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BACKGROUND: The United Nations Development Programme (UNDP) has adopted an approach entitled Community Conversation (CC) to improve community engagement in addressing health challenges. CCs are based on Paulo Freire’s transformative communication approach, in which communities pose problems and critically examine their everyday life experiences through discussion. We adopted this approach to engage communities in maternal and newborn health discussions in three rural districts of Zambia, with the aim of developing community-generated interventions. METHODS: Sixty (60) CCs were held in three target districts, covering a total of 20 health facilities. Communities were purposively selected in each district to capture a range of rural and peri-urban areas at varying distances from health facilities. Conversations were held four times in each community between May and September 2014. All conversations were digitally recorded and later transcribed. NVivo version 10 was used for data analysis. RESULTS AND DISCUSSION: The major barriers to accessing maternal health services included geography, limited infrastructure, lack of knowledge, shortage of human resources and essential commodities, and insufficient involvement of male partners. From the demand side, a lack of information and misconceptions, and, from the supply side, inadequately trained health workers with poor attitudes, negatively affected access to maternal health services in target districts either directly or indirectly. At least 17 of 20 communities suggested solutions to these challenges, including targeted community sensitisation on the importance of safe motherhood, family planning and prevention of teenage pregnancy. Community members and key stakeholders committed time and resources to address these challenges with minimal external support. CONCLUSION: We successfully applied the CC approach to explore maternal health challenges in three rural districts of Zambia. CCs functioned as an advocacy platform to facilitate direct engagement with key decision makers within the community and to align priorities while incorporating community views. There was a general lack of knowledge about safe motherhood and family planning in all three districts. However, other problems were unique to health facilities, demonstrating the need for tailored interventions.
Zambia has predominantly free health care services, with only a few private providers in urban areas. Government policy encourages women to attend at least 4 antenatal care (ANC) visits during a single pregnancy and to deliver in health facilities attended by qualified health personnel. Current statistics indicate that 66% of births occur in a health facility, while 31% occur at home; births in urban areas are more likely to be at a health facility (89%) than births in rural areas (56%). Socio-cultural and structural factors, as well as a lack of knowledge of maternal and newborn care, act as barriers to seeking health care among families, particularly those in rural areas [4]. The BHOMA II project was a community intervention funded by Comic Relief to address maternal and newborn health in three districts in Zambia. BHOMA II was a follow-on to BHOMA I, which focused mainly on strengthening the health system in the same districts. CCs were held as part of the baseline activities of BHOMA II to facilitate the design of appropriate interventions while accounting for community concerns. This paper focuses on this baseline assessment. CCs were expected to be repeated again after 12 months of intervention. CCs were used to collect information in relation to maternal and newborn health in three rural districts of Zambia. The goal of the CC was to establish baseline challenges to address during the 12-month intervention period. After 12 months, CCs were designed to be repeated to assess the extent to which the interventions had addressed the baseline challenges. The questions were tailored to elicit challenges to maternal and newborn health and to establish actual and latent local responses that capitalised on strengths existing within the community. CC facilitators were trained community residents who were familiar with the local context and the languages spoken in target communities. Sixty (60) CCs were held in three target districts. Communities served by 10 health facilities in Chongwe, 4 in Luangwa and 6 in Kafue were purposively selected to participate in CCs. Purposive sampling within each district was performed to ensure representation of rural and peri-urban areas that were pre-determined varying distances from a health facility. Three of the sites were classified as peri-urban, while the remaining 57 were considered rural. Distance from health facilities was used as one of the criteria for community selection to capture a representative spectrum of the challenges facing communities in maternal and child health. Four sessions were held in each community between May and September 2014, consisting of three CCs and one validation session that followed standard procedures [2]. The first CC session focused on exploring issues that affected communities in relation to family planning, ANC attendance, labour and postnatal services. The second session explored in detail the specific themes and challenges identified in the first session. Session three summarised the issues raised and allowed participants to suggest related solutions and community contributions to enacting these solutions. Session four was a validation session in which key stakeholders such as district and health centre staff, traditional leaders and politicians were informed of the issues discovered in the preceding three CCs and invited to provide suggestions on how these issues could be best addressed. The conversations lasted approximately 2 h each, and both men and women participated in each conversation. The questions focused on maternal and child health and explored the following themes: Within each theme, we explored some of the perceived benefits of health care service utilisation and the underlying causes for failure to use these services. In addition, community responses to the challenges were discussed, which led to summary action plans with clear roles for the community and the project. We used a fishbone diagram to graphically summarise the linkages between challenges and outcomes. Interviews were recorded, transcribed and coded inductively. Three research assistants trained in qualitative methods transcribed the interviews. Transcripts were cleaned and exported to NVivo 10 (QSR International; Melbourne, Australia) for analysis. Two of the authors (WM and RC) reviewed the interview transcripts, validated the pre-determined themes and identified additional themes and subthemes that emerged. Two researchers coded the data, and Cohen’s Kappa statistic was used to assess inter-coder reliability [6]. Data were organised by pre-determined themes. These formed the basis for broader themes, which were further sub-categorised to increase the explanatory ability of the data. To ensure that sustainable projects emerged from the data collected, stringent criteria were set a priori, and only proposals that met these criteria were selected for consideration. These criteria included the following: Ethical approval was granted by the University of Zambia Bioethics Committee. Participants were informed about the purpose of the conversations. Verbal consent was obtained from each participant.
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