Category Archives: CNA

Community Needs Assessment in Mozambique: Personal Insights, Tailored Focus

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This is the second (first) in a series of posts about implementing health projects in a developing country. It is meant to introduce a reader to the inner workings of public health training and action, especially the collection of baseline information, and share with the world data, stories, and personal thoughts about the ongoing challenges of global health in Mozambique.

Public health is all about knowing who matters most.

We want to believe that all information that we need to be successful in any area or field is advice, input, and research from those who we deem as “experts.” While these voices are crucial in public health to develop a robust assessment, there are lesser-heard voices that act to compliment the information gained from national health statistics and evidence-based research and provide a more personal insight and tailored focus of the CNA.

The lesser-heard voices belong to those in the community who are living with and seeing the daily effects of any given disease or health issue: the mother of two who is HIV-positive along with her children, the community leaders who have daily discussions with their neighborhoods about issues, the volunteers in the health system that work to seek out the patients who have abandoned their treatment. They all have voices and deserve to be heard. The simplicity of public health: Listen to these people and, often, solutions will reveal themselves.

Public health is all about understanding those who matter most.

Before we can collect personal information from those in the community, we need to first better understand the community itself. Sure, we have national statistics, photographs of key places in the town, a history of the community, and an overall opinion about the health issues that matter most to people, but we need to round out our understanding with a current snapshot of the community and its resources to better understand the people.

Community Map

Everyone shook their heads in confusion when I first asked about a map of my community. From the local health leaders to those who work in the local government, nobody was able to provide a detailed map of the neighborhoods and main streets. Having an overall view of the layout of the community is crucial in understanding proximity, abundance, and availability of local resources for those living in the neighborhoods. Good place to start.

Instead of walking the entirety of the community and sketching out a rough map, I thought about who would already have this information through experience and knowledge of the community. The answer was simple. Located in each hospital in Mozambique are activistas, or volunteers from the community who search out patients who have either abandoned treatment or are in need of crucial medication. Each day, these volunteers are given stacks of cards with patient information. Their task sounds simple: search the neighborhoods, find the patients, give them treatment or bring them back to the hospital. The reality is much more difficult, but we will discuss that more later.

Working with the activistas, we created a detailed community map (below) with the district hospital as the central point, names and borders of neighborhoods, and the locations of key resources, including the markets, the police station, and churches.

Mapa_de_Namapa

Seasonal Calendar

Now that we have a better understanding of the locations of key points in the community, we also need to better understand specifics about some of these points, mainly the abundance of food in the markets. Since nutrition and availability of food is firmly linked to the overall health of the community, we need to know which foods are available during which parts of the year, thus knowing which foods we are able to use in future interventions and health programs.

Working with the chefe (boss) of the market located to the east of the hospital as well as vendors who work daily in the market, we together created a seasonal calendar complete with the name of the product, the months along the top of the calendar, the time in which the crop is planted (plantar), harvested (colher), and sold/eaten (consumir). The yellow bars are the crops that are available all year. It is clear that Namapa has a high abundance of available food items. While the issue is usually cost, we now know that food is available.

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Additional Resources

In addition to an abundance of food from the markets, other resources in the community include: a community radio station that airs health messages in both Portuguese and the local language; water pumps around the community that provide a constant (with energy) supply of water for the neighborhoods; access to the national highway for travel and import of crucial supplies; cellular networks for both phone calls and internet access; and Namapa is home to the district government offices.

Public health is all about listening to those who matter most.

Now that we have a detailed profile of our community, a general opinion from the public and patients regarding health problems, a precise community map, and more information regarding the availability of food items, we are able to start collecting qualitative information from the community to best identify our direction for future health programs.

Activistas

Who better to understand both the inner-workings of the hospital system as well as the health issues in the community than those who are volunteering their time to locate lost patients and reduce the burden of diseases in the community? The activistas not only have detailed information on the best direction to take future activities, but since they are volunteer workers they also have an unbiased view to provide honest answers and a personal motivation that will help us to better understand Mozambican’s values.

At the time of this assessment, my hospital had six activistas (now seven). Using a sign-up sheet, I scheduled interview times with each activista. During each interview, I first collected demographic information (below) regarding the activistas, including age, where they are from, time as an activista, the reason for becoming an activista, daily hours in the hospital, daily hours out in the field, with how many patients they speak in the hospital, and with how many patients they speak out in the field.

