COMMUNITY MOBILIZATION IN THE UNICEF/MINISTRY OF HEALTH CMAM PROGRAMME, AUGIE & BIRNIN KEBBI LOCAL GOVERNMENT AREAS KEBBI STATE, NIGERIA
MAY 2009
Emmanuel Mandalazi
Social & Community Development Advisor
Valid International
TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS 2
ACKNOWLEDGEMENTS 2
1. INTRODUCTION 3
2. IDENTIFICATION OF PILOT SITES 3
3. COMMUNITY MOBILISATION 4
3.1. Community Set up/features 4
3.1.1 Key Community Figures 4
3.1.2 Perceptions of Malnutrition 4
3.1.3 Health Seeking Behaviour 5
3.1.4. Barriers to Access 5
3.2. Community Mobilisation Process 6
3.2.1. Community Sensitisation 6
3.2.2. Case-Finding & Screening 7
3.2.3 Follow up 9
3.2.4. Ongoing Engagement 9
3.2.5. Monitoring & Evaluation of Community Mobilisation 10
4. CONCLUSIONS AND RECOMMENDATIONS 11
Annex I: Timetable of Activities 13
Annex II: Sensitisation handbill for key community figures: English version 14
Annex III: Sensitization handbill for key community figures: Hausa version 15
Annex IV: Sample photos for Community Mobilisation 16
Annex V: Training Content for CMAM Outreach Workers 17
Annex VI: Referral Slip Monthly Tally Form 20
ACRONYMS AND ABBREVIATIONS
CHEW: Community Health Extension Workers
CHO: Community Health Officer
CMAM: Community-based Management of Acute Malnutrition
CORPs: Community Owned Resource Persons
CTC: Community based Therapeutic Care
CV: Community Volunteers
GAM: Global acute malnutrition
JCHEW: Junior Community Health Extension Worker
LGA: Local Government Area
MAM: Moderate acute malnutrition
MOH: Ministry of Health
MUAC: Mid-Upper-Arm-Circumference
NGO: Non Governmental Organizations
OTP: Out-patient Therapeutic Program
SAM: Severe acute malnutrition
SFP: Supplementary Feeding Programme
TBA: Traditional Birth Attendant
TFP: Therapeutic Feeding Programme
UNICEF: United Nations Children Education Fund
ACKNOWLEDGEMENTS
Thanks to the entire UNICEF and Ministry of Health team for facilitating this visit. In particular I would like to thank Dr Naawa Silipiwe, Professor Frank Onyezili, and Mr San San Dimanche of UNICEF Abuja for their valuable insights and support rendered during this visit. Mrs Florence Oni of UNICEF Kaduna Regional Office was also instrumental in the daily logistical arrangements and guidance of the various community mobilisation activities conducted during the current visit. Last but not least, my gratitude goes to the Kebbi State (Birnin Kebbi and Augie LGAs) - Deputy Director of Health, Nutrition Officers and Health Educators for their positive disposition throughout the visit.
1. INTRODUCTION
This support visit aim was to provide technical support to UNICEF and the Ministry of Health in setting-up a pilot Community-based Management of Acute Malnutrition (CMAM) programme in Nigeria. The technical support was specifically provided to in two Local Government Areas (LGAs) – Augie and Birnin Kebbi of Kebbi State in Nigeria. The primary aim of the pilot project was to set up an alternative approach for the treatment of severe malnutrition in the state. The success of the pilot project would therefore, provide the necessary foundation for a state-wide scale-up strategy of the approach.
Valid International’s involvement in Nigeria started with an initial assessment, sensitization and planning visit conducted in December 2008. The strategy developed after this visit included the provision of further technical support by Valid International to assist in the selection of pilot sites and design and implementation of a context-specific, culturally-appropriate CMAM programme in the area. This report outlines the process of Community Mobilisation undertaken in the current pilot programme. The visit aimed to conduct a rapid socio-cultural assessment to inform the design of a community mobilisation strategy for the Kebbi State CMAM programme. The report presents the findings, activities and recommendations based on the work conducted between 22nd April and 22nd May, 2009 in Kebbi State (see Annex I). A rapid assessment was carried out at the start of the visit (first week), which involved identifying pilot sites, identification and training of outreach workers- volunteers (mainly for case-finding). The assessment also focused on gaining an understanding of the community perceptions and recognised treatments for malnutrition (paths to treatment/health seeking behaviour for malnutrition); key community figures, existing community groups and organizations; and potential barriers to the success of the CMAM programme. A thorough understanding of these issues was meant to help in devising a community mobilisation strategy which is proposed and discussed in the subsequent sections of this report. The second week of the visit was dedicated to community sensitization meetings and screening of SAM children by the trained volunteers in preparation for the opening of the OTP sites scheduled in the subsequent week in each of the two LGAs.
