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Newborn Community Health Project

AIC Kijabe Hospital

Emily Gall

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Newborn Community Health Project

AIC Kijabe Hospital

Emily Gall

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Copyright © 2013 by Equipping Africa ISBN 0-9720587-3-7

All figures and statistics are from the 2008-2009 Kenya Demographic and Health Survey unless specified (in which case they are from the NCH survey). See Kenya National Bureau of Statistics (KNBS) and IFC Macro, Kenya Demographic and Health Survey, 2008-09 (Calverton Maryland: KNBS and IFC Macro, 2010). See also Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of Level One Services (Nairobi: Ministry of Health, Afya House, 2006). Tables of referrals and number of people taught are NCH statistics.

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Acknowledgements Thanks to the board and the senior management team of AIC Kijabe Medical Center for their multifaceted support and encouragement of the project and to the German Institute for Medi-cal Mission (DIFAEM), Intergreen Kenya, Ltd., and Equipping Africa for making this project possible through their financial and technical support. Thanks to the community leaders and government authorities from the Ministry of Health for continued collaboration and support for the project. Grateful acknowledgement to the pastors and the growing team of community health workers who work tirelessly as volunteers to reach their communities with this project. Finally, thanks to the project staff for their efforts to reach the community with accurate health information and with the love of Jesus Christ regardless of the challenges they meet while on duty.

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Project Team

Project Director Dr. Mary Adam (from 1.1.2011) Deputy Director Dr. Peter Meissner (to 1.1.2011) Project staff Simon Mbugua (KRCHN), Priscilla Mumbi (KRCHN), Joram Ndungu (KRCHN), Robina Anene-Mulli (KRCHN), Eunice Waweru (KRCHN) Community Health Workers in Naivasha District (Eburru), Nyakio District, and Lari District Scientific Advisors Dr. Gisela Schneider (DIFAEM director) Dr. H. Weigold (DIFAEM—Germany) Dr. J. Bitzer (DIFAEM—Germany)

Note on Interviews Interviews (the text in columns) of the project staff (Simon Mbugua, Priscilla Mumbi, Joram Ndungu, and Robina Anene-Mulli) took place in July and August 2012.

Abbreviations AIC Africa Inland Church ANC Antenatal Care APHIA+ Aids, Population, and Health Integrated Assistance CBO Community Based Organization CHAK Christian Hospital Association of Kenya CHW Community Health Worker CHAK Christian Health Association of Kenya DMOH District Medical Officer of Health DPHN District Public Health Nurse HCF Health Care Facility KRCHN Kenya Registered Community Health Nurse NCH(P) Newborn Community Health (Project) NGO Non-Governmental Organization NHIF National Health Insurance Fund TBA Traditional Birth Attendant A CHW is a government-trained health worker. NCH also uses CHW to describe community members who have gone through NCH training to teach health messages to community mem-bers.

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Introduction According to the Kenya Demographic and Health Survey of 2009, about 43% of the population is under the age of 15, and three-fifths of the population are under the age of 25. Kenya’s population is youthful; a large number of women are at the childbearing age. This makes maternal and newborn health of ut-most importance to both those who are in the childbearing age and the over-whelmingly high percentage of women who will have children over the next ten to twenty years. More than half of all women in Kenya give birth at home. The most common reason that mothers provided for not giving birth in a health center was dis-tance from a center combined with lack of transport (42% of all mothers sur-veyed gave this answer). Having a birth plan is the best way to remedy this problem, and making this plan of action is a key component of the NCH cur-riculum. The second most commonly cited reason was that giving birth in a health center was unnecessary. This reflects a widespread attitude towards newborn death—that it simply happens and must be accepted as a normal part of life.

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In one of the trainings in Kirasha in Lari District, I was teach-ing a group in one of the community health facilities about danger signs during pregnancy. At this particular time, I was talking about early rup-ture of membranes, the dangers asso-ciated with it, and the correct proce-dures to take when it happens.

Immediately after I finished teaching on this topic, one of the community health workers I was teaching approached me. She told me how she lost her baby several years ago because of an early rupture of membranes—what I had just dis-cussed. When this had happened to her, she had decided to stay at home. Later, she went to a government health facility, where she stayed for three days before delivery, but she was not put on antibiotics. Nor-mally, with early rupture of mem-branes, antibiotics are used to pre-vent infection inside the uterus and in the baby. After three days, she was induced, she delivered, and she went back home.

