Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar

European Journal of Scientific Research ISSN 1450-216X Vol.73 No.3 (2012), pp. 373-381 EuroJournals Publishing, Inc. 2012 http://www.europeanjournalofscientificresearch.com Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar Htoo Htoo Kyaw Soe Assistant Professor, Department of Community Medicine Melaka-Manipal Medical College, Melaka 75150, Malaysia E-mail: htoo2ks@gmail.com Tel: +60-62925849/50/51 Ratana Somrongthong Assistant Professor, College of Public Health Sciences Chulalongkorn University, Bangkok 10330, Thailand E-mail: sratana3@chula.ac.th Tel: +66-22188152/3 Soe Moe Associate Professor, Department of Community Medicine Melaka-Manipal Medical College, Melaka 75150, Malaysia E-mail: soemoe2006.40@gmail.com Tel: +60-62925849/50/51 Kay Thi Myint Assistant Professor, Department of Ophthalmology Melaka-Manipal Medical College, Melaka 75150, Malaysia E-mail: kaythimyint.eye@gmail.com Tel: +60-62925849/50/51 Han Ni Assistant Professor, Department of Medicine Melaka-Manipal Medical College, Melaka 75150, Malaysia E-mail: hanni.dr@gmail.com Tel: +60-62925849/50/51 Abstract Community participation is seen as central to public health arena and closed collaboration with existing community structures was essential for all community level intervention. However, community participation is poorly understood and there have been few published process evaluations of community participation especially in developing countries. This study aimed to assess the level of community participation to safe motherhood health education program in three Pa-Oh villages in Shan State, Myanmar. Observation, individual in-depth interviews and group discussion using qualitative spidergram analytical framework approach were employed. Illustration of the spider-gram framework provided from this study was simple and practical way of visually

Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar 374 demonstrating the extent of community participation. This study indicated that the participatory approach used in this program empowered the community and community members in resource mobilization and allocations according to the existing resources, developing action plans to address the priority problems, and having responsibilities in implementation of action plans. Keywords: Community participation, assessment, safe motherhood health education program, Myanmar 1. Introduction Approximately 1.3 million women give birth each year in Myanmar (WHO, 2009) when only 50% of the whole country is covered with safe motherhood (Ministry of Health and Ministry of Social Welfare, Relief and Resettlement, 2008). According to the Nationwide Cause-specific Maternal Mortality Survey, carried out by Department of Health in 2004-2005, maternal mortality ratio was estimated at 316 per 100,000 live births at the national level. 89% of all maternal deaths were reported from the rural areas where maternal mortality was 2.5 times higher than that in urban areas (Ministry of Health and Ministry of Social Welfare, Relief and Resettlement, 2008). In order to save women s lives from preventable causes of maternal death, crucial information is needed; so that the most effective and efficient treatment can be organized (WHO, 2005). Health education to mothers is one of the strategies which many countries have adopted to improve maternal health (Annet N, 2004). Health education includes not only instructional and other strategies to change individual health behavior, but also includes organizational efforts, policy directives, economic supports, environmental, community level programs and community participation (Glanz K, 1997). Community participation is seen as the key to the success of virtually every community-based project (Yoddumnern-Attig B, et al, 1993) and the interest in community participation in programs in the world is not new (Ozcebe H and Akin L, 1998). Since 1978, community participation has become importance in the public health arena with Alma Ata declaration (WHO, 1978). The rationale for engaging community participation includes promoting positive health behavioral change; improving service delivery; mobilizing human, financial and other material (including in-kind) resources for health services; and as a means of empowering the community. Community participation initiated by outside actors is only likely to be effective and lasting if the local community achieves a sense of ownership (Jacobs B and Price N, 2003). Closed collaboration with existing community structures was essential in primary health care (Mushi D, et al, 2010); however, community participation is poorly understood (Chilaka MA, 2005) and there have been few published process evaluations of community participation especially in low income countries (Draper AK, et al, 2010). In Myanmar, there are about 135 ethnic groups living in the highlands, eastern and western borders (Ministry of Health Myanmar, 2009). Pa-Oh is the second largest ethnic group comprising 12.5% (approximately 600,000 populations) of total population in Shan State, Myanmar. Safe motherhood health education program was implemented in three Pa-Oh villages during 2010 and this program emphasized on providing health education on maternal health care including breastfeeding and family planning and also HIV/AIDS. Women s group health education sessions were carried out by village health volunteers using pictorial handbook which was developed in their social and cultural context. Even though the program aiming to improve knowledge, attitude and practice of maternal health care among reproductive age Pa-Oh women, the program also focused on enhancing participation of village leaders, village and the community member in the

