Community Approaches for Health and Measuring Community Capacity

2. The Context SC is a partner on the USAID-funded Population Communication Services 4 Project led by JHU/CCP (1996-2002). SC provides T.A. in community mobilization to the PCS4 project. This presentation shares SC experience on building and measuring community capacity from three health field projects and other similar work in the field.

3.  What is community mobilization?

4. Operational Definition Community mobilization is a process through which action is stimulated by a community itself, or by others, that is planned, carried out, and evaluated by a community�s individuals, groups, and organizations on a participatory and sustained basis to improve health.

5. What is community? Geographically defined Shared interests, identity and/or characteristics Shared resources

6. Why strengthen community capacity?

8. Evaluating CM programs Current SC (JHU/PCS4) community mobilization projects are attempting to measure indicators related to: Health outcomes Community competency/capacity outcomes (including linkages/ relationships between communities, providers & others)

9. Measuring capacity & efficacy of... Individuals Groups Organizations/institutions Communities Broader society

11. Perceived Control Scale(B. Israel, et al.) 12 factors related to perceived control/influence over decision-making at individual, organizational and/or community levels. (e.g. I can influence decisions that affect my community (Agree strongly, agree somewhat, disagree somewhat, disagree strongly))

12. Participation Needs assessment Management Resource mobilization Organization Leadership Susan Rifkin, et al. 1988 Note: UNICEF later modified mgmt to several areas including administrative management and operational management.

13. Measuring a Group�s Social Standing and Capacity for Collective Action Increased access to resources Increased collective bargaining power Improved status, self-esteem and cultural identity The ability to reflect critically and solve problems The ability to make choices Recognition and response of people�s demand by officials Self-discipline and the ability to work with others (Suzanne Kindervatter Non-formal education as an empowering process: case studies from Indonesia and Thailand. Amherst: Center for International Education, University of Massachusetts, 1979.)

14. Using the Community Action Cycle as a Guide to Develop Indicators of Community Capacity For example: Community Organizing #/% of �priority� individuals/families participating in community meetings/programactivities (age, sex, most affected, poor, etc.) # community organizations regularly participating in program (# mtgs attended, actions taken, etc.) Existence of mutually agreed upon structure Leadership (see CDC indicators & others) Demonstrated linkages between participating community actors/orgs and other internal and external resources/networks/coalitions.

15. Dimensions and Sub-Dimensions of Community Capacity Citizen participation that is characterized by: Strong participant base Diverse network that enables different interests to take collective action Benefits overriding costs associated with participation Citizen involvement in defining and resolving needs Identifying and Defining the Dimensions of Community Capacity to Provide a Basis for Measurement, Robert M. Goodman, Ph.D. et al., Health Education and Behavior, Vol. 25 (3): 258-278 (June 1998).

16. Leadership that is characterized by: Inclusion of formal and informal leaders Providing direction and structure for participants Encouraging participation from a diverse network of community participants Implementing procedures for ensuring participation from all during group meetings and events Facilitating the sharing of information and resources by participants and organizations Goodman, et al (1998)

17. Leadership that is characterized by: Shaping and cultivating the development of new leaders A responsive and accessible style The ability to focus on both task and process details Receptivity to prudent innovation and risk taking Connected-ness to other leaders Goodman, et al (1998)

18. Skills that are characterized by: The ability to engage constructively in group process, conflict resolution, collection and analysis of assessment data, problem solving and program planning, intervention design and implementation, evaluation, resource mobilization, and policy and media advocacy The ability to resist opposing or undesirable influences The ability to attain an optimal level of resource exchange (how much is being given and received) Goodman, et al (1998)

19. Resources that are characterized by: Access and sharing of resources that are both internal and external to a community Social capital, (the ability to generate trust, confidence, and cooperation) The existence of communication channels within and outside the community Goodman, et al (1998)

20. Social and inter-organizational networks that are characterized by: Reciprocal links throughout the overall network Frequent supportive interactions Overlap with other networks within the community The ability to form new associations Cooperative decision-making processes Goodman, et al (1998)

21. Sense of community that is characterized by: High level of concern for community issues Respect, generosity, and service to others Sense of connection with the place and people Fulfillment of needs through membership Goodman, et al (1998)

22. Understanding of community history that is characterized by: Awareness of important social, political, and economic changes that have occurred both recently or more distally Awareness of the types of organizations, community groups, and community sectors that are present Awareness of community standing relative to other communities Goodman, et al (1998)

23. Community Capacity (AID CSTS Project) Capacity Levels Individual skills & abilities Organizational systems Institutional change Capacity Areas Strategic management practices Organizational learning Use & management of technical knowledge and skills Financial resource management Human resource management Sustainability