When she returned home, the baby developed yellow skin coloration. She decided to take the baby to a nearby clinic, but the baby did not re-ceive the necessary care. The mother was told that it was a normal sickness, and she received some medicine and went home.

The baby’s condition grew worse, so the mother decided to go to a main hospital. The baby died on the way.

When the mother was narrating this scenario, it caused her pain. She said that if she had had the knowledge, she probably could have gone earlier o a main hospital like Kijabe, received antibiotics, and avoided the baby’s death.

She also wondered how she was mismanaged in this clinic. Jaundice is a clear sign that the patient should be referred to a big hospital like Kijabe, where the patient receives photother-apy and stays for more than a week.

She said again, “If I had had knowledge at that time, my child could be alive.” A

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More than one fourth of Kenyan women give birth with only a tradi-tional birth attendant (TBA) helping. Since most TBAs lack the knowledge that would enable them to diagnose complications during pregnancy and provide needed care to mothers and children, relying solely upon a TBA during childbirth is dangerous and of-fers at best a false sense of security. 53% of women in Kenya receive no postnatal care. Those in urban areas are twice as likely to receive postnatal care than those in rural areas. This trend of more health care and greater education about health issues for women living in urban rather than ru-ral areas occurs in almost all areas of maternal and newborn health. The nutritional component of NCH teaching in communities is also of vi-tal importance, given that over one third of all children under the age of five years are stunted in growth. NCH training includes the education of community health workers in proper nutrition for mothers and children.

See Kenya National Bureau of Statistics and IFC Macro, Kenya Demographic and Health Survey, 2008-09.

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Strategies to prevent maternal and newborn morbidity and mortality ulti-mately fail when focused solely on managing complications that arise and not also on prevention of these complications. Problems in pregnancy often cannot be predicted and arise quickly, making it difficult to refer a patient quickly enough to a clinic with a health professional who can deal with the problem. In addition, many women suffer serious and sometimes permanent damages to their health through childbirth. This number of women greatly outstrips the number of women who die while giving birth. A focus on mortality alone ig-nores the variegated causes of maternal and newborn health issues and under-mines the real work that community health work in the public health sector can do to ensure the health of mothers and newborns.

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community health workers who work at community health facilities had been in NCH training for about four months. One day, we discussed danger signs in pregnant mothers.

One trainee recounted how he had been called from his neighborhood. People in his community had told him about a young woman who was preg-nant and that something was wrong with her.

That the neighbors told him in-dicates that they knew that he was get-ting information or knowledge from somewhere and that he had some train-

ing. They trusted him enough to bring a community issue to him.

When he went to the woman, he saw that she was bleeding massively. He referred her to the nearest health facility, and from there, the woman went to a bigger facility. There, she un-derwent check-ups and ultrasounds and was put on bed rest.

This man who was a trainee managed to share that knowledge with the family, that they needed to refer the patient to the hospital. The woman was on bed rest for a while, and she contin-ued to go in for antenatal clinics until she was ready to deliver.

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While better obstetric care is indeed needed, an increase in the capability of communities to care for themselves with correct knowledge requires prenatal care and maternal and newborn health education. This education in turn re-sults in a greater decrease in mortality.

One mother in Matura (a sub-location of Magumu in Kinangop Dis-trict), who was pregnant for the third time, noticed that she had some swelling all over her body. She assumed that it was normal weight gain in pregnancy and that she was fine. Most of her friends and her neighbors were telling her, “You’re looking different.”

She in fact had high blood pres-sure, which caused the swelling. She didn’t know until one of the community health workers, who was a relative of hers, noticed that there was something wrong. He immediately sent her to a district hospital, where they diagnosed her with very high blood pressure and referred her to Kijabe, because she could not get sufficient care at the district hospital. The health worker identified the problem and referred her to a hospi-tal—not just a health clinic, but a hospi-tal, where she could be receive the proper care.

When she arrived in Kijabe, they called me. I did follow-up procedures, and she was rushed to theatre to get the

baby out by Caesarean section. The baby was a premature baby and had some abnormalities. The baby lived for two days, but she did not survive.

