Community Health I (60 hours)

Unit 0. Introduction to concepts in community health

0.1 Definitions of terms
 Community - A group of people who: 1) live in a defined geographical
area; 2) share common cultural values, norms and identity; and 3) are
arranged in a social structure according to relationships
 Health - A state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity
 Community health - A field of study which focuses on the maintenance,
protection, and improvement of the health status of population groups
and communities
 Population coverage - The proportion of the population to which the
service is available.
 Household - Those who dwell under the same roof and compose a family
0.2 Concepts in community health
 Determinants of health – These are factors that promotes or demotes
health. These are:
1) Economic determinants - including income, employment and
working conditions
2) Social determinants - including social support, safety at home and
community, participation in civic activities, education and literacy
3) Physical environmental determinants - including state of the natural
environment, availability of transportation, and adequate housing
4) Individual characteristics and behaviors – this includes lifestyle and
habits
5) Health services –this includes preventing, curative, rehabilitative
and promotive
 Need for health care services
o Given that everybody need to be healthy, we therefore need to
access health services.
o Access to comprehensive, timely and quality health care services is
important for:
1) Promoting and maintaining health,
2) Preventing and managing disease,
3) Reducing unnecessary disability and premature death,
4) Achieving health equity for all,
5) Impacting on one's overall physical, social, and mental health
status and quality of life.
o Components of health care service needs:
1) Insurance coverage - Health insurance coverage helps
patients gain entry into the health care system. Lack of
adequate coverage makes it difficult for people to get the
health care they need. When they do not get care, they get
burdened with large medical bills. Kenya is piloting Universal
Health Coverage (UHC) in some selected counties
 2) Health services - These services can be categorized as:
 Curative (treatment of patient when sick e.g. uses of
medicine, surgery etc.),
 Preventive (activities that control or stop diseases from
occurring e.g. nutrition, immunization, family planning,
safe motherhood, environmental sanitation, prophylaxis
etc.),
 Promotive (activities that advocates for good health
practices e.g. education, mobilization and sensitization
etc.) and
 Rehabilitative (activities that brings back the damaged
condition to normal e.g. physical treatment,
occupational treatment, counselling, psycho-social
support etc.)
3) Timeliness of care – also known as prompt health care seeking
behaviors. Timely access to health services means "the
immediate use of personal health services to achieve the best
health outcomes. We need to seek for health services
immediately we feel unwell without waiting for the disease to
complicate. It involves:
 Accessing a location where needed health care services
are provided (geographic availability). Recommended
distance to nearest health facility is less than 5
kilometers radius
 Finding a health care provider whom the patient trusts
and can communicate with (personal relationship)
o Barriers to accessing health services needs include:
 High cost of care,
 Inadequate or no insurance coverage,
 Lack of availability of services,
 Cultural beliefs, myths and misconceptions.
 Ignorance
o These barriers to accessing health service needs can lead to:
 Unmet health needs,
 Delays in receiving appropriate care hence disease gets
complicated,
 Inability to get preventive services,
 Financial burdens,
 Unnecessary hospitalizations,
 Death
 Demand for health services
o Individuals make choices about medical care. They decide on:
 When to visit a doctor when they feel sick,
 Whether to go ahead with an operation,
 Whether to immunize their children,
 How often to have checkups.
 o The process of making such decisions can be complicated, because
it may involve seeking advice from friends or authority from bread
winners.
o Other people weigh risks and benefits, and even missing other
types of consumption that could be financed with the resources
used to purchase medical care.
o Every individual, family, community or entire population has a right
to demand for essential and quality health services.
 MDGs and SDGs
o In 2000, there was a Millennium Summit for the United Nations
o The summit discussed approaches to achieve health for all and
came up with eight Millennium Development Goals (MDGs)
o During the summit, all the 189 United Nations member states
committed to achieve the following Millennium Development Goals
by 2015:
1) To eradicate extreme poverty and hunger
2) To achieve universal primary education
3) To promote gender equality and empower women
4) To reduce child mortality
5) To improve maternal health
6) To combat HIV/AIDS, malaria, and other diseases
7) To ensure environmental sustainability
8) To develop a global partnership for development
o Given that most of the United Nations did not achieve the
millennium development goals by 2015, a set of Sustainable
Development Goals (SDGs) replaced the Millennium Development
Goals.
o The following are the 17 goals that are to be met by 2030:
1) End poverty in all its forms everywhere
2) End hunger by achieving food security, nutrition and
agriculture
3) Ensure healthy lives and promote wellbeing for all at all ages
4) Promote quality education and lifelong learning
5) Achieve gender equality and empower all women and girls
6) Ensure availability of water and sanitation for all
7) Ensure access to affordable, reliable and modern energy for
all
8) Promote economic growth, employment and decent work for
all
9) Build infrastructure, industrialization and innovation
10) Reduce inequality within and among countries
11) Make cities and human settlements safe
12) Ensure sustainable consumption and production
patterns
13) Take urgent action to combat climate change and its
impacts
 14) Good use of oceans, seas and marine resources for
sustainable development
15) Protect, restore and promote ecosystems
16) Promote peaceful societies, justice and accountability
17) Strengthen global partnership
o The following are the differences between the MDGs and SDGs:
 The SDG has brought all three aspects of sustainable
development - the economic, social and environmental
 Goals in the SDGs are more integrated than the MDGs
 The SDGs go much further than the MDGs by addressing the
root causes of poverty and the universal need for
development that works for all people.
 There were only eight MDG goals while the SDGs has 17
 The SDGs apply to all countries whether rich or poor
 The SDGs will now finish the job of the MDGs, and ensure that
no one is left behind
0.3 Aims of community health
 Bringing essential health services closer to the community members,
 Empowering community members to initiate, implement and own
activities promoting their health,
 Enhancing community access to health care in order to reduce poverty,
hunger, and deaths,
 Achieving health for all through health and development interventions
 Improving health and environmental conditions,
 Achieving better quality of life,
 Reduce disease occurrence hence decongest hospitals
 Helps to reduce health gaps caused by differences in factors that can
affect health (e.g. income, education, race and ethnicity, location and
other)

0.4. Community health services

 Counselling and support services,
 Health promotion activities,
 Medical and nursing services,
 Dental and oral health,
 Prevention services such as water and sanitation, expanded program on
immunization, child welfare services, safe motherhood,
 Other health related services including nutrition, physiotherapy,
occupational therapy,
 Referrals and follow up.
0.5. Barriers of accessing health services
 High cost of care
 Distance to health facility
 Ignorance
 Attitude of health care providers
 Inadequate or no insurance coverage,
 Lack of availability of services,
 Cultural beliefs, myths and misconceptions.
0.6. Principles of community health
1) Promoting health,
2) Building individual and community capacity,
3) Recognizing potentials of the community
4) Engagement and participation,
5) Building relationships,
6) Ownership,
7) Facilitating access and equity,
8) Demonstrating professional responsibility, accountability and
sustainability.
0.7. Community entry process
 Refers to the process of initiating desirable relationship with community
so as to win their interest
 It involves recognizing leadership in the community so as to interacting
and working with them.
 Process involve:
o Knock and enter upon response,
o Introduce yourself to the chief elders and other local leaders,
o Inform them of your work with them,
o Ask for their permission and advice and state your mission e.g.
getting information about the village or introduction of new health
programme.
o Thank them for their co-operation,
o Identify contact persons

Unit1. Drugs and substance abuse

1.1. Definitions of terms
 Drug – Any substance that causes a change in a person's physiology or
psychology when consumed. The drugs are typically distinguished from
food and substances that provide nutritional support.

 Drug Abuse – Chronic use of a drug, or compulsory use of drugs for a

reason other than for which it was intended. It is the bad use of a drug
leading to dependency and dependence.
 Drug misuse – Using a drug for a reason other than its clinical purpose.
When a person starts taking drugs regularly, the drugs produce tolerance,
addiction, withdrawals and psychological dependence
 NACADA – stands for National Agency for the Campaign against Drug
Abuse (Kenya)
1.2. Classifications of drugs
 Drugs can be categorized based upon their effects on users.
 There are essentially seven different drug types, each with its own set of
characteristics, effects and dangers.
 Drugs are classified as:
1) Stimulants - impact the body’s central nervous system (CNS),
causing the user to feel as if they are “speeding up.” These drugs
increase the user’s level of alertness, pumping up heart rate, blood
pressure, breathing and blood glucose levels.
 Doctors prescribe stimulants for, narcolepsy and asthma
(because the drugs can open up breathing passages). The
drugs can also help aid weight loss, as they can decrease
appetite in users.
 Stimulant abuse occurs in high school when teens wish to
enhance performance in school or sports.
 Examples are:
 Cocaine – commonly known as blow, bump, candy,
coke, rock (are smoked or injected)
 Amphetamine – commonly known as black beauty,
hearts, track driver (swallowed, smoked, injected)
 Methamphetamine – known as ice, chalk, go fast,
glass (swallowed, smoked, injected)
2) Depressants - Like stimulants, depressants also impact the body’s
CNS, but with the opposite effect, making users feel as if things are
“slowing down.” Thus, they are often called “downers” on the
street.
 Doctors prescribe depressants for anxiety, insomnia, and
other medical issues that prevent the sufferer from fully
relaxing.
 These drugs often offer a sedative experience to users,
making them a tempting choice for teens who wish to escape
everyday stresses.
 Examples are: Valium, alcohol,

3) Hallucinogens - Hallucinogens work by disrupting communication

within the brain.
 Users report intense, rapidly shifting emotions and
perceptions of things that aren’t really there. Hallucinogen
user might believe that they see a person speaking to them -
when that person does not even exist.
 Example:
 LSD – known as acid, blue heaven, yellow sunshine
(smoked, eaten, mixed with beverages)
  Psilocybin – known as magic mushroom, purple
passion

