Community Mobilization

1
Community Approaches for Health and Measuring
Community Capacity
2
The Context

• SC is a partner on the USAID-funded Population
  Communication Services 4 Project led by JHU/CCP
  (1996-2002).
• SC provides T.A. in community mobilization to the
  PCS4 project.
• This presentation shares SC experience on
  building and measuring community capacity from
  three health field projects and other similar
  work in the field.

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• What is community mobilization?

4
Operational Definition

• Community mobilization is a process through which
  action is stimulated by a community itself, or by
  others, that is planned, carried out, and
  evaluated by a communitys individuals, groups,
  and organizations on a participatory and
  sustained basis to improve health.

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What is community?

• Geographically defined
• Shared interests, identity and/or characteristics
• Shared resources

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Why strengthen community capacity?
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Dimensions of Community Participation
Collective action
Outsider Control
Co-learning
Collaborating
Consulted
Sustainability
Cooperating
Co-opted
Adapted from Andrea Cornwall, 1995, IDS
8
Evaluating CM programs

• Current SC (JHU/PCS4) community mobilization
  projects are attempting to measure indicators
  related to
• Health outcomes
• Community competency/capacity outcomes (including
  linkages/ relationships between communities,
  providers others)

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Measuring capacity efficacy of...

• Individuals
• Groups
• Organizations/institutions
• Communities
• Broader society

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Perceived Control Scale(B. Israel, et al.)

• 12 factors related to perceived control/influence
  over decision-making at individual,
  organizational and/or community levels.
• (e.g. I can influence decisions that affect my
  community (Agree strongly, agree somewhat,
  disagree somewhat, disagree strongly))

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Participation

• Needs assessment
• Management
• Resource mobilization
• Organization
• Leadership
• Susan Rifkin, et al. 1988
• Note UNICEF later modified mgmt to several areas
  including administrative management and
  operational management.

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Measuring a Groups Social Standing and Capacity
for Collective Action

• Increased access to resources
• Increased collective bargaining power
• Improved status, self-esteem and cultural
  identity
• The ability to reflect critically and solve
  problems
• The ability to make choices
• Recognition and response of peoples demand by
  officials
• Self-discipline and the ability to work with
  others
• (Suzanne Kindervatter Non-formal education as an
  empowering process case studies from Indonesia
  and Thailand. Amherst Center for International
  Education, University of Massachusetts, 1979.)

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Using the Community Action Cycle as a Guide to
Develop Indicators of Community Capacity

• For example Community Organizing
• / of priority individuals/families
  participating in community meetings/programactivit
  ies (age, sex, most affected, poor, etc.)
• community organizations regularly participating
  in program ( mtgs attended, actions taken, etc.)
• Existence of mutually agreed upon structure
• Leadership (see CDC indicators others)
• Demonstrated linkages between participating
  community actors/orgs and other internal and
  external resources/networks/coalitions.

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Dimensions and Sub-Dimensions of Community
Capacity

• Citizen participation that is characterized by
• Strong participant base
• Diverse network that enables different interests
  to take collective action
• Benefits overriding costs associated with
  participation
• Citizen involvement in defining and resolving
  needs
• Identifying and Defining the Dimensions of
  Community Capacity to Provide a Basis for
  Measurement, Robert M. Goodman, Ph.D. et al.,
  Health Education and Behavior, Vol. 25 (3)
  258-278 (June 1998).

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Leadership that is characterized by

• Inclusion of formal and informal leaders
• Providing direction and structure for
  participants
• Encouraging participation from a diverse network
  of community participants
• Implementing procedures for ensuring
  participation from all during group meetings and
  events
• Facilitating the sharing of information and
  resources by participants and organizations
• Goodman, et al (1998)

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Leadership that is characterized by

• Shaping and cultivating the development of new
  leaders
• A responsive and accessible style
• The ability to focus on both task and process
  details
• Receptivity to prudent innovation and risk taking
• Connected-ness to other leaders
• Goodman, et al (1998)

18
Skills that are characterized by

• The ability to engage constructively in group
  process, conflict resolution, collection and
  analysis of assessment data, problem solving and
  program planning, intervention design and
  implementation, evaluation, resource
  mobilization, and policy and media advocacy
• The ability to resist opposing or undesirable
  influences
• The ability to attain an optimal level of
  resource exchange (how much is being given and
  received)
  Goodman, et al (1998)

