Attendees gathered for the Community Dialogue Day.
This example was contributed by Ithar Hassaballa through a World Health Organization (WHO) Health Promotion Internship (summer 2012).
BACKGROUND ON THE COMMUNITY OF KOMO
The Thika West District, is a town located in the Central Province, about 40km north-east of Nairobi. Home to about 2000 residents, Komo’s main source of income is coffee farming with in Thika. Community Dialogue Day (CDD) is an open monthly community forum attended by Community Health Workers (CHWs), Community Health Extension Workers (CHEWs), community members, the director of malaria prevention, the chief, and elders. Also in attendance are representatives from the Ministries of Education, Agriculture, Water, and Health for the forum. The purpose of CDD is to draw conclusions on the state of the town. People are to celebrate their accomplishments of attaining goals (e.g., immunize all children for polio virus). Individuals are also expected to address their concerns and are held accountable to deliver their promises (e.g., each home in Komo will have at least one malaria net. Another purpose of the meeting is to give people ownership of their own health. As part of the meeting, the community chants in Swahili, “Afya yetu, jikumu letu.” “Our health is our responsibility.”
THE CONTEXT OF COMMUNITY HEALTH WORK IN KOMO
In November of 2010, 24 community members were trained in malaria prevention, health education, and water safety and sanitation as part of the Ministry of Health’s comprehensive plan for promoting healthy living and disease prevention. Community Health Workers serve as health advocates and have a wide range of roles that will be raised in this piece.
The key components of the intervention included:
- Malaria prevention: Providing malaria nets and education about the disease
- Health education: Basic nutrition and warning signs not to ignore (e.g., fever)
- Water safety and sanitation: Forms of water purification (e.g., boiling water), the importance of hand washing, and using a toilet
Monthly Community Dialogue Days provide a forum where CHWs and their supervisors from the Health Extension Office (CHEWs) meet with the community and share successes and health improvement within the community. This forum is also used to address challenges and seek community participation and suggestions for improving health outcomes in their communities. Ruth from the Ministry of Public Health & Sanitation noted, “We are able to mingle with the community openly. This community health strategy has been working. Health indicators are being captured by the community itself, which in return motivates the community to work on their weaknesses and celebrate their successes.”
IDENTIFY THE COMMUNITY PROBLEM/GOAL TO BE ADDRESSED AND WHAT NEEDS TO BE DONE.
Contaminated drinking water resulting from improper sanitation has become cause for concern in Komo. Residents in the area, particularly young children, have been suffering from diarrhea and other waterborne illnesses. Many homes in this community do not have toilets and most residents live far from public restrooms. As a result, residents often relieve themselves outdoors, creating unsanitary environments for others in the area. The negative consequences for those directly affected by sanitation issues range from diarrhea and worms to polio and even death.
Moreover, Komo supports itself through agriculture, which provides few opportunities for access to restrooms. The Ministry of Health has begun to address this issue by building public bathrooms, but more are needed. The Ministry of Health must continue to help the community build more public restrooms in Komo so that people may have access to restrooms within an appropriate distance from where they live and work.
ASSESS THE LEVEL OF THE PROBLEM/GOAL.
Community members within Komo have directly observed both young children and adults relieve themselves on the grass, and have expressed their concern for the sanitation hazards posed in the area by this practice. Although no statistics exists on the severity of the problem, the community had consensus that it is an important problem to address.
DESCRIBE THE PRIORITIZED GROUPS TO BENEFIT AND THOSE IMPLEMENTING THE INTERVENTION.
The population that is directly affected by health issues related to sanitation are the residents of Komo in Thika West District. The targets of change are the community members of Komo and their children. The negative consequences for those directly affected by sanitation issues range from diarrhea to death. Thus, it is essential that agents of change such as CHWs continue to provide skills and support to improve issues related to sanitation. Other agents of change include the chief, elders, CHEWs, the Ministry of Health, and the Ministry of Public Health & Sanitation of Thika West.
INDICATE HOW WILL OBTAIN CLIENTS' INPUT.
In addition to home visits to assess each family’s needs, focus groups were used as a space for sharing personal input and thought during CDDs. This format allows health promoters to understand what challenges Komo is facing and what improvements the community believes to be important. Focus groups also allow community members to be informed regarding what changes the government is implementing to help the local people, and what changes others in the community are doing to improve their own health. Every month, the community members, health workers, and representatives of different ministries get together for a baraza, a group forum, to discuss challenges, improvements, and current community health work and its progress within their community.