4) Dissociative - Dissociative distort the user’s perception of reality,

and cause users to “dissociate,” or feel as if they are watching
themselves from outside their own bodies. They may gain a false
sense of invincibility, then engage in risky behavior such as driving
under the influence.
 These drugs work by interfering with the brain’s receptors for
the chemical glutamate, which plays a significant role in
cognition, emotionality and pain perception. Dissociative can
be taken as liquids, powders, solids or gases. The drugs
include:
 Katamine – known as vitamin K
 PCP and analog – known as angel dust, love boat
5) Opioids - Opioids are powerful painkillers that produce a sense of
excitement or joy in users. They are extremely habit-forming,
sometimes even causing addiction in as little as three days.
 Are often prescribed by doctors to patients who are suffering
from intense pain.
 Opioids can be smoked, eaten, drank, injected or taken as
pills.
 Examples:
 Heroin – known as horse, brown sugar, white horse)
 Opium – known as black stuff, block, gum, big O
6) Inhalants - These drugs cause brief feelings of joy and excitement.
As the name suggests, inhalants are always inhaled as gases,
sprays or fumes.
 Examples: are gasoline glue, room deodorizers, aerosol sprays
7) Cannabis - Most commonly recognized as marijuana, cannabis acts
like a hallucinogen, but also produces depressant-like effects. It has
a high potential for addiction.
 Cannabis can be smoked, vaporized, and even eaten
 Examples of cannabis include:
 Marijuana leaves known as blunt, ganja, herb, Mary
Jane, weed
 Hashish known as Shisha
1.3. Commonly used drugs
Alcohol
 Alcohol is contained in drinks such as beer, wine, brandy, spirits and
whisky.
 It acts on their body primarily as a depressant and lowers down the brain
activity.
 However, in low doses it can be a stimulant. If used in excess, it will
damage or even kill body tissues including muscles and brain cells.
  Its consumption causes a number of marked changes in behavior. Even
low doses impair judgment and coordination.
 With extreme intoxication the drinker may lapse into comma.
 Alcohol has produced many enjoyable moments and sad ones as well.
Tobacco
 Tobacco comes in form of cigarettes, cigars, snuff and in smokeless
tobacco.
 Smokers are more likely to contract heart disease. Lungs, larynx,
esophagus, bladder, pancreatic and kidney cancer also strike smokers.
 Smoking during pregnancy poses serious risk e.g. spontaneous abortion,
preterm birth, low birth weight and fatal and infant deaths
 The most dangerous substance in tobacco is nicotine.
 The street names used for tobacco include cigs, smokes, monzo, fegi and
butts.
Cannabis
 It is commonly known as bhang, marijuana and hashish
 The cultivation of the herbal cannabis commonly known as bhang is
spread throughout the country especially Mt. Kenya region, Kisii, Vihiga.
 All forms of cannabis have negative, physical and mental effects.
 Substantial increase in heartbeat, blood shot eyes, a dry mouth and
throat and increased appetite are characteristics of its use.
 Use of cannabis may impair or reduce short term memories, reduce ability
to perform tasks requiring concentration and coordination.
 Research shows that those use them like students do not retain
knowledge when under influence.
 Because users often inhale the unfiltered smoke deeply and then hold it in
the lungs for as long as possible, marijuana is damaging the lungs and
pulmonary system
 Long term users of cannabis may develop psychological dependents,
damaged lungs, chest pains, bronchitis, hallucinations/fantasies,
abnormal sperm forms in the male and decreased ovulation or increased
menstrual irregularities in female.
Heroin:
 This is a narcotic drug that lowers perception of pain.
 Kenya nationals have also been arrested for trafficking the drug locally
and abroad
 Local abuse of this drug is prevalent in Nairobi, Mombasa and Malindi
towns.
 The use of this drug leads to Euphoria, reduced appetite, chronic
bronchitis, tetanus, hepatitis and endocarditic.
 Overdose leads to reduce oxygen to the brain, suppressed respiration,
coma or even death. It is medically used as anesthetic and cough
suppressant.
Cocaine:
 It is a whitish powder chemically produced by cocoa leaves.
 The availability and abuse in Kenya is minimal.
 The leaves traditionally are chewed to suppress hunger.
  It is applied to the gum of the mouth, tongue, eyelids or private parts to
delay orgasm.
 It is also injected and sniffed.
 Its use causes sleeplessness, excitement, loss of appetite, increased
sexual desire and feeling of self-satisfaction.
 Prolonged use leads to loss of weight, impotence, blindness, orgasm
failure, stomach problems, liver and lung damage.
 Overdose leads to death due to respiratory paralysis or cardiac arrest.

Top 10 most commonly abused drugs

1.4. Effects of drugs to individual, household and community

 Individual
 Alters judgment, vision, coordination and speech and also leads to risk
taking behavior.
 Increases chances of being involved in traffic accidents which may lead
to death or injury.
 Drug use leads to poor performance in learning.
 Drugs erode self-discipline and motivation
 It may lead to death from, for example alcoholic poisoning.
 Youngsters may resort to embezzlement, forgery, corruption, bribery
and extortion
 Leads to psychiatric disorders such as delusional state and chronic
dementia.
 Involvement in fights and these get them into trouble with the law.
 Because drugs lead to irresponsible sexual behavior, female abusers
may get pregnant.
 Employed youth lose their jobs due to absenteeism and sometimes
inefficiency.
 Household
 Affecting users’ relation with family members and friends.
 Associated with crime and misconduct that disrupt the maintenance of
an orderly and safe neighborhood.
 Stigmatizing the family
  Giving bad reputation of the family
1.5. Illnesses associated with drug abuse
 HIV - The human immunodeficiency virus (HIV) causes HIV infection and
the acquired immunodeficiency syndrome (AIDS).
 Depression - A depressive disorder is a syndrome (group of symptoms)
that reflects a sad, blue mood exceeding normal sadness or grief,
changes in bodily functions (for example, eating, sleeping, and sexual
activity).
 Erectile dysfunction - Erectile dysfunction (ED), also known
as impotence, is the inability to achieve or sustain an erection for
satisfactory sexual activity.
 Schizophrenia - referred to as split personality disorder, schizophrenia
is a chronic, severe, mental illness
 Steroid withdrawal symptoms - can bring many other medical
problems. Weakness, fatigue, decreased appetite, weight
loss, nausea, vomiting, diarrhea (which can lead to fluid and electrolyte
abnormalities), and abdominal pain are common. Blood pressure can
become too low, leading to dizziness or fainting. Blood sugar levels may
drop. Women also may note menstrual changes. Less often, joint pain,
muscle aches, fever, mental changes, or elevations of calcium may be
noted.
 Stress - is a fact of nature in which forces from the inside or outside
world affect the individual. The individual responds to stress in ways that
affect the individual, as well as their environment.
 Stroke - also known as a cerebrovascular accident or CVA, occurs when
part of the brain loses its blood supply. A stroke is a medical
emergency because strokes can lead to death or permanent disability
 Hepatitis C infection - is an infection of the liver caused by
the hepatitis C virus (HCV). It is difficult for the human immune system to
eliminate hepatitis C from the body
 Microcephaly - is a medical condition in which the circumference of the
head is smaller than normal because the brain has not developed
properly or has stopped growing.
 Low blood pressure - also called hypotension. Blood pressure becomes
low enough that the flow of blood to the organs of the body is inadequate
and symptoms and/or signs of low blood flow develop shock.
 An aortic aneurysm - is dilation or bulging of the aorta. Aorta, the
major artery that leaves the heart to supply blood to the body.
 Others – child abuse, nose bleeding, brain damage, alcoholism, cancer,
Hepatitis B, chronic pain, suicide, antisocial personality disorder, learning
disability, sexual problems, anxiety, hypersomnia, hyper sensitivity,
domestic violence,
1.6. Behavior change communication (BCC) strategy
 Behavior Change Communication is a process of working with individuals,
communities and societies to develop communication strategies to
promote positive behaviors and to provide a supportive environment
which will enable people to initiate and sustain positive behaviors
 Steps of BCC
1) Unaware
2) Informed/aware
3) Concerned
4) Knowledgeable and skilled
5) Motivated to change
6) Trial change of new behavior
7) Maintenance/adoption of new behavior
 Audience segmentation:
o People mostly affected
o People directly influencing them
o People indirectly influencing them
 Message development process involved defining the following:
o Existing behaviors
o Desired behaviors
o Benefits of desired behaviors
o Difficulties of desired behaviors
o Alternative behaviors