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Following the collection of demographics, I asked each activista a series of questions about logistics, strengths, and challenges of improving health in Namapa. Below I will share a couple insights from each category, but all are located in my assessment that will be available once it has been reviewed and corrected for grammar by Peace Corps staff.

Logistics

Besides some of the demographic questions asked above, I asked the activistas, “What do the members of the community think about activistas?” All of the activistas agreed that the people of Namapa, especially those patients who abandon treatment early, believe that the activistas are improving the health of the community. People know that the activistas are linked to the hospital and, therefore, are able to provide information regarding health, illnesses, and prevention.

All of the activistas discussed the importance of the palestras (health talks) that they both create and complete out in the neighborhoods. Community health workers and Peace Corps Volunteers (PCVs) complete palestras in the community because of the lack of information regarding prevention and limited resources. The activistas discussed the fact that since they are seen daily in the community with important health information, they are trusted. It is more difficult for a PCV to enter the community with information since they are new.

Strengths & Motivations

I asked the activistas, “What motivates you to work as an activista?” Since the activistas don’t earn any money for their work (besides the occasional money given by one of our team members), they all agreed that helping to diminish the burden of disease in the community was their main motivation. The demographics show that five out of six of the volunteers are from Namapa, so they have a strong connection to the community.

One of the female activistas described how her son is living with HIV. Looking down as she describes the disease, it’s clear that the issue is close to her heart and family. Also, another volunteer said that he himself is living with a disease, and by working in the community, he knows he is helping others and decreasing the likelihood that they’ll acquire the disease.

Challenges

I asked the activistas, “What are the challenges of the job?” While they are all motivated by improving the health of the community, they all agreed that one challenge is actually diminishing the burden. They are out in the community each day searching for patients or giving health talks, yet the diseases continue to tear through the neighborhoods. They discussed how it is difficult for six people to reach so many people. With a population of more than 60,000 people, Namapa is too large of a town for such a small group.

Another challenge that is seen throughout the health system in Mozambique is the organization of the patient cards in the hospital. All patients are registered when entering the hospital, but because the system is not (yet) electronic, the paper forms are put into filing cases that are disorganized, dirty, and confusing to understand. The activistas spend crucial time in the morning simply searching for the patient’s information before heading out into the community. A faster system could help them reach more patients.

Finally, a problem that is also seen nationwide is transportation for the activistas. Since they are volunteers and there is limited funding for the hospitals, the activistas have to search the community by foot. With so many neighborhoods and limited time, not as many patients are reached. In the past, the volunteers had bicycles, but because of thieves, poor quality of the bikes, and poor maintenance, the bikes don’t last very long. Additionally, a motorcycle or car is out of the question because of cost.

Final Thoughts

I asked the activistas, “If you could change one thing about your position, what would it be?” While all of the volunteers said they were content with the job, they mentioned the need for a little bit of money for their families, transportation to get around the community, and the need for more material. The activistas enter the community without any physical pamphlets or information. Their palestras are just through speaking. However, there is the issue of literacy in the community as well as those who only speak the local language.

Public health is all about continuing the conversation.

The conversations with the activistas were crucial in developing a focused assessment. However, the conversation needs to continue into the implementation of the interventions or health programs. Additionally, we need to continue to speak with as many members of the community as possible to make sure all voices are heard and all voices are included.

Next, we need to better understand our organization’s reach in the community, speak with those directly affected by our organization, and identify any areas of improvement.

Questions? Concerns? Contact me!

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Community Needs Assessment in Mozambique: Where Do We Begin?

Shybut_CNA_Cover

This is the first in a series of posts about implementing health projects in a developing country. It is meant to introduce a reader to the inner workings of public health training and action, especially the collection of baseline information, and share with the world data, stories, and personal thoughts about the ongoing challenges of global health in Mozambique.

Public health is complicated.

The area of study and practice, focused more on the prevention and detection of disease rather than the actual treatment of it, is underfunded, underreported, and largely misunderstood (case in point). The area isn’t without its controversy, but each day public health workers are attempting to diminish the burden from diseases for millions of people across the globe through epidemiology, monitoring & evaluation, and education (although, as we’ve seen in the states, even education can be somewhat ineffective against an individual’s personal beliefs).

Public health in a developing country is more complicated.

When you first arrive in your host country for Peace Corps service, you spend two months living with a host family, learning about the language and culture, and receiving a mountain of information about health statistics throughout the country. This training often leaves one feeling overwhelmed, living and working in the constant shadow of statistics, findings, recommendations for future research and programs. The voices heard during training are many, and the statistics forced into a volunteer’s conscious are intimidating.

