Every day in a small village in central Ghana, she crosses a river to reach her subsistence farm on the other side. She climbs up a dirt hill out of the water and soon forgets about her traverse across as her wet feet dry in the sun. She spends the day farming okra until it is time to make the journey back home when she once again crosses the river and directly trudges through the water. She spends the evening caring for her large family and sweeping dirt out of her home, but she is very tired while she works. She knows something is not right; she knows her fatigue, bloody urine and diarrhea, and fever are resulting from her walk through the river. She cannot afford to not walk through the river, and her village cannot afford to build a bridge. Every day she and many others in the community are knowingly affected by the chronic disease schistosomiasis, caused by a parasitic flatworm, as they walk through the river. This condition started to change once a massive intervention occurred in the community.
In 2003, researchers from the Department of Family and Preventive Medicine at the University of Utah were asked to assess and recommend health interventions in the community of Barekuma, a village in Ghana, West Africa. According to Dr. Steve Alder, a lead investigator, “We started out with the idea we would go in and fix things (the typical approach that is often taken), but we realized quickly that was not going to work.” The initial assessment vision rapidly evolved into a participatory evaluation process that extended beyond the outside researchers to rely on local experts, local interpreters, village chiefs and elders, leadership counsels, community members, and researchers and physicians from the neighboring hospital and university. Dr. Alder reflected, “We had a very receptive village, a capable village, and an enlightened leader, Chief Nana Kwasi Tabiri—it was that combination of circumstances that took us from what would have been an unfortunate path to take initially to a much better approach that I am now convinced represents the way this type of work should be done almost exclusively.” Now, the “basic thrust of the community development projects is to build upon the self-reliance of communities and look to see ways in which we can capitalize on resources that are there and access resources that aren’t there with the specific focus of reducing health disparities.” The outcome of this collaboration was the Barekuma Collaborative Community Development Project (BCCDP), a partnership that views the community as a unit, is of mutual benefit to partners, creates a space for co-learning, fosters intervention sustainability, and builds on existing strengths and resources (Duncan). The project impacts a cohort of approximately 40,000 rural village residents within Barekuma and its surrounding villages.
The project began with a needs assessment that involved community members in the decision-making process so the interventions would reflect the priorities of the community members, and would incorporate the beliefs and cultural etiologies of the community members. In earlier interventions, prior to the BCCDP presence, standpipes, were introduced to replace drinking water from the river and wells. Standpipes are freestanding pipes which provide a communal source of clean drinking water. Barekuma used the standpipes while water was free, but when a small fee was introduced, community members rejected the water and rationalized the refusal by saying the water was poisoned. If a community assessment was done prior to the project, instead of merely postulating community needs, they would have discovered the importance of wells to community members and would have learned to incorporate changes that enhanced existing wells. Implementing standpipes has been beneficial in other impoverished rural areas, but did not meet the community needs of Barekuma because of the way they were implemented without interacting with the community.
Prior to researchers from the Department of Family and Preventive Medicine at the University of Utah implementing and evaluating interventions, a community assessment was developed that included several elements: census and demographic information, physical exams, water and sanitation analysis, focus group and community member interviews, and a disease cluster map of the community. Community assessment is a continual process whereby the changing needs of the community are evaluated. The researchers had not anticipated the need for economic and agriculture components, but due to the information community assessments yielded, these have become integral components of the intervention. Over the course of four years, the project has defined a variety of community needs and priorities. Methodologies for key learning involved both the collection of quantitative data in the form of GPS disease cluster mapping, medical exams, and malaria rapid test kit use and qualitative data in the form of focus group and individual interviews. Challenges in focus group interviews included women answering in unison reflecting a collective culture and a hesitance to answer questions of a sensitive nature. This challenge was ameliorated by augmenting focus group responses with individual interviews. Women were found to be key players in the health of the villages so they were the main population targeted in focus group interviews. Questions in a variety of areas assessed breastfeeding, immunizations, health priorities, health beliefs, finance, and food security. A direct priority that was identified through the interviews was to increase sanitation, and flush toilets were subsequently built. Listening sessions and meetings with community elders identified satisfaction and experience of the intervention and additional community priorities.
It became evident that the health of the community was complex and multifaceted. Women were sometimes sick with malaria three times a year, which impacted their ability to bring income to their families and therefore limited their opportunity to provide nutritious foods. This cyclical process was penetrated by practices such as the creation of microfinance projects, a fruit plantation that took the village beyond subsistence farming, and altering local wells to prevent standing water and increase water quality. With income from the orange plantation, the community hopes to build a bridge to reduce the prevalence of schistosomiasis from walking through the river. Future activities for the area are to provide a field site for community trials to expand the research base, implementing the Integrated Management of Childhood Illness (IMCI) scheme, and scaling up and adapting the intervention to other villages in West Africa. IMCI is World Health Organization’s “integrated approach to child health” that “promotes the accurate identification of childhood illnesses in outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers, and speeds up the referral of severely ill children” (WHO). Dr. Alder said of the process, “We experienced growth pains, but now having gotten through those, we are really positioned well to not only do this in Ghana but to take the framework with appropriate tailoring to other countries.” Because the project involved local community members and addressed pertinent community needs, the project has increased sustainability and now is moving toward efforts to make the BCCDP a completely Ghanaian led project.
For others engaging in similar participatory research and intervention projects, Dr. Alder recommends being “very self-reflective before engaging in the process of truly what strengths or weakness one would have to offer to that type of a setting, to be able to recognize where the community, academic, or other expertise comes together, and to look at the many examples of successes and failures to find where to begin.”
Alder, S. Telephone interview. 23 Oct. 2007.
Duncan, M. "Using Community Based Participatory Research to Develop Effective Health Interventions in Rural Ghana." Global Health Education Consortium. 16 Feb. 2007. University of Utah Department of Family and Preventative Medicine. 10 Oct. 2007. Using Community Based Participatory Research to Develop Effective Health Interventions in Rural Ghana.
Integrated Management of Childhood Illness. World Health Organization. 2005. 06 Dec. 2007.