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Resources that are characterized by

• Access and sharing of resources that are both
  internal and external to a community
• Social capital, (the ability to generate trust,
  confidence, and cooperation)
• The existence of communication channels within
  and outside the community
• Goodman, et al (1998)

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Social and inter-organizational networks that
are characterized by

• Reciprocal links throughout the overall network
• Frequent supportive interactions
• Overlap with other networks within the community
• The ability to form new associations
• Cooperative decision-making processes
• Goodman, et al (1998)

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Sense of community that is characterized by

• High level of concern for community issues
• Respect, generosity, and service to others
• Sense of connection with the place and people
• Fulfillment of needs through membership
• Goodman, et al (1998)

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Understanding of community history that is
characterized by

• Awareness of important social, political, and
  economic changes that have occurred both recently
  or more distally
• Awareness of the types of organizations,
  community groups, and community sectors that are
  present
• Awareness of community standing relative to other
  communities
• Goodman, et al (1998)

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Community Capacity (AID CSTS Project)

• Capacity Levels
• Individual skills abilities
• Organizational systems
• Institutional change
• Capacity Areas
• Strategic management practices
• Organizational learning
• Use management of technical knowledge and
  skills
• Financial resource management
• Human resource management
• Sustainability

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MAP/Bolivias 13 Dimensions of Community
Participation

• Each on a 5-point scale
• Existence/origin of organization
• Need determination
• Planning
• Resource mobilization
• Resource control
• Leadership/responsibility
• Decision-making methods

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MAP/Bolivia 2

• Inclusion of local values and culture
• Inter-organizational relations
• Relationship to power structure(s) understood
• Locus of monitoring evaluation
• Participation of marginalized groups
• Consciousness about participation

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UNICEF Synthesizes Other Models to Identify 8
Variables

• Leadership
• Organizational capacity
• Communications channels
• Needs assessments
• Decision-making
• Resource mobilization
• Administrative management
• Operational management

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Towards a Unified, Useful Model (Marsh, Plowman)

• Reviewed the literature experience at hand
• Captured every real or theoretical indicator on
  a yellow sticky
• Arranged them linearly in sequential bands, one
  band per paper or case
• Sought patterns
• Combined into fresh model

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Personal Experience in Collective Action (Indiv.
Back.)
Personal Experience with X (Indiv. Bkgrd)
Identificatn with Comm/grp recogn (Ind. Bkgrd)
Beliefs of Cost/Benefit for Joining collective
Action (Preditors)
Beliefs of re Severity Vulnerability (Preditors)
Prior Comty Action ( Bkgrd Comm.)
Perception of Acceptability of collective Action
(Preditors - Norm)
Past Comm. Support for X ( Pred. Bkgd.)
Perception of what others do or think re
X. (Preditor - Norm)
Belief of Cost/Benefit for Action (Preditors)
Collective Efficacy ( Pred. Facil.)
Self-Efficiency (Preditor - Facil.
GETTING ORGANIZED
Inclusion of Local Values Culture
Intention for Collect. Action (Outcome)
Prior Ext,l Support (Bkgrd Extl)
Resources Available (Bkgrd Extl)
Personal Networks (Pred. Facil.)
Relation to power Structure(s) understood
Legal status (Autonomy)
Needs Assessment
Leadership/ Responsibility
Group Solidarity
COMMUNITY. ACTION CYCLE
Administive Mgt
Commun. channels
Magnitude of X (Comm. Bkgrd)
COMMUNITY STATUS CHANGE
Decision making Methods
ORGANIZATL GROWTH
Resource control
Orgtl Capacity
Collective Action
Decision making
Mutual Respect b/w teachers students
Resource Mobilization (Autonomy)
Participatory self-mgt
Spread to other Areas
M E (Knowledge)
Partners Retreat to review Problem-solve
(ME)
School Mgt Cmtee know roles, respon.,benefits
Child from every village /Compound
Building Supplies Maint. By SM Cmtee
Change in comm. Status (outcome)
Innovative Approaches (Knowledge)
Progress towards self-reliance
Comm. Selects School site
Operational Management
Parents Teachers determine Calendar
LINKAGES
Parents attend PTA
Linkages within Projt
Inter-grp support
Comm. Contrib. Labor Mat.
Teachers Sal. Collectd, stored, paid
Inter-org. relations
INDIVIDUAL STATUS CHANGE
Linkages with other org. (Broaden)
Linkages to Govt. Extl Agencies
Knledge Sharg with mbers (Membership)
Broader benefits beyond group members
Members Self-confidence
Gender equality
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Community Empowerment

• Empowerment in what sense?
• Attitudinal dimensions
• Consciousness dimensions
• Skill dimensions
• Structural dimensions
• Other aspects
• P. Hawe, Minkler, Gruber, et al

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Social Change Indicators (Feek, et al.)

