“Participatory Reflection and Action” framework: Increasing ownership for health issues

Involving Communities in NCD Control in Tajikistan

Von Gulzira Karimova and Till Mostowlansky / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)

The Swiss funded Tajik-Swiss Health and Family Medicine Support Project (Project Sino) has been working with rural communities in Tajikistan since 2007. It provides an example of how primary health care providers and members of village communities can cooperate in the prevention of non-communicable diseases (NCD).

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The breakup of the Soviet Union 1991 and a civil war between 1992 and 1997 have left Tajikistan’s primary health care services severely damaged. Against this backdrop, the Tajik-Swiss Health Reform and Family Medicine Support Project (Project Sino) aims to contribute to the improvement of the access to health services for the population in several rural districts of the Central Asian republic. One of Project Sino’s main goals is to establish functional family medicine services whose employees are actively engaged in the involvement of village communities. In doing so, Project Sino facilitates the implementation of the National Health Strategy of the Republic of Tajikistan 2010 – 2020 which focuses among else on disease prevention and the promotion of health through interventions and services at the primary health care level.

Family medicine and community involvement

Project Sino recognises that village communities play a central role in promoting health in rural contexts. This central role is taken into account and materialises in the linking of community members and family medicine teams on the occasion of common activities such as community meetings and health awareness campaigns. Since 2007, the cooperation between health care providers and community members has resulted in increased knowledge on health within the communities as well as in the establishment of mutual trust.

In order to find an entry into communities in Southern and Western Tajikistan, Project Sino has worked with groups consisting of active individuals or expert patients who are embedded in their village communities. Project Sino has defined active individuals as people who are willing to engage with health topics and to take ownership for community health. While the interest in ownership in health on a local level also defines expert patients, difference is constituted by personal experiences of disease. Expert patients have knowledge on particular diseases (e.g. TB, brucellosis) since they have lived through the healing process and are willing to share their specific knowledge with other community members. As a result, active individuals as well as expert patients have been involved into decision-making processes by the health care providers and have served as important mediators with their communities.

Rather than managing communities Project Sino involved over the last 6 years village communities into health structures in order to convey a sense of agency to their members. In this regard, the use of participatory approaches has served the goal of handing over ownership of knowledge on health to active community members. In the following, a description of Project Sino’s methods and approaches shall serve as background for a better understanding of community activities related to non-communicable diseases (NCD) such as hypertension, iodine deficiency, heart diseases, diabetes and allergic diseases.

Methods and approaches

After initial trial periods a ‘bottom-up’ approach to community involvement has proved to be appropriate for the rural contexts in which Project Sino is active. The core of the approach constitutes the establishment of community groups that consist of active individuals which develop a sense of ownership for health within their communities. These individuals do neither receive payment nor other material incentives but become active on the basis of their interest in knowledge on health and in the social capital which it includes.

In the beginning, active individuals gather in the framework of a “Participatory Reflection and Action”, an interactive session in which they prioritise health problems in their village and discuss possible solutions. Such sessions enable active individuals, and subsequently the communities in which they live, to act on their own for the improvement of their health. In this regard, “Participatory Reflection and Action” allows active individuals to be main actors on different levels:

1. Local communities analyse their conditions of life, health needs and priorities themselves (“they do it”).

2. Health professionals are first of all listeners; they learn from local people in face-to-face interaction.

3. The participants share their knowledge during the sessions (“community members – professionals”, “community members – community members”, “professionals – professionals”).

In the aftermath of “Participatory Reflection and Action” skills that are available in the communities are utilised and strengthened through common interventions. Ideally these interventions result in increased self-confidence and community mobilisation. While the results of the sessions with active individuals are discussed on village level, they are also taken seriously by professionals working in state structures on district level. Project Sino has trained these professionals in community involvement and the conduct of “Participatory Reflection and Action”. As a consequence, the results of the sessions strongly influence further interventions and decision-making.

Documentation on Project Sino’s recent activities shows that alone in January 2013 526 “Participatory Reflection and Action” sessions could be conducted, involving a total number of 7541 individuals. As a result of these activities Project Sino currently collaborates with 74 community groups whose members are involved in health promotion through trainings by primary health care staff and the dissemination of information materials.

To be sure, health priorities vary from community to community and solutions have to remain within a flexible framework which is shaped by active individuals and primary health care staff in the villages. In the following, the depiction of concrete examples of interventions will focus on specific cases in which community members have chosen non-communicable diseases (NCD) as major problem in their villages.