The mother then took time to heal, and she improved and went home. From this whole experience, she learned that swelling in the body was not nor-mal and that she needed to attend clinic early to check with the health personnel about whether it was abnormal. The second thing she learned was that she needed to have a hospital insurance card, which would have covered most of her bill. They had a very big bill to pay. because they had to sell a piece of land and do harambee (fundraising) to pay the bill. It was almost Ksh 100,000 (over US$1000, an extremely high fig-ure for most people in Kenya).

The woman decided to tell her friends and her neighbors not to assume that something that appears out of the ordinary is normal. She wants to tell them to rush instead to the hospital or at least to a clinic as opposed to relying upon an attendant during birth. L

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Although prenatal care and maternal and newborn health education can pre-vent few complications during pregnancy, care and education greatly increase knowledge and use of referrals to hospitals. Education fosters a link between the community and the health care system. Community health education teaches mothers and their families that using health services is appropriate and that traditional birth attendants cannot adequately deal with symptoms and complications that arise during pregnancy. Health education also allows com-munity members to formulate protocol for care and transport during emergen-cies. Community health work, therefore, is just as essential as excellent care at the referral level in order to improve maternal and newborn health. Both must be present.

The Newborn Health Community Project seeks to cultivate hope in places where resignation dominates attitudes about maternal and child mortality. Changing hearts and minds about health practices saves lives and contributes to a structure of health message exchange. This structure sustains itself and produces long-term change. The results of the project show that changes have occurred with tangible and measurable differences in the communities where the project has operated. Education has saved lives and created a beneficial model that the community can perpetuate for itself.

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A mother who is a community health worker was travelling from one place to another on public transporta-tion. As she was about to alight from the vehicle, she noticed a group of women somewhere off the road. She approached them to ascertain what was happening. She discovered that just across the road was a woman in labor and on the verge of delivery. This lady had been on her way to the hospital but could not reach it.

The others had distanced them-selves from the mother who was in la-bor, and the community health worker asked them, “Why are you so far from the patient? Maybe you can assist her.”

They didn’t even answer, so im-mediately she went to help the woman. She had never done any deliveries, but she thought, This is just a way that I can help someone who’s in need and not in the hospital. This was an emergency.

Because she was a mother, the desire to help a fellow mother moved her to assist the woman. The commu-nity worker went on to help her without gloves. She finished and cut the cord of the baby and wrapped the baby well. They didn’t have any clothes, but they just found some lesos or shukas (swaths of material) to wrap the baby in.

Then, the health worker went back to this group of ladies and asked them, “Why did you allow her to go

through this alone? You should have helped her.”

They replied, “You know, she’s HIV positive, and we cannot assist her, we cannot be near her.” They were all afraid to catch the virus.

Of course, the community health worker was then shocked that she had touched the mother’s blood and that she had not been wearing gloves. She con-soled herself with the knowledge that she had no cuts.

She asked the women to take this mother who had just delivered the baby to the hospital for a check-up. The mother had no transportation of her own, so the worker gave the money she had, and the other women took her.

The community health worker did follow-up and one visit. During the home visit, she found that the baby and the mother were doing well. The com-munity health worker went to a coun-seling center for HIV, and she had test-ing done. The first time, she tested negative, although she must go every three months to be checked again. As of now, thought, she’s fine.

From this experience, we thought of donating even a few pairs of gloves. It may not be sustainable, but the few we provided will take them a while now. They don’t use them every day—they carry about two pairs in their bag, just in case. A

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The project work increases capacity in newborn and health intervention in Kenya. Kenyans—whether NCH staff, community health workers, community health workers, or community members—have benefited from the NCH project and have established complete cycles of self-sufficient teaching, message deliv-ery, and mentorship.

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Specifically, the project staff seeks to reduce neonatal mortality and morbidity in the project regions. The project also seeks to increase knowledge about safe motherhood and skilled attendance at delivery. The project objectives include the following:

Analyzing the situation of newborns in regions around Kijabe; Evaluating socio-cultural risk factors with regard to newborn health at

the community level; Developing teaching materials and standards for the improvement of the

care of newborns; Creating awareness about neonatal health and safe motherhood in the

communities; Building the referral system; Decreasing neonatal morbidity and mortality; and Improving antenatal attendance and vaccination rates of pregnant

women and infants.

