Health animators
Table
1 summarises the total number of HAs trained, villages and populations of the three focal areas. In total, two trainings, one for focal area A and one combined focal area B and C were funded and conducted by MMP; 77 HAs from all focal areas completed the five-day malaria HA training. Between 33% and 48% of the HAs were female. During the three annual cycles of implementing the workshops, seven animators were replaced: two underperformed (were not conducting workshops) and five relocated from their villages. Replacement HAs underwent a two-day orientation with MMP staff for the malaria manual and were provided additional on-the-job training by their fellow HAs.
Table 1
Population and number of Health Animators trained
Population size (2014) | 4131 | 8444 | 11,578 | 24,153 |
Number of villages | 21 | 11 | 30 | 62 |
Number of households | 857 | 2139 | 2400 | 5396 |
Persons per household | 4.8 | 3.9 | 4.8 | 4.5 |
Number of Health Animators (% female) | 23 (48%) | 24 (33%) | 30 (40%) | 77 (40%) |
Households per Health Animator | 37.2 | 89.1 | 80 | 70.1 |
Number of community workshop sites* | 21 | 12 | 21 | 54 |
Population per community workshop site** | 197 | 704 | 551 | 447 |
From the qualitative interviews, some of the animators mentioned that they already had some understanding about malaria before the introduction of the programme and were making use of bed nets and adopting desirable behaviour for malaria prevention. Other animators believed malaria could not be controlled in their community prior to their training, similar to the community beliefs.
“This project has really helped me. Before I started working for the project I had ignorant thinking about malaria, I was fond of using medicine at home. Even when my wife was sick I would not take her to the hospital immediately. I would rush to buy Brufen® (ibuprofen) and Panadol® (paracetamol), and I would give it to her. When her fever dropped a little I would think she had recovered. Within three days she’d start up again. So, I really suffered with this. Even a child… if the mother suffered from malaria, the child would be next. There was chaos in my household.” HA (FGD 010 HA).
Equipped with a change of mind-set and new knowledge on the cause of malaria and prevention methods, they made sure to lead by example through the choices made in their own home to influence their peers into taking their lessons seriously.
“I was among the people who did not believe malaria could be controlled, even at the time we were being taught, but now I believe it is possible” HA (IDI 006 HA).
Attendance of village workshops
The total number of community workshops from January 2015 to June 2017 in all focal areas was 2704. From a sample of 172 workshops conducted, each workshop was conducted by three HAs on average (Table
2). The average attendance of workshops was 45 persons per workshop; focal area B had the highest attendance (75.5 per workshop) among the three focal areas; attendance appeared to be constant over the 3 years. Reported female attendance was 56% and 66% in focal areas A and C, respectively. All focal areas reported attendance of the village chief in 100% of the workshops. Attendance of HSA varied by focal area and year; focal area B and 2015, the first year of implementation, had the highest reported HSA attendance while focal area A and the year 2017 had the lowest. About 90% of the workshops on average had a village health committee member in attendance. The village health committee is an intermediary between the community and the health system, presenting and discussing health related concerns from the community with health facility personnel and vice versa.
Table 2
Total number of village workshops and attendance
Annual average number of community workshops completed per site** | 24 | 23 | 24 | 24.7 | 22.7 | 15.7 | |
Number of community workshops for which records are available (n) | 86 | 44 | 42 | 39 | 52 | 81 | 172 |
Number of Health Animators present per community workshop | 3.1 | 4.1 | 2.7 | 4.1 | 3.0 | 3.0 | 3.3 |
Participants per community workshop | 34.0 | 75.7 | 54.3 | 46.4 | 45.3 | 45.9 | 45.8 |
Average % of female participants | 56% | | 66% | | | | |
Average % of population participating per community workshop | 17% | 11% | 10% | 10% | 10% | 10% | 10% |
Community workshops with village chief present (%) | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
Community workshops with HSA present (%) | 22% | 66% | 26% | 62% | 46% | 14% | 34% |
Community workshops with health committee member present (%) | 88% | 93% | 88% | 92% | 88% | 89% | 90% |
According to the qualitative interviews of HAs, the workshops were attended by men, women and the youth. Women were the highest number attending. Occasionally men and the youth would attend. Some of the reasons for low male attendance and participation were: (i) working to earn a living for the household, (ii) other activities occurring in the village, and (iii) a belief that health information and activities are the responsibility of the woman in the household.