 Chanel mix:
o Community dialogue
o Interpersonal
o Mass media
o Outdoor advertising
 Factors affecting BCC
o Intention;
o Environmental constraints;
o Skills;
o Anticipated outcomes (or attitude);
o Norms;
o Self-standards;
o Emotion;
o Self-efficacy.
Unit 2. Primary health care
2.1. Definition of PHC and Community based health care
Primary health care
- ‘‘essential health care’’ that is universally made accessible to all individuals
and families in a community through scientifically sound and socially acceptable
methods and technology
Origin
 The Alma-Ata Declaration of 1978 declared that “Everyone has the right
to a standard of living and wellbeing of himself and of his family, including
food, clothing, housing and medical care and necessary social services’’.
It further identified primary health care as the key to the attainment of
the goal of Health for All.
 Goals and targets were set for achieving ‘’Health for All’’ by the Year
2000. Some of these goals were that:
o At least 5% of gross national product should be spent on health;
o At least 90% of children should have a weight for age that
corresponds to the reference values;
o Safe water should be available in the home or within 15 minutes'
walking distance, and adequate sanitary facilities should be
available in the home or immediate vicinity;
o People should have access to trained personnel for attending
pregnancy and childbirth; and
o Child care should be available up to at least one year of age.
  It expressed the need for urgent action by all governments, all health and
development workers, and the world community to protect and promote
the health of all people
 The PHC approach has since then been accepted by member countries of
the WHO as the key to achieving the goal of "Health for All".
Importance
 Respond to rapid economic, technological, and demographic changes that
affect well-being
 Effective and efficient in preventing and addressing main causes and risks
of poor health
 Achieves health-related sustainable development goals (SDGs) and
universal health coverage
 Create the conditions that help people to become and stay healthy and
well
 Reach everybody – particularly those in great need
 Involve a continuity relationship with persons and families
 Improving family health - with particular focus on mothers and children
 Increase coverage and accessibility of essential health services
 Improve the quality of services
 Pursue an integrated inter-sectorial and multi-disciplinary approaches
 Increase community participation in the planning, delivery, and
monitoring of health services
2.2. Principles of PHC
- The following are the principles or pillars of PHC:
1) Equitable distribution
 Equity is the fair distribution of available resources to all individuals
and families so that they can meet their fundamental and basic
needs.
 Services should be physically, socially, and financially accessible to
everyone
 People with similar needs should have equal access to similar health
services
 Equal access, resource distribution and coverage of PHC services
should be greatest in those areas with the greatest need
2) Manpower development
 PHC aims at mobilizing human potential to use available resources in
the community
 This principle facilitates identification, training and development of
necessary personnel to serve the community
3) Community participation
 This is the process by which individuals, families and communities
take responsibility in promoting their own health and welfare
 Full participation is important in decision making and taking care of
own health
 Community members and health providers need to work together in
partnership to seek solutions to problems facing the communities
  Communities should participate in:
o Creating and preserving healthy environment;
o Maintaining preventive and promotive health;
o Sharing information about own needs with higher authorities;
o Implementing health care priorities and managing health
facilities
4) Appropriate technology
 This is a kind of technology that is scientifically or technically sound
and adoptable to local needs, and the community can afford to
maintain it for their self-reliance
 Caregivers should be trained to deliver services using the most
appropriate and cost-effective methods and equipment for their level
of care
5) Multi-sector of Inter-sector approach
 Health sector cannot achieve much in isolation
 PHC requires coordinated effort with other related sectors whose
activities impacts on health e.g., agriculture, water and sanitation,
transportation & communication, education etc.
6) Social justice
 Ensure cultural sensitivity
 Respect for social identity, norms and etiquette
7) Accessibility
 Make health care accessible to every member of the community
 Taking health care services closer to the people
8) Affordability
 Make health care services lest costly so that every member of the
community can afford at reasonable cost
9) Sustainability
 Ensure continuity of the health care services even after donor or
external funder withdraw the funding
2.3. Concepts of PHC
 The main concept of primary health care is provision of essential health
services by personnel at community level. This involve:
o Prevention
o Diagnosis
o Treatment
o Rehabilitation
o Promotion
2.4. Strategies of PHC
– Are approaches or methods of implementing an activity. There are three main
PHC strategies:
1) Community Based Health Care
 These are health care activities initiated and implemented by
 community own resource persons
 It is for people of all ages who need health care assistance at home.
 Community care services include home support, home nursing,
physiotherapy and other rehabilitation services.
 For example: A CHV visits a sick person at home to help with
medication.
2) BAMAKO Initiative
 This initiative was a formal statement adopted by African health
ministers in 1987 at Bamako in Mali.
 It was meant to implement strategies designed to increase the
availability of essential drugs and other health care services
 This was an initiative of drug revolving funds as income generating
activity to sustain PHC activities.
3) Community strategy
 This is the concept of taking health services close to the people in the
village
 It is aimed at taking the Kenya Essential Package for Health to the
community.
 It is a strategy for the delivery of level one service
 The overall aim is to involve the communities in addressing the
downward trend of deteriorating health status.
 It is a mechanism through which households and communities take an
active role in health and health-related development issues.

2.5. Elements of PHC

1) Education on health problems and how to prevent and control them
2) Food supply and proper nutrition
3) Maternal, child healthcare and family planning
4) Adequate supply of safe water and basic sanitation
5) Immunization against major infectious diseases
6) Prevention and control of local endemic diseases
7) Treatment of common diseases and injuries
8) Essential drugs and basic medication
Kenya added the following elements:
9) Mental Health
10) Dental Health
11) TB Control and Treatment
12) STI and HIV/AIDS prevention and Control
13) Community Based Rehabilitation
14) Eye Care

2.6. Levels of health care services

– A level is a stage or position of something. Levels of PHC are the units of care
or implementation of activities. The levels of health care are:
 Individual Based Health Care
 Family Based Health Care
 Community Based health care
 Facility Based Health Care (Dispensary, Health center, District hospital,
Provincial hospital)
2.7. Roles/functions of HRIO in implementation of PHC programs
 Designing, developing and distribution of PHC data collection tools
 Data collection, analysis and dissemination
 Training of CHW on data collection and management
 Advising the PHC team on targets and achievements of PHC
 Monitoring and evaluation of PHC implementation

2.8. Roles /functions of community and CHWs in PHC programmes

 Identify and refer patients
 Treatment of minor illnesses
 Cary out health education
 Defaulter tracing
 Support home based care services
 Home follow up
2.9. Community based health information systems
 This is a concept that involves:
o Making decision of program indicators to be collected in community
health programming
o Data collection, analysis and presentation of information by
community members
o Utilization of health information at community levels by the
community members
 Information collected by the CHVs is presented in to a community
dashboard called Chalkboard
 Information collected include:
o Population
o Administrative units
o Births and deaths
o Common diseases
o Prevention services i.e. latrines, water sources, hygiene
o Community activities performed such as referrals, case findings,
health education, treatment of minor illnesses
o These information feeds in to the regional health information
systems through the CHEWS
2.10. Challenges faced by PHC
 Lack the capacity to provide essential health-care services
 Poor distribution of health workers and inadequate equipment
 Poor quality of health-care services
 Poor condition of infrastructure
 Lack of essential drug
 Management of finance
 Community participation not sustainable due to voluntarism
 Inappropriate use of community health workers,
 Balancing the needs of the community with those of health professionals
 Many ordinary people felt PHC was a cheap hence bypassed this level to
attend secondary and tertiary centers because of a lack of staff and
essential medicines at the PHC level.
 Civil war, natural disasters
 Political commitment was not sustained after the initial euphoria of Alma-
Ata.
 Issues of governance and corruption in the use of resources resulted in
donors
Unit 3. Maternal and child health
3.1. Introduction
 Maternal health is the health of women during pregnancy, childbirth, and the
postpartum period.
 It encompasses the health care dimensions of family planning,
preconception, prenatal, and postnatal care in order to reduce maternal
morbidity and mortality.
 Preconception care can include:
o Education,
o Health promotion,
o Screening
o And other interventions for women of reproductive age to reduce risk
factors that might affect future pregnancies.
 Postnatal care include:
o Recovery from childbirth,
o Newborn care,
o Nutrition,
o Breastfeeding,
o Family planning
 The goal of prenatal care is to:
o Detect any potential complications of pregnancy early,
o Prevent them if possible,
o Direct the woman to appropriate specialist medical services as
appropriate.

 Objectives of MCH include:

o Increasing healthy birth outcomes;
o Promoting and assuring comprehensive primary care for children
o Promoting healthy lifestyles among children with special health care
needs;
o Assuring access to safe, healthy child care up to age five
o Preconception, pregnancy testing and planning.
 In Africa, one out of 210 mothers dies during pregnancy or delivery.
 Most maternal deaths are due to causes directly related to:
o Pregnancy
o Childbirth,
o Unsafe abortion
o Obstetric complications such as:
 Severe bleeding
 Infection
  Hypertensive disorders
 Obstructed labor
o Other indirect cause like:
 Relatively low rate of hospital deliveries,
 Due to transport problems
 Lack of infrastructure,
 Due to cultural prejudices and resistance against giving birth
outside the family circle
 The fifth Millennium Development Goal (MDG) aims to reduce the maternal
mortality ratio by 75% between 1990 and 2015.
 In Kenya, maternal mortality remains high at 488 maternal deaths per
100,000 live births.
 The MCH/FP clinic offers quality and afford-able services that advocate for
safe motherhood, proper child development, and a healthy family.
3.2. MCH services (Immunization, FP, antenatal)
 The services offered in MCH clinic are as follows:
o Focused antenatal care.
o Targeted post natal care.
o Providing all family planning methods: short term, long term,
permanent i.e. vasectomy & tubal ligation.
o Screening of Breast and Cervical cancer in all women of reproductive
ages.
o Giving immunization i.e. BCG, Pentavalent, Polio, Measles.
o Growth monitoring for children under the age of five.
o Counseling and testing of antenatal mothers and partners on PMTCT -
eMTC
o Create awareness through Micro teaching on various topics i.e.
Nutrition, Breast feeding, Weaning etc.
 Focused Antenatal care (FANC)
o Aims to promote health of mothers and their babies through
targeted assessments of pregnant women to facilitate:
 Identification and treatment of already established disease
 Early detection of complications and other potential problems
that can affect the outcomes of pregnancy
 Prophylaxis and treatment for anemia, malaria, and STI
including HIV, urinary tract infections and tetanus. Prophylaxis
refers to an intervention aimed at preventing a disease or
disorder from occurring.
o Aims to give holistic individualized care to each woman to help
maintain the normal progress of her pregnancy through guidance
and advice on:
 Birth preparedness
 Nutrition, immunization, personal hygiene and family planning
 Danger symptoms that should make pregnant woman get
immediate help from a health professional
 o The first FANC visit should occur before 16 weeks of pregnancy; 2 nd
FANC visit at 24-28 weeks of pregnancy; 3rd FANC visit at 30–32
weeks of gestation; and 4th FANC visit between weeks 36-40 of
gestation
 Post-natal care.
o The care given to mother and her newborn baby immediately after
birth and for the first six weeks of life
o It aims at:
 Supporting the mother for an easy transition
 Early diagnosis and treatment of any complications
 Provision of nutritional and breastfeeding guidance
 Guiding on contraception and family planning
 Guiding on immunization
 Family planning methods: short term, long term, permanent i.e.
vasectomy & tubal ligation.
o Family planning can be short term, long term or permanent
o The choice of one method depend on individual medical condition,
taste and partner
o Family planning are classified into four: (i.e. natural, barrier,
hormonal and surgical)
 Natural method
 Does not involve use of drugs or device
 Examples are:
o Withdrawal (coitus interrupters);
o Safe periods (rhythm method) - No sex between
day 8(eight) and day 20 (twenty) of a woman’s
circle i.e. a total of 12 days without sex in a month
o Breast feeding amenorrhea method
o Cervical mucus membrane - couples are advised
against using this if they don’t understand the
physiology of ovulation
o Basal body temperature (BPT) – Involves daily
reading of body temperature
 Barrier method
 This method includes:
o Male and female condoms
o Spermicides
o Diaphragms
o Cervical caps
 Whereas condoms, diaphragms, and cervical caps are
mechanical barriers, spermicides are chemicals that
interfere with the movement of the sperm and its ability
to fertilize the egg
 Hormonal method
 This is the most commonly used method
  They include hormone taken orally, by injection or
implanted to prevent development and maturation of
woman’s eggs (ovum’s)
 Examples are:
o Emergency contraception (e-pills)
o Ordinary pills
o Injectable contraceptives
o Contraceptive Implants (Jadelle, Implanon, Zarin)
o Hormone-releasing intrauterine systems (e.g.
Copper T)
 Voluntary surgical methods
 The following are surgical family planning methods:
o Tubal ligation
o Vasectomy
 Screening of breast and cervical cancer in all women of
reproductive ages.
o Services offered for breast and cervical cancer screening and
diagnosis include:
 Clinical breast exams
 Mammograms
 Pap tests
 Human papilloma virus (HPV) tests
 Pelvic exams
 Referrals for treatment

