Health Promotion Through Existing Community Structures

Introduction

Rural populations worldwide have less health care access and worse health outcomes than urban populations, with rural Africa suffering most from these disparities. ¹ Sixty percent of Zambia’s population lives in rural areas, which have worse maternal and infant mortality rates than urban areas partly due to Zambia’s geography, climate, and economy—all of which prevent health care from reaching rural populations.^1-4 The rural population of Africa is expected to continue growing for the next 20 years, and unequal distribution of health care resources in Zambia and across Africa needs to be addressed.^1,2

Specifically, rural Zambians have less access to safe water, fewer use improved drinking water sources, and sanitation facilities are often absent. ⁴ All these contribute to an environment of increased diarrhea from unsafe drinking water and poor sanitation. Diarrhea is the third leading cause of child mortality in Zambia, leading to an estimated 15 000 deaths per year, a third of which are due to rotavirus infection. ⁵

Rotavirus is the most common cause of severe acute gastroenteritis in infants and young children globally, leading to 500 000 deaths per year and 5% of under-5 children’s deaths.^6-8 Impoverished rural households are at highest risk for child mortality. ³ In an effort to curb this risk, rotavirus vaccines with clinical efficacy and safety have been introduced in 19 countries in Africa in the past 3 years, including in Zambia.^6,7,9

Community health workers (CHWs) are trained community members who are recognized and supported by the health system. ¹⁰ They are effective means for promoting health messages and improving immunization rates, but more research is needed to assess their effectiveness in delivering prevention information, particularly in sub-Saharan Africa.^11-13 Eighty-seven percent of Zambia is Christian, and church is a large part of rural Zambian culture, yet the role of CHWs in church structures is understudied. ¹⁴ One randomized controlled trial in North Carolina attempted to evaluate the role of CHWs in rural African American churches, but it was of poor quality and was underpowered.^15,16 Churches are a valuable existing structure for CHWs to tap into as a means of spreading prevention messages, specifically regarding diarrheal disease and rotavirus vaccination.^17-19

In conjunction with the Centre for Infectious Disease Research in Zambia’s (CIDRZ) efforts to pilot the national rollout of rotavirus vaccination in Zambia, a strategy was developed for CHWs to deliver health messages regarding diarrhea and rotavirus vaccination within women’s groups at Christian churches in a rural district of Zambia. While previous work has been done in African American churches, this approach was novel as it was set in rural Zambia and could potentially influence CHW policies and practices in the future. This study sought to evaluate the reach and efficacy of this novel community health outreach strategy within a rural community.

Methods

Intervention

The intervention was delivered weekly, with each of the four health messages covered in a month (1 per week) and cycled monthly. A training manual and flip chart outlined the 4 key messages. Materials were designed to guide users’ communication with women’s groups and approved by the Ministry of Community Development Mother and Child Health. Rotavirus immunization card invitations (Rota Cards) were handed to mothers with infants below the age of 15 weeks (Figure 1). Mothers were encouraged to present the Rota Card to a health care provider when their infants were immunized against rotavirus. CHWs, community development assistants (CDAs), and environmental health technicians (EHTs) were trained on the field manual and flip chart. Trained CHWs facilitated health-related workshops within church’s women’s groups and documented all relevant activities. EHTs/CDAs supervised the CHWs and collected reports monthly. The project team conducted quarterly supportive supervision visits to mentor CHWs and discuss progress.

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Figure 1.

Sample Rota Card.

Results

Sample

Thirty-two churches were recruited and 2 declined to be part of the program (Figure 2). Nineteen churches completed at least 4 months of intervention and were included in the analysis, ranging from 6 to 13 months. A total of 64 CHWs, 15 CDAs, and 11 EHTs were recruited and trained. The project team conducted four mentoring visits over the course of the year. The characteristics of the final sample of 19 churches are outlined in Table 1.

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Figure 2.

Overall flow of churches, participants, and Rota Cards.

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Table 1.

Characteristics of Included Churches.

