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Community-Based Reproductive Health: the only way to go. Mary Beth Powers Senior Reproductive Health Advisor Save the Children/US. Today’s Agenda. Background on community based RH Save the Children’s approach to CBRH Results Framework for Health

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Community based reproductive health the only way to go l.jpg

Community-Based Reproductive Health: the only way to go

Mary Beth Powers

Senior Reproductive Health Advisor

Save the Children/US

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Today’s Agenda

  • Background on community based RH

  • Save the Children’s approach to CBRH

  • Results Framework for Health

  • Community level interventions to address barriers to good RH (behavior and care)

  • Practicing community interventions

  • Community participation will be requested…

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Community-Based Reproductive Health

  • Who owns your reproductive health?

  • What is a community?

  • What do we mean by community based?

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A SC working definition

Community based reproductive health

  • Suggests that health information and services are not merely located within the community, but are “owned by the community”

  • Recognizes that much of health itself is “owned” by the individual through their own behavioral choices and may not require any interaction with the health system

  • and that community members understand their responsibility and contribution to good health and good health care.

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How SC works…

  • Four modes of operation:

    • Direct service delivery (especially in emergencies)

      and in partnership with MOHs & NGOs to:

    • Expand service delivery points

    • Improve the quality of services available through strengthening existing providers

    • Mobilize communities to utilize and/or improve existing or expanded services

      focusing typically on underserved/marginalized/ disenfranchised populations.

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Results Framework for Health Program Design, Monitoring and Evaluation

Strategic Objective: Improved Health Status

Improved practice of key behaviors/use of appropriate services that protect/promote health status

Access/Availability of information & health services

High quality health services/counseling

Demand for health services/intention to practice healthy behaviors

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Some examples of access/availability concerns Evaluation

  • Adolescents

  • Pregnant women/women in labor

  • Family Planning clients

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Expanding service delivery points to increase ACCESS to care Evaluation

  • Identification of community depot holders (contraceptive supplies, drug boxes)

  • Adding new service to local health post

  • Training local health workers/community volunteers to deliver some services

  • Partnering with private sector to sell needed health care supplies

  • Improving hours of operation

  • Addressing cost concerns

  • Making services more culturally acceptable

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Quality challenges Evaluation

  • Provider communications skills

  • Provider technical knowledge/skills

  • Patient understanding/compliance

  • Infrastructure problems

  • Drug availability/method mix

  • Patient flow

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Improved Quality of Health Services Evaluation

  • Standards/protocols in place/used

  • Diagnosis/Counseling skills

  • Infrastructure improved

  • Patient flow improved

  • Interpersonal communications

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Demand/Behavior Challenges Evaluation

  • Knowledge of illness/wellness and of services available

  • Perceptions of services/service providers

  • Risk/symptoms assessment

  • Cultural “prescriptions”

  • Social barriers/social pathways to care

  • Etc…

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Increased Demand for Services/ EvaluationIntention to practice healthy behaviors

  • Knowledge (of services, symptoms, behaviors)

  • Positive attitudes/Acceptance

  • Community norms supportive

  • Intention to practice

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Internal Determinants of Behavior Evaluation

  • ·Self-efficacy: an individual’s belief that he or she can do a particular behavior

  • ·Perceived Social Norms: perception that people important to an individual think that’s/he should do the behavior; norms have two parts: who matters most to the person on an particular issue, and what s/he perceives those people think s/he should do

  • ·Perceived Consequences: what a person thinks will happen, either positive or negative, as a result of performing a behavior

  • ·Knowledge: basic factual knowledge

  • ·Attitudes/associations: a wide-ranging category for what an individual thinks or feels about a variety of issues

  • ·Perceived Risk: a person’s perception of how vulnerable they feel

  • ·Intentions: what an individual plans or projects s/he will do in the future; commitment to a future act. Future intention to perform a behavior is highly associated with actually performing that behavior

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External Determinants of Behavior Evaluation

  • ·Skills: the sets of abilities necessary to perform a particular behavior.

  • ·Access: encompasses the existence of services and products, their availabilityto an audience and the audience’s comfort in accessing desire types of products or using a service

  • ·Policy: laws and regulations that affect behaviors and access to products and services

  • ·Culture: the set of history, customs, lifestyles, values, and practices within a self-defined group. May be associated with ethnicity or with lifestyle

  • ·Actual Consequences: what actually happens after performing a particular behavior

  • ·Relationship Status: type of relationship, i.e., short-term/long-term, casual/serious, monogamous/multiple partners

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SC responses/methodologies to address community level barriers

Community Mobilization

  • a process by which individuals, groups and institutions at different levels of society engage in sustained and concerted action around a common objective.

