Outcome Evaluation of Community Health Promotion Intervention within a Donor Funded Project Climate in Papua New Guinea

"In this study community members who were engaged in addressing their community needs were enthused to change. The new governance structure generated renewed respect for leadership and a willingness to participate, claim 'ownership' of changes, and commit to future changes."

Published in Rural and Remote Health (Vol. 9), this 14-page paper examines the Australian Agency for International Development (AusAID)-funded Women and Children's Health (WCH) Project, which was carried out in Papua New Guinea from 1998 to 2004. As detailed here, the project utilised education, community development, and health promotion interventions to increase community support for the health of women and children.

Two main strategies were employed under the WCH Project's community component:

1. Community Action and Participation Program (CAP) - The CAP Guide incorporated principles of community development and health promotion, to the end of assisting rural health workers in encouraging improved health practices and self-reliance in health in their community. The CAP Tool Kit utilised activities that motivated community participation to identify priorities for action, develop a plan, and take positive steps to improve the community's health. The project trained more than 1,100 individuals in the use of CAP at the district and village levels.
2. The Village Health Volunteers (VHV) programme focused on supporting VHVs - women and men who are respected and chosen by their community. The project supported development of national policy, minimum standards, generic training materials, and supportive resources for VHVs. Training materials utilised black and white line drawings appropriate for training people with varying levels of literacy across multiple language and cultural groups. Technical advisory meetings, programme management training, and train-the-trainer courses were designed to strengthen the capacity of VHV programme managers. Existing village-level health volunteers (birth attendants, health promoters, health aides/assistants, health educators) were re-trained to update and broaden their knowledge and skills. Other individuals selected by their community were also trained as a VHV.

Key indicators of a healthy lifestyle were incorporated into 2 visual tools for monitoring community and family progress. The visual tool used 16 simple line drawings to depict each indicator (see the image at left, which is a small version of figure 2 within the document). These tools were designed to help the community understand, for example, the link between the CAP process (community development principles) and VHV activities (educating about health).

In 2006, 2 years after completion of formal project activities, an outcome evaluation investigated the long-term impact of the community interventions on maternal and child health. The evaluation used a multi-method approach and covered 10 selectively sampled provinces, 19 districts, and 93 communities. Qualitative data were collected from 175 interviews (national to village level) and 77 community discussions. Quantitative data from national, provincial, and district levels were examined to attempt to validate findings.

In short, the interventions were found to have resulted in communities taking increased responsibility for their health through healthy lifestyle changes. Communities that partnered with the local health system increased their use of health services to help improve the health of women and children. This pattern was linked to "[a] renewed sense of belonging from reworked community leadership [which] reduced resistance to change and influenced individual participation in initiating and maintaining changes. Increased trust, reciprocity and collective action were evident." For instance, community members who previously believed that sanguma (sorcery) caused illness gained increased knowledge and understanding of the root cause of illness. Individuals reported experiencing benefits from simple, small, and inexpensive changes (such as improved sanitation and waste disposal practices) that motivated changing traditional ways. Positive benefits from these changes have resulted in people accepting a more hygienic environment and improved sanitation practices as the social norm. Participants repeatedly reported that they now realise that improvements are not likely to come from the government, and so they have taken up the challenge to improve the environment themselves. Changes in one community have influenced nearby communities because they see the benefits to family health in their neighbours.

Successful villages identified changes leading to improved physical health with unintended consequences in other aspects of life. For instance, participants in large community meetings described how improved relationships had reduced social problems caused by using marijuana, alcohol, and smoking.

Some findings highlight gender issues explicitly. Leaders believed that establishing a village health development committee (a strategy advocated through the VHV programme) helped strengthen women's authority, improved cooperation and respect between the sexes, and increased women's participation in weekly community activities. Community leaders and local women in 69 villages (84%) surveyed spoke of how women are no longer dying in childbirth. The reasons given were that women, now supported by a VHV, attend antenatal care and are more likely to give birth at a health facility. Success in initiating hygiene and environment changes was attributed to the combination of health workers and trained male and female VHVs working together. Along these lines, the study found that, in patrilineal regions, men needed more convincing of the benefits to society before considering the introduction of change. However, those communities with a strong religious affiliation had a sense of connectedness that was quickly strengthened following the intervention.

Centrally, "[t]his study identified well-informed individuals, driven by vision and commitment as the catalyst in motivating community action towards healthy behaviour changes." However, a one-off training is not enough; additional practical learning strategies increased health workers' application of knowledge and skills. These were: visiting a "successful" community, use of visual tools, and additional training in management and teaching techniques. In particular, the visual tools developed as part of the VHV programme were found to have provided a pictorial guide to help individuals identify priority needs and appropriate solutions, and also motivated action for change. The mutual enhancement of all these activities created a synergy that worked to produce a sustainable outcome.

"The evidence collected for this research from many disparate villages demonstrated those communities, which themselves initiated changes, had maintained those changes more than 2 years after the completion of project input. They explained this was because they owned these changes and were proud of their achievements."