375 Htoo Htoo Kyaw Soe, Ratana Somrongthong, Soe Moe, Kay Thi Myint and Han Ni understanding of health problems, design and implementation, monitoring and evaluation of intervention. 2. Research Objective This study aimed to assess level of community participation to safe motherhood health education program in three Pa-Oh villages in Shan State, Myanmar. 3. Research Methodology The assessment of community participation was carried out in three Pa-Oh villages located in Shan State during November 2010. Each village had total population of 350-550 and had no health facility. They have little education and most are illiterate; and there was language barrier which made them less accessible to health facilities. The only health resource was the midwife working in rural health centre located in other village which was 45 minutes one hour far by walk. Methodological triangulation was employed for validity by applying observation, individual indepth interviews and group discussion for the assessment of community participation in the health education program. Firstly, community members were purposively selected and invited for need assessment in which participatory learning and action tools such as village mapping, seasonal calendar, daily timeline, problem tree, planning table etc were used for identification of women s health problems in the study area. Extent of the community member s contribution was noted. Series of community meetings and group discussions were carried out for design and implementation, monitoring and evaluation of health education program. Observation was made by the researcher in every community meeting and participation in terms of number of person attending, their interest and opinion to the health education program were noted. For individual in-depth interviews and group discussion, respondents were purposively selected. Individual in-depth interviews were conducted with three health committee members, three traditional birth attendants and one auxiliary midwife for exploring their reasons for level of participation. In group discussion, total of eighteen respondents participated including three village leaders, six health committee members, one auxiliary midwife, two traditional birth attendants and six village health volunteers. The respondents were explained about the procedures and basic concept of spider gram (pentagram) framework for measuring the community participation. Guidelines developed based on the Rifkin s framework for five areas were used. The respondents were also asked to select from a 5 point scale in each area of community participation in the framework which later provided the visual presentation of spider-gram. Qualitative spider-gram (pentagram) analytical framework developed by Rifkin and colleagues was used in this study for five areas which were (1) needs assessment, (2) leadership, (3) organization, (3) resource mobilization and (5) management for measuring community participation (Appendix 1). For each area, a continuum was developed with wide participation at one end and narrow participation at the other. Then the continuum was divided into a series of 5 points and a mark was placed at the point which most closely described participation in the health education programs (Rifkin SB, et al, 1988). A five-point ranking scale that measures the degree of participation is ranged from minimal (ranked 1) to maximal (ranked 5) with three levels in between of restricted (ranked 2), fair (ranked 3) and open (ranked 4) (Eyre R & Gauld R. 2003), and the criteria against which rankings were listed in Table 1. In-depth interviews and group discussion were recorded with the consent of the respondents and transcribed and crosschecked with respondents before translating them into Myanmar. Translation from Myanmar to English language was done by researcher and was checked for consistency before

Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar 376 finalization. All the study procedures were approved by Ethical Review committee for Research Involving Human Research Subjects, Health Sciences, Chulalongkorn University, Bangkok, Thailand. 4. Results Community meetings were held once in every month and sometimes, twice in a month. The participants were village leaders, health committee members, education committee members, business loan fund and income generation committee members, traditional birth attendants, village health volunteers and villagers. At least one representative from each group attended in every meeting. The number of participants ranged from 20 to 8 where as there was some absence. In in-depth interviews, all of the respondents stated that community meetings were held regularly in every month, but there was absence of village leaders and village committee members in the meetings sometimes. They all mentioned that village leaders and members supported the program since program preparation, planning, monitoring until evaluation; however, some of them gave the reason for absence in the meetings. In first few months, all the village leaders and other members attended community meetings. In later months, they were busy with seasonal crops and market days, so some of them were absence. (Health committee member) (Village 1) In my village, we always tried to arrange meeting in the days when they were free and when it was not market day in township. But some members kept on running away from meeting. (Health committee member) (Village 3) Our village is divided into two parts, so every meeting at least one representative for each committee came and shared information to other members who were absence. Only one health committee member from west part never came because she moved to live in her farm and it is very far from village. (Health committee member) (Village 2) Table 1 and figure 1 showed the community participation in five key areas; (1) needs assessment, (2) leadership, (3) organization, (4) resource mobilization and (5) management, based on the group discussion. For each area, one of the five points ranking scales (narrow, restricted, fair, open and wide) was provided which most closely described participation in the health education program. Table 1: Leade rship Organ ization Ranking scale of five areas of community participation in safe motherhood health education program Minimal 1 Restricted 2 Fair 3 Open 4 Maximal 5 No collaboration Village There is some among village Village collaborating village for represents community health; different groups in represent only the Worker appointed the community, is wealthy minority functioning under by outside expert active and takes and acts only in an outside expert - works independent initiative in their interest appointed health of social interest community health worker groups does not use village or imposes one for project, which then remains inactive imposes a village, but these develop some imposes village, but these become fully active Existing village actively cooperate in community health Village represents the variety of interests in the community and has ownership/control of community health Existing village incorporate or create their own mechanisms for introducing community health.

