A training approach for community health volunteers increased skilled birth attendant rates in rural Zambia by 63 percent from baseline over a two-year period.
The UK aid-funded Mobilising Access to Maternal Health Services in Zambia (MAMaZ) programme, implemented between 2010 – 2013, was set up to design and test innovative approaches to reduce demand-side barriers to utilisation of maternal and newborn healthcare services. The programme’s working hypothesis was that community health volunteers could be effectively trained to mobilise communities around a safe motherhood agenda leading to sustained impacts on maternal and newborn health behaviours.
A key strategy for the programme was to support the Zambian government’s Safe Motherhood Action Group initiative, which trained community volunteers to raise awareness of maternal, newborn and child health issues. When MAMaZ started, many of the Safe Motherhood Action Group volunteers had poor capacity and limited confidence to carry out their intended role. Part of the problem was that they were expected to learn about a wide range of health issues in a single short training. A further problem was that with its heavy emphasis on lectures and note-taking, the training methodology was unsuitable for adult learning in a low literacy setting.
Working closely with government partners, MAMaZ adapted the Safe Motherhood Action Group training approach to help increase its effectiveness. The new approach was based on decades of experience of adults as learners. The didactic teaching approach was replaced with a participatory approach grounded in the use of adult learning methods. Innovative teaching and learning methodologies were introduced so that volunteers could acquire knowledge quickly, retain this, and quickly develop the capacity to train others effectively.
The content of the training was designed to respond to the gaps in knowledge and to the problems identified by local communities. The training approach was developed for adult community health volunteers operating in a low literacy context. The training began very deliberately with a focus on maternal emergencies as a way to engage the volunteers, following which other health and related topics were added. Emphasis was placed on improving the volunteers’ facilitation skills. Because many of the community health volunteers had poor literacy, and a large number lacked reading and writing skills altogether, a ‘paper free approach’ was devised so that the volunteers did not need to access a training manual.
A methodology called the rapid facilitation imitation method was used to train core trainers and volunteers to become competent facilitators of community health discussions. Training content was expertly demonstrated by a senior trainer and then imitated by trainees who were then reviewed by other trainees. Subdivision of the sessions into discrete segments focused the trainees’ attention on one or at most two facilitation techniques at a time making it easier for them to master each skill.
An emphasis on peer review enabled trainees to get positive feedback or to learn from their mistakes in a constructive and supportive environment. The repetition of training segments and support given to participants to critically review their own and other trainees’ efforts enhanced their learning and ability to assimilate a large amount of material.
Participatory behaviour change communication tools called communication body tools were core to the training approach. These work as follows: key messages are represented by a gesture or ‘pose’ that helps participants remember the verbal message associated with the action. Participants learn to ‘do’ the action and to ‘say’ the message. Participants were involved in the creation of the body tools. Comprehension of and willingness to participate in doing the action and saying the message were enhanced because the gestures that were used were locally recognised.
Songs, sometimes combined with mime, were also used to reinforce key issues. A number of songs were composed in the local dialect by community health volunteers participating in the various MAMaZ-supported training workshops. These songs, which focused on a range of maternal and newborn health issues, were very popular and were transferred from person to person with minimal effort. Singing also proved to be an effective way to tackle sensitive issues such as gender violence, with many communities composing their own songs on the theme of “Zero Tolerance for Wife Beating.”
The community health volunteers received coaching and mentoring support from district health teams, programme staff, and a cadre of supervisory volunteers. This enabled the volunteers to improve their facilitation techniques over time, and helped to remind them of key training content. The coaching and mentoring visits were intensive in the early stages of the intervention, becoming less frequent over time.
The training approach proved extremely popular with the core trainers, who were drawn from district health teams and national level, and Safe Motherhood Action Group community health volunteers alike. One member of a district health team argued: “It’s a new type of technology and works well with those with low literacy skills; a very effective way to fully involve community members and give them a sense of ownership.” Ordinary members of the community also found the approach used by the volunteers very engaging. One volunteer reported: “The community like these things. They enjoy it when you demonstrate the danger signs, the importance of antenatal care and so on. When you sing, they remember automatically.”
The true test of whether or not a training approach has been effective is if it leads to desired outcomes and impacts. MAMaZ’s operations research component captured the situation before and after the training intervention. Skilled birth attendance rates increased by 63 percent from baseline (equivalent to an absolute increase of 27 percent) in less than two years. The proportion of pregnant women who knew to attend antenatal care in the first trimester increased from 27 percent to 43 percent, and use of modern methods of family planning increased from 21 percent to 33 percent over the same period. These results were all statistically significant. Results from survey control sites indicated significantly less positive change. The MAMaZ interventions were therefore responsible for the behaviour change seen in the programme’s intervention communities.
The MAMaZ training approach is in the process of being scaled up by the Comic Relief funded MORE MAMaZ programme (2014-2016). The approach shows good sustainability potential and can be adapted for use in other countries in support of maternal and newborn health goals. Elements of the MAMaZ training approach that were crucial to its success were:
- Grounding training in principles of adult learning: the MAMaZ training material was learner-centred and the teaching methodologies were problem-based, collaborative and participatory.
- Using training methodologies that were conducive to adult learning: these enabled quick assimilation of information and good capacity to train on.
- Using training methods that helped participants assimilate and remember information: this reduced the need to refer to training manuals or notes in order to remember key content.
- Removing the need for multiple training aids: this lowered replication costs and reduced the likelihood that training activities would be undermined by logistical constraints.
This blog is based on the following article and was originally posted on the HEART blog: Green, C., Soyoola, M., Surridge, M., Kaluba, D., 2014, ‘A training approach for community maternal health volunteers that builds sustainable capacity’, Development in Practice Vol 24 (8): 1-11.
MORE MAMaZ is being implemented by consortium partners Transaid, Health Partners International, Development Data and Disacare.
Top centre: Learning the danger signs of labour, Zambia MORE MAMaZ. Photo credit: Cathy Green
Bottom right: Community health workers training workshop, Zambia. MORE MAMaZ. Photo credit: Cathy Green