2. IDENTIFICATION OF PILOT SITES
Selecting appropriate project sites was crucial, to ensure the smooth development of the CMAM pilot project, and thus to facilitate effective roll-out of the programme into other LGAs in Kebbi State and even beyond. The role of Valid International in this process was to help and guide UNICEF State and Local Government Departments of Health in the selection of pilot sites. In order to facilitate this, the support visit was divided into two stages; a one-week period by the Valid Social and Community Development Advisor, and the implementation period conducted jointly by the Social and Nutrition advisors. The selection of pilot sites (both at State and LGA levels) was based on the following criteria;
· Health Infrastructure: including number of active Community Health Officers (CHOs), Community Health Extension Workers (CHEWs), and Junior Community Health Extension Workers (JCHEWs).
· Motivation: amongst health staff, and amongst community members to support the programme
· Accessibility: of selected areas to guarantee adequate monitoring by UNICEF/MoH.
· Potential for Scale-Up: taking into account the shared characteristics between the pilot sites and the rest of the LGA.
· Political and ethnic considerations to ensure that there is equal representation between the northern and southern divide of the LGA.
Following discussion with UNICEF and the Director of Health and Nutrition Officers and their Assistants in Augie LGA; Augie North, Bayawa North, Birnin Tudu, Garu and Tiggi were selected as the pilot project sites. Whilst in Birnin Kebbi; Ambrusa, Gulumbe, Kardi, Makera and Marafa were identified as pilot sites. This stage then led to the community mobilisation process in the selected pilot sites.
3. COMMUNITY MOBILISATION
The second and main objective of this visit was to develop a strategy for community mobilisation. In order to achieve this, preliminary socio-cultural data was collected and then specifically utilised for individual mobilisation activities. The process was geared towards identifying relevant information that would allow for a community mobilisation approach to be context-specific, culturally-appropriate with focus on existing mechanisms for sensitising and mobilising communities.
3.1. Community Set up/features
3.1.1 Key Community Figures
Through discussions with MoH and local communities, a number of key community figures were identified; influential individuals and groups who are generally responsible for disseminating information and mobilising communities. The characteristics described below reflect their roles and responsibilities in both of the LGAs (pilot sites). Due to their role in the communities and their potential contribution to mobilisation activities, these key community members became the community links for all CMAM mobilisation activities:
· District/Ward Head (Uban kasa): traditional leaders of communities. Each district head is responsible for a geographical portion called ward and represents a point of authority and reference for the communities. They are traditionally elected by important figures in their communities. There are 10 and 15 district heads in Augie, and Birnin Kebbi LGAs.
· Village headmen (Mai gari): these are also traditional. Also elected by members of each village.
· Traditional Birth Attendants (Unguzuma): traditional midwives at a community level. The role and skills are traditionally passed down through the generations. They continue to provide women with special ante-natal and post-natal care – through the use of herbal remedies and massages for example. As elderly women, they are a source of care and advice for women who cannot access or afford other health services.
· Immunization community-based volunteers who assist the health centre staff at during outreach activities in the communities (e.g. vaccination campaigns). The number varies between villages and they are not found in every village. They also receive remuneration (Naira 500 per day) for every activity they participate in.
· Ward/Village Development & Health Committees: These are found both at ward and village levels responsible for the coordination of all health activities. However, membership is male dominated. They could serve as an entry point at village level. It was reported that most of the committees are not very active as such when engaging with them effort has to be made to make sure that they are active.
