs) of reproductive age who had given birth during the project’s implementation and men (6 FGDs) whose wives had delivered during the same period. Each of these FGDs consisted of eight to 12 participants. The participants for the focus group discussions were chosen purposively with the help of the local council one chairpersons who are the gatekeepers in the community. Verbal informed consent was sought from the focus group participants. All tools were translated from English to the three local languages used in the study districts i.e. Lusoga, Lugwere and Ateso by three pairs of research assistants (RAs) who speak both English and the respective languages. All FGDs were tape recorded and the notes transcribed into English. Discussions on average lasted between 1 and 1.5 h. The qualitative data were analysed thematically. Analysis began with a detailed reading of the transcripts. Codes were then developed to identify and tag segments of text on the research topics of interest. After applying these codes to the transcripts, the researchers examined the coded text and generated broader themes that emerged from the data. The main themes in relation to key achievements were: awareness about maternal and newborn health, multi-sectorial collaboration, male involvement, improved care seeking, financial empowerment. The main themes in relation to challenges and lessons learnt were: poverty, facilitation, technical support and flexibility in the research approach. The quality checks that were implemented included the training of research assistants, pretesting of tools, field debriefing and review of data.
N/A