  • SC identifies, organizes and works with key groups and individuals to engage and mobilize them through participatory adult education techniques to plan sustained action on a mutually defined problem through a cyclical process.

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Why Community Mobilization for behavior change? barriers

  • Belief that behavior change at the individual level is in part conditioned by community norms

  • Greater likelihood of sustainable change

  • Diffusion of innovation – moving the tipping point

  • Community action in “spreading the word” allows for greater relevant dialogue

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SC methods for Community Mobilization (under documentation for behavior change outcomes)

  • Positive Deviance Inquiry/Hearth

  • Appreciative Community Mobilization

  • SECI


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Positive Deviance Defined for behavior change outcomes)

  • “Positive Deviance is a departure, a difference, or deviation from the norm resulting in a positive outcome”

  • Identifying the positive deviants – and their beliefs and practices – can reveal hidden resources from which it is possible to devise solutions that are cost effective, sustainable, and internally owned and managed

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Criteria for use of Positive Deviance for behavior change outcomes)

  • The objective is social/behavioral change in a prevalent practice

  • The problem to be addressed is widespread or the norm

  • There are some individuals (a minority of the population) in the community who already exhibit the desired (positive deviant) behavior

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Who are the Positive Deviants? for behavior change outcomes)



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What are we trying to understand through PDI? for behavior change outcomes)

Policy environment

Peer pressure


Desired Health Promotive/Protective Behavior




Desired Health Outcome or Health Status

PDI subject

PDI subject

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Illustrative Uses Of Positive Deviance for behavior change outcomes)

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PD applied to Malnutrition for behavior change outcomes)

  • Defined community norms that affect the nutritional status of children

  • Identify well nourished children from poor families in the community

  • Conduct home visits to look for what they are doing differently

  • Analyze findings and design intervention

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PDI/Hearth Model for behavior change outcomes)

Hearth components usually include:

  • Positive Deviance Inquiry

  • Nutritional assessment of children

  • Training volunteers and staff

  • Two week nutrition and rehabilitation sessions: mothers prepare meals based upon PD foods/practices (including active feeding) and adult learning on other health practices

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Results: Assessment Indicators for behavior change outcomes)

  • Increments in Weight-for-age: the indicator child and the siblings

  • Increments in Knowledge, Skills, and Attitudes of Mothers/Caretakers

  • Creation of well-functioning and sustainable volunteer community structures

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Vietnam: Longitudinal Impact on Weight-for-Age: All Children < Age 3 (n=1893)


Tinh Gia District, Thanh Hoa Province, 1993-1995

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SC Egypt - Minia < Age 3 (n=1893)

  • Reduction in malnutrition (-2 SD wt./age) among children 6 mo. to 3 years of age from 47 percent to 13% over a period of 6 months

  • In control village malnutrition level did not change (48.1% to 46.4%)

  • PD foods: cheese and salad

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SC Haiti – Central Plateau < Age 3 (n=1893)

  • Reduction in 3rd degree malnutrition (wt/age) from 26 to 6 percent, three years after foyer participation (Dubuisson, 1993)

  • Weight for Age Z-score gain between entry in hearth and follow-up between 2-6 mo. was 0.34 (1997, Wand evaluation)

  • PD behavior: frequency and variety of feeding

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A quick PDI exercise… < Age 3 (n=1893)

Policy environment

Peer pressure


Desired Health Promotive/Protective Behavior




Desired Health Outcome or Health Status

PDI subject

PDI subject

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What about community involvement in access and quality improvement?

  • Moving beyond the demand mobilization piece of the framework

  • Can communities themselves intervene to improve the access and quality of health services?

  • What responsibility do communities have for their own health?

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Community Defined Quality: improvement?a partnership approach to Quality Improvement

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Changing the hypothesis improvement?

  • If you build it, they will come.

  • If you improve it, they will come.

  • If THEY build and improve it, they will come.

    SC’s role is BUILDING community capacity to participate in decision making process.

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What is CDQ? improvement?

A methodology to improve quality and accessibility and utilization of services with greater involvement of the community in

  • defining,

  • implementing and

  • monitoring

    the quality improvement process.