The trick isn’t lowering the mountain, but looking at it from the right angle.

While many volunteers arrive at site ready to destroy (or slightly reduce) this mountain of information with absolute force, strength, and ideas passed along from experts, the public health practitioner first takes a step back, looking at the larger community, researching the entire story, before taking a step forward toward public health practice. One of the main tools used during this analysis is a community needs assessment (CNA). AKA my baby.

The CNA asks you to collect all the necessary information relevant to your site, speak with as many people within the community (leaders, business owners, members of the community), and identify any gaps in service, or areas of health that aren’t already being addressed by other organizations, community groups, or available resources. Instead of doing a cannonball into the deep end of the pool, the CNA both eases you into the pool and helps you find an open area to swim. (There must be an analogy for urine in the pool, but I can’t yet place it). And as we all know, it’s better to (ideally) have a swimming buddy.

Collection of information & sharing the experience with a counterpart

In terms of sustainability (especially in developing countries), it’s important to share your research methods with a host-country national, or in non-Peace-Corps-speech, someone from the country in which you are serving. I arrived at my site with a supervisor but no counterpart, so I first sought out an interested mind in the ways of health. This came in the form of a young man who was new to the area and wanted to keep busy. His name is Flex.

Flex and I eased our way into the water. The Internet is overflowing with information regarding health around the world. With the right sites (here, here, here, yes also here) or even a quick Google Scholar search, you’re able to paint a pretty vivid portrait of the current health culture in any given area of the world. Here is a small sample of what we found on Mozambique, simply by huddling around a computer:

  • The country is home to about 25 million people with a life expectancy of 52 years
  • Low United Nations Human Development Index classification of 184/186 countries
  • The national prevalence of HIV, the primary cause of death among adults and tertiary cause among children, is 11.5% with a province (Nampula) prevalence of 4.8%
  • HIV testing in Mozambique is low with 34% women and 17% men receiving treatment, and testing is less prevalent in the north (23%) than the south (50%)

While the Internet will provide nation-wide statistics on health, it’s more difficult to find information on (in order from hard to solid diamond) the province, district, town, or neighborhoods in which you are serving. In order to build a complete case for whatever decision you decide to do for projects, you need to also collect your own information.

A lesson in language & early morning drunkenness

Since we have already decided to take a broad look at our community, we need to first start broad with our information collection. Would it be very helpful to full aside someone from the community and start to ask them about their sexual health habits if we haven’t yet heard from the community that sexually transmitted infections are an issue? On a first date, would you jump to asking your date about his or her divorced parents or first start by asking about family? Both situations are bound to end in a frustrated party (maybe a slap).

Results_Survey_Public

I decided that I first wanted to collect information demographics (sex, age, if they live in Namapa, speak Portuguese, speak the local language), the general population’s ideas about major health concerns in the community, and where people are receiving their health information. Using the survey above, I spoke with 100 members of my community over the course of one day. By walking down our main street with a clipboard and an inquisitive expression, people were curious and interested to share their thoughts. The problem is always with language (attempting the survey after a few weeks at site) and attracting unwanted attention.

A common habit of many people in Mozambique is to drink at every hour of the day. Because of joblessness and a lack of understanding about the health effects of drinking, it is very common to see someone with a beer at 9:00 a.m. It makes for great business for local stores and bars, but the environment is often difficult to navigate with constant distractions from conversations with people who have had one too many cold beverages.

During my survey, a young man grabbed my wrist, pulled me into a dark, smoky bar, and sat me in front of a heavy-set man sitting down in a chair facing the front door. I looked around and saw many faces staring in my direction as I was placed in the chair. With a smile on my face, I greet the man. He tells me he is the chefe (boss) of the neighborhood and wanted to know what I was doing on his street. The tension soon faded when I told him my role as a health volunteer. Tension turned to absurdity as they laughed, shook my hand, and led me out the front door with the original young man by my side. He vowed to help me with my survey, but instead he stumbled about, yelled at passerby’s, and was eventually dismissed by me to head back to the bar.

Distraction alluded, I was able to finish the survey and collected the following results: (1) information about the perceived health problems in Namapa, and (2) where people obtain information about health in the community.

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Moving forward slowly

The information provided important details about the direction of my service; however, I still wasn’t satisfied with the information and knew that the collection of information would need to continue with more personal, detailed, and qualitative information, mainly in the form of in-depth interviews with key members from the community and focus groups with community support organizations around Namapa.

Questions? Comments? Contact me!