• Increased flow of information about the issue of
  concern
• Increased public debate about the issue of
  concern
• Increased resonance of the issue with other major
  interests of everyday life among those affected
  by the issue
• Increased linkage between and among groups and
  individuals previously unconnected to each other
  regarding the issue of concern

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Social Change Indicators

• Increased support for efforts of those affected
  by an issue to participate in the debate
• Increased leadership and decision-making role by
  people previously disadvantaged re the issue of
  concern
• Feek, et al. The Communication Initiative

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A Community Action Cycle
ORGANIZING COMMUNITY GROUPS FOR ACTION
EXPLORING C.M. HEALTH FOCUS SETTING
PRIORITIES
EVALUATING TOGETHER
PLANNING TOGETHER
COMMUNITY ACTION
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SECI Process

• Health promoters collect data on key indicators
  from families monthly
• Service providers collect service utilization
  data
• Together they consolidate data at the end of the
  month.

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SECI Process--contd.

• The SECI team uses simple tools to share the data
  with the community.
• Community members review and analyze the
  information.

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SECI Process--contd.

• Participants then set priorities and develop
  plans to improve their priority health
  indicators.
• They monitor their progress every month and
  adjust their strategies.

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SECI Process at the District Level

• Consolidated monthly community data are entered
  into the SECI software at the District level.
• District health staff can compare community data
  and analyze trends over time.
• Reports can be printed in easy to read graphics
  that can be shared with communities.

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June 1999 Evaluation Methods

• A. Qualitative
• SECI records for all 10 SECI communities
• Ethnographic study in 3 SECI communities
• B. Quantitative
• Household survey comparing 7 SECI and 7 control
  communities

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Qualitative Results I

• Participants adopted more self-reliant and
  responsible attitudes toward their health.

Now, this year, the doctor is coming twice each
month to visit us. We are responsible to care for
ourselves and if we dont attend it is our own
fault. Mother speaking at SECI meeting
about prenatal care, Chojñohuma
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Qualitative Results II

• Nine of the ten SECI communities planned and
  implemented their own health promotion strategies.

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Qualitative Results III

• Health personnel who participated built better
  working relationships with SECI communities.

...the treatment now is more communicative, to
gain trust/confidence, one shouldnt be so
distant, or believe that one is more than them
Health provider, Cañohuma
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Qualitative Results IV

• At least 8 of the 10 SECI communities acted to
  make local health services more responsive and
  accountable.

We have realized, it seems, that we have to
take our proposals from here. The more we ask for
a particular change for a particular reason, the
hospital will improve a little, no?
male citizen,
Tarucamarca
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Qualitative Results V

• Information from the CB-HIS motivated and
  empowered communities. Want to continue to
  improve on analysis skills.

Before we were careless and almost never spoke
of the problems of the community. Now it is
different, we can do our part and everyone with
their opinions can improve the system and the
conditions of living.
promoter, Tarucamarca
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Appreciative Community Mobilization in the
Philippines
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The 4D Cycle
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ACM indicators

• Actual vs.
• planned
• accomplishments

• Review Action Plan /
• every six months
• 100 accomplishment for community projects
  leading to improved child survival outcomes for
  the first round of ACM (Example potable water
  supply, public and family toilets, home
  gardens)
• Now on second round of community plans mostly
  focused on family planning

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ACM indicators

• Community
• monitoring system

• Comparison pre-post
• Use of participatory monitoring methods
• Use of spot maps and Family Wall Charts

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ACM indicators

• Special survey, masterlist of priority groups
• Increased awareness and skill in use of growth
  monitoring charts (lt10 to gt50)
• Increased percentage of mothers going for at
  least one pre-natal visit per semester of
  pregnancy
• Overall increase in participation of priority
  families in the 4Ds
• Increased awareness and personal intentions to
  practice FP (based on action cards)