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Why CDQ? improvement?

Quality improvement efforts often…

  • begin with external definitions and standards that may not address community concerns, definitions and perspectives about quality of care.

  • do not reach the most peripheral services, or do not reach them in a timely way.

  • look for answers only inside the health system.

  • talk with clients, but not with non-clients.

  • don’t necessarily empower health workers, nor the communities they serve.

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Why CDQ? improvement?Other advantages...

  • Accountability rests in the community rather than with distant supervisors with limited interest in the actual quality of services.

  • Beyond educating clients about their rights, encourages dialogue and action about the right to quality care and suggests the responsibility of the client in getting quality care.

  • Begins to establish a concept of consumerism for health services.

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Key features of CDQ improvement?

  • Creation of a quality improvement partnership between the community and health workers

  • Exploration and sharing of both community and health worker perceptions of quality

  • Emphasis on mutual responsibility for problem identification and problem solving - not blame

  • Operationalizes a rights based approach

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CDQ PROCESS improvement?

Getting Started

Introduce Concept

Build support (MOH, HW, Community)

Step 1

Explore Quality

Health Worker View

Explore Quality

Community View

Step 2


Bridging the Gap: Problem & Solutions

Step 3

Quality Improvement Team

Working for Change:


Step 4

Health Workers



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Results from Haiti FGDs improvement?Community and Health Worker Definitions of Quality



  • Welcome

  • Access/Distance

  • Waiting time

  • Consultation Style

  • Information/Counseling


  • Referral System

  • Confidentiality

  • Order

  • Acceptance of traditional meds

  • Follow up

  • Integration

  • Environment

  • Cost

  • Equal relationship

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Early Experience in Nepal improvement?

  • Through partnership, seeking to:

    • Make services more accessible and friendly to disadvantaged/marginalized people.

    • Establish a quality concept, and then create demand, while fostering shared responsibility for, and ownership of, services among community members.

    • Mobilize advocates for health services among the community that can assist health workers to find solutions to problems in delivering quality care.

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Problems frequently cited in Community Discussion Groups / Siraha, Nepal

  • Poor treatment – based on caste, wealth, gender, age, and type of health problem (discrimination).

  • Lack of information – about prevention, medicines, illness, and about services in general.

  • Interpersonal relations

    • -wide range of problems associated with provider attitude (rather than “communication skills”)

    • -poor listening skills

    • -rudeness

  • Problems associated with medicines

    • -health care frequently equated with medicines

    • -lack of sufficient medicines, range of medicines, information

  • Lack of awareness of preventive services. Health services viewed mainly as curative.

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Some solutions proposed during CDQ workshop (health worker & community):

  • Lack of access to emergency services:

    • Health worker should be accessible 24 hours / day, but clients would pay for services during non-working hours.

  • Lack of water and sanitation at health facility:

    • Mobilize community members to help build latrine and water pump. Seek material support from VDC.

  • Lack of medicines:

    • Approach VDC and HMG to provide initial support for a revolving drug fund (CDP).

  • Communication problems:

    • Training of staff, monitoring by CDQ QI team.

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Priority problems identified for follow-up by QI team: community):

  • Lack of information on available services

  • Provider behavior (communication with clients)

  • Discrimination by gender, age, status

  • Need for physical examination

  • Medicines

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Evaluating CDQ community):

  • Established quality standards met

  • Consumer standards met (as articulated and monitored by community members)

  • Utilization patterns changed, coverage improved

  • Community capacity increased

  • Analysis of actions taken and results

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Some Preliminary Results community):

  • PDQ is breaking new ground - reported to be first-ever dialogue between providers and community members on quality of care.

  • Feedback provided reported affecting quality of C-PI.

  • Early data suggest significant increase in use of some services (TT and measles immunization).

  • Innovative tools developed and used to monitor quality (e.g. pictorial exit survey for non-literates).

  • High level of participation by community members, especially women, and health workers.

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Preliminary Lessons Learned community):

  • Problems of technical competence and safety may not be mentioned or prioritized by the community. Standards and health worker perspective must enter into the prioritization process.

  • While community members may not have the knowledge to recognize problems, they can still be involved in demanding change.

  • The process can be locally driven. While it is complementary to more centralized ‘trickle-down’ quality improvement initiatives, it does not depend on a period of waiting for capacity and resources to reach rural areas.

  • Has not required a huge investment of additional resources.