 Giving immunization i.e. BCG, Pentavalent, Polio, Measles.

o Basic principle of immunization is to administer into a healthy
person a vaccine that will prevent that person from getting a certain
disease.
o Vaccines may be of:
 Live attenuated: (e.g. Rubella, OPV, Measles and BCG),
 Inactivated or killed (e.g. Hib, IPV)
 Micro-organisms
 Detoxified toxins (e.g. Tetanus)
o BCG, OPV, DPT-HeB-Hib and Measles vaccines can be given
simultaneously if the child is of the appropriate age and has not
received the early immunizations.
o A critically ill child needing hospital admission must be given the
appropriate vaccines upon recovery
o The following are common vaccine-preventable diseases
 Whooping cough (Pertussis):
 A communicable disease.
 Spread by droplets. Symptoms include: Severe cough
followed by a whoop and vomiting, leads to
malnutrition, can cause death, Severe in under 1-year-
old.
  Diphtheria:
 An infectious disease.
 Spread by droplets.
 Symptoms include: Difficulty in breathing, Swallowing,
Enlarged neck.
 Very severe when it occurs.
 Tetanus:
 A clinical syndrome involving primarily the central
nervous system and resulting from the tetanus toxins.
 Enters through open wounds, cuts and umbilical stump.
 Symptoms include: Stiffness, Locked jaw, Inability to
suckle and muscle spasms.
 Has a very high mortality (>50%).
 Immunizing pregnant mothers ensures protection of her
new born baby.
 Measles (Rubella):
 Highly infectious killer disease.
 Symptoms include: Rash, Fever, Cough, Red eyes;
 Is associated with: blindness, malnutrition, deafness,
pneumonia and death.
 Poliomyelitis (Infantile Paralysis):
 An acute communicable disease.
 Spread by droplets and oral-faecal contamination.
 Symptoms include:
o Pain and flaccid paralysis in limbs, fever, vomiting;
can lead to permanent deformity, and can cause
death.
 Tuberculosis:
 A communicable disease.
 Spread by droplet.
 Symptoms include: fever, wasting, deep chesty cough,
Night sweats, may have lymphadenopathy.
 Leads to lowered resistance to other diseases and may
be fatal.
 Hepatitis B:
 Is a highly infectious disease.
 Transmitted mainly by:
o Parenteral route,
o From person to person
o By close contact
o Through exchange of body fluids such as:
 Saliva, Secretions from open wounds, Blood,
Vaginal secretions and semen.
 Transmission between children is common, since they
are often more infectious than adults.
 Transmission from carrier mothers can occur in up to
80% of babies during the perinatal period,
  Infection may be transmitted either:
o Vertically (trans-placentally from mother to
unborn baby)
o Horizontally by close contact.

Childhood immunization schedule in Kenya

Vaccine Age Remarks

BCG POLIO (OPV At birth Or at first contact with child
O) Birth
Dose
DPT1-HeB1-Hib1 6 weeks Or at first contact with child after that age
DOSE POLIO (OPV (1 ½
1) months)
DPT2-HeB2-Hib2 10 4 weeks after DPT 1 and OPV 1 can also be given any
DOSE POLIO (OPV weeks time after this period, when in contact with the child.
2) (2 ½
months)
DPT3-HeB3-Hib3 14 4 weeks after DPT 2 and OPV 2 can also be given any
DOSE POLIO (OPV weeks time after this period, when in contact with the child.
3) (3 ½
months)
Measles 9 May be given between 6 and 9 months if child is
months admitted to hospital for any other illness. Repeat at 9
months as per KEPI schedule.

 Kenya Expanded Program on Immunization (KEPI) was established in June,

1980 by the Kenya government to oversee and monitor vaccinations to all
children in Kenya against five common diseases at that time.
 Its goals are:
o Sustaining polio-free status
o Eliminating maternal and neonatal tetanus
o Eliminating measles
o Accelerating control of hepatitis B
o Eliminating rubella
o Introducing new vaccines
o Meeting regional vaccination coverage targets
 The KEPI has changed to Unit of Vaccines and Immunization Services
(UVIS)
 UVIS mandates are:
o To coordinate vaccination services for all vaccine preventable
diseases through the provision of guidelines and selected priority
vaccines
 o Advice on immunization schedules for all age cohorts in line with
the Kenya Essential Package for Health
 Roles of UVIS are:
o Policy regulation and oversight
o Commodity security & quality assurance
o Monitoring and evaluation
o Advocacy and Resource Mobilization
o Capacity strengthening
o Conduct appropriate operational research
 Growth monitoring for children under the age of five.
o This is the regular recording of a child's weight
o Measuring height and weight is important when monitoring an
infant or child's health.
o Height and weight measurements are used to calculate your body
mass index, or BMI, a measure of healthy versus unhealthy weight.
 Counseling and testing of antenatal mothers and partners on
PMTCT – eMTC
o Mother-to-child transmission of HIV is the spread of HIV from a
woman living with HIV to her child during pregnancy, childbirth (also
called labor and delivery), or breastfeeding (through breast milk).
o Pregnant women with HIV receive HIV medicines during pregnancy
and childbirth to prevent mother-to-child transmission of HIV. In
some situations, a woman with HIV may have a scheduled cesarean
delivery to prevent mother-to-child transmission of HIV during
delivery.
o Babies born to women with HIV receive HIV medicines for 4 to 6
weeks after birth. The HIV medicines reduce the risk of infection
from any HIV that may have entered a baby's body during
childbirth.
o Women who take HIV medicines during pregnancy and childbirth
and whose babies receive HIV medicines for 4 to 6 weeks after birth
have a low risk of transmitting HIV.
 Create awareness through Micro teaching on various topics i.e.
Nutrition, Breast feeding, Weaning etc.
o This educating the mother on delivery preparedness, safe delivery
and postnatal care after the delivery
3.3. Health education
 Health education is provided at the MCH before the services begin
 Topics covered are those related to:
o Family planning
o Antenatal services
o Preparations for safe delivery
o Postnatal care
o Care of the newborn
 o Nutrition and dietary supplements
o Hygiene
o Preparation of food for infants and children
 Various teaching methods are used to include short lectures,
brainstorming, case studies, illustration and demonstrations
3.4. Community based maternal and child health care
 The following are objectives of community based maternal, newborn and
child health care:
o Reduce deaths among mothers, newborns, and young children by
improving the health services available in the community
o Provides women with greater access to good-quality, reliable health
services.
o Ensure that counties offer essential health services for women and
children through outreach and in static facilities;
o Provides training for health care workers in emergency care for
pregnant women, new mothers, and newborn babies;
o Strengthens the management and supervision practices in health
care facilities.
o Improves ability of men and women in the communities to
recognize, prevent, and respond to maternal and child health
issues.
 The community MCH services include:
o Organizing community events and mass media campaigns,
o Training community theatre groups,
o Selecting peer youth educators and male champions to raise
awareness about potential health issues;
o Conducting home visits to provide pre-natal and post-natal care and
care for newborns and young children;
o Equipping community health workers to provide services in remote
areas and to refer patients to health centres where necessary.
o Build capacity of traditional birth attendants to identify and refer
pregnant mothers to health facilities for safe delivery
o It emphases the role that men can play in helping to improve the
health of women and children.
Unit 4. Nutrition and health
4.1. Introduction
 Nutrition - The science that interprets interaction of food nutrients in
relation to maintenance, growth, reproduction, health and disease of an
individual. It is the intake of food in relation to the body’s dietary needs.
 Good nutrition - is an adequate, well balanced diet combined with
regular physical activity. Poor nutrition can lead to:
o Reduced immunity
o Increased susceptibility to disease
o Impaired physical and mental development
o Reduced productivity
 Diet - is what an individual eat, which is largely determined by the
availability and palatability of foods. A healthy diet includes preparation
and storage of food that:
o Preserve its nutrients
o Reduce risks of foodborne illness
 Nutrients – Are chemical components of food that can be classified into:
o Carbohydrates
o Proteins
o Fats
o Vitamins
o Minerals
o Water – Water not a nutrient, but it is essential for the utilization of
nutrients.
 Importance of nutrition include:
o A healthy diet allows adults to work productively and feel their best
o Good food choices help to prevent chronic diseases, such as heart
disease, certain cancers, diabetes, stroke A proper diet reduce
major risk factors for chronic diseases, such as obesity, high blood
pressure and high blood cholesterol
o Nutrition is essential for growth and development, health and
wellbeing
o Eating a healthy diet contributes to preventing future illness and
improving quality and length of life
o Your nutritional status is the state of your health as determined by
what you eat.
 An individual's food choices depend on energy needs, nutrient needs and
enjoyment.
4.2. Basic nutrition
 There are two main types of nutrients:
o Macronutrients i.e. carbohydrate, protein, and fat
 o Micronutrients i.e. vitamins and minerals
Carbohydrates
 Carbohydrates can be classified as:
o Monosaccharide (e.g. glucose, fructose, galactose)
o Disaccharide (e.g. sucrose, lactose, maltose)
o Polysaccharide (e.g. starch, fibre)
 Carbohydrates must be reduced to the simplest form of glucose (through
digestion) before your body can make use of them
 Carbohydrates should make up at least 55% of your total energy intake
 The brain is a special part of the body that depends primarily on glucose
for its energy and requires about 100 g/day of glucose for fuel
Protein
 Protein is important for the production, maintenance and repair of tissues
in the body
 When energy intake is insufficient, protein intake must be raised. This is
because ingested proteins are directed towards glucose (sugar) synthesis
and oxidation
 The tissues and organs in the body are made up of protein and protein
compounds
 Enzymes (catalysts), antibodies and hormones consist of protein
 The building blocks of protein are called amino acids
 For adults, the recommended dietary allowance of protein is about 0.75
g/kg body weight per day
 Animal products have the highest amount of proteins, followed by
legumes (beans), cereals (rice, wheat, corn) and roots
Fats and oils
 Fats we consume occur in foods like nuts, avocados, oil, etc.
 Salad oil (omega-6 fats reduce inflammation and prevent certain chronic
diseases such as heart disease and arthritis
 Saturated fatty acids raise blood cholesterol levels
 Trans fat are harmful to your health. Trans fats are found mainly in deep-
fried fast foods and processed foods made with margarine.
 It is recommended that your total fat intake is no more than 30% of your
energy (calorie/kilojoule) intake.
Vitamins
 Vitamins are needed in small quantities
 Vitamins cannot be made in the body and must be obtained from dietary
sources
 Only vitamin D can be manufactured by the body
 Essential vitamins are grouped into two families:
o Water soluble - Can dissolve in water (vitamin C, folic acid)
o Fat soluble - can dissolve in a fat medium (vitamins A, D, E, K)
 Vitamins helps in disease prevention, formation of hormones and blood
cells
Minerals
 Minerals are essential, acting as cofactors of enzymes (i.e. enzymes would
not exist or function without minerals). Some of the minerals necessary
for health are:
o Calcium – Helps in blood clotting, build and maintain strong bones.
o Iron – Helps in blood cell formation
o Zinc - Essential for synthesizing protein, DNA and RNA. It is required
for growth in all stages of life. Sources include meats, oysters and
other seafood, milk, and egg yolk.
 Nutrition is required during phases of life
 This is the nutrition required during: Pregnancy and early childhood;
Childhood and adolescent; School going age; Adults; and older age.
o Pregnancy and early childhood
– Starting early with breastfeeding and providing good nutrition
for children gives the best start to a healthy life.
– Good nutrition in pregnancy is essential for keeping a
developing baby and mother healthy
– Breastfeeding is the natural way to feed babies
– Breastfeeding is extremely important for the health outcomes
of infants and their mother
– Solids should be introduced at around six months of age when
the infant is developmentally ready
– For young children, a healthy diet is required for optimal
growth and development. It can also help to improve
concentration, fight illnesses, and prevent long term health
complications.
o Children and Adolescents
– Children and adolescents need sufficient foods to grow and
develop normally.
– Growth should be checked regularly for young children.
– Physical activity is important for children and adolescents.
– Many infants suffer and die because of ignorance, meanness
of parents and inability to understand the infant
communication language
o School aged children
– Childhood is an important period when children develop the
knowledge, skills and behaviors for lifelong health and
wellbeing
– We know that education and health are inseparable and that a
healthy child learns well.
o Adults
– Healthy eating during adulthood is vital for effective
functioning of body systems and immunity, maintaining a
healthy weight, and preventing and managing chronic
conditions such as diabetes and heart disease.
o Older people
 – Good nutrition is important for older people to help promote
independence and to reduce illness and premature death.
– Maintaining a healthy lifestyle, including good nutrition, plays
an important role in ensuring older people can live well at
home for longer.