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Inaugural Address

It seems somewhat serendipitous that my first post falls on the same day as the swearing in of the new President, Filipe Nyusi, under the familiar Frelimo party. The ceremony is a national event with government organizations, businesses, and hospitals closing their doors to watch as the newly elected president takes office. Fellow health volunteers from around the country are writing online of arriving for work at the hospital only to find staff and administration limited to a few personnel while patients wait for treatment.

The ceremony follows a highly contested election among the already reigning party, Frelimo, and its primary opposition, Renamo and Democratic Movement of Mozambique (MDM) (Bloomberg). While the Renamo party still argues that the election wasn’t fairly organized or implemented, the votes were cast and counted with Frelimo winning the majority of the votes with higher percentages in the southern part of the country than the north. Now begins another term under the Frelimo party just as the infrastructure of the country is called into question with massive flood damage, loss of life, and thousands displaced because of collapsed bridges and destroyed homes (BBC).

A Flood of Information

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I am writing this entry from a packed bar in my community of Namapa, a medium-sized town in the northern part of Nampula province near the border of the province of Cabo Delgado and built along the main stretch of highway that connects the north to the south. The bar is filled with people at 10:30 a.m. to not only watch the coverage of the ongoing inauguration ceremony in the south, but also because for the past three days the entire northern half of the country has been without power due to the floods. The bar owner offers the electricity from his diesel-powered generator for community members to charge their telephones and get updates on the status of the rest of the country.

Stories about the damage are pouring in from around the country through news outlets, social media, and conversations with close friends who are either witnessing the damage first hand or hearing from other volunteers about being stranded due to collapsed bridges. Some of the more devastating stories are coming from the town of Mocuba in the Zambezia province, where a collapsed bridge led locals to attempt to swim across the river. A fellow volunteer who was visiting the area called to recount the sight of the bridge disintegrating under the river. Displaced persons are interviewed on the local news and speak about moving forward, rebuilding, and preventing future events.

Progress & Development in a Developing Country

The country of Mozambique is gorgeous with its lush landscape, miles of beaches along the Indian Ocean, and architecture from both the time before independence and the time after. The country gained independence in 1975 and is still in the process of developing its infrastructure, growing its economy, and planning for the future. One of the ways in which the country is looking forward is through partnerships with international organizations, including the Peace Corps, for which I currently serve as a health volunteer.

I arrived in Mozambique at the beginning of June, 2014, and was placed at my permanent site at the beginning of August of the same year. The organization for which I’ve been serving is ICAP, an international non-governmental organization out of Columbia University dedicated “to improve the health of families and communities.” As the first health volunteer to be placed at my site, expectations were both inexplicably high as well as a tad off base. Basically, the local staff at the hospital had no idea what to do with me. What is a health volunteer? Luckily, following a two-year degree in public health, my personal direction was established ahead of time, and I was able to share these directions with my team.

For the past six months at site, I’ve been completing a community needs assessment (CNA) to study the community, collect data on demographics, beliefs, and health issues, and develop a list of recommendations both for community activities that can be implemented immediately and future research to be completed by my host organization or a future volunteer. While I won’t go into great detail about the specifics here (I’ll post the results once I’m able to get a few fresh eyes on it to correct it for grammar, inconsistencies, etc.), I can list the top three things I learned from completing a CNA in Mozambique:

  • Projects and ideas can move at an unbearably slow pace if you don’t push the conversation each day with supervisors, staff, and the community
  • While rumors and inconsistencies exist regarding health and prevention in the country, the majority of people in my community are able to identify the most severe health issues (malaria, HIV/AIDS, etc.) and the general symptoms
  • There are countless questions regarding why patients abandon treatment, why people aren’t properly using mosquito nets, etc., and usually the group that has the answers to these questions is the one we often forget to ask: the community.

Moving Forward

As Nyusi takes office and starts to look ahead at future projects and ways to improve the country, health volunteers hope and ask that he and his administration look to the community first for answers before looking elsewhere. During my conversations with the community regarding health, countless ideas were shared about rebuilding the infrastructure of the country, promoting and emphasizing education, and eliminating government corruption from the top down. The people want improvements. It’s clear.

The country is currently broken because of the flooding throughout the country. Thousands of citizens are displaced and in the process of rebuilding their lives. Millions of people are currently without power and without much transparency about the reasons and expected solutions. On the first day of a new presidency, the country looks to him for solutions. As Peace Corps volunteers, while we will also look to him for future solutions, we continue to direct our attention toward the community and its members where real action thrives.

Questions? Contact me!

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