Putting communities into action I: iodine deficiency

An example for recent community action against non-communicable diseases (NCD) is a health awareness campaign on the effects of iodine deficiency in the district of Tursunzoda. In the district, communities had prioritised health problems related to iodine deficiency and subsequently planned prevention activities together with the primary health care and family medicine staff. The activities included diverse elements such as information campaigns on iodine deficiency, role plays on the topic within the communities, testing salt in households and shops by community members, dialogue and cooperation of primary health care staff with the endocrinology service of district as well as the sharing of experiences between different communities. In the course of the prevention activities in Tursunzoda test kits for salt-selling shops were distributed. The shopkeepers were furthermore asked to test salt at whole sale markets before buying it. As a result of the activities, awareness of iodine deficiency diseases has increased. The establishment of prevention strategies as a cooperation between primary health care staff and community members has also had an effect on the level of ownership in the affected villages, as the following example shows:

In a village in the district of Tursunzoda a group of active individuals defined goitre as major health problem in their village. As a result, family medicine practitioners provided the group with information on iodine deficiency diseases. The active individuals then distributed informational materials to households in their neighbourhoods and explained the effects of iodine deficiency to other villagers. In this process it turned out that many salt samples, which had been taken from households in the community, had no iodine content. In reaction to this, the active individuals publicly explained the need for iodised salt and distributed test kits for salt-selling shops.

From then on, salt that was meant for sale in the village was being checked by community members. For instance, salesmen who attempted to deliver iodine-free salt to the village on a truck were prevented from doing so by active individuals after testing. Community members prohibited the salesman to sell their salt and forced the truck to leave the village.

As this example demonstrates, “Participatory Reflection and Action” led to an increased level of health awareness in regard to the effects of iodine deficiency as well as to the establishment of a sense of ownership of health in the village. In addition, community members began to regularly visit family practitioners for examinations, which also points at an enhanced level of trust towards local health specialists.

Putting communities into action II: reproductive health

Apart from the successful and tension-free implementation of “Participatory Reflection and Action” as shown above in regard to iodine deficiency, there are also cases that are marked by social and cultural challenges. As to that, an example from the district of Shahrinav in Western Tajikistan points to the importance of gender and religion in community involvement.

In a village in Shahrinav, a group consisting of active women prioritised problems related to reproductive health as prevalent in their community. As a consequence, family medicine practitioners provided them with training sessions on reproductive health. After having gained knowledge of methods of birth control, the active women began to disseminate leaflets in Tajik on the topic among the people of their village.

In the beginning no problems arose and the women expressed their satisfaction with the enhanced access to information on reproductive health. However, the male mosque community had noticed the women’s activities in the village and considered them a threat to morality in the community. Soon after, the man who had agreed to host the training sessions on reproductive health in his house was harshly criticised. Furthermore, the men intended to prohibit future activities on the topic and a climate of distrust emerged in the village that seemed difficult to disperse.

Finally, a wise intervention of the local family medicine practitioner and a nurse could calm the waves. Members of the women’s group had turned to the family medicine staff for help and they then decided to seek dialogue with the mosque community. Doctor and nurse went to the mosque when a congregation was held and asked to speak in front of the crowd. They legitimised their claims on health topics by reference to Islam, which is the dominant faith in Tajikistan. In their speech, they argued that health awareness and people’s responsibility for the integrity of their own and other bodies were central visions in Islam. As another central point, they stated, that seeking knowledge generally and knowledge on health and the functions of the human body more specifically were religious demands.

The integration of the male mosque community and their religious leaders had a positive effect and disseminating knowledge on reproductive health became accepted. The way of religious legitimacy had worked and has led to the fact that ownership of health is now considered locally rooted in the village.

Conclusion

As the examples above show, involving communities in disease prevention by the help of participatory approaches has proved to be promising. Such involvement not only gives community members the chance to actively claim ownership for their health but also reaches out into extended families and neighbourhoods. In addition, through the cooperation with family medicine staff the links with primary health care services are strengthened and trust towards health care professionals increases.

In this context, the use of the “Participatory Reflection and Action” approach constitutes a key element. Apart from its effectiveness, the approach is cheap and therefore fits rural environments in Tajikistan where health facilities are cash-strapped and have no or little budgets for community involvement. In addition, “Participatory Reflection and Action” is an approach that stands for playfulness and the creation of a sense of community among its participants. This aspiration is emphasised by the use of visuals and the participants’ common reflection about their own geographical and social environment.

In regard to the control of non-communicable diseases (NCD), “Participatory Reflection and Action” contributes in two ways. On the one hand, the approach raises the level of awareness in village communities and therefore supports the prevention of non-communicable diseases (NCD) through testing salt for iodine, monitoring blood pressure and weight as well as referring vulnerable community members to the family practitioner. On the other hand, the communities’ increasing ownership for their health and the explicit formulation of demands also suggest to medical professionals that it is high time to take the role of community members seriously and to perceive them as vital and valuable parts of primary health care and prevention programmes.

*Gulzira Karimova is a community specialist and works for Project Sino (Swiss TPH) in Tajikistan. She has been active in the field of community mobilisation and health education for the past thirteen years. Since 2008 Gulzira particularly focusses on health promotion and community health within rural communities. Contact: gulzira.karimova@swisstph.org

**Till Mostowlansky, PhD, is a researcher in Central Asian Studies at the University of Bern (Switzerland). His current research project focusses on the anthropology of development in Northern Pakistan and Tajikistan. Till has acted as an international consultant on community participation for the Swiss TPH in Tajikistan since 2007. Contact: till.mostowlansky@relwi.unibe.ch