Creating Comprehensive Care Groups Using Front Line Teams [Updated Jan 5]
Nyaka AIDS Orphans Project's idea is a community campaign that tackles the problems of children's interaction with the environment, lack of green vegetables in diet and life skills for both parent and child, by organizing pregnant women in rural southwestern Uganda into comprehensive care groups where health education, life skills, developmentally appropriate games and parenting techniques are taught by front line health workers [Updated 15/12/2014] . The women will be enrolled during pregnancy until their child reaches age five. They will be given incentives to attend ante natal, post natal, and group meetings. The tools given to these women will allow not only the baby enrolled to thrive but also all future children and their families.
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The importance of early childhood development is not common knowledge in Kambuga sub-county in southwestern Uganda. Young children spend most of their time on the backs of the mothers. Often times the highly nutritious foods are reserved for the fathers and older children in the family. Currently, pregnant women in this area have only one place where they can deliver and go for ante natal and post natal care, the local area hospital. This means that many women must travel a long distance to get the care that they need. It is our hope that in the next 5 years the clinic that Nyaka AIDS Orphans Project currently runs will have a maternity ward to aid in the difficulty pregnant women currently face.
Nyaka AIDS Orphans Project has been working in this area for over 10 years. It is a local NGO that employees individuals from the area to assist the community. Currently it runs 2 primary schools where orphans attend free of charge and are given uniforms, school supplies and two meals a day. It will also be opening a secondary school in February 2015. In addition to education, Nyaka works with grandmothers who care for orphaned children. We provide micro finance loans and education opportunities for these grannies. Nyaka also runs a clinic that provides basic services for free to Nyaka students and grannies. We plan on expanding these services in the next five years to provide more comprehensive care. The organization strives to provide a holistic approach to development and has realized that we are lacking in early childhood development. This is why this challenge was accepted. Nyaka has the knowledge and trust from the community to have an effective program.
Devising the Program:
We wanted to use the organizations already existing resources, relationships and partnerships to better inform us in how we could tackle this question. We talked with mothers with young children, pregnant women, traditional birth attendants, health facility staff, medical professionals at the local hospital and clinic, community leaders as well as motorcycle drivers. What we determined is that over half of the women do deliver at health facilities. Ideally we want to make the number higher. Many women, however, do not attend all ante natal visits and especially do not attend post natal care. Also, many women are unaware of the importance of early childhood development and of best ways to care for the young children.
We discussed the biggest challenges that these women face in attending ante natal, post natal and deliveries at the hospital. They said that transport was the most difficult. We made sure to address this in our intervention. We also asked what they thought would be the biggest challenges in raising children. All of these answers were taken into consideration when designing the program.
The organization also runs grandmother groups that have been successful within these communities. We have also noticed that many other groups, such as savings groups, are effective. We discussed with the women with small children if they thought a group format would be well received. They said yes. This is why we decided to uses this format in our intervention.
Front Line Health Care Workers:
Front line health care workers will be trained and employed to visit all houses in a pre-determined catchment area. Currently, in this area there are a form of voluntary front line health workers (VHT) trained by the Ministry of Health. Their role is to be the eyes and ears for the Ministry of Health within the community as well as to provide health education and referrals to health facilities. This has had varying effects depending on the commitment of the VHT to the area they serve. The front line workers in this program will build off of active existing VHTs as well as create new front line workers. These workers will be given a salary for their work increasing their motivation and accountability. The front line workers will manage chronic illness by dispense medicines that need to be taken regularly, distribute family planning and triage health concerns for the local health facilities. After discussing this with the community members we have decided that only bringing prescribed long term medicine such as family planning but nothing more. The community members feel more comfortable recieving care from doctors and nurses[updated jan 5]
The front line workers will also be responsible for identifying pregnant women and enrolling them in a comprehensive care group. They will keep records of these pregnant women's phone numbers and will be able to text the women reminding them when group meetings are and when they are due for ante natal and post natal care. These phone numbers may also be used to alert community members of upcoming health events such as immunization campaigns or visiting doctors. Appropriate health education, based on prominent health challenges at that time, will also be disseminated via text to community member.
Comprehensive Care Groups:
The comprehensive care group will be established for pregnant women and women with young children. The composition of the groups will depend on the area that these women live in and the number of pregnant women. Ideally, women with similar due dates will be enrolled in a group. The women will be expected to attend ante natal care at the clinic or hospital and health education sessions, run by the front line health worker, while pregnant to prepare them for the birthing process and caring for a new born.
The women enrolled in the comprehensive care groups will continue attending meetings until the child is five years old. At least one meeting a month will be run by the front line health worker. The mothers will be taught about exclusive breast feeding, proper nutrition for both mothers and baby, developmentally appropriate games to play with the children, family planing, the importance of saving as well as other topics that are appropriate. The front line worker will also be able to asses children at these meetings to make sure that they are meeting their developmental milestones and are gaining the proper amount of weight. They will also bring immunizations for the children to ensure that the children are fully immunized.
Currently in this part of Uganda women often do not attend all of their antenatal visits and many still decide to have home births. In order to encourage women to go to the health facilities for these visits we've decided to incentivize the visits. Women who attend 1 health education session will be given a piece of kitenge material. The reason for the kitenge material is that each women is required to bring kitenge material to each ante natal visit and during delivery in order to cover the examination bed. The kitenge given will remain at the clinic with their name and be used during all ante natal visits. After delivery the women will go home with the kitenge material. This will encourage women to deliver at a health facility. The reason that this incentive was deemed appropriate is currently a women is given a “delivery kit” at the hospital when she comes in for labor. When speaking with 2 nurses 1 doctor and many mothers of young children it was determined that a kitenge would be a good incentive to encourage women to continue attending ante natal and attend the clinic for delivery.
