This piece was written by Cathy Green, Technical Lead, Community Health Systems, Health Partners International. Miniratu Soyoola, MORE MAMaZ Programme Director, Dr. Tony Klouda, consultant, and Cathy Green, Lead Technical Adviser to MORE MAMaZ were involved in designing and supporting the activities outlined in this blog.
Operationalising the global health policy commitment to reaching every woman, every child and every adolescent is a challenge for many countries, especially in a context where there is limited documented evidence on approaches that have helped to deliver this agenda.
The MORE Mobilising Access to Maternal Health Services in Zambia programme (MORE MAMaZ) (2014-2016) worked with district health teams in five rural districts to devise a practical strategy to reach difficult-to-reach individuals and include them in a community-based maternal and newborn health intervention. The programme adopted an approach to targeting that placed emphasis on the social factors that led to and maintained social exclusion. This approach proved effective in helping to identify women and girls who were most in need of attention.
Background and Context
At the beginning of MORE MAMaZ, social exclusion was accepted as a fact of life in the programme’s five rural intervention districts. Community members associated social exclusion and vulnerability with poverty. Where support was given, this was generally in the form of financial and in-kind support. There were many different ideas, including some underlying prejudice, about how these individuals had come to be socially excluded or vulnerable, and different views on whether they deserved to be supported at all. Yet what was clear was that communities were aware of who these individuals were, and where they were located.
At health facility level, a survey of front-line health providers found that the least-supported individuals bore the brunt of health providers’ frustrations with everyday health systems challenges. Providers admitted to discriminating against the individuals who were least likely to challenge them – those who lacked confidence, did not communicate well, and who generally lacked social support – when under pressure.
MORE MAMaZ and its DHMT partners in five districts used two complementary strategies for reaching the hard-to-reach:
Mainstreaming a focus on social inclusion into community volunteer training: A focus on social inclusion was mainstreamed into the training of community health volunteers known as Safe Motherhood Action Group volunteers (SMAGs). The volunteers were trained to facilitate community discussion groups on a wide range of maternal health topics. These sessions provided an opportunity for communities to reflect on the women and girls who were most likely to need help in order to achieve a safe pregnancy and delivery. Discussion group participants were encouraged to consider the wide range of situations that could potentially lead to vulnerability or social exclusion. The idea was to increase understanding at community level of the range of situations and issues – in addition to poverty – that could leave women and girls in a vulnerable position, lead to their exclusion from the community, or restrict their access to health and other services. This included women affected by gender-based violence, or women who lacked the support of husbands or families due to marital conflict, jealousy, disputes over land, or unreasonable behaviour.
The volunteers also conducted door-to-door visits to the homes of pregnant and newly-delivered women. Households in which the occupants failed to participate in community discussion groups were earmarked for special attention. The SMAG volunteers took time to find out what the constraints to participation were and offered support to resolve these.
The volunteers helped their communities to establish community systems to support pregnant women. These included food banks, emergency savings schemes and community-based emergency transport schemes. The emphasis was on ensuring that these systems were accessible to all women and girls who needed them.
Training health providers in communication skills and social inclusion: A training provided to front-line health providers focused on improving their communication skills so that they could increase their support to under-supported women. The training focused on making health providers aware of the social factors that caused vulnerability or led to social exclusion, and encouraged them to probe the reasons why they were rude to, or neglectful of, some but not all clients. The training gave providers methods to control their own frustrations, recognise people who looked as though they suffered from neglect, poor support or abuse, and ideas about how to work with communities to ensure that these women and girls were supported within the community.
In the MORE MAMaZ intervention sites significant steps were taken to promote social inclusion. The programme’s endline survey found that 73% of women and 70% of men in intervention communities were aware of efforts to include socially excluded women and girls in group activities. The respective percentages in control sites were 51% and 61%. Moreover, socially excluded women and girls in intervention sites received substantially more support, and a wider variety of support, than in control sites. They were more likely to have been involved in group activities, and more efforts were made to develop friendships with these women. Both types of support are known to improve mental and emotional well-being.
Women’s involvement in participatory group activities is an evidence-based strategy for improving maternal and newborn health.1 Hence, the programme’s strategy to draw the hardest-to-reach women and girls into these groups was an appropriate and highly effective way to improve their maternal and newborn health.
Communities could cite many examples of steps taken to support the least-supported women. The importance of linking these women and girls to other resources and institutions within the community was also recognised.
“Most of the least-supported women are coming to the meetings now. They are participating. This is a change in the community.” Female community member
A review of the training in communication skills and social factors given to health providers working in rural health facilities found that it:
• Helped to improve communication between health staff and their clients
• Led to a stronger, more nuanced and supportive focus on under-supported women in clinics
• Resulted in stronger collaborative links between health centre staff, SMAGs and communities
• Helped considerably in their willingness to provide services to young unmarried pregnant women.
Almost all the health centres involved in the training reported that attendances by under-supported women and their children increased as a result of the training. Health providers reported that they spend more time with clients who appeared to lack confidence. They counselled these women, tried to interview domestic partners and suggested and arranged other forms of community support for the women.
“Before the training we did not bother to pay attention to the reasons for women’s circumstances. Like looking dirty, unkempt and late for clinic. After the training we became more aware – we began to pay attention to these people and identify their situation better.” Health provider
• Rather than focus on general categories of the hard-to-reach (i.e. the disabled, women living with HIV/AIDS, the poor), MORE MAMaZ adopted a nuanced approach to targeting which focused on women’s and girls’ social situations. The programme hypothesised that two sets of indicators would provide a proxy for vulnerability and social exclusion: the extent to which women looked after themselves and their surroundings (indicative of women’s mental health); and the extent to which they felt supported and respected, particularly by husbands and families. The programme’s endline survey found that these indicators were significantly associated with service utilisation, the quality of service obtained, and women’s perceptions of the extent to which disabling social norms had changed at community level. Interventions that intend to target hard-to-reach individuals would benefit from including a stronger focus on the social factors that affect health care access and outcomes.
• The short training given to health providers in communication skills and social inclusion led to rapid and significant attitudinal and behaviour changes. Such changes will help to create an enabling environment for Zambia to realize national policy commitments to reaching every woman, every child, and every adolescent. Going forward, it will be important to identify opportunities to roll out this training nationwide, and to integrate it into pre-service and in-service training curricula.
1 Prost, A., et al, 2013, ‘Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis’, Lancet, 381: 1736–46.
MORE MAMaZ was implemented by a consortium comprising Transaid, Health Partners International, Development Data and Disacare. The programme was funded by Comic Relief.