 The body mass index is a value derived from the mass and height of a
person. The BMI is defined as the body mass divided by the square of the
body height, and is universally expressed in units of kg/m², resulting from
mass in kilograms and height in meters

___weight (kg)___
BMI = height x height (m2)
4.3. Community nutrition
 Community nutrition is the process of helping individuals and groups
develop healthy eating habits in order to promote wellness and prevent
disease
 The goal of community nutrition is to educate individuals and groups so
that they adopt healthy eating habits.
 Community nutrition focuses on all age groups.
 Community nutrition programs are administered by organizations such as
public health agencies, public schools, residential facilities for the elderly,
hospitals, social service organizations, and health-care systems
 Community nutrition entails the following components:
o Surveillance of food chain – This is assessing food for possible
infestation with germs, toxic. It’s also called food contamination
monitoring
o Nutritional epidemiology – A study on relationship between
nutrition and health. It is the study on effects of dietary intake and
nutritional status on health of individual or community.
o Clinical nutrition and diabetes - Involves assessing the
effectiveness of clinical nutrition in diabetes care and outcomes
o Nutrition education - Is any combination of educational
strategies, accompanied by environmental supports, designed to
facilitate voluntary adoption of food choices and nutrition-related
behaviors conducive to health and well-being.
o Food and nutrition policy – Government rule for:
 Making healthy food available
 Disclose the calorie content of restaurant foods
 Teach people how to make healthy eating easier
 Nutrition standards for school lunches
 Regulation of food additives.
o Food industry and standard agency - is a global collective of
diverse businesses that supply much of the food and food energy
 consumed by the world population e.g. UNILIVER. It is concerned
with food industry – from farming, food production and distribution,
to retail and catering. It addresses food safety issues at every stage
of the chain, providing information and guidance on best practice
and legal requirements.
o Mass catering - Food and drink supplied by a caterer to large
numbers of customers at the same time
4.4. Nutrition in pregnancy and lactation
 Pregnancy is physiologically and nutritionally a highly demanding period.
Extra food is required to meet the requirements of the fetus.
 A woman prepares herself to meet the nutritional demands by increasing
her own body fat deposits during pregnancy.
 A lactating mother requires extra food to secrete adequate quantity/
quality of milk and to safeguard her own health.
 A pregnant and lactating woman requires nutrient that contain an
additional 350 calories, 0.5 g of protein during first trimester and 6.9 g
during second trimester and 22.7 g during third trimester of pregnancy.
 A breastfeeding mother needs a lot of energy and nutrients such as
protein, calcium, iron and vitamins
 Pregnant woman should adhere to the following dietary plan:
o Eat more food during pregnancy.
o Eat more whole grains and fermented foods.
o Take milk/meat/eggs in adequate amounts.
o Eat plenty of vegetables and fruits.
o Avoid superstitions and food taboos.
o Do not use alcohol and tobacco. Take medicines only when
prescribed.
o Take iron, folate and calcium supplements regularly, after 14-16
weeks of pregnancy and continue the same during lactation.
 Folate helps in synthesis of hemoglobin, increase birth weight
and reduce congenital anomalies.
 Iron helps hemoglobin synthesis, mental function, provide
immunity against diseases.
4.5. Malnutrition and other related conditions
 Malnutrition is the condition that develops when the body does not get
the right amount of the vitamins, minerals, and other nutrients it needs to
maintain healthy tissues and organ function.
 Individuals are malnourished if their diet does not provide them with
adequate calories and protein for maintenance and growth, or they
cannot fully utilize the food they eat due to illness.
 Growth failure malnutrition is the failure of an individual to grow as
expected in height or weight, according to his/her age and gender.
 Growth failure malnutrition can take three serious types:
o Acute malnutrition or wasting - arises out of sudden, drastic
weight loss. It leads to three clinical malnutrition types:
 Marasmus: this occurs when body fat and tissues
degenerate at an alarming rate to compensate for the lack
of nutrients. As a result, the body’s internal processes
begin to slow down alarmingly fast as does the activity of
the immune system.
 Kwashiorkor: this is characterized by bilateral pitting
edema (fluid retention) in the legs and feet. As a result, the
under-nourished child may actually look plump.
 Marasmic-kwashiorkor: This is characterized by both
severe wasting and edema.

o Chronic malnutrition or stunting - happens over a long period

of time and has more long-lasting consequences. It begins before
birth due to poor maternal health and leads to stunted growth in
an otherwise normally proportioned child. Poor breast feeding,
infections and lack of availability of proper nutrients are the main
causes behind it. Stunting is dangerous because it becomes
irreversible after an age. Therefore, it becomes important to nip
it in the bud by providing proper medical treatment to pregnant
women and young girls.
o Micronutrient malnutrition - implies a moderate to severe
lack of Vitamins A, B, C and D, Calcium, Folate, Iodine, Iron, Zinc
and Selenium. These vitamins and minerals are of utmost
importance in various body processes and their deficiency can
make an otherwise healthy person malnourished:
 Iron deficiency causes anaemia, poor brain
development and cardiac functioning.
 Iodine deficiency leads to impaired thyroid functioning
and mental retardation.
 Vitamin D deficiency causes rickets and other bone
development related disorders.
 Selenium deficiency leads to poor cardiac function,
weak immunity and osteoarthritis.
 Vitamin A deficiency is a cause of poor vision, bone
development and immunity.
 Vitamin B12 deficiency leads to nerve degeneration and
poor RBC formation
 Folate or vitamin B9 deficiency causes slow growth and
anemia
 Zinc deficiency can cause poor immunity, sensory
perception and anemia.
 Signs and symptoms of malnutrition-
o A symptom is something the patient feels and reports, while a sign
is something other people, such as the doctor detect. For example,
pain may be a symptom while a rash may be a sign. The general
signs and symptoms include:
 Loss of fat (adipose tissue)
 Breathing difficulties, a higher risk of respiratory failure
 Depression
 Higher risk of complications after surgery and lower healing
hence longer recovery
 Higher risk of hypothermia - abnormally feeling cold and low
body temperature
 The total number of some types of white blood cells falls;
consequently, the immune system is weakened, increasing
the risk of infections.
 Lower sex drive and problems with fertility
 Reduced muscle and tissue mass
 Tiredness, fatigue, apathy and irritability
o In more severe cases:
 Skin may become thin, dry, inelastic, pale, and cold
 Eventually, as fat in the face is lost, the cheeks look
hollow and the eyes sunken
 Hair becomes dry and sparse, falling out easily
 Sometimes, severe malnutrition may lead to
unresponsiveness (stupor)
 If calorie deficiency continues for long enough, there
may be heart, liver and respiratory failure
 Total starvation is said to be fatal within 8 to 12 weeks