Additionally, concerned surveys were used to gather the community’s input regarding the specific issue of sanitation.
The following survey questions were asked as an interview format:
- Are there any new cases of diarrhea or sanitation related illness in Komo?
- Does your family have a toilet available within an appropriate distance?
- Do you witness behaviors that can be environmentally hazardous to Komo residents?
- What are the problems related to your community?
- Where can there be improvements?
ANALYZE THE PROBLEM OR (GOAL ) TO BE ADDRESSED BY THE INTERVENTION.
There are factors that put the community at increased health risk. For instance, Komo is a remote farming community about15km away from Thika Hospital, the primary care facility in the area. This puts the community at risk from lack of access to health care when waterborne illnesses arise in the community. The behavior that maintains the problem is the use or misuse of bathrooms and basic hygiene, like washing hands and keeping a clean environment. The appropriate level at which the problem should be addressed includes a range of individuals. The change must start with individuals and their families first. They must work on sanitation and teach one another sanitation habits and expectations. Families are expected to then connect with their neighbors and share information about sanitation and health. The city is required to share information and concerns during CDDs. The district has a responsibility to provide its ideas and important updates on the progress of the community. The Ministry of Health must also provide the communities with financial and technical support.
There are personal and environmental factors that need to be influenced in order to address the sanitation problem in Komo. People’s experience and history have posed a challenge for needed change; most people did not grow up using toilets so it has been a difficult to adopt the practice of using the bathroom. Personal factors include people’s limited knowledge and skills; also, the limited opportunities (toilets) for them to respond (use the bathroom). Environmental factors include physical barriers or the distance between where people live, work, and play and bathrooms.
Some of the challenges affecting the issue of sanitation include:
- Rainy conditions increase the prevalence of malaria and increase waterborne illnesses
- The lack of transportation to Thika Hospital (15km) so people can seek help from a healthcare professional
- The lack of early detection of disease
- Children are not going to school—a place where basic sanitation and hygiene is taught—instead they are working in local farms to support their families.
- The voices of those who are unable to attend CDDs (due to distance) are often not heard
There are barriers, but at the same time, there are also opportunities for improvement.
The opportunities affecting the issue are:
- APHIA (AIDS, Population and Health Integrated Assistance) recognized Komo for their continued improvement and APHIA is funded by USAID (United States for International Development)
- The Ministry of Health created a better referral system where people can go if they need help, assistance, or medical service.
- Komo’s improvement efforts and strategies have been recognized by WHO and by the Ministry of Health
- Due to the recognition by a number of organizations, financial and social support to Komo residents increased.
SET GOALS AND OBJECTIVES FOR WHAT "SUCCESS"WOULD LOOK LIKE.
Significantly reducing the number of illnesses, and subsequent mortality rates, caused by sanitation issues would be a good indicator of success. Reaching the goals of proper nourishment, immunization, and antenatal (prenatal) care are essential to achieving larger aspirations. The mission of the initiative is to build a bathroom in every home. The intervention would be successful if all people in the Komo community had a restroom available to meet their needs.
Goals and Objectives:
- By December 2014 each family will have access to a nearby bathroom (no more than 200 feet)
- By January 2015, waterborne illnesses related to sanitation should decrease by 50%.
IDENTIFY AND ASSESS “BEST PRACTICES ” OR “EVIDENCE-BASED INTERVENTIONS ” tTHAT COULD HELP ADDRESS THE PROBLEM OR GOAL IN YOUR SITUATION.
The Kenyan government developed its own intervention using CHWs as mobilizers within each county in Kenya. The intervention utilizes the CHWs as messengers between the people and the ministry. The ministry’s goal was to develop a culturally appropriate task force who understand the community’s cultural traditions and practices. Community Health Workers must be willing to improve the conditions affecting the local people, they must reside within the community, and must be keen in paying attention to health matters. There is emerging literature on CHWs and their role in communicating culturally competent information have been shown to make change in adapting healthy behaviors amongst minority populations.
SPECIFY THE CORE COMPONENTS AND ELEMENTS OF THE INTERVENTION.