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History of the project

The project began in July 2008. Results from the initial survey carried out be-tween July and December 2008 indicated that over 80% of the women in the project regions delivered at home. Of these,

about 20% of all those women were attended by a semi-skilled birth attendant;

35-70% received unskilled help from a relative or neighbor; and 10% of mothers delivered completely on their own.

Lack of knowledge about safe motherhood and newborn care is the principal cause of maternal and neonatal health problems. The project staff decided that teaching community members, and especially mothers, about these issues was the best approach to eliminate this problem. This strategy concurs with Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of Level One Services (2006). Socio-cultural factors that negatively affect maternal and neonatal health in the project regions include

early marriages and pregnancies; early school drop-outs; and lack of awareness on the part of most men concerning their role in the family.

These factors result in lack of support for the women, who bear the burden of all factors associated with childbirth.

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Individual birth plans Danger signs in pregnancy Danger signs in the newborn Immediate care of the newborn Importance of antenatal care The importance of exclusive breast feeding and immunization Danger signs in the postnatal mother

NCH initiated various activities to move towards resolution of prominent issues that arose in the survey. These activities included 1. Teaching women in their groups; 2. Creating awareness of the issue among individual mothers; 3. Training CHWs to ensure knowledge retention in the community; 4. Conducting home visits for follow-up; 5. Empowering men to ensure they are aware of their role in safe motherhood; 6. Developing activities geared towards elimination of early marriages and

subsequent pregnancies; and 7. Collaborating with other stakeholders to ensure that results are achieved.

Core topics addressed in teaching:

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When we visited Eburru, a re-gion that we had phased out over the past few months, we went to the com-munity health work unit there to train health workers. When we went, we happened to pass through the health center. One of the CHWs told us how happy they were about what we had taught and the knowledge that we gave to mothers and community health workers. She added that they had seen a community health worker identify a case of a mother who was almost convulsing—they said that it was an emergency and that they needed to act quickly.

The health worker identified

the classic signs of an impending eclampsia: the mother had a swollen face, swollen hands, and swollen legs, and she had a headache and was close to blackout with extreme dizziness and upper abdominal pain. The health worker found transportation to the health center, where the mother was referred immediately to Kijabe Hospi-tal, where she delivered her baby.

It was a success story of a baby and a mother who were saved. Their lives were saved as a result of the community health worker’s ability to identify danger signs because of the knowledge that he had gained from the NCH teaching. A

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Approaches

Achieving the dream of healthier mothers and newborns requires close work with local populations in their unique contexts, including understanding and overcoming the on-the-ground, system-level obstacles to reliable care. Several underlying elements—including people’s priorities, beliefs, habits, and loyal-ties—ultimately determine how people decide to change their behavior regard-ing health care. Making change in health care practices requires addressing obstacles in changing these elements. Four approaches to understanding com-munities has helped NCH in fostering the kind of relationships and education that make changes in health care possible.

Recognizing that communities resist change and understanding that addressing health care challenges involves some sort of loss for the community are essential to progress. Whenever change involves an experience of loss, real or potential, people cling to what they know, choosing to function in their comfort zone.

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Changing health behaviors also involves social consequences. The loss of approval is a result of diverging from behavior sanctioned by

elders or taught by family. Negotiating the allocation of family fi-nances requires leverage within the family if funds are to be re-served for health care. The necessity of family members to assist with finances results in a loss of perceived independence—this pro-ceeds from an inability to care for and provide for oneself. Further-more, conveying incorrect messages that are only later considered wrong results in a loss of social status, which has serious conse-quences within the community.

After NCH had completed a cycle of training in Eburru and was no longer actively involved in the area, another NGO came to Eburru to do additional training and capacity building of the community health workers. The leaders of Eburru chose people whom the NCH team had trained because they all had a good reputation and were known for their reliability and good work. The NGO taught about post-abortion care. After that, the community health work unit that existed before the incep-tion of the NCH project came up with a methodology that they had learned from the project. The volunteers who had the NCH training said, “The people who have just been trained do not know how

to deliver health messages in the com-munity.”

Now that the newborn project is no longer there, the only thing that we can do is to continue to mentor them in order to increase their ability to deliver health messages. Some of them fear standing before people, and some of them don’t know what to say. We build their confidence by working alongside them, and they stand there and give a health message for one minute. By practicing this, they learn competence in delivering health messages like we do.