 Causes of malnutrition are:

o Poor diet - if a person does not eat enough food, or if what they eat
does not provide them with the nutrients they require for good health,
they suffer from malnutrition. Poor diet may be caused by one of
several different factors. If the patient develops dysphagia (swallowing
difficulties) because of an illness, or when recovering from an illness,
they may not be able to consume enough of the right nutrients.
o Mental health problems - some patients with mental health
conditions, such as depression, may develop eating habits which lead
to malnutrition. Patients with anorexia nervosa or bulimia may develop
malnutrition because they are ingesting too little food.
o Mobility problems - people with mobility problems may suffer from
malnutrition simply because they either cannot get out enough to buy
foods, or find preparing them too arduous.
o Digestive disorders and stomach conditions - some people may
eat properly, but their bodies cannot absorb the nutrients they need
for good health.
 o Alcoholism - this is a chronic (long-term) disease. Individuals who
suffer from alcoholism can develop gastritis, or pancreas damage.
These problems also seriously undermine the body's ability to digest
food, absorb certain vitamins, and produce hormones which regulate
metabolism. Alcohol contains calories, reducing the patient's feeling of
hunger, so he/she consequently may not eat enough proper food to
supply the body with essential nutrients.
o Food shortage, price and distribution
o Lack of breastfeeding
4.6. Impact of malnutrition on health and development
 Malnutrition and starvation have devastating impact on children, adults
and especially on pregnant women. They also have severe and far-
reaching socio-economic impacts.
o Effects on children - Mental retardation, stunted growth, poor
immune system, micronutrient deficiency, GI tract infections, anemia
and inevitably – death.
o Effects on pregnant women - Besides the health of the child being
poor, a pregnant woman might have difficult labour, postpartum
hemorrhage and anemia.
o General effects - Weak immunity, inactivity of muscles, apathy,
depression, and kidney function impairment.
 Malnourished children experience developmental delays, weight-loss and
illness as a result of inadequate intake of protein, calories and other
nutrients. Because orphaned and institutionalized children may
experience one or several macronutrient and micronutrient deficiencies,
they are at risk for a variety of short-term and long-term complications:
o Short-Term Implications - Because so much development occurs in
the first few years of life, nutrient deficiencies can have major short-
term implications in young children.
 Immune Implications - Malnourishment can greatly
compromise a child’s immune system, making them more
susceptible to infectious diseases. Particularly in institutions
where there are poor sanitary practices, children are vulnerable
to infections from other children or caregivers.

 Growth Implications - A child may contract an infection due to

poor nutritional status. In turn, a gastrointestinal infection places
the child at even greater risk for nutrient deficiencies because
nutrients are unable to be absorbed properly. Consequently,
nutrient deficiency combined with infection can cause growth
retardation.
 Additionally, a deficiency in one nutrient may lead to a deficiency
in another nutrient. For example, deficiencies in iron, magnesium
and zinc can cause anorexia and thereby result in reduced intake
of other important nutrients such as protein. Low lipid intake can
 also affect the absorption of important fat-soluble vitamins such
as vitamins A and Zinc and protein deficiencies can retard bone
growth and development, putting a child at risk for long-term
complications.
o Long-Term Implications - The short-term implications of malnutrition
eventually give way to long-term complications, such as growth and
cognitive delays:
 Growth Implications - Malnutrition not only impacts growth
in the short term, but can also limit total bone growth.
Additionally, children classified as low height-for-age (stunted)
may never be able to regain lost growth potential if they
continue to live in a nutritionally deprived situation.
 Cognitive Implications - Malnutrition negatively effects
brain development causing delays in motor and cognitive
development, such as:
 Attention deficit disorder
 Learning disabilities and impaired school performance
 Decreased IQ scores
 Memory deficiency
 Reduced social skills
 Reduced language development
Unit 5. Community partnership project
5.1. Concepts in partnership
 Partnership
o This is a voluntary collaborative agreement between two or more
parties in which all participants agree to work together to achieve a
common purpose or undertake a specific task and to share risks,
responsibilities, resources, competencies and benefits.
o This is a form of relationship and collaboration formed by
agreement between two or more individuals who carry out activities
as co-owners and share management and profits.
o Those people who invest money in the partnership are called
partners
o A good partnership has the following qualities or characteristics:
 Mutual contribution
 Division of profits or losses
 Co-ownership of contributed assets
 Mutual agency
 Limited life
 Unlimited liability
 Partners' equity accounts
o One of the strategic directions articulated in Kenyan community
strategy is “to build effective local partnerships.”
 Principles of partnership
o Context - a full understanding of the social and political
environments that determine the mandate of the partners
o Common vision and planning - desired outcomes need to align with
strategic priorities
o Sustainability of the outcomes - Mechanisms for monitoring the
outputs
o Complementarity - Efficiency through the allocation of tasks so that
each partner’s comparative advantage is utilized
o Shared responsibility - each partner’s roles and responsibilities
should be clearly defined over time
o Intellectual Property Rights (IPR) A clear understanding of ownership
of knowledge and data
o Transparency of financial arrangements - a true partnership calls
for openness and negotiation with regard to how financial resources
are allocated and used
 o Monitoring and evaluation of partnership - this needs to be
conducted at various stages for accountability and informed
decision making
o Core Values – Clarity of agreed goals and recognizing contributions
irrespective of the partners’ institutional size, history or division of
labor
o Governance - Good leadership and regular communication between
partners
o Building trust, mutual understanding and solidarity among members
 Types of partnership
o General partnership
– The partners share equal rights and responsibilities in
connection with management of the project
– Any individual partner can bind the entire group to a legal
obligation.
– Each individual partner takes full responsibility for all of the
business's obligations.
o Limited partnership
– Allows each partner to restrict his or her personal liability to
the amount of his or her project investment
– Not every partner can take lead.
– At least one participant must take full lead for the project’s
obligations
 Community partnership
o This is formal and informal local community connections,
collaborative projects, and relationships that advance the
community development goals.
o Levels of community partnerships are
 Partnerships among community-based organizations
 Cross-sector partnerships (between community and the
government or learning centers
 Partnerships between community and donor organizations
o Importance of community partnership
 Leveraging and maximizing resources by pooling talent,
expertise, and resources
 Better co-ordination and integration in the delivery of services
 Greater understanding of challenges and greater capacity to
plan and develop solutions
 Build synergy and tap into opportunities provided by
institutions and organizations
 Effective communication and engagement to achieve
outcomes
 Generating broad based support—including other
stakeholders from both private and public sectors
 Increasing credibility beyond the scope of the individual
organization
  Promote local participation in advancing health and
development
 Creating better ways to reach audiences where they spend
time—live, work, play
 Realizing that no one stakeholder can solve the problem
 Building on public health’s expertise and evidence based tools
and information to improve the health of the community
 Increased innovations and new ideas
 Assure the long-term sustainability of efforts to scale up
community livelihood
 Shared responsibility
 Increase understanding of a community’s needs and assets.
o The following can be areas of partnering with the community
 Environmental health
 Reproductive health and safe motherhood
 Nutrition and dietary assistance
 Immunization
 Hygiene maintenance
 Psycho-social behavioral support
 Health awareness and demand
 Physical fitness and wellness
 School programs
 Disease prevention programs
 Community modelling dialogue
 Community research
o Examples of community partnership
 Partnership project: Nutrition program
 Project goal: Reduction of nutrition related diseases
 Project objective: To increase production and intake of dark
green vegetables
 Partners: Student, Community Health Volunteer,
Agricultural worker
 Effective implementation of this partnership strategy will enable KMTC to:
o Achieve objectives in relevant areas that can contribute to food
security, poverty alleviation and environmental sustainability
o Improve the relevance of our research and development activities
and strategies
o Complete the chain from analysis of research needs through
technology development, testing, adoption and implementation of
innovations with effective links to scaling up systems and
organizations that can help to leverage impact
o Incorporate active participation of local institutions in advancing
natural resource management science and practice, thereby
incorporating indigenous knowledge and expertise into work
o Contribute to policy and institutional transformations as appropriate
to create conditions and practices that transform livelihoods and
landscapes
 o Achieve mutually beneficial alignment of research with partner
research agenda
o Attain a meaningful division of labour among different players in the
research-development continuum.
 Challenges in partnership
o Conflicts of interest
o Loss of autonomy and reduced independence
o Drain on resources to establish and maintain partnership
relationships
o Miscommunication based upon disparate vocabularies and business
models
o Value disagreements.
o Personality conflicts.
o Communication misunderstandings.
o Doubts about priority need for partnership.
o Confusion over differing degrees of members’ autonomy.
o Different power interests.
5.2. Identification of sites for community partnership development
o Selection of sites for partnership depends on:
o Nature of the problem to be addressed
o Community burden
o Capacity of college and student in terms of resources
o Reception by the community
o Process of identifying a community partnership site
o Carry out exploratory visit to the community
o Identify community development projects available
o Carry out a rapid assessment of the community projects
o Make a SWOT analysis of the projects to determine
weaknesses and threats
o Visit the community project with more gaps and threats
o Approaches of selecting a site for community partnership
o Instruction by lecturer or funding agencies
o Recommendations from past projects
o Exploratory observation
o Personal interest and experience
o Request by the community members