Figure 1: Table of intervention components, elements, and mode of delivery.
The main community health strategy is to prevent disease and offer supports for people to become responsible for their own health by adopting healthy behaviors. Community Health Workers —elected by their own communities—must meet certain criteria:
- They must be a resident of the area for 5 or more years
- They must be able to read and write
- They must be able to have influence or impact the community positively
Community Health Workers ask their assigned 100 households about the status of the family’s health (i.e., how many people live in the house hold, is the wife pregnant, how many wives does the man have, is there enough food, are the children immunized, is there a bathroom at home, where is the trash disposed, etc.) . Each community health worker visits each of the 100 households and collects health data twice per year. The CHWs then give the reports to the CHEWs who then pass the data along to the ministries. CHWs provide training and guidance to CHWs. They have more experience working in the field and are promoted after working as CHWs.
Community Health Workers utilize home visits to provide health education to Komo residents. In addition, they clean homes of mosquitos, distribute condoms, administer deworming treatments to children, encourage the use of health facilities, participate in national health days (e.g., National HIV Awareness Day), prompt healthy practices, and promote health and sanitation practices such as hand washing and toilet use. With the help of the Community Health Workers, community residents are now aware of their right to health and wellbeing. Residents also understand the role they can play in their own health and the health of others within the community. There is a strong tie between the hospital and the community as a result of the efforts of the Community Health Workers promoting health services to the people of Komo as a part of this intervention—a linkage-to-care or referral system.
IDENTIFY THE MODE OF DELIVERY THROUGH WHICH EACH COMPONENT AND ELEMENT OF THE INTERVENTION WILL BE DELIVERED IN THE COMMUNITY.
The mode of delivery of the components of the intervention is through direct communication by CHWs to the community during CDDs; there are also monitoring communications through mobile phones and through home visits. These health advocates reach Komo residents and collect personal health data and administer health education and promotion. Please see Figure 1 for a list of modes of delivery.
INDICATE HOW YOU WILL ADAPT THE INTERVENTION OR “BEST PRACTICE ” TO FIT THE NEEDS AND CONTEXT OF YOUR COMMUNITY.
The intervention that was created by the Kenyan government took into account the cultural values of its citizens. In some cases, it is found that some people are unable to read or write in rural communities in Kenya. Also, developing an intervention format that meets those at all literacy levels was an important consideration to assure that rural farmers, benefit from the efforts of the initiative. Additionally, during the monthly Community Dialogue Day, two languages are used to assure that all participate in the discussion. The local language is used to reach everyone (Kikuyu) and the national language (Kiswahili) is used to make sure all representatives and those from the ministries understand the community.
DEVELOP AN ACTION PLAN FOR THE INTERVENTION.
Figure 2: Action Plan Example
This intervention will be maintained until the community’s health improves and until sanitation is not the main issue in Komo. The intervention will be maintained until each family has a bathroom to use within close distance.
PILOT-TEST THE INTERVENTION ON A SMALL SCALE.
The intervention was first implemented in 2007 in rural Kenya and it proved to be promising in engaging the community and lowering health issues. This intervention was scaled up to other parts of Kenya a year later, in 2008.
IMPLEMENT THE INTERVENTION, AND MONITOR AND EVALUATE THE PROCESS (E.G., QUALITY OF IMPLEMENTATION, SATISFACTION AND OUTCOMES (E.G., ATTAINMENT OF OBJECTIVES).
The intervention did improve the health of the community and it is still continuing to improve community outcomes. Because of this intervention, more residents are boiling their water and adopting sanitary behaviors. Other important outcomes are being measured in Komo; pregnant women are attending antenatal (prenatal) clinics prior to their deliveries. The number of deliveries by unskilled birth attendants has decreased to 0 in June 2012. There are more indicators that show individuals are taking responsibility for their own health in Komo including the increase of CDD attendees per month. This example is available so neighboring African countries and the global community can understand the value of CHWs and whether they are able to adopt (or adapt) such an intervention.
After the CDD, children of Komo posed for a picture with Cara Smith and Ithar Hassaballa
- APHIA Plus Kamili
- Kenya’s Ministry of Public Health & Sanitation (Miss Ruth)
- The community of Thika West (Komo)
- WHO office in Nairobi, Kenya