377 Htoo Htoo Kyaw Soe, Ratana Somrongthong, Soe Moe, Kay Thi Myint and Han Ni Table 1: Ranking scale of five areas of community participation in safe motherhood health education program - continued Needs assessm ent Manag ement Resour ce mobiliz ation solely projects possible problems or conducts survey Activities induced by outside expert and only outside expert conducts supervision of Token amount contributed by community. Village does not decide on any resources allocation viewpoint dominates but community interests are considered, often through input of health committee An outside expert appointed health worker manages independently, under supervision of outside expert Mechanism established for resource generation, but village have no control over use of resources Health committee assessment of community views and needs dominates Health involved to some extent in management of but without control of Continuing contribution of local resources, but no or limited village control of resources Health committee actively involves in seeking out community members' viewpoint, and in analysis of needs Health committee is self-managed and involved in supervisor of Continuing contribution of local resources, and village control use of funds Community members involve in research and analysis of needs under active village direction The and supervision of the are the responsibility of the health committee Considerable resources contributed by community or obtained otherwise by village. Village allocate available resources Figure 1: Spider-gram framework showing community participation in safe motherhood health education program Management 5 4 3 2 1 Need Assessment Organization Resource Mobilization Leadership 4.1. Needs Assessment In qualitative needs assessment, participatory learning and action tools used were explained to the community members and facilitated by researcher. Even though women in the community, health committee and auxiliary midwife played main role in identifying and analyzing women s health needs and problems, facilitators assisted them in every participatory learning and action exercises. The women helped giving detailed plans specifying responsibilities, resource mobilization in terms of

Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar 378 allocation labor and resource needs, implementation timetables and monitoring indicators of the health education program in their social and cultural context. I participated in meeting which was very new for us. We had to think about women s health problems, solution, plan, etc. We could identify some problems but it was difficult for us to make a plan to solve. But luckily, the doctors helped us for planning and we had some idea. (Health committee member) (Village 2) Survey for evaluation of the effectiveness of the program was designed by the researcher and conducted by trained interviewers. All of the respondents stated that they were explained about aims and objectives of survey and reason for participating in that. Though they did not participate in analysis of survey, they had a chance to know the result of the pre-intervention survey. According to 5 point scale, overall needs assessment was ranked as restricted (Table 1). 4.2. Leadership All the members in leadership team and village such as health committee, education committee, business loan fund members were elected based on their interest, dedication to community service and, and commitment in the community. All of them acknowledged that community meeting was carried out before electing the members. The members were selected from different parts of the village to represents the whole village and work cooperatively and effectively. The leadership team and committee members stated that they made decision together with villagers and NGO for maternal health education and promotion in the village. Therefore, leadership was ranked as fair (Table 1). Whatever organization come and provide support for the of our village, we are willing to welcome and work with them. (Village leader) (Village 2) 4.3. Organization In this study, most of the safe motherhood health education program were initiated and facilitated by health professionals. However, village especially health committee contributed to the health education program implementation aiming to improve health knowledge of reproductive age women. Health committee supported the program by means of social mobilizing for village health volunteers training and health education sessions organized by village health volunteers. We have mobile clinic and doctor come and see us every month. But we also want to have some training as we do not have enough knowledge and we are not sure that we are practicing good health behavior. So we were hoping some training to our villagers. (Health committee member) (Village 1) They also took part in monthly meeting facilitated by health professionals for monitoring program in recording, reporting and reviewing of volunteer. Therefore, the overall organization was ranked as fair (Table 1). 4.4. Resource Mobilization The village had business loan fund and income generation program initiated by NGO. The funding from business loan fund and income generation program was distributed to health committee and education committee. The village leaders and village decided together on resource allocation and control of resources. Meetings were carried out, and expense and future budget were discussed. For safe motherhood health education program, they arranged accommodation for health professionals, arranged places and called for meeting, gave support to village health volunteers for conducting health education sessions throughout project.