5.3. Involvement of community in prioritizing areas of corporation (portfolio

analysis)
 Community involvement is defined as the process of:
o Engaging the community members to take part in addressing issues
affecting their own health
o Making the community members play their roles in community
projects and activities to solve their own problems
 What are the purposes of involving community in development project
 o Enhance community participation
o Builds ownership and accountability
o Allows for team building
o Workforce retention
o Build community relationship
o Promotes similar values of the project
o Abolish the differences among individuals
o Develop spirit of common interest and sacrifice
 What hinders community involvement
o Lack of awareness among members
o Undefined roles and responsibilities
o Communication and information sharing barriers
o Incompetent management capacity
o Capital inadequacy and inconstant funding cycle
o Mistrust, hatred and corruption levels
5.4. Establishment of project committees
 A project committee is:
o The key body within the governance structure which is responsible
for the project issues that are essential to the ensuring the delivery
of the project outputs and the attainment of project outcomes.
o An advisory committee made up of high level stakeholders and/or
experts who provide guidance on key issues such as policy and
objectives, budgetary control, marketing strategy, resource
allocation, and decisions involving large expenditures.
 What are roles of project committee
o Provide both technical and non-technical advice
o Ensure delivery of the project outputs , achievement and project
outcomes
o Providing advice (and sometimes making decisions) about changes
to the project as it develops.
o Provides support, guidance and oversight of progress
 Process of establishing a project committee
o Find a location for regular meetings
o Decide on the type of committee
 Taskforce - usually designed to accomplish 1-3 major goals
over a six- to nine-month period and is dissolved after charge
is completed
 Standing - meets regularly and is consistent year to year
 Ad hoc - short term committee to accomplish a specific goal
and is dissolved once committee charge is completed
o Call a public meeting and ask for individuals to form a committee to
carry forward the issue.
 o Talk to people or groups with similar interests, let them know about
the new group, and let them know you’re looking for people who
really want to make a difference for children and parents
o Define the scope/purpose of the committee
 Develop the goal and objectives
 State the mission and terms of reference of the committee
o Define membership
 Ensure membership is representative
 Most committees have between 12 and 15 members
o Role definition
 Official bearers (chairman or champion, secretary, treasurer)
 Each member’s function
o Define expected outcome of the committee
 Develop target
 Define desired outcome
o Draw a meeting schedule
5.5. Building of partnership
 The following is a model for partnership agreement
1. General information
1.1. Name of partnership
1.2. Type of partnership
1.3. Principle reason for establishing
1.4. Priority and aim to which the partnership will contribute
1.5. Date partnership commence
1.6. Expected lifespan
2. Partnership objectives
2.1. Partnership vision (clear, long-term, agreed by all partners, achievable
and contributes to all partner priorities and defined service outcomes)
2.2. Partner contribution (how and what each partner contributes; business
plan define how goals will be achieved by which partner and when)
2.3. Publication (to promote understanding and ownership)
3. Terms of reference
3.1 Purpose (what the partnership is for including expected benefits and
outcomes)
3.2 Scope (what the partnership is and isn’t intended to do)
3.3 Agreement (documented agreement to the scope by all partners at an
appropriate level)
3.4 Code of conduct (partners may be bound by their own organization’s code
and if so this should be stated and a link to those codes provided for
clarity)
4. Partnership principles
4.1. Referring to the principles in the framework, the principles agreed by the
partners should be set out
5. Membership
5.1. Partners (the full list of agreed partners, number of representatives each
partner may have and whether they must be member or officer, and
names of nominated representatives)
5.2. Non partner participation (explain why they are their e.g. professional or
technical advice, provide view of service users, representational role etc.,
and how they were selected)
5.3. Voting powers (terms of office and voting rights of partners.
5.4. Time limits (frequency of membership review, limits of time an individual
representative can serve on a partnership)
5.5. Representation (if/how the membership is expected to reflect the
characteristics of the area/people it serves)
5.6. Roles and responsibilities (for each constituent member; it may be
appropriate to list members by sector and areas of activity they are
responsible for; list each partner and specify what, where and when they
will provide to the partnership activity)
5.7. Secretariat (who will provide it; who pays for it)
5.8. Chair (method and criteria for appointing; term of office; vice chair)
5.9. Accountable body (who will be accountable for the finances; who will pay
for that function)
6. Accountability and communication
6.1. Reporting (how will the partnership report, to whom is it accountable to;
communication strategy for reporting externally and internally;
boundaries between activity of the partnership and of individual partners)
6.2. Audit (arrangements for internal and external audit and how these will be
resourced)
6.3. Value for money (how the partnership adds value, how it measures and
monitors that added value)
7. Governance
7.1. Corporate and individual governance (how governance arrangements link
to partner bodies arrangements, how decisions are recorded, who makes
sure they are acted on, who scrutinizes them, to whom are they reported)
7.2. Statutory powers/obligations (specify and legislative or regulatory
requirements the partnership must comply with and say how it will be
assured that it does so)
7.3. Transparency (say how the principles of transparency will be complied
with including access to meetings and information; register of interests)
7.4. Delegations (who is responsible for what decisions and any limits on that
delegation)
7.5. Policies (any policies of the partnership needed to operate, or policies of
individual partners which must be adopted by the partnership)
7.6. Meetings arrangements – to include:
 Setting dates of meetings
  Minimum number of meetings in a period
 Publicity re meetings (and if open or private)
 Process for convening extraordinary meetings
 Responsibility for setting agenda, circulating papers, minutes etc.
 Venues/timing/duration
 Representation/deputizing and quorum
 Expectation of behaviors/attendance
 Declarations of interest and withdrawal
 Voting
 Written procedure
 Attendance via video/tele-conference facility
7.7. Timescales (review of governance, review of partnership, exit strategy
once objectives achieved)
8. Financial and resource management
8.1. Inputs (sources of funding including partner funds and grant funding;
assets, in kind resources, staffing and any limits on the use of these
resources by partners)
8.2. Financial regulations (may follow those of the accountable body but must
be agreed by the partners)
8.3. Financial decision making (limits both upper and de minims)
8.4. Financial reporting (what information will be provided, to whom and
when)
8.5. Accountability (how staffing and in kind resources will be managed and
accounted for)
8.6. Services (what services will the partnership require and how will they be
procured)
8.7. Assets (how will the assets of the partnership be recorded, who retains
ownership of them, and how they will be distributed when the partnership
is dissolved; to include intellectual property rights)
9. Performance and risk management
9.1. Arrangements (performance management methodology and
arrangements, targets and indicators; complaints and compliments
processes)
9.2. Data quality (arrangements for assuring quality of data, information
storage and management; data sharing)
9.3. Delivery (how the partnership will monitor and report on progress towards
objectives)
9.4. Outputs and outcomes (list deliverables linked to objectives, and give
timescales
9.5. Risks (arrangements for recording, reporting and managing risk)
10 Disputes and termination
10.1. Resolution of issues (systems and processes to resolve conflicts within the
partnership)
10.2. Termination (how partners may exit and how the partnership may be
dissolved)
11. Equality duty
11.1. How the partnership will operate to ensure the duties under the Equality
Act are met?

 There are 9 steps in building partnership

Step 1: Determine the need and readiness
 Is there a need for partnership?
Consider:
o Do we need other people/organizations to achieve a goal
o What is the “added value” in partnering?
o What benefits will be gained in this collaboration?
o What will the partnership be achieving?
 Is there already a collaboration elsewhere doing something similar?
Consider:
o Has research been done if other collaborative work being done in
this area?
o If so, have you considered opening up a discussion with them about
the possibility of becoming part of their partnership arrangement
and potentially avoiding duplication of services/work?
o If not feasible, have you talked to them about their experiences and
lessons learned as a useful tool in setting up a collaboration?
 Is there commitment within your campus to support a partnership?
Consider:
o Have you identified potential partners to approach as to the
possibility of collaborating?
o What additional expertise or benefits would the partner organization
bring?
o Is this being supported at the appropriate level of management
(correct work???) on your campus?
Step 2: Recruit the right people and organizations
 Start discussions with potential partners
Consider:
o Who should be involved in this collaboration and why?
o How many people/organizations should be involved?
o What level of involvement is needed?
 o Are there any issues or past history that need to be addressed
before partnering?
o Is there an element of trust between each partner?
o What would each bring to the table that would be beneficial and
complementary to a partnership?

 Gather all potential partners together for discussion about elements of the
collaboration
Consider:
o What is the main objectives of collaborating?
o At what level and function is the relationship (advisory, networking,
service collaboration, joint working group, project-based, etc.)?
o What is our shared vision and goals?
o Who will take the lead?
o What governance structure and accountability arrangements need
to be put in place?
o Do all members agree to these procedures?

 Get commitment for proceeding from those agreeing to partner

Consider:
o Is the purpose of the collaboration clear with a genuine shared
vision and goals identified?
o What will be the initial time commitment for the collaboration to
achieve their aims?
o Is there consensus on what each organization is agreeing to in the
collaboration?
o Is it a Win-Win relationship for all?
o Are all members satisfied for the benefits they will be receiving and
giving?
o Are there monies or resources to maintain and sustain the
collaboration…does additional funding need to be sought out?
(It can be helpful at this stage to develop a clear written statement outlining
what has been agreed to in the discussions such as commitments, who will take
the lead, main objectives, vision and goals, partnership structure and function,
responsibilities and accountability arrangements to date…and then share with
potential partners)
Step 3: Assess resources needed
 Identify the skills and competences needed to manage and support the
collaboration
Consider:
o What individual and/or organizational skills and resources are
needed to be successful in this venture (human resource, financial,
technical, others)?
o What can be leveraged from each organization to fulfill those needs
(tangible and intangible)?
o How will this be funded or resources realigned?
o Who are potential leaders and staff champions to actively advocate
and support the work?
 o What training might be needed for individual staff or organizations?
o To whom are staff accountable?
o Are there additional resources to support the collaboration itself?
 Identify any barriers that might be a risk to success for the collaboration
Consider:
o Is the collaboration congruent with policies and procedures of all
partners
o Have ground rules and norms for communication been established?
o Are all members committed to open, honest and transparent
conversations? How do you know this?
Step 4: Determine Structure of the Collaborative Partnership
 Ensure there is clarity among partners as to the mission, values and
principles that will guide the collaborative partnership
Consider:
o Is there a stated shared vision?
o Has a mission statement been devised (how the collaboration will
achieve their vision)?
o Are there guiding principles for the collaborative partnership agreed
upon by members
 Set out the processes needed to manage and sustain the partnership
Consider:
 What will be the governance structure for the collaboration and
have the roles and responsibilities of all member organizations been
defined and agreed upon?
 What shared or allocated resources have been agreed upon and
how funded/realigned?
 How will the work get done and what structure is needed to ensure
this happens (steering committee, advisory group, and executive
committee with work groups)?
 When, where and how will partners meet and who are the key
people needed for meetings?
 Is there an agreed process as to the timeline of the partnership in
terms of change, renewal and ending?
 Is there an accepted decision making process?
 Who is the accountable individual(s) or champion in each
organization for this collaboration?
 Have accountabilities, roles and responsibilities for lead
organization (if applicable) and member partners been specified
and is the reporting structure clear?
 To whom will the partnership report and is there a process in place
to report on progress?
 Is there a process to resolve conflicts in a fair and productive
manner?
 Have guidelines/ground rules for participation been established and
agreed upon?
 Ensure a formal written agreement incorporating the above has been
developed and signed by all partners.
 Consider:
o Are there any unresolved issues that need to be addressed before
signing?
o Does the collaboration require a simple or more formal agreement?