24. MAP/Bolivia�s 13 Dimensions of Community Participation Each on a 5-point scale: Existence/origin of organization Need determination Planning Resource mobilization Resource control Leadership/responsibility Decision-making methods

25. MAP/Bolivia: 2 Inclusion of local values and culture Inter-organizational relations Relationship to power structure(s) understood Locus of monitoring & evaluation Participation of marginalized groups Consciousness about participation

26. UNICEF: Synthesizes Other Models to Identify 8 Variables Leadership Organizational capacity Communications channels Needs assessments Decision-making Resource mobilization Administrative management Operational management

27. Towards a Unified, Useful Model (Marsh, Plowman) Reviewed the literature & experience at hand Captured every real or theoretical indicator on a �yellow sticky� Arranged them linearly in sequential bands, one band per paper or case Sought patterns Combined into fresh model

29. Community Empowerment Empowerment in what sense? Attitudinal dimensions Consciousness dimensions Skill dimensions Structural dimensions Other aspects P. Hawe, Minkler, Gruber, et al

31. Social Change Indicators (Feek, et al.) Increased flow of information about the issue of concern Increased public debate about the issue of concern Increased resonance of the issue with other major interests of everyday life among those affected by the issue Increased linkage between and among groups and individuals previously unconnected to each other regarding the issue of concern

32. Social Change Indicators Increased support for efforts of those affected by an issue to participate in the debate Increased leadership and decision-making role by people previously disadvantaged re: the issue of concern Feek, et al. The Communication Initiative

33. A Community Action Cycle

35. SECI Process Health promoters collect data on key indicators from families monthly Service providers collect service utilization data Together they consolidate data at the end of the month.

36. SECI Process--cont�d. The SECI team uses simple tools to share the data with the community. Community members review and analyze the information.

37. SECI Process--cont�d. Participants then set priorities and develop plans to improve their priority health indicators. They monitor their progress every month and adjust their strategies.

38. SECI Process at the District Level Consolidated monthly community data are entered into the SECI software at the District level. District health staff can compare community data and analyze trends over time. Reports can be printed in easy to read graphics that can be shared with communities.

39. June 1999 Evaluation Methods A. Qualitative: SECI records for all 10 SECI communities Ethnographic study in 3 SECI communities B. Quantitative: Household survey comparing 7 SECI and 7 control communities There were three parts to the evaluation. For a qualitative perspective, we reviewed minutes from SECI community meetings, diaries kept by SC fieldworkers, and project records from all ten of the pilot communities. We also carried out an ethnographic study in three intervention communities that included fifty key informants and nine focus groups. I'll review the qualitative findings from the intervention communities, first. Then I'll show you the quantitative results from the third part of the study, a cross-sectional household survey that compared seven intervention and seven control communities.There were three parts to the evaluation. For a qualitative perspective, we reviewed minutes from SECI community meetings, diaries kept by SC fieldworkers, and project records from all ten of the pilot communities. We also carried out an ethnographic study in three intervention communities that included fifty key informants and nine focus groups. I'll review the qualitative findings from the intervention communities, first. Then I'll show you the quantitative results from the third part of the study, a cross-sectional household survey that compared seven intervention and seven control communities.

40. Qualitative Results I Participants adopted more self-reliant and responsible attitudes toward their health. All ten SECI communities used the information collected from local households to lead discussions about maternal and child health at community meetings. Immunization, nutrition, prenatal and obstetric health were the most commonly addressed topics. Citizens indicated that this health information gave them a new understanding and appreciation for women's and children's health. When they realized the scope and severity of problems such as malnutrition and child illness in their communities, these participants became concerned and motivated to learn how they might prevent and alleviate these problems. Families emphasized that they were taking more responsibility for their own health. For example, mothers proudly reported that they were preparing more nutritious meals for their children and taking them regularly to growth monitoring sessions. All ten SECI communities used the information collected from local households to lead discussions about maternal and child health at community meetings. Immunization, nutrition, prenatal and obstetric health were the most commonly addressed topics. Citizens indicated that this health information gave them a new understanding and appreciation for women's and children's health. When they realized the scope and severity of problems such as malnutrition and child illness in their communities, these participants became concerned and motivated to learn how they might prevent and alleviate these problems. Families emphasized that they were taking more responsibility for their own health. For example, mothers proudly reported that they were preparing more nutritious meals for their children and taking them regularly to growth monitoring sessions.