That was positive feedback from what they learned from NCH. They demonstrated their desire to continue the same teaching and to mentor others. C

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We went to teach a session in Heni, Karati, and we received many re-ports from the community health work-ers.

One report in particular sparked my mind. It was about one mother who was not attending antenatal clinic. She never attended clinic, despite being encouraged to, although she was not directly linked to any of our CHWs. She carried the pregnancy to term and delivered the baby at home. The family lost the baby at one and a half months.

In the worker’s report, she noted that NCH had encouraged health workers to share maternal and child health-related messages at any time to anyone. These are issues that affect all of us. If you are not in the reproduc-tive age, you are a relative of someone in the reproductive age. If you are not a father, you are a brother or a neighbor in the community. There’s a tight community link.

When the CHW realized that this mother had gone to no NCH ses-sions nor any antenatal visits, and that she delivered at home, the CHW saw that this mother did not know how to care for the baby. The CHW took ad-vantage of the funeral service to at-tempt to prevent this from happening again.

During the service, the CHW requested ten minutes to deliver mater-nal health messages to the crowd. I heard that with passion, because that was a ripe opportunity for the congre-gation to listen keenly and absorb the message positively. Apart from hear-ing the message, they felt the conse-quences of poor maternal and newborn care because of the death of this baby. During the delivery of this message, the crowd appreciated the work of the CHWs. The community realized that they had someone in their midst who had the right knowledge and who was trained to save the lives of the mothers and the newborns.

In the African community set-ting, when you deliver a child, it is not just your baby. It is the community’s baby, so the community as a whole feels the loss. Taking that opportunity to deliver a health message during the burial, ensures that it will be taken up with seriousness, because the conse-quences are clear. Ignoring what we teach—antenatal visits, frequent check-ups, adverse effects during pregnancy, danger signs of pregnancy, danger signs of the neonate—result in dire consequences. We end up losing ba-bies and mothers.

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Character counts. Content can be taught, and the way that the com-munity absorbs it depends on the prior relationships built. This ap-plies to collaboration between the NCH staff and community health workers, as well as to the relationships fostered between community health workers and community members. Those teaching must also practice what they teach; real change occurs when teachers and the community work together, rather than when teachers simply present information. Bonds of trust must be built and used for the good of the community.

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Some of the trainees had taken the initiative and had gathered in a church, and they did teaching on their own. I thought it good that they took their own initiative to teach in a big group of about one hundred mothers. The trainees had requested a chance to teach, and one of the trainees told me that an assis-tant chief was present, and she was so happy that she told me she was going to organize meetings.

Chiefs have many meetings, and she said that this group of train-ees had been pleading for permission to go and teach. The assistant chief was extremely happy about these people who had knowledge and cour-age and who were doing the right thing by teaching. In that particular community, many women were de-livering at home, and few people took their children for immunization. So the chief was extremely happy that these people were encouraged and that they knew how to teach on their own.

I was also encouraged, be-cause this group had not even com-pleted training. They were just trainees, yet they took it upon them-selves to teach in my absence. I knew I had chosen the right kind of workers. There is a general protocol in place for what’s supposed to be done. Chiefs should call barazas (a commu-nity meeting) and choose people one by one. Our approach is different. We pass through the church, because the communities where we are work-ing are basically Christian. Even though community volunteers are seconded by their communities, we emphasize the participation by reli-

gious leaders in the process of choos-ing volunteers from churches, because it is an organ of the community. The volunteers, then, have integrity and are accepted with respect in the com-munity.

After choosing a volunteer, we start teaching in his or her church before we branch out. A sense of respect that other people have for the volunteers is vital, be-cause the community will not trust a volunteer who is not respected, de-spite the excellent knowledge that the volunteer might have. People in the community accept a volunteer as a person before accepting what he or she wants to say. Heeding the cul-tural structure and understanding who commands respect in the com-munity results in a great gain in so-cial leverage.

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Trust is essential. Trust proceeds from recognition by community members that a health worker cares about the community, and only after this trust is established do the community members care about the knowledge that a health worker imparts. Trust drives behav-ioral change. Trust grants courage and motivation to community members to take risks that could change the status quo. Trust frees individuals and communities to explore new possibilities and to evaluate the gains and the losses in approaching health care differ-ently. Trust comes through relationship-based mentoring, which must take place until competency is achieved and even afterwards, until the new behaviors become habits develop into a lifestyle.

