Community Dialogues for Child Health: Results from a Qualitative Process Evaluation in Three Countries

"The CD approach fills a gap in reaching out to rural communities with basic health information and providing a platform for low-literacy rural communities to reflect on how information applies to their life in con- text.”

From the Journal of Health, Population and Nutrition, this research "assessed the implementation process of a theory-driven community dialogue (CD) intervention specifically designed to strengthen the support and uptake of the newly introduced iCCM [integrated community case management of childhood illnesses] services and related behaviours in three African countries."

The study looks specifically at strategies to engage communities on the demand side of services by involving them in awareness raising, dialogue, and programme design. In 2012, the intervention developed a CD operational model implemented by local health workers in Uganda, Mozambique, and Zambia, with the intention of incorporating flexible, "easy-to-use” tools and features that could eventually be adopted by national Ministries of Health for scale up within national iCCM programmes.

In the three countries, the intervention selected about 150 - 300 communities. Community health workers (CHWs) had already been trained by their respective Ministries of Health (MoHs) and were deployed to provide services in their respective villages. Based upon the Integrative Model of Communication for Social Change, the CD intervention called CHWs and community leaders for a complementary 2 to 3 days training focused on the community dialogue methodology and use of visual tools, which included a guidebook and four core topic guides with a set of visual tools for using "a repeatable 10-step process, around four core topics: the new child health community-based services provided by CHWs and each of the three major childhood illnesses (malaria, pneumonia and diarrhoea)." Visual tools included, depending on location: guide book cards, interactive poster, flash cards, and flip charts in Portuguese, English, and Bemba. In the dialogues, community members were intended to "explore a topic, identify and prioritise specific issues, and collectively agree on actions and mechanisms for the community to resolve these, within their own means and strengths." After 1 year of implementation, a process evaluation was conducted to assess communities' response to the CD approach, in terms of outreach, relevance, and intermediate results.

A qualitative process evaluation methodology was chosen and "used secondary project data and primary data collected in two districts of each of the three countries" including "67 focus group discussions and 57 key informant interviews, totalling 642 respondents, including caregivers, CD facilitators community leaders, and trainers." Thematic analysis of the data examined:

• "fidelity (the extent to which the intervention was delivered as planned),
• dose delivered (the amount of CDs delivered and the quality of these),
• dose received (the extent to which participants actively engage with and value the intervention),
• reach (the proportion of the target audience that participates in the CD intervention),
• recruitment (the procedures used to approach and attract participants and their relevance) and
• context (other aspects of the larger social, political and economic environment that may influence intervention implementation).

The changes in care-seeking and disease prevention practices were self-reported by respondents and collected in order "to understand... how the Community Dialogue model was implemented in context and how it contributed to increased community awareness and support for" services and prevention practices. Results indicate that the CD approach has been "embraced by both facilitators and participants for its relevance, ease of use and participatory approach." It is noted that CHWs extended its use to other kinds of health topics. CHWs asked for further training on difficult conversations. The study notes that active engagement of community leadership greatly influenced community members’ participation, as did the act of agreeing and committing in public to individual and collective changes. The dialogues increased CHWs' visibility as health service providers and linked the community to health services. The study found that flash cards made for a more interactive session than flip charts, as they could be used by participants to illustrate their story or thinking. However, the hindering factor for communities appeared to be a lack of basic resources and services, including health staffing. More evidence is needed for showing the role of CD in improving "community organisation for completion of timely referrals for severely ill children and community monitoring and local accountability mechanisms for iCCM implementation."