3.1.2 Perceptions of Malnutrition
The following local perceptions of malnutrition - its causes in particular were found to significantly influence the choice of the available treatment options to different sections of the community for treating individual cases;
3.1.2.1 Feeding Habits
Across both programme areas (Augie and Birnin Kebbi LGAs) visited in Kebbi State, malnutrition is commonly associated with inadequate food intake by the child or the mother during pregnancy or when the child is not yet weaned. Poor food intake by the mother is perceived to affect the quality and quantity of breast milk the mother can produce and this would compromise the overall health of the child. Discussions with mothers at OTP sites and health workers suggested that solid foods such as porridge and rice are introduced into a child’s diet from a very early age (i.e. before six months).
3.1.2.2 Cultural and traditional beliefs and child care practices
The community believes that children would become malnourished due to parent’s failure to adhere to certain customs during pre and post-natal care. For example, breast feeding a child when the mother becomes pregnant and lack of insufficient food intake is believed to lead to wasting (tamowa) or oedema (shanciki). The breast milk of a pregnant mother is believed to be spoilt or poisonous and once the child suckles it may develop diarrhoea and become weak. Sometimes children may have a combination of signs and symptoms of wasting and oedema. As a result, a lactating mother is expected, upon discovering that she is pregnant, to wean the child prematurely in order to prevent the child from developing the disease.
Supernatural factors/causes were also found to play an important role in the interpretation of malnutrition. For example, evil spirits (chiwon iska or mereniya) were also identified as responsible for negatively impacting on a child’s health. It is important to note that families who attribute malnutrition to supernatural and cultural causes are more reluctant to be seen in public with such children because of the shame associated with the condition. This is particularly so where a failure to observe some cultural proscriptions during the pre and post-partum periods is concerned.
3.1.3 Health Seeking Behaviour
The paths or methods chosen by affected families when seeking treatment for malnutrition appear to be mainly determined by a number of factors including the perceived causes of the condition, the perceived quality and cost of the available treatment, and accessibility in terms of distance involved between homes and the services in question.
On the one hand, in many cases, families elevate traditional treatments to the first tier of health seeking behaviour as a result of the high quality of services they offer. This contrasts with dispensaries where often there is a shortage of drugs and no trained staff or where facilities are closed most of the time. This was apparent in Augie than Birnin Kebbi. Because the services of most clinics/dispensaries are comparatively expensive, some carers would opt for care from TBAs and Sheiks initially on account of their greater availability and low or non-existent fees. Distance, therefore, is an important factor in the decision as TBAs and Sheiks in particular may simply be the closest option available. This, of course, makes them to be a potential vehicle in the community mobilisation process.
On the other hand, when malnutrition is mainly associated with a deficiency in diet, families are most likely to improve the child’s diet by adding in cow’s milk as the first option. Such families are also reported to take their children to the dispensary for further assessment. But when the condition is associated with failure to adhere to the customs highlighted above, traditional or informal treatment is sought. As a first option, some family members (especially elderly women of the family or clan) may administer some local herbs to treat such conditions. When these simple remedies fail, then local health practitioners such as, sheiks, TBAs, herbalists or butcher men are consulted.
In instances when carers suspect supernatural causes such as evil spirits and breast feeding during pregnancy, traditional health practitioners become instead the first tier in health seeking behaviour. Only when such treatment is deemed ineffective by the carer is treatment from formal health structures sought. It was reported that when this happens it is the mother’s responsibility to take the child to the health facility. This practice may therefore, lead to late presentation of malnourished cases at the OTP sites when the condition would be difficult to reverse.
It is clear that paths to treatment of malnutrition in the current CMAM programme in Kebbi are complex. Further in-depth investigation of these socio-cultural issues is recommended so as to help develop more culturally appropriate social mobilisation component. In order for the community mobilisation component to achieve high programme coverage, it is important to engage with the various health practitioners and tap into the existing elements of the community and address the issues highlighted above.
3.1.4. Barriers to Access
A number of barriers to accessing health care were identified during this visit including culture, quality and cost of health services, shame and distance.
Culture: was also found to account for limited uptake of health services in the programme area. Culturally, in Kebbi men are not allowed to go into people’s homes/compounds on their own and talk to women. Women are also not allowed to go out of their compounds and talk to men unless if their spouses gives them permission. However, elderly women are free to go into any compound/houses freely.
Perceived quality and cost of services in the dispensaries: community members are often distrustful of the health care available. The poor health infrastructure and shortage of qualified health staff especially in Augie clearly contributes to lack of trust from the communities. The quality of care at the dispensaries, for example, as well as the quality of the drugs used is widely questioned.