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In the Rwanyambo community in Nyakio, I was invited to teach a group after having taught there previ-ously. The community health workers had asked me why I had delayed so much in returning and suggested that I return to see what they were doing.

I returned after a year to evalu-ate whether they had continued the one-to-one delivery of health mes-sages. They said, “Yes, we have been delivering health messages one-on-one.”

This answer was not sufficient to determine what was happening. I could not know whether they had been delivering health messages one-to-one unless I assessed what teaching had happened in the community. I asked them, “Has any child been sick in the last six months?”

One worker said, “She was ad-mitted to the hospital.”

One of the mothers also re-sponded: “We have been acting on your messages, and the community health workers you taught have been supporting us very much, especially when it comes to the follow-up. But we realize that our community is

blessed, because we have experienced a difference from those people who are on the other side of the community. They have experienced infant deaths and new-born deaths during the last few months, but we have not experienced any infant deaths. What you did for us was of great help, and you should visit the other community.”

They had been delivering the messages, then, and to such an extent that other communities had heard about this teaching and had requested it.

After that, I received invitations from the other communities. Some peo-ple said, “Come here and start the same things you started in that community.”

Some community health workers told me that they had also received invi-tations to go to the other side of the community. They wanted me to go and to confirm that they had been trained and sent by us, so that they would have the authority to teach about maternal and newborn health issues in the other community.

The community, then, recog-nized the workers as agents of change and identified other areas where health messages would also effect change. C

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Project maturation: what has been learned

A community that knows how to take care of itself is a healthy community. Promoting the mindset of using available resources to improve health—rather than persisting in the expectation that an outside source should solve the prob-lem—constitutes an ongoing struggle. The structure of the NCH training does involve the element of an outside source. As community health workers gain more knowledge, however, the community grows in its own resources and learns the positive results of empowerment.

Another challenge and learning experience has been the task of how to encour-age people to take ownership of their own health care needs. The links formed between the NCH staff and the staff of governmental health centers have im-proved this situation. As training progresses from one session to the next, com-munity members gain confidence and realize that they can share important health messages without the presence of NCH team members. The community health workers also learn about the extent and limits of their abilities and how to know when to make referrals.

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This story is sorrowful, because it involves a funeral of a girl who died a little while after she had an operation done. Yet it also shows how our part-ners in Germany are involved and how health care has the power to alleviate suffering.

When we were in a particular community, Ruth and Marion (two health workers there) referred me to a child who had multiple disabilities. She was five years old and had club fingers, she was dumb, she could not sit, she could not walk, and she had deformities all over her body. The only thing she could do was meet you.

The father and the mother had separated: when the father realized that the child had deformities, he had di-vorced his wife. The mother lived with her sister and her mother. She had lit-tle money for health care.

When I went to visit the child, I took a photograph to share this case with my colleagues, and I felt so badly

about the child. I talked with my col-leagues, and we decided we could help this child. I thought of one of our friends associated with this project, from Germany, and when I took the picture, I scanned it and sent it to her.

This was fortunate, for she paid the NCIH (Kenyan health insurance) for one year, so the baby was brought to Kijabe and underwent an operation. The woman from Germany sent money for the child’s operation, and after that, the girl began to improve. She still could not stand up, so I inquired whether they could provide a wheel-chair. The woman from Germany did provide a wheelchair, and she also trav-elled to Kenya to visit the child. That woman just cried when she saw the child, and the girl was just smiling. She was a beautiful girl—I still have the pictures.

The wheelchair was a great help to the child, because life was an effort, and she had to sleep in the bed during C

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the day. She could not experience sun, and she could not enjoy the company of other children. With the wheelchair, she could go outside. She could smile, and she could hold my hand—her fingers were not very strong, but she held my hand and just smiled.

We planned a second operation to correct her club fingers, and the child im-proved even more. All of a sudden, I re-ceived a call and was told that the child had died. She had shown a lot of improve-ment. For me to hear that—it affected me completely.

I was invited to the funeral, along with Ruth and Marion, the community workers who had been helping the child and who had referred her to me. We at-tended the funeral, and we were given a chance to say what we had been doing, and I thought, Just let me introduce the commu-nity workers, let me not be seen, let them be seen.