Which format best meets your need? (See examples of Letter of Agreement,
Service Collaboration Agreement, and Memorandum of Understanding)
Step 5: Develop a communication strategy
 Set up an effective communication plan between partners
Consider:
o What is the overall purpose for communicating and what does the
partnership hope to achieve?
o Identify who is responsible for communication between partners?
o What type of information needs to be shared, with whom and how
often?
o What needs to be documented, what and how will it be shared?
o Are there additional funds and/or resources needed?
o Does the plan ensure consistent, transparent and timely
communication?
 Get consensus on the means and methods that will be used to
communicate
Consider:
o What types of methods are available for communication and what
would work best in this initiative?
o Any technologies needed to do this successfully?
o Is any training needed for staff to use effectively?
o Are communication systems compatible among partner
organizations?
Step 6: Agree on and develop an action plan
 Develop an Action Plan to meet goals/objectives of collaborative
partnership
Consider:
o Have benchmarks been established - Where we are now (the
baseline) and what we need to achieve (the objective)?
o What steps have to be taken to reach these objectives?
o What is the desired timeline for how long it is likely to take?
o Who will be responsible for seeing the action task is successfully
completed?
o What resources are needed?
o Has the scope of the collaboration been identified…which activities
are inside the scope of the initiative and which activities are outside
of it?
o What is the indicator (measurable outcome) to know the goal has
been achieved?
o Has a plan been developed to evaluate the collaboration?
o Is there a plan in place for sustaining the partnership?

Step 7: Identify risk factors for the collaboration

 Make a list with partners as to potential risks to the collaboration
 Consider:
o What risks might be involved in setting up and starting the
collaborative partnership?
o What risks might be involved in organizing the partnership?
o What risks might be involved in meeting the timelines for the
collaboration?
o What risks might be involved in meeting the objectives of the
collaboration?
o What risks might be involved in not having all the resources/funding
needed to manage the partnership?
o Are there any liability issues (insurance, collective agreements,
funding obligations, legal situations, confidentiality requirements,
intellectual property)?
o Are there any other risks to consider?

 Be proactive in developing strategies to deal with the risks

Consider:
o Have the partners concurred on methods to deal with the risks
(accepting, transferring, mitigating or eliminating the risk)?
o Have specific steps been decided upon to address?

Step 8: Create an open environment

 Identify factors which create and build trust
Consider:
o What are behaviors that contribute to trust and good relationships
between partners?
o Is there mutual accountability built into the processes of the
collaboration?
o Is there expectation for self-interest disclosure and is this practiced?
o Is the group open to diverse thinking and alternative ways of
working
o Is diversity training available for support, if needed?
o Does the group look at conflict as an opportunity for collaborative
discussion, problem solving and growth?
o Are all members respectful of the established, agreed upon ground
rules?
 Identify factors which cultivate and support equality and diversity
Consider:
o Is the group sensitive to cultural practices?
o Is the group cognizant of how personal and organizational power
can impact a collaboration and is it openly acknowledged and dealt
with if conflicts should arise from use of power?
o Does the group operate with a no-judgment attitude where
members feel comfortable with diverse perspectives?
o Is there a culture where conflict and “turf” issues are seen as an
opportunity for collaborative discussion and problem-solving?
o Is conflict in general acknowledged and dealt with openly and
without favoritism?
  Have a plan in place for reflection, renewal, managing change and closure
of collaboration
Consider:
o Was a date set for the initial time length of the collaboration?
o Is there a mechanism in place for renewal of the agreement?
o Is there a process for leaving the partnership before termination
date?
o Is there a process for terminating the partnerships and what actions
need to be taken?
o Is there a process to measure, manage and control change
throughout the term of the partnership?
o Have the partners had a period of reflection on their experience
with the collaboration…what worked and what didn’t, lessons
learned and has this been documented?
o Has the collaboration used this input as well as evaluations to
determine if initiative is worth renewing, if anything needs to
change in order to continue or have objectives been met and work
is now complete?
 Continually evaluate the partnership based on the initial goals and action
plan set out in the partnership agreement and readjust if necessary
Consider:
o What are the costs versus benefits of the partnership?
o Is the partnership achieving what it is meant to achieve?
o Have the goals changed/evolved and need to be amended?
o What’s missing/ can be improved upon?
o Are all parties abiding by the terms laid out in the agreement?

Step 9: Celebrate successes

 After all your hard work, remember the value of celebrating your success
with the entire team involved in your collaboration.
 Celebrating accomplishments fosters the great alliances you have created
and it can also promote future successes for new and innovative
partnerships.
 Requirements of effective partnership
o Government must be open, receptive, sensitive, responsive and must
internalize, accept and institutionalize partnership at appropriate levels

o Local people, particularly the rural poor must develop skills in negotiation
and claim-making to effectively engage the government in participatory
local development planning and partnership- building; and
o NGOs must be open to collaboration with the government, share risks and
be creative.
 How to address/reduce conflicts in partnership
o Conflict management in partnerships should focus on encouraging open
communication and ways of negotiating expressed differences to meet at
least some of the needs of all partners.
o The following are steps in addressing conflicts in partnership:
 1. Choose a person who is seen as being neutral to serve as a process
observer. The role of this observer can vary from keeping time,
offering clarification or remarks, to suggesting possible ways of
managing or resolving the conflict. It is important, however, that all
partners agree upon the process observer’s role.
2. Select a specific conflict that is important to the partnership and the
partners concerned.
3. Have the conflicting partners state their positions without
interruption.
4. Have each opposing partner paraphrase the other side’s
explanations or point of view. This effort to understand more clearly
and fully each other’s position often results in useful conflict
management. However, more work may be needed.
5. Start an open dialogue for questioning, obtaining more information
and further explanation. This helps ensure that each side
understands the other. As the dialogue continues, it is necessary to
move beyond explanations. This would require two interacting skills
- both parties should behave assertively and cooperatively.
6. Summarize the position of each party, emphasizing their major
points of view. Provide an opportunity to each party to correct
misinformation or clarify points.
5.6. Governance of partnership
 Governance is the way rules (policies), norms and actions are structured,
sustained, regulated and held accountable.
 Functions of governance (portfolio)
o Define purpose, structure and membership
 Aims, objectives, outputs and outcomes are agreed and
communicated
 Membership is aligned to objectives to provide relevant interests
experience and expertise
 There is an appropriate board and committee structure with clearly
defined remits
 Personal interests of members do not impact on decisions
o Accountability and decision-making
 Good leadership promotes supportive culture and behavior
 Roles, responsibilities and accountabilities are understood
 Decision-making is open and transparent
 Reporting to officers and/or members supports scrutiny of decisions
and activity
o Monitoring and review
 There is regular review and evaluation of membership, policies,
performance and risk
 Awareness is maintained of what is working and what is not, and
action is taken to address issues
  There are strategies for change and exit.
 Disputes between partners are addressed effectively
o Financial management
 The partnership is resourced to deliver its aims and objectives
 Responsibility for financial decisions is clear
 The partnership can show that it manages funding appropriately to
add value efficiently and effectively
o Leadership roles
 Determining the ethics and culture of the organization
 Document the policies that are to be used to implement the
principles
 Designing and implementing the governance framework for the
organization
 Direct, support and monitor
 Ensuring compliance by the organization
o Meetings
 Meetings operate efficiently and are of sufficient frequency to
facilitate business
 The chair ensures meetings address the agenda, promotes
contributions from all and ensures decisions are open and
transparent
 Attendees bring expertise, knowledge and experience relevant to
the objectives of the partnership and have the necessary authority
to make decisions
 The governance structure of your partnership can influence:
o Performance and leadership
o Productivity and engagement
o Success in accessing resources.
 Characteristics (elements) of good governance in community partnership
o Participatory
o Consensus oriented
o Accountable
o Transparent
o Responsive
o Effective and efficient
o Equitable and inclusive
o Follows the rule of law
Things to note:
1. Engage all partners in developing a governance structure after the
priorities of the partnership have been identified.
2. Create a governance structure before they clarified the vision of the
partnership and defined its priorities or objectives.
3. Separate the process of developing a governance structure, from the
process of discovering the purpose and priorities of the partnership.
 4. Develop a governance structure that is lean

5.7. Operationalization for resilience building of community health

 Needs assessment
o Cary out needs assessment through community diagnosis or survey
o Work with the community to analyze and prioritize their needs
o Select intervention that is accepted by the community

 Operation plan
o Use the community priorities to develop a plan
o Use simple template of planning i.e. objective – activity – time – who –
where
o It is required to develop a project planning matrix (also called Detailed
Implementation Plan)
o It gives a description of the community health project
o Decide on the duration of the plan with the community and the college
Example:

Goal: Improve health of the community in Huduma community

Objecti Activity Time Responsi Amou Source Threats/
ve ble nt of funds assumpti
person ons
To [Link] Jan CPHