FINAL REPORT
ON
A QUALITATIVE EVALUATION OF THE JOINT NSGA/CIAM PEER HEALTH EDUCATION PROJECT ON MALARIA
AUGUST 2004
Evaluation Team:
Mr. Yusupha F.J. Dibba – Lead Consultant
Mr. Sakou Jobe- Associate Consultant
Mr. Mamadou A. Bah- Associate Consultant
TABLE OF CONTENTS
i.List of Abbreviations and Acronyms
ii.List of Tables
iii.Acknowledgement
iv.Executive Summary
1.Introduction
1.1Background to the Study Area
1.2Background to the Peer Health Education Programme
1.3Aims/Objectives of the Peer health Education Programme on Malaria
1.4Justification
1.4.1Objectives of the Evaluation
2.Methodology
2.1Introduction
2.2Sampling Procedure
2.3Training of the Enumerators/Facilitators
2.4 Questionnaire Administrations and FGD Guide
2.5Quality Control
2.6Data Processing, Analysis and Reporting
2.7Limitations/Constraints
3.Main Findings and Discussions
3.1Quantitative Findings
3.1.1Training of the Peer Health Educators
3.1.2Issues and concerns raised by the PHEs during the training
3.1.3Other activities undertaken by the Regional Coordinators
3.1.4Malaria Intervention Activities undertaken by PHEs
3.1.5Integration of the Malaria module into the school curriculum
3.2Qualitative Findings
3.2.1Introduction
3.2.2Sensitization and Community Awareness
3.2.3Community Participation in the PHEP on Malaria
3.2.4Message Delivery: Contacts, Type, Channels, Methods and Frequency
3.2.5Community Perception and Understanding about the Effectiveness of Messages
3.2.6Advantages of using PHEs
3.2.7Potentials/opportunities of using teachers
3.2.8Barriers, Constraints and Challenges
3.2.9Issues Around Change and Impact
3.2.10Sustainability
4.Conclusions and Recommendations
4.1Conclusions
4.2Recommendations
List of Appendices
Appendix 1The Terms of Reference for the Consultants
Appendix 2Profile of Peer Health Educators registered in the Evaluation
Appendix 3Focus Group Guide (Checklist of Issues Addressed)
Appendix 4Evaluation Questionnaire
Appendix 5Number of FGDs conducted by Location
List of Tables
Table 3.1: Distribution of schools by type of school
Table 3.2:Distribution of PHEs by division and gender
Table 3.3:Opinion about the duration of the training by number of days trained
Table 3.4:Issues/concerns raised by PHEs by Local Government Areas
ACKNOWLEDGEMENT
This evaluation was executed with the invaluable technical and moral assistance of different institutions and individuals, without which the exercise would not have been carried out successfully.
We wish to acknowledge the contribution of all those who in one-way or the other made the realization of this endeavour possible. The enumerators and supervisors who carried out the fieldwork and supervision were very cooperative and hardworking throughout the course of the evaluation. Without them the field investigations would not have been completed, we thank them all for their invaluable support. Head teachers, teacher coordinators and other teachers and students also played an important role in various ways. We wish to extend our sincere gratitude to them.
The community members: men and women who are the target beneficiaries of the Peer Health Education Programme (PHEP) must be commended for the understanding, tolerance, cooperation and commitment demonstrated by them during the focus group discussions FGDS despite their busy work schedule on the farms.
Essential background information on the PHEP was provided for use in this evaluation by Nova-Scotia Gambia Association (NSGA) in addition to discussions held with them. Special thanks are extended to them for their kind support.
Centre for Innovation Against Malaria (CIAM) Gambia were most helpful and understanding. We express our most sincere gratitude to them for their meaningful briefing, comments and suggestions on the first draft, which has contributed significantly to the final outcome of this exercise. We are particularly grateful to the leadership of CIAM for giving us this opportunity to play a role in the global efforts to prevent and control the spread of malaria in The Gambia in particular and the world at large.
Finally, we take full responsibility for any shortcomings associated with this report.