The community workers explained how they had referred the child to me, how they had been taking care of her, and how they had been going there, cleaning the

wound and caring for the child. When the pastor stood, he said what good work the health workers had been doing, and the mourners were full of gratitude. This was essential as an opportunity for the commu-nity to establish a relationship with Ruth and Marion, who had taken care of the child indirectly. They had repeatedly vis-ited the mother to talk with her and to en-courage her. Before the funeral, not everyone in that community knew about the project, because we go to specific areas to teach in health centers. The pastor knew some his-tory of what we did there, but after we de-scribed how the child had come for the op-eration and how the community workers had helped and sent the child to us, the pastor understood to a much greater ex-tent.. The community was extremely thankful. They had some knowledge about the projects going on, like teaching about newborn health, but this was an opportu-nity that they were able to understand that we do more than teaching— all of the teaching was in the service of the larger purpose of saving lives.

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Perpetuating a beneficial cycle During the project so far, the NCH staff has gained a better understanding of how to build networks within existing community structures. As community leadership sees direct benefits from the development of lay volunteers, the de-mand for the training increases. As the CHWs graduate, they support the new volunteers during the training process.

The first group that was trained in Mukeu area provided a report of their work over the month after their training. They wanted to do some-thing to bolster their economic stabil-ity. One community health worker identified an income-generating activ-ity that was happening in the Njabini area: an apparel organization provided work for vulnerable and disabled fami-lies. They requested that I go and talk to the manager of the organization for them. Even before then, one of the mothers met with the manager to talk and to established an acquaintance.

I decided to go just to explain that the health workers comprised a volunteer group in the community, that they had been working on maternal and newborn health issues, and that the manager should evaluate whether he

could invest in that model. I talked to the manager, and he

said, “Yes, I know that mother. I know they are promoting education in that community, and I want to support them. Before I can support them, they will have to come to one of the training sessions about financial management, so that when they start, they will know how to manage their finances.”

He agreed to give them knitting materials to knit pullovers and scarves for export. When these items are ex-ported, they produce income that is brought back to the communities, to help these mothers. This is a project that is ongoing.

This is such a good example of collaboration in the community to im-prove both health and economic secu-rity side by side. C

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On a visit to a health center in

an area in Nyakio, I assessed the contin-ued involvement of health workers. Of the initial group that we trained about maternal and newborn health, some members have dropped off because of various issues. Many community health workers, however, have continued to dedicate themselves to community work.

One mother, Tabitha, is one out-standing women in this group. She teaches mothers during clinic days, and the mothers line up for review. She has also been teaching in the community about maternal and newborn health, and she refers patients to clinics and hospi-tals. After a period of time in the com-munity, the people there developed trust with Tabitha. The person in charge of the health center recognized her work, and others frequently follow her to ob-

serve her at work. One day, those in charge of a

USAID-funded program visited, and they requested a community worker who could link the NCH project with the health center and work with the health center. The program workers promised funds, an indication that they had already recognized that the commu-nity boasted strong volunteer teachers.

The health center took pride in Tabitha because of her dedication and put her name forth. Her sustained effort in teaching health messages has made her a great resource in the community. Her work in the health center enables her to continue teaching mothers in the clinic about maternal and newborn health issues. We see the value that she put in this health center as its work be-comes more sustainable.

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Linking communities with nearby health centers is one goal of the project. At a health center in Karati, we discovered that the staff shared almost no health messages with mothers, so we decided to schedule a weekly visit to the health center.

During our first visit, we shared taught about the importance of ANC, immunization, male involvement in ma-ternal and child health care, and good nutrition during pregnancy.

The twenty mothers who came that day reacted positively. The health professionals there reacted with uncer-tainty, though; they did not know how to behave towards us or how to receive our messages. Beforehand, we had fos-tered rapport with them, and they had given us permission willingly and openly to deliver our messages. We scheduled another meeting for the next week, and we requested that they de-liver health messages once a week.

The next week, the nutritionist from the heath center called me. The health center staff showed appreciation for the work that we had done and re-minded us that we had promised to re-turn, so I went and delivered health messages to forty-three mothers. The number of mothers had doubled from the previous week, and the staff con-firmed that the message was powerful and well-received.