Catchment Area	Church	Months of Intervention	Total Women’s Groups	Average No. of Women Attending Church	Average No. of Women at Groups	Total EHT Visits	Total Eligible Babies	Total Cards Distributed	Total Cards at Clinic
Chiawa	St. Martin Catholic Church	8	28	39.4	35.4	15	16	3	10
Chikupi	Holy Spirit Roman Catholic	13	100	46.3	25.5	27	64	60	12
	SDA	9	48	64.8	39.0	22	52	42	9
Chinyanya	SDA	11	115	44.2	17.7	15	61	46	0
Chipapa	SDA	6	15	49.0	20.6	5	12	13	16
Chisankane	SDA	13	40	63.3	40.5	3	83	60	13
Kafue Estate	Upper Room–Pentecostal	7	24	93.3	28.4	14	5	5	4
	ZAOGA–Pentecostal	7	22	51.4	20.4	4	2	8	16
Kafue Mission	Grace Ministries	13	62	46.0	14.8	15	3	1	18
	UCZ	11	52	83.6	17.6	13	1	4	10
Kambale	SDA	12	44	57.2	43.5	18	25	15	20
	St. Joseph Catholic Church	8	30	137.8	58	9	8	31	10
Kazimva	UCZ	13	55	80.3	10.3	12	14	15	13
Mt. Makulu	UCZ	13	54	103.2	24.9	39	32	104	133
Mwembweshi	St. Luke Catholic Church	7	25	66.3	20.8	8	24	12	10
Railway	St. John Catholic Church	7	52	534.1	78.9	2	33	18	0
	UCZ	11	44	169.0	127.9	3	357	4	0
Shimabala	St. Paul’s Catholic Church	11	52	140.4	63.8	17	15	17	19
	UCZ	8	28	28.8	14.4	8	23	10	4
Total		188	890	1898.4	702.4	251	830	468	317

Abbreviation: EHT, environmental health technician.

Discussion

The study’s overall reach and efficacy rates demonstrate that churches in developing countries can be effective conduits for delivering preventive care messages to rural populations, specifically immunization promotion. This study developed an important new methodology of tracking individual health behaviors in a low-income rural setting through the Rota Card system. Though previous literature supported CHWs as particularly effective regarding exclusive breast-feeding and immunization coverage, it was believed that one-on-one personal encounters were required through door-to-door canvasing.^11,13 This study demonstrates that using existing structures within churches for group preventive health promotion can link rural mothers to new vaccines through a low-cost community initiative.

Our efficacy rates ranged from 0% to 1800%, which suggests that rural populations are dynamic between catchment areas. Rota Cards were not differentiated based on where they were distributed; it was impossible to determine if an infant’s Rota Card turned in at the health center originated from the catchment area’s closest church or not. It is common cultural practice for young mothers to relocate to the parents’ homestead and stay there around the period of delivery before moving back to their own home. Aggregate data in resource-poor rural settings may need to adapt to the flow of individuals between homes and clinics.

Environmental health technicians consistently visited churches monthly but did not routinely collect Rota Cards from health clinics. Thirteen of the 19 churches included in analysis averaged at least one EHT weekend visit per month on average, boosted through transport fee reimbursement, but only 60 of the 317 Rota Cards collected at clinics were collected by EHTs. The study team had to collect the remaining 257. While this is consistent with previous evidence of unsatisfactory record keeping in 2 rural Kenyan hospitals, it is also surprising since EHTs should be visiting health facilities regularly. ²¹ Future efforts working with EHTs and other governmental health officials should attempt to garner more buy-in from assisting staff as well as developing electronic data capabilities.

A major strength of this study was the innovative use of Rota Cards for tracking health behaviors. It provided direct evidence that rural communities reached through church can be linked to health facilities. Second, it suggests that existing rural structures like churches can be a sustainable addition to health systems’ outreach activities in low-resource communities. In Zambia, where the doctor to population ratio is in excess of 1 to 14 000, and the nurse to population ratio is 1 to 1700, there is no other way to effectively reach the population with heath care than to capitalize on such existing structures. ²²

Several limitations existed in this study. First, aggregated women’s group attendance does not delineate how many unique individuals attended health sessions, so the assumption that the same cohort of women came each week underestimated reach. Second, lack of a control group led to an overestimate of efficacy since it is unclear what proportion of rotavirus vaccination behaviors were due to the CHW’s health messaging versus mothers’ initial intent to immunize their children regardless of health messaging. Third, knowledge and attitudes were not directly measured to more directly assess health-messaging efficacy. Fourth, many mothers did not remember or were confused on when to drop off Rota Cards, leading to an underestimate of efficacy. Fifth, the inability to verify the actual number of eligible babies within the church because mothers might not bring babies younger than 15 weeks to church in an attempt to protect them from infections underestimated efficacy. Sixth, some CHWs complained about not receiving any form of money for the work they were doing and the study did not offer any incentives. This could be one of the reasons that churches dropped out of the study. Finally, a large number of eligible babies did not receive Rota Cards, but this can almost entirely be explained by the likely inaccurate reporting of 357 eligible babies and only 4 cards distributed by the Railway–UCZ church (Figure 3).

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Figure 3.

Reach and efficacy by church.

Future studies should examine how much knowledge is gained and how health behaviors change compared with a control group through church-based preventive health promotion. This study could be improved and extended by adding a control group, assessing baseline knowledge and attitudes about a health topic, assessing change in knowledge and attitudes after health programming, tracking individuals’ attendance and knowledge scores rather than aggregate tracking, better training CHWs for data collection, adding more quality control to limit missing data, and designing incentives to retain churches and reduce the attrition rate.

Conclusion

Churches are effective existing community structures for community health workers to use as a platform for communicating preventive health messages to rural populations in low-income countries.