A Qualitative Exploration of How a Community Engagement Approach Influences Community and Health Worker Perceptions Related to Family Planning Service Delivery in Togo

"Community engagement approaches are a promising mechanism to support collaboration and enhance mutual understanding between health workers and communities to achieve improved FP service quality."

There is a growing body of evidence showing that community engagement approaches that address the drivers of sexual and reproductive health (RH) behaviour can contribute to increased contraceptive use and a reduction of unintended pregnancies. In Togo, unmet need for contraception is high (34%), and only 23% of all women of reproductive age are currently using a modern method of contraception - in part due to socio-cultural norms. This study qualitatively explored how a community engagement approach developed by West Africa Breakthrough ACTION (WABA) and AmplifyPF influenced health worker and community perceptions related to family planning (FP) service delivery in and around the city of Lomé, Togo, within the context of the broader integration of social and behaviour change (SBC) and service delivery.

As detailed in the paper, WABA is a regional United States Agency for International Development (USAID)-funded initiative to increase coordination and effectiveness of SBC interventions to drive demand for RH services in four countries: Burkina Faso, Côte d'Ivoire, Niger, and Togo. WABA works in partnership with AmplifyPF, USAID's flagship FP project implementing the Integrated Learning Networks (ILN) model to strengthen service delivery in these four countries. The ILN model applies a multisectoral approach that convenes stakeholders at the district level to coordinate resources through ILN technical support committees to ensure the delivery of high-quality FP services and to build health provider capacity. Together, these programmes aim to improve community perceptions of service quality and FP methods through a community engagement approach.

Launched in 2019, the community engagement approach encompasses 3 interventions:

1. Community dialogues (CDs), which aim to create a platform for open discussions and knowledge sharing between the community and the health system - During the CDs, groups of up to 100 community members, as well as clinic staff, are each given a chance to share their concerns, desires and frustrations of local FP service access and delivery. An important element of the CDs is male engagement - both in terms of reaching men as heads of households and as opinion leaders (religious leaders, community chefs, etc.), as they often serve as gatekeepers to FP use. Women's participation in the CDs fosters empathy among community members and supports the identification of needs and solutions that enables the delivery of quality FP services. An intended outcome is that communities develop a better understanding of the work of the providers, and the challenges the provider faces in the delivery of quality services, and vice versa, the provider understands the difficulties of community members who come for services including their right to obtain quality FP services.
2. Health facility site walk-through (SWT) visits, whose purpose is to enable community members to provide direct observation and feedback to the health workers at the facilities - Following the CDs, a smaller group of approximately 25-30 community leaders, including religious leaders, women's group leaders, and local officials, are invited to participate in guided SWT visits at the health facilities, where they can ask questions or express concerns on behalf of their constituents related to each health service they visit, engaging in dialogue with facility staff and administration, to learn first-hand about FP services that are offered.
3. The development of community action plans, which are intended to generate strategies for addressing observed challenges to improve service delivery quality and outcomes - Following the SWT visits, the leaders sit with health facility staff to jointly develop community action plans to prioritise and address the problems identified in the delivery of quality services. In some instances, the plans also highlight the need for greater involvement of community leaders to challenge and correct rumours and misinformation about FP methods or the services themselves. In 2020, WABA developed a discussion guide to help community groups discuss sensitive topics that may be barriers to increasing use of FP, such as gender-based violence or the lack of couple communication or intergenerational dialogue about family planning between supportive adults and youth.

From October 2020 through September 2021, approximately 347 men and 424 women participated in CDs in Togo. During that timeframe, CDs and SWT visits in all 17 ILNs across the four WABA and AmplifyPF programme implementation countries were conducted at a rate of at least two CDs and at least five SWT visits per ILN.

For the qualitative study, the researchers conducted 19 in-depth interviews with FP service providers from health facilities participating in the intervention and 9 focus group discussions (FGDs), with 8-10 community leaders per FGD. Data collection took place from December 2021 to January 2022.

Based on the findings, the researchers explore enabling factors and challenges associated with implementation of each of the 3 components of the community engagement approach. For example, in instances where district supervisors and WABA and AmplifyPF trainers organised follow-up after meetings to discuss progress, community members acknowledged how the follow-up facilitated execution of the activities outlined in the action plans. However, both community members and health workers reflected on the challenges in mobilising resources to implement activities outlined in the action plans.

The researchers found the 3 components of the approach worked synergistically together to support collaborative action between communities and health workers to increase mutual understanding of their collective needs related to FP services. For example:

• Community members cited improved reception at the health facilities by health workers and indicated that the SWT visits created a greater sense of empathy towards the providers and the challenges faced in their work environment. Improvements implemented at the facility provided community leaders with a sense that their feedback was heard and addressed, which in turn created trust between the community and the health workers. In addition, community leaders perceived that the CDs led to a decrease in community fears/constraints toward FP providers and services. Per the researchers, programmes might consider layering a community score card (CSC) approach into the existing programme to strengthen collective action and ensure that communities make continued progress towards achieving their planned activities.
• Health workers acknowledged a greater understanding of barriers at the community level following CDs, particularly among community members that are not routinely encountered at the health facility for RH services, such as youth. They noted that the activities enabled them to better understand how to address misunderstandings related to FP so that they could provide better quality of care through improved counseling with clients. Per the researchers, programmes should consider developing specific interventions at the community level designed to address youth needs, in particular, such as separate youth-centred meetings or youth-only SWT visits. Breakthrough ACTION's mass media campaign Merci Mon Héros (MMH, Thank You My Hero) provides an example of how programmes can promote an environment conducive to young people's access to FP/RH services in the four WABA and AmplifyPF countries.

In concluding, the researchers indicate that additional research is needed to understand if the WABA approach has contributed to increases in contraceptive uptake. "Future programs should consider incorporating additional mechanisms to monitor community action plans and provide support to address structural challenges at the facility level particularly those that require financial resources."