LIST OF ABBREVIATIONS AND ACRONYMS
AAASThe American Association of Advance Science
BCSBasicCycleSchool (Grades 1-6)
CIAMCenter for Innovation Against Malaria
CRDCentralRiver Division
DOSEDepartment of State for Education
FGDs Focus Group Discussions
GBAGreater Banjul Area
GRTSGambia Radio and Television Services
ITNs Insecticide Treated Bednets
KAPKnowledge, Attitude and Practice
KMCKanifing Municipal Council
LRDLowerRiver Division
NBDNorth Bank Division
NSGANova-ScotiaGambia Association
PHEsPeer Health Educators
PPAParticipatory Poverty Assessment
UBSUpperBasicSchool (Grades 7-9)
UNICEFUnited Nations Children Educational Fund
SPACOStrategy for Poverty Alleviation Coordinating Office
SSSSenior Secondary School (Grades 10-12)
URDUpperRiver Division
WAISWest AfricaInternationalSchool
WDWestern Division
WHOWorld Health Organization
Executive Summary
This evaluation/study was commissioned by CIAM to determine how the joint CIAM/NSGA Peer Health Education Programme on the Prevention and Control of malaria was implemented in the school communities they work with and its likely impact and sustainability in a school setting.
To this end, both quantitative and qualitative data were obtained from the students, teachers and a cross section of the 27 school/communities in different parts of The Gambia covered in this evaluation.
The main findings suggest that it is possible to implement the PHE programme on malaria by working directly with teachers to communicate non-sensitive issues such as malaria to the community. It also found out that the integration of the malaria module (component) into the school system has been effective in raising awareness of ways of preventing and controlling the spread of malaria.
This programme has helped the people to be aware of the means of addressing their malaria burden and improve their well-being. The task has not been easy as could be seen in the barriers, limitations and challenges discussed above. The intervention is obviously well appreciated by the beneficiaries and there is merit in expanding and taking it forward with continued support from CIAM/NSGA. It can be made more innovative through continuous research and consolidation, for example the use of teachers or say extension workers in communities where this is culturally and logistically applicable.
As disclosed by the focus group discussions, mothers/caretakers are quite aware of the involvement of the NSGA trained PHEs in malaria control activities. Evidently, the PHEs have done some good work going by the observations made by several community members, e.g. receiving and acting on the malaria messages and the reduction in malaria cases
Across all divisions the malaria messages are well perceived and understood. They do not seriously conflict with any given community values/cultural norms. Generally, community members/respondents have trust in the PHEs and their malaria messages and are of the view that the malaria messages are effective.
In some rare cases people appear to recognize and lay emphasis on modern medicine rather than traditional means. Taking sick children to health centres (clinics) and taking the medication accordingly are identified as their ways of handling malaria cases. Understanding the cause - effects relationships of malaria, acting on messages, reduction of malaria cases (prevention and control) and the request for increased interaction with PHEs are other positive aspects.
As indicated in the findings mothers/caretakers used a combination of traditional and modern ways of handling malaria, with greater success now, especially on the preventive side. It was noted that community handling of malaria cases is generally better than its control. Meetings and drama approaches are seen as effective.
To a greater extent, there is evidence of significant benefits, change and outcomes/impact as a result of the Peer Health Education Programme on malaria. These include increased awareness and knowledge about malaria including prevention and control, reduction in malaria cases and malaria related visits to health facilities, eagerness to learn more and take forward the malaria programme. The knowledge and skills gained by PHEs and mothers/caretakers is a useful social development and community resource. Attitudinal and behaviour change towards participation and involvement in improving malaria response and general health is noted, e.g. increased community action towards malaria prevention and control, particularly the environmental sanitation activities.
The PHE programme is innovative and has a high potential for considerable multiplier effect. A considerable amount of progress and positive outcomes have been generally registered, e.g. reduction in malaria related cases, and people taking control of malaria management in their communities by acting on messages promptly and effectively. PHEs are generally accepted in their communities and are generally listened to. Women are the main beneficiaries and actors in the programme. This fact is shown in the FGDs where women participants overall form the majority.