We will also offer pregnant women who attend 4 comprehensive care group meetings a voucher to give to the motorcycle taxi drivers when they go into labor. The drivers will pick them up and when they arrive at the hospital present the voucher to be paid for the service.
Once a women delivers she will be expected to attend post natal care at a health facility. Few women attend post natal care in this area because they feel that their baby is alive and healthy so there is no reason to travel to the health facility. This is why women who attend all post natal visits will be given a cloth diaper for the baby. This again was determined after speaking with women who have young children and consulting with nurses and doctors.
Women who attend 4 comprehensive care group meetings after delivery will receive a receive a sachet of seeds for kale or other green leafy vegetables high in nutrients. In the target area many children and families rarely eat green vegetables due to difficulty in obtaining these foods. The women will be able to grown their own green leafy vegetables to eat and sell, enabling them to better the health of their family.
Again, women who attend an additional 4 comprehensive care group meetings will receive a Moringa tree. The front line worker will teach women how to plant and care for there tree. In addition they will be taught the benefits the different part of the tree possess, such as the seeds with water purification and the leaves with the great nutritional benefits, and how to prepare food using the leaves from the tree. This will allow for nutritional benefits for the family for years to come.
In addition to Moringa trees and green vegetables, women who attend a 12 comprehensive care group meetings after delivery will be qualified to receive a micro finance loan. The group will have to decide among the group members who is most deserving of these loans. These loans will be approximately $60 and will allow women to being small business such as goat rearing or selling vegetables. This will allow the families to gain a more secure financial footing and allow for the families to be able to buy nutritious foods and begin saving for school fees. Currently, this organization provides micro finance loans to granny groups in the area. After researching and evaluating the loans program we determined that the loan amount that had the greatest impact on a grandmother’s life was $60. Since grandmothers in this area are often caring for large families due to the HIV epidemic creating orphans, we've determined that mothers and grandmothers are in similar situations and the same loan amount should be awarded to members of the comprehensive care groups.
Nyaka AIDS Orphans Project has a relationship with this community already. This prior relationship will be invaluable in the success of the comprehensive care group program. It also aligns well with Nyaka's future goals and current partnerships. We will be able to use our partnership with the government run hospital in the area and the grandmothers in the area to enable us to identify women and deliver babies in hospital settings. We already have a clinic where patients attend and successful programs are run. Nyaka will be building off of what it already has in place to better address the needs of children under five.
These groups will provide a place for health education by the front line worker and a gathering of people for health facilities staff to easily access. It also provides a place for children to interact with other children engaged in developmentally appropriate games helping the child develop fine motor skills and social skills. The incentives encourage women to initially attend group meetings and once this occurs the women will become more invested in the program itself and begin to see the benefits of attending meetings. The women within the group create a support network with other women in their own community. These women will be able to rely on one another to assist with problems they are facing and get advice from others who have gone through similar difficulties. This support network will continue even after their child has reached the age of 5.
Who will benefit from this idea and where are they located?
This program itself identifies pregnant women to enroll in comprehensive care groups. Women will remain enrolled in groups until their child reaches the age of five. Not only will women and children enrolled in the comprehensive care groups benefit from this program but also the other family members. The family will benefit from the health education and life skills that the mothers have gained and the changes towards more healthy behavior as well as the profits from the business started through the micro finance loans. It will also benefit the entire community. The front line worker is responsible for visiting all houses in a catchment area. They are responsible for treating, triaging and referring all community members.
The area that this program is targeting is a rural village in south western Uganda. People in this area are subsistence farmers and many survive on less than $2 a day. The main crops that are grown are bananas, beans, millet, and maize. People in this area raise cattle, goats, sheep, chickens and pigs. Malnutrition is a problem, especially with individuals lacking the ability to eat vegetables. Health facilities are often a far distance from families making health care difficult to access. Women tend to have many children in the understanding that not all of their children will make it past their fifth birthday.
How could you test this idea in a quick and low-cost way right now?
The first way we would test the idea would be to test giving kitenges to ante natal clients. They would be given a kitenge at their first visit and it will remain at the hospital until the time of the delivery. This will help us to determine if that is motivation for the women to continue attending all of the ante natal visits and delivery. We would measure the number of patients that returned for their following ante natal visits and who delivered at a health facility. We could also measure the number of women who were referred to the clinic for ante natal by those who received kitenges.
We could hold a test session of the comprehensive care group to determine how best to engage mothers and children and determine the best incentives to keep women coming to group meetings.
We could also hold these sessions with the same group of women to determine if receiving a packet of seeds after attending a pre determined number of sessions keeps the same mothers coming and if new mothers attend wanting to know more about the program.
What kind of help would you need to make your idea real?
We would need expert advise to ensure the program be successful. We would like advise on best practices in engaging mothers in learning about early childhood development and pregnancy and delivery. We would also need an expert in early childhood development to assist in developing games for mothers to play with their children or facilitate between children using locally available resources.
We also need monetary assistance in order to begin the funding for the micro finance loans, incentives, assisting with the salary for the front line health care workers and other incidental costs.
We also would like partner organizations that could compliment the program well. An example would be Text for Change. They could assist in the dissemination of health messages through mobile phones and reminders for ante natal and post natal appointments. Another example would be health facilities that have a maternity ward.
Is this an idea that you or your organization would like to take forward?
Yes. I am ready and interested in testing this idea and making it real in my community.