379 Htoo Htoo Kyaw Soe, Ratana Somrongthong, Soe Moe, Kay Thi Myint and Han Ni We have business loan fund and income generation program initiated by NGO, but we could get profit since last month. So before that, we did not have a chance to contribute into the health education program in terms of money. But we helped the doctors providing accommodation and food every month they came, helping for arranging meetings and trainings. (Village leader) (Village 1) Our village is far and it s difficult to come in raining season. During that time, we provided cow cart to doctors to come and do meeting and training. (Village leader) (Village 3) We provided our home for village health volunteers for doing group health education every week. So it was more comfortable for women and village health volunteers. (Village leader) (Village 2) According to 5 point scale, resource mobilization was ranked as open (Table 1). 4.5. Management Even though most of the health education program were initiated and facilitated by health professionals, village leaders and all actively involved in the phase of implementation and monitoring of the health education program. They organized monthly meetings with health professionals for discussion on progress and village health volunteer s accomplishment, and future planning. It was difficult to call for meeting sometimes but meeting could be arranged at least once a month as a result of their effort. Whenever there was health education session, we visited to provide necessary things. But we cannot assess their performance and guide them because it was a new thing for us (Village leader) (Village 1) Therefore, management was ranked as fair (Table 1). 5. Discussion and Conclusion The spider-gram (pentagram) framework developed by Rifkin (Rikin SB, et al, 1988) was used in this study assessing and highlighting community participation in needs assessment, leadership, resource mobilization, management, and organization. The framework and concept of the spider-gram (pentagram) itself intended to show the changes and the process of participation in specific health programs (Draper AK, et al, 2010). Although the breadth of the participation along the continuum showed the community involvement in the health education program, these could not be concluded as good or bad participation nor associated to improved women s knowledge, attitude and intention to practice regarding maternal health care. In this study, resource mobilization is the highest participatory activity followed by leadership, organization and management while needs assessment is the lowest participatory activity. Although the participatory learning and action tools used for needs assessment were appropriate for illiterate, it was new experience for the women. In addition, prior knowledge and awareness of health problems are necessary for them to participate in needs assessment. The village has business loan fund program and that might be the reason of getting high participation in resource mobilization. The health education program was initiated by health professionals from NGO, but the community was in support of the program since they knew it was for their own benefit. Though the community involvement at the activity plan and implementation phase was encouraging, their involvement in monitoring and evaluation of the program was quite satisfactory as implementation and monitoring and evaluation phases were driven by health professionals. As in the previous study (Draper AK, et al, 2010), illustration of the spider-gram framework provided from this study was simple and practical way of visually demonstrating the extent of community participation. This approach was widely used to assess the community participation in varieties of community level intervention (Jacobs B & Price N, 2003, Eyre R & Gauld R, 2003, Chilaka MA, 2005). However, there were some shortcomings in utilizing of the framework in this study which were in similar view as the study done in Lawrence (Eyre R & Gauld R, 2003). Firstly, the