Considering the findings and the potentials of the programme, there are high prospects for sustainability. The programme has a stable infrastructure being both school and community based. It has the support of the Department of State for Education Government. Malaria in the Gambia remains an endemic health problem and initiatives of this nature should be extended and enhance.
1.Introduction
Malaria is acomplex and major health problem, which pose a great challenge especially to Africa. About 80 to 85 percent of malaria cases and 90 % of malaria related deaths worldwide take place in the continent. The problem is most acute in sub - Saharan Africa. Malaria in the Gambia is endemic and seasonal with more cases reported during the rainy season (June to October). As reported by the National Malaria Control Programme between 1989 and 1999, a total of 2.6 million cases of malaria were reported in the Gambia of which, 200,000 cases were children under the age of five years and 15,000 were pregnant women who are the most vulnerable groups susceptible to the disease (CIAM/NSGA 2002 (a) P10 and CIAM/NSGA 2002 (b), P12). In addition, in the Gambia, individuals may be bitten by infected mosquitoes as many as 1000 times in the year. Malaria account for up to 40% to 60% of out patient consultations at health facilities in the country. At least 1000 children aged 1-4 years die from the direct effects of malaria each year. In 1998 alone, an estimated 80,000 infants under the age of 12 months and 100, 000 children between the ages of 1-4 years were reviewed and treated in MCH clinics for chemical malaria.
Meanwhile, studies conducted in Africa and in the Gambia, demonstrate that insecticide treated bed nets (ITNs) can reduce deaths among children under five years of age by up to one third. It is in recognition of the gravity of the malaria pandemic, especially on women and children that in the Abuja Declaration, African Heads of States resolved to provide effective malaria interventions to 60% of women by 2005.
As malaria is not merely a medical problem but it also a behavioural one, strategies, they must take into consideration, social, cultural and economic factors. Community–based participatory strategies yield far greater results than top down ones because they match better with what prevails at community level where people are playing leading roles and taking decisions related to malaria prevention and control.
In the face of limited awareness, prevailing poverty, and established social and cultural norms and overall health challenges, the design and implementation of locally innovative and sustainable approaches at community level are critical.
1.1.Background to Study Area
The poverty and human development indicators for the study area: KMC, WD, NBD, LRD, CRD and URD shows that poverty is a prevalent and limiting factor. This corresponds to the national poverty situation which according to the Participatory Poverty Assessment (1999-2002), can be summarized as follows:
- Overall, 69% (1998 Household Poverty Survey), of Gambian households lived below the poverty line compared to 33% in 1992/1993.
- More than 50% of Gambian households live in abject poverty, meaning that they are extremely poor.
- Extreme poverty has more than double ( from 15% in 1992/1993 to 51% in 1998).
The implications of this poverty situation for the communities in the study areas include the following:
- High disease prevalence during the rainy season mainly because diets are poor at that time and there is little or no cash for health care, particular malaria control. Due to poor environmental sanitation, stagnant ponds and mosquitoes breed abundantly;
- Food scarcity leads to sickness especially among children under five years of age who have to be taken care of. Furthermore, food shortage undermines the productive potential of the communities;
- Among the reasons given for some children not attending school, is the high cost of education for parents i.e. school fees, books and uniforms. Cost according to the 1999-2002, is the most frequently cited reason why parents are reluctant to send their children to school.
- The road conditions in all study divisions are extremely poor and this affects the economic potential of the communities. Telecommunication facilities are not easily accessible in many places and few villages have telephone facilities;
- Access to potable and safe drinking water for domestic use varies across villages. Access to water is more difficult in areas such as the north bank of URD, where the water table is predominantly very low. The use of open wells and river water contribute to poor health;
- Health problems in the study areas are quite numerous, a fact also stated by the 1999-2002 PPA National Summary Report. The problems include lack of drugs at health facilities and the high cost of private pharmacies. In several cases people rely on traditional medicine. Another major problem is the usually long distance people have to travel to reach health facilities;
- The national report on the Health Sector PPA (December 2003) highlights similar problems in the study divisions. Key factors hindering the full utilization of modern health care services include: peoples’ poverty, which is restricting expenditure on their health and that of their families. Transport cost to travel health facilities and the affordability of cash to adequately pay for health services e.g. consultation fees and laboratory fees;
- Limit in terms of type of services available in their locality;
- Periodic shortage of drugs, personnel as well as medical equipment, consequently inducing frequent referrals to major health facilities; Therefore, communities often rely on traditional healers and medicine as coping strategies.