41. Qualitative Results II Nine of the ten SECI communities planned and implemented their own health promotion strategies. As individuals took more responsibility for their health, they began to act together. Following health presentations, nine communities planned and implemented their own health promotion projects. Their efforts to improve the indicators of maternal and child health most frequently included collective agreements to attend prenatal care, growth monitoring, and immunization sessions organized by their promoters. Following this type of community agreement, several communities discussed the problem of reticent parents. One of these communities decided to set a deadline for parents to bring their children's immunization status up-to-date, and enforced it with a fine for non-compliance. As individuals took more responsibility for their health, they began to act together. Following health presentations, nine communities planned and implemented their own health promotion projects. Their efforts to improve the indicators of maternal and child health most frequently included collective agreements to attend prenatal care, growth monitoring, and immunization sessions organized by their promoters. Following this type of community agreement, several communities discussed the problem of reticent parents. One of these communities decided to set a deadline for parents to bring their children's immunization status up-to-date, and enforced it with a fine for non-compliance.

42. Qualitative Results III Health personnel who participated built better working relationships with SECI communities. Participants from the pilot communities had been dissatisfied with the local health services prior to the SECI project. Citizens perceived that the doctors and nurses had treated them rudely and had provided inadequate treatment. Health personnel, on the other hand, indicated that citizens had shown little concern for their children's health. Health personnel attended SECI meetings in nine of the ten pilot communities. In these communities, the doctors and nurses began to build positive working relationships with citizens. Women became less fearful to speak with the doctors, citizens began to develop trust in the abilities and intentions of the health staff, and the health professional gained a new understanding of the communities' culture and living situation. We saw a different situation in the pilot community of Tarucamarca, however, where health personnel had refused to attend SECI meetings. In that community, citizens indicated that there had been no improvements in relationships with health personnel, and claimed that they continued to treat rural patients with negligence and discrimination. Participants from the pilot communities had been dissatisfied with the local health services prior to the SECI project. Citizens perceived that the doctors and nurses had treated them rudely and had provided inadequate treatment. Health personnel, on the other hand, indicated that citizens had shown little concern for their children's health. Health personnel attended SECI meetings in nine of the ten pilot communities. In these communities, the doctors and nurses began to build positive working relationships with citizens. Women became less fearful to speak with the doctors, citizens began to develop trust in the abilities and intentions of the health staff, and the health professional gained a new understanding of the communities' culture and living situation. We saw a different situation in the pilot community of Tarucamarca, however, where health personnel had refused to attend SECI meetings. In that community, citizens indicated that there had been no improvements in relationships with health personnel, and claimed that they continued to treat rural patients with negligence and discrimination.

43. Qualitative Results IV At least 8 of the 10 SECI communities acted to make local health services more responsive and accountable. Every pilot community critically analyzed their health services at SECI meetings. At least eight of the ten communities acted to make services more responsive and accountable to their needs. The communities addressed access to services, availability of medications, and quality of services most frequently. I will give you just a few examples of actions taken by the communities. Five communities improved their access to services by requesting and organizing outreach visits by the doctors and nurses from the hospital or another organization working in the area. Three made arrangements for emergency ambulance services. Three communities challenged the hospital about charging clients for services that should be covered by the National Health Insurance Program. Similarly, three communities lodged complaints because insured medications were unavailable at the hospital. Several communities discussed quality concerns directly with visiting health personnel who attended meetings. In Tarucamarca, where health personnel did not participate in the SECI meetings, the community demand for quality services led them to challenge the local health system with a formal letter of complaint presented to the hospital. Every pilot community critically analyzed their health services at SECI meetings. At least eight of the ten communities acted to make services more responsive and accountable to their needs. The communities addressed access to services, availability of medications, and quality of services most frequently. I will give you just a few examples of actions taken by the communities. Five communities improved their access to services by requesting and organizing outreach visits by the doctors and nurses from the hospital or another organization working in the area. Three made arrangements for emergency ambulance services. Three communities challenged the hospital about charging clients for services that should be covered by the National Health Insurance Program. Similarly, three communities lodged complaints because insured medications were unavailable at the hospital. Several communities discussed quality concerns directly with visiting health personnel who attended meetings. In Tarucamarca, where health personnel did not participate in the SECI meetings, the community demand for quality services led them to challenge the local health system with a formal letter of complaint presented to the hospital.

44. Qualitative Results V Information from the CB-HIS motivated and empowered communities. Want to continue to improve on analysis skills. Use of the health information system gave every SECI community new skills and confidence to collect and analyze local information for their own use. Citizens learned the strength of acting together to achieve their objectives and saw the benefits of their work reflected in the improving indicators of the health statistics. SECI participants expressed determined attitudes, a sense of solidarity, and community pride in their new knowledge and skills, suggesting that the SECI project had capacity and community-building outcomes applicable to other situations. Use of the health information system gave every SECI community new skills and confidence to collect and analyze local information for their own use. Citizens learned the strength of acting together to achieve their objectives and saw the benefits of their work reflected in the improving indicators of the health statistics. SECI participants expressed determined attitudes, a sense of solidarity, and community pride in their new knowledge and skills, suggesting that the SECI project had capacity and community-building outcomes applicable to other situations.