This second talk stirred up the minds of the health workers. During a meeting with the public health officer, the nutritionist, and the DPHN (district public health nurse), the nutritionist said, “Robina, do you know the influence you have had in our health facility?”

I replied, with some confusion, “We are just delivering health mes-sages.”

Then she said, “It has had a huge impact on the mindset of the health pro-fessionals. They have asked why it is

necessary for NCH staff to deliver mes-sages. We are trained to do this, yet we are not doing it. It sparked our minds.”

The health professionals there are registered community health nurses, trained by the government. Their cur-riculum includes a community health component, including the delivery of health messages to mothers in the ma-ternal and child health clinic.

They knew what they should have been doing, yet they neglected to do it. Our presence and our conviction that mothers needed to hear health mes-sages relevant to them made the work-ers there consider doing this kind of teaching, especially after they saw how the mothers appreciated the messages.

We planned to involve the com-munity health workers we had trained and to link the workers with health cen-ters. The workers could deliver health messages when the institution staff were too busy to do so.

Soon afterwards, the nutritionist reported that the staff had decided to outline maternal and child health-related topics and to match up topics with staff members for them to deliver weekly.

Now they have a structure that they can use in the future, and every nurse delivers health messages twice a week. Even in our absence, these health messages are being delivered.

Ch

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0

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1000

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July 2008 -June 2009

07/2009 -06/2010 **

07/2010 -06/2011**

07/2011 -06/2012 **

07/2012 -12/2012

Referrals

Referrals

Total referrals done by CHWs

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Challenges Difficulties with the project vehicle (substantial repair work and loss) resulted in increased costs and decreased work efficiency as a result of time spent with-out a vehicle. The Kijabe facility management team has recommended replace-ment of the vehicle, for which funds are needed. In addition, rain often results in impassable roads and increased difficulties (with or without a large vehicle) in accessing some areas.

Working daily in areas that are so impoverished—where there are such sub-stantial immediate needs that the team is unable to address them—takes a weighty emotional toll on the staff. Home visits during the past year have re-vealed a child with disabilities who needed corrective surgery, a mentally re-tarded mother who was unable to care for her child, and a mentally handi-capped child who was tied in the house during the day while the mother worked in the fields. While the NCH staff always do their utmost to mobilize commu-nity resources, needs remain great. The almost weekly admission to the hospital of a neonate who is severely dehy-drated and septic demonstrates that, in spite of substantial progress, needs are so great that the task to change community practices remains enormous.

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The research identified multiple independent church groups that prohibit all health care, including childhood immunizations and antenatal care. Accessing the health care system, an indication that the individual lacks trust in God, re-sults in expulsion from the church. These groups resist educational efforts, and this resistance necessitates the development of new ways of working with the leadership of these groups.

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Future development At present, NCH exists to support the governmental health structures in their mutual goal of delivering care to all communities, even those difficult to reach. The project seeks to continue increasing the number of CHWs and CHWs in each district with the goal of achieving the Kenya goal of one CHW per 20 households. Invitations to expand the project into new areas exceed current project capacity. Another goal is expansion of training to health professionals, especially for those who will supervise community health workers. This will provide a stronger framework for training and sustaining the spread of accurate health messages. The project also seeks to explore opportunities to grow into a learning labora-tory and a center for operational and implementation research in community health. This includes gaining additional partners and donors for the NCH pro-ject and developing financial partners within Kenya and abroad, which will make it possible to achieve the aforementioned goals.

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Summary

As the productivity and influence of those trained has increased, demand for the project in new areas has also increased. In addition, the national Ministry of Public Health has given more attention to the NCH project. One exciting example of government interest occurred in Eburru, where the project was phased out in early 2011. Community health workers in Eburru continued to replicate themselves by training others in depth, at the request of the local government public health officer, who desired more trained volunteers in the community. This health officer supervised their progress as the volun-teers meticulously employed each aspect of the NCH methodology, including mentoring and ensuring the delivery of accurate health messages. NCH methods have attracted attention locally and nationally, and the Ministry of Public Health has learned from the mentoring and community-based ap-proach. Efficiency in training has increased, and this efficiency along with the stability of the volunteers (especially in Eburru), provides a promising level of success and sustainability that serves as a model for other communities. The NCH project is in an excellent position to participate in the development of other health care professionals by growing as a learning laboratory in com-munity health engagement in the future.

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