- To some extent the heavy work load and economic burden especially on women limits their timely access to health care services.
1.2.Background to the Peer Health Education Programme
The Centre for Innovation Against Malaria (CIAM), was established in August 2001. Its overall goal is to reduce the malaria burden and improve the health and well being of Gambians and those in the sub-region through the design and implementation of innovative, effective and appropriate health promotion activities.
One of CIAM’s current activities is the integration of a malaria module within an existing school-based Peer Health Education Programme implemented by the NGO Novo Scotia Gambia Association (NSGA).
The Nova Scotia Gambia Association (NSGA) Peer Health Education Programme is a development project initiated in April 2001, in The Gambia, West Africa. The NSGA, a Canadian based NGO with a long history in the Gambia, bears sole responsibility for implementing and managing the programme.
The NSGA Peer Health Education Programme was designed to expose junior and senior high school students throughout Gambia to a comprehensive health education programme delivered by peers. The programme is directly managed by the executive director, through Regional Coordinators responsible for each of the administrative divisions in The Gambia. The regional coordinators liaise with teacher coordinators at each school as well as divisional focal persons representing the Department of State for Education (DOSE). The teacher coordinators are designated by their principals to work with the PHEs and provide them with technical support. The programme is considered an extra-curricular activity, even though most of the activities take place during the school day and within the classroom. Some schools have up to two teacher coordinators.
The peer health education team in each school generally comprises 10 boys and 10 girls, though this varies in certain cases and can be bigger especially in larger schools. The NSGA also recruits professional drama troupes, usually comprising of former PHEs, in each of the divisions in the country. The main purpose of the troupes is to present health promotion skits in public venues. They are also often enlisted to help train and mentor PHEs.
The objectives of the Peer Health Education Programme is to improve the health and well being of youth by empowering them with the knowledge, skills and confidence to take responsibility for their own health. The integration of the malaria module in this programme is expected to improve the community’s knowledge on malaria, particularly mothers and careers of children under 5 years of age.
NSGA implements the malaria programme in over 120 upper basic and senior secondary schools in The Gambia covering a wide range of health related issues. In each of these schools, the NGO recruits an average of 20 Peer Health Educators, who are supported by one or two Teacher Coordinators. Teacher Coordinators receive a two-day malaria training conducted by regional coordinators who supervise 20 schools each.
The malaria component of the PHEP was implemented in two phases – 5 schools in 5 communities (April to July 2003) and 22 schools in 12 communities (September 2003 to July 2004). Peer Health Educators received two-day malaria training course, following which they had ten weeks to transfer key malaria messages to mothers/caretakers of children under the age of five years living in their compounds or neighbourhood. The evaluation of phase 1 was undertaken by CIAM and its field assistants visited the homes of the PHEs to conduct KAP surveys before and after ten weeks of intervention.
In September 2003, the malaria component of the peer health education programme was scaled up. This phase was evaluated in 22 schools that are located in 12 communities across the country.
1.3.Aims/objectives of the PHE Programme on Malaria
- The aim of the programme is to establish well-informed teams of PHEs in schools and equip them with the knowledge, skills and strategies to conduct ongoing presentations to children and youth in their own schools and communities about malaria prevention and control
- Assess how school–based peer health education programme on malaria impacts on knowledge and attitudes in the broader community, particularly on careers of children under the age of 5 years.
- Demonstrate an effective model for addressing malaria prevention and youth health issues which can be used in other countries in Africa.
1.4.Justification