45. Appreciative Community Mobilization in the Philippines

48. ACM indicators Actual vs. planned accomplishments Review Action Plan / every six months 100% accomplishment for community projects leading to improved child survival outcomes for the first round of ACM (Example: potable water supply, public and family toilets, home gardens) Now on second round of community plans mostly focused on family planning

49. Community monitoring system Comparison pre-post Use of participatory monitoring methods Use of spot maps and �Family Wall Charts�

50. Change in knowledge, attitudes and practices of priority groups in relation to family planning and CS Special survey, masterlist of priority groups Increased awareness and skill in use of growth monitoring charts (<10% to >50%) Increased percentage of mothers going for at least one pre-natal visit per semester of pregnancy Overall increase in participation of priority families in the �4Ds� Increased awareness and personal intentions to practice FP (based on action cards)

51. ACM indicators Amount and type of resources contributed by the community towards project goals Volunteer time Finances (including donations raised physical space materials attendance At least 30% community counterpart for materials excluding labor (through barangay IRA) Budget allocation for ACM activities such as planning sessions, transportation of barangay health workers for referrals, equipment such as weighing scales, medicines )

53. Project Goal Develop and strengthen shared responsibility between health service providers and communities for the quality of health care in order to improve the population�s reproductive health and health in general.

54. Increase utilization of public health services in selected project areas. Improve interaction and communication between clients and health service providers. Establish mechanisms and systems to improve coordination and collaboration between health services and community organizations. Objectives

55. The Providers Speak Spanish University educ-ation/literate Upper/middle class Western dress Biomedical paradigm Vertical/hierarchi-cal organization Prefer to be indoors

56. The Community Speak Aymara or Quechua Primary education, many illiterate Poor, lower class Traditional dress Aymara/Quechua health paradigm Rel. horizontal org. Prefer to be outdoors

57. Barriers to Quality and Utilization of Services  INTANGIBLE FACTORS Limited opportunities for interaction Emotional level Rupture of confidentiality Feeling of being cheated Paternalistic attitude Abuse of power Discrimination Lack of empathy TANGIBLE FACTORS Cost Lack of supplies, medicines, equipment Scarcity of human resources Physical space (from Rapid Assessment)

59. Getting to knoweach other: A visit to the health center

60. Getting to knoweach other: A visit to the community

61. Viewing the videos

62. Defining Quality

63. Planning

64. Community & Provider Action Some examples of actions taken: Hospital posted prices/services & schedules of its staff in the reception area, suggestion box Established an emergency fund Arranged health education sessions on topics of interest to community members Coordinated schedules of health providers visits Transport arrangements improved

65. Community & Provider Action- continued Established mechanisms to lodge & deal with complaints (for both providers & clients) Shifted some health personnel assignments Improved stock of medicines at low prices Reduced waiting time Improved health facility space (more private, better equipment, etc.)

66. Achievements in relation to service providers They are more attentive and friendly with the community The community believes that providers have improved health care according to what the community wants They make a greater effort to respond to community complaints

67. Achievements in relation to health services Services are now better organized Services take into account the opinions of the community Increase in clients using the services

68. Achievements in relation to the community Active community participation More interested in health Have more trust in health workers There is greater respect for the community customs/beliefs Community members know that they need to pay for services There are more meetings between health workers and the community Community members go to the health facilities with greater confidence

69. Achievements related to self-care The community [more often] identifies their illnesses The community notifies health personnel when people are sick The community knows more about health service programs The community now requests health education.

70. General Achievements Community-provider relations have improved There is better treatment Better communication Puentes has strengthened other quality improvement efforts

71. Vision for the Future There will be more communication between communities and providers We will complete more of our joint plans Community authorities will be committed to the process The experience will be expanded to other communities Quotes from participatory evaluation (2000)

72. Some lessons learned This is a rapidly evolving field and there are many approaches to measuring change. Most are �messy� and context specific.�[] � Our own organizational capacity greatly influences how we approach community capacity building. Do we �walk the talk�? This is not a rapid process�it takes time. Every community has strengths and resources to build on. Can�t do everything. Need to set priorities with communities, preferably these are closely related to helping communities achieve their objectives.

73. Small group exercise What did we learn during this session (and based on our own experience with community approaches)? How can we apply what we have learned to our own field programs? Homework: What assistance do we need/want to build our capacity to support effective community capacity building?