“Sometimes we have only women attending, say fifteen… At other times with ten attendees, only two men… As you know, at the moment there is a problem of famine, and although we get handouts, people rush for piece work in the gardens...” HA (IDI 002 HA).
“Other times very few people came, especially if the meetings coincided with other activities… For example if we held a meeting on the day there was a football match, that meant that we shared the crowd and we would have fewer people attending,” (IDI 005 HA).
“Men do not attend these meetings in large numbers. It is mostly women. Because the woman is the one that witnesses the illness of her children most often” HA (IDI 004 HA).
The qualitative interviews suggested that the presence and reputation of a village chief had a strong influence on the numbers of people attending. The authority of the chief would be used to advertise and invite people to attend the meetings and if the chief was well respected, attendance would be high.
“To call for a meeting we need to use the chief, without announcing through the chief people would not come to our meeting” (IDI 002 HA).
At times, when the attendance was declining, the HAs sought permission to utilise meetings already organised by the chief to present a short workshop to the audience available.
“The method we are using now is that when a chief calls for his own village meeting we take this opportunity to ask if we can use his meeting to relay our [malaria] message. This is because now, when the chief calls for our meetings the people would say ‘oh that [meeting] is useless, the project has no benefits’, they would say that even though we know the benefits of the project” (FGD 001 HA).
In focal area B, where HSAs most frequently attended, the number of participants was also high (Table
2). The HAs reported that collaborating with staff from their local health centres helped validate their work to the community. They would at times run workshops with the HSA when they needed help with giving information in a part of the manual where they did not feel confident.
“We did work with the health centre staff. They would help us at times when we forget the sentence, or to confirm an important message” (FGD 001 HA).
A temporary decline in attendance was also attributed to the lack of incentives for people to invest time in attending.
“When we started running the workshops things were working well. But at the moment there are a few things that have put people off [attending meetings]. As animators, we try to work well with the community but there are things that they had been promised they would be given; things [bed nets] to protect them from malaria. They held on to that promise. When we have meetings we do not have the high attendance like we did when we started” (FGD 001 HA).
Community engagement and malaria workshops
According to the responses to open questions on the self-reporting forms, there was active interaction and involvement of the participants in the workshops (Table
3); 40% and 20% of the workshops reported as strength of the workshop that participants asked and/or answered questions, and participated actively, respectively. Areas such as
drama, songs or poems (29%), preparation of the topic by the HA, interacting more with participants and the time of starting the workshops, needed to improve. Workshop attendants were concerned with the inadequacy of health services and lack of bed nets.
Table 3
Self evaluation responses
Strengths |
Participants able to ask and/or answer questions | 31% | 38% | 46% | 40% |
Active participation | 38% | 12% | 16% | 20% |
Participants able to follow/understand the topic | 21% | 13% | 11% | 14% |
Time management | 3% | 4% | 6% | 5% |
Participants able to give comments | 0% | 4% | 5% | 3% |
Areas needing improvement |
Conducting drama, songs or poems | 21% | 25% | 36% | 29% |
People to come on time | 13% | 27% | 15% | 18% |
None needed | 0% | 10% | 19% | 12% |
Encourage people to come to the community workshops | 21% | 13% | 4% | 10% |
Animator needs to prepare for the day’s topic | 18% | 4% | 9% | 9% |
Timely inform village chief about next community workshop | 10% | 2% | 0% | 3% |
Community concerns |
Inadequate health services nearby | 13% | 23% | 17% | 18% |
Insufficient bed nets received | 21% | 6% | 19% | 15% |
Delayed distribution of bed nets | 49% | 4% | 0% | 12% |
Need for house improvement and/or larval source management | 3% | 10% | 10% | 8% |
Need to continue the community workshops | 0% | 4% | 5% | 3% |
Implementation problems |
None reported | 0% | 25% | 35% | 24% |
Rains (affecting attendance) | 31% | 21% | 11% | 19% |
Funerals (affecting attendance) | 5% | 23% | 14% | 15% |
Low attendance | 26% | 2% | 6% | 9% |
Sickness (affecting attendance) | 3% | 12% | 9% | 8% |
Inadequate materials | 0% | 6% | 6% | 5% |
The qualitative interviews suggested that malaria was considered the biggest threat to health in all three catchment areas. This was the main motivation for the initial commitment with attending meetings as the villagers were seeking to discover alternatives to managing the disease in their homes. The workshops were first met with scepticism, due to the novelty of information delivery method. The community perception of the possibility of existing without malaria was preventing them from accepting the information in the workshops at the start of the programme.