Assessment of Community Participation in Safe Motherhood Health Education Program in Shan State, Myanmar 380 degree of participation produced from the group discussions with representatives was subjective. Secondly, the result was based on the discussion with village leaders, health committee, traditional birth attendants, village health volunteers and some women; the result was view of the representatives of community and not the villagers perspective. Community intervention is more likely to succeed if the program is rooted in established community structures (Jacobs B & Price N, 2003). This study indicated that the participatory approach used in intervention program empowered the community and community members. Since the assessment of community participation in the study area was carried out in 8 months of intervention program, resource mobilization and allocations according to the existing resources, developing action plans to address the priority problems and having responsibilities in implementation of action plans were only improved to some extent. To enable community commitment and contribute resources willingly towards safe motherhood health education program, the sense of ownership, which could be achieved by organizations contribute to community, is important. Therefore, the study recommends that conveying messages regarding of village to the community should be done from times to times. Moreover, capacity building to village through organizational training, records keeping and other capacity building training should not be neglected to achieve full participation of community as a whole. This study assessed the level of community participation only once, it was recommended that the future assessment should be carried out for seeing the changes in community participation to the health education program to achieve the program goals. 7. Competing Interests The authors declare that they have no competing interest. 8. Acknowledgements The authors deeply acknowledge Chulalongkorn University and all the organizations for financial support and all in-kind support. We also thank Mrs. Orapin Laosee for her suggestion on the study design and analysis, and Dr. Cynthie Tin Oo, Dr. Khaing Zar Oo and Ms.Pajaree Abdullkasim for their kindly support. References [1] Annet N (2004). Factors influencing utilization of postnatal services in Mulago and Mengo hospitals, Lampala, Uganda [master s thesis]. University of the Western Cape. [2] Chilaka MA. 2005. Ascribing quantitative value to community participation A case study of the roll back malaria (RBM) initiative in five African countries. Journal of the Royal Institute of Public Health. Vol 119. 987-994 [3] Draper AK, Hewitt G & Rifkin S. 2010. Chasing the dragon: Developing indicators for the assessment of community participation in health programmes. Social Science & Medicine. Vol 71 (2010). 1102-1109 [4] Eyre R and Gauld R. 2003. Community participation in rural community health trust: the case of Lawrence, New Zealand. Health promotion international. Vol 18, 3. 189-197. [5] Glanz, K, Lewis, F.M and Rimer, B.K. 1997. Health behavior and health education: Theory, research and practice. 2 nd ed. Jossey-Bass Inc. California. [6] Jacobs B & Price N. 2003. Community participation in externally funded health projects: lessons from Cambodia. Health Policy and Planning. Vol 8 (4). 399-410.

381 Htoo Htoo Kyaw Soe, Ratana Somrongthong, Soe Moe, Kay Thi Myint and Han Ni [7] Mushi D, Mpembeni R and Jahn A. 2010. Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy and Childbirth. 2010. Vol 10 (14). Retrieved from http://www.biomedcentral.com/1471-2393/10/14 [8] Ministry of Health Myanmar. Health in Myanmar. 2009. Ministry of Health Myanmar. Yangon. Retrieved from http://www.whomyanmar.org/linkfiles/health_in_myanmar_2009_healthinmyanmar2009.pd f [9] Ozcebe H and Akin L, 1998. Community participation in primary health care. Journal of Public Health Medicine. Vol 20 (2). 234-235. [10] Rifkin SB, Muller F and Bichmann W. 1988. Primary health care: on measuring participation. Social Science Medicine Journal. Vol 26, No 9. 931-940. [11] World Health Organization (WHO). 2003. Antenatal care in developing countries: promises, achievements and missed opportunities : an analysis of trends, levels and differentials, 1990-2001. WHO. Geneva. [12] World Health Organization (WHO). 2005. World Health Day 2005: Make every mother and child count: Improving maternal, newborn and child health in South-East Asia region. WHO. India. [13] WHO. 1978. Declaration of Alma-Ata. International conference on primary health care, Alma- Ata, USSR. 6-12 September 1979. Retrieved on 23 rd December 2010 from http://www.who.int/hpr/nph/docs/declaration_almaata.pdf [14] Yoddumnern-Attig Allen-Attig G, Boonchalaksi W, et al. 1993. Qualitative methods populations and health research. Institute for Population and Social Research, Mahidol University. Bangkok. Appendix 1 1. Needs assessment is the process in which researcher and community members who plan the program can determine what problem might exist in a group of reproductive age women. 2. Leadership refers to whom the existing village represent and how does the leadership act on the interest community members. 3. Organization: The program with community organization created by planners will see the indicator at narrow end, where community incorporate or create its own mechanism for introducing health program, the mark will fall near the broad end. 4. Resource mobilization is a symbol of commitment of the community to safe motherhood health education program. 5. Management refers to not only the management of the village responsible for the health education program but also the management of the program itself.