• Change in knowledge, attitudes and practices of
  priority groups in relation to family planning
  and CS

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ACM indicators

• Amount and type of resources contributed by the
  community towards project goals
• Volunteer time
• Finances (including donations raised
• physical space
• materials
• attendance

• At least 30 community counterpart for
  materials excluding labor (through barangay
  IRA)
• Budget allocation for ACM activities such as
  planning sessions, transportation of barangay
  health workers for referrals, equipment such as
  weighing scales, medicines )

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Project Goal

• Develop and strengthen shared responsibility
  between health service providers and communities
  for the quality of health care in order to
  improve the populations reproductive health and
  health in general.

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Objectives

• Increase utilization of public health services in
  selected project areas.
• Improve interaction and communication between
  clients and health service providers.
• Establish mechanisms and systems to improve
  coordination and collaboration between health
  services and community organizations.

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The Providers

• Speak Spanish
• University educ-ation/literate
• Upper/middle class
• Western dress
• Biomedical paradigm
• Vertical/hierarchi-cal organization
• Prefer to be indoors

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The Community

• Speak Aymara or Quechua
• Primary education, many illiterate
• Poor, lower class
• Traditional dress
• Aymara/Quechua health paradigm
• Rel. horizontal org.
• Prefer to be outdoors

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Barriers to Quality and Utilization of Services

• INTANGIBLE FACTORS
• Limited opportunities for interaction
• Emotional level
• Rupture of confidentiality
• Feeling of being cheated
• Paternalistic attitude
• Abuse of power
• Discrimination
• Lack of empathy

• TANGIBLE FACTORS
• Cost
• Lack of supplies, medicines, equipment
• Scarcity of human resources
• Physical space
• (from Rapid Assessment)

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Getting to knoweach other

• A visit to
• the health center

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Getting to knoweach other

• A visit to the
• community

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Viewing the videos
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Defining Quality
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Planning
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Community Provider Action

• Some examples of actions taken
• Hospital posted prices/services schedules of
  its staff in the reception area, suggestion box
• Established an emergency fund
• Arranged health education sessions on topics of
  interest to community members
• Coordinated schedules of health providers visits
• Transport arrangements improved

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Community Provider Action- continued

• Established mechanisms to lodge deal with
  complaints (for both providers clients)
• Shifted some health personnel assignments
• Improved stock of medicines at low prices
• Reduced waiting time
• Improved health facility space (more private,
  better equipment, etc.)

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Achievements in relation to service providers

• They are more attentive and friendly with the
  community
• The community believes that providers have
  improved health care according to what the
  community wants
• They make a greater effort to respond to
  community complaints

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Achievements in relation to health services

• Services are now better organized
• Services take into account the opinions of the
  community
• Increase in clients using the services

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Achievements in relation to the community

• Active community participation
• More interested in health
• Have more trust in health workers
• There is greater respect for the community
  customs/beliefs
• Community members know that they need to pay for
  services
• There are more meetings between health workers
  and the community
• Community members go to the health facilities
  with greater confidence

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Achievements related to self-care

• The community more often identifies their
  illnesses
• The community notifies health personnel when
  people are sick
• The community knows more about health service
  programs
• The community now requests health education.

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General Achievements

• Community-provider relations have improved
• There is better treatment
• Better communication
• Puentes has strengthened other quality
  improvement efforts

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Vision for the Future

• There will be more communication between
  communities and providers
• We will complete more of our joint plans
• Community authorities will be committed to the
  process
• The experience will be expanded to other
  communities
• Quotes from participatory evaluation (2000)

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Some lessons learned

• This is a rapidly evolving field and there are
  many approaches to measuring change. Most are
  messy and context specific.
• Our own organizational capacity greatly
  influences how we approach community capacity
  building. Do we walk the talk?
• This is not a rapid processit takes time.
• Every community has strengths and resources to
  build on.
• Cant do everything. Need to set priorities with
  communities, preferably these are closely related
  to helping communities achieve their objectives.

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Small group exercise

• What did we learn during this session (and based
  on our own experience with community approaches)?
• How can we apply what we have learned to our own
  field programs?
• Homework
• What assistance do we need/want to build our
  capacity to support effective community capacity
  building?