“The people did not believe it was possible to exist without malaria because this was a disease that [even] their ancestors had left behind” (FGD 002 HA).
Some people in the community believed that malaria originated from sources other than a mosquito bite.
“The people thought malaria is caused by walking long distances, or maybe eating [too much] sugarcane…these beliefs come from parents, these are habits that we are born into” HA (IDI 002 HA).
There was variation in the time it took for participants to comprehend the message in the lessons.
“People did not know what malaria was and what caused it…that was before they were given any information on malaria [through the project]” HA (IDI 006 HA).
Some people understood and took the advice immediately. Others required repeated lessons to understand the importance of preventing illness and seeking appropriate treatment with modern medicine.
“We would tell them to just try to adhere to advice from the hospital. They should take all the medication prescribed and complete the dose to test if it really helps. Then they can decide for themselves whether the interventions work. So slowly people would understand” HA (IDI 002 HA).
According to the HAs, the measure of understanding was based on the frequent interaction with the crowd. People asking questions signified a level of critical thought. It showed that they understood better when things were explained more elaborately and their questions were addressed.
They [workshop participants] used to take an active role, and that was pleasing… It meant that they understood… They participated, they asked and answered questions appropriately. So we knew that people were pleased and understood what we were doing” (IDI 005 HA).
Through explaining the causal pathway and the role of an intervention in ending the life cycle of malaria, it seemed that people were better able to understand the use and importance of malaria control interventions.
“…because we explained how important mosquitoes are with malaria transmission. So they appreciated the protection from sleeping under a net…” (IDI 005 HA).
The attendance increased and the sessions became more interactive with people freely asking questions and appearing to comprehend the message.
The HAs mentioned in the interviews that they advised the participants to test the lessons learned; sleeping under a bed net and seeking treatment early. The most frequently reported change noted by the HAs was the adoption and practice of seeking treatment early when fever develops.
“In the beginning people would just take pain killers when they had a fever…now they know and understand the importance of going to the hospital to test for malaria” (FGD 002 HA).
Self-medicating with painkillers and visiting traditional healers were a common practice because of how easily accessible and convenient they were in the community.
In some instances, the message promoted by the animator was not complemented well with the service provision of the health systems in their communities. There were times the advice the animator was giving to the community was not supported with standard practice in the health centre. This difference was evident with the promotion of testing for malaria to confirm infection. Some health centres did not have a supply of malaria rapid diagnostics tests, to confirm malaria infection, and, consequently, they treated presumptively. Therefore, although the information was understood, it did not encourage the necessary change in behaviour due to weaknesses in the health system.
On average, each workshop took 1 h from the objective assessment. By both objective and subjective assessment, the workshops were appropriately implemented (Table
4). The major objectively assessed weaknesses were: not recapping the previous or announcing upcoming topics, a lack of drama/songs to pull the crowd, and forgetting to self-report malaria cases since the previous workshop. During the objective assessment, it was also noted that most of the HAs were conversant with the topics. However, some of the weaknesses observed objectively included gaps in knowledge in a few HAs.
Table 4
Self-reported and MMP assessment for fidelity of the workshops
% community workshops where the agenda is explained | 100% | 83% |
% community workshops where new participants are introduced | 98% | |
% community workshops where the previous workshop is summarized | 100% | 58% |
% community workshops where drama, song or a poem was done | | 42% |
% community workshops where key points addressed | 100% | 75% |
% community workshops where topic content is accurate | | 75% |
% community workshops where lively discussion | 100% | 83% |
% community workshops where self-reporting of malaria cases | 100% | 42% |
% community workshops where next workshop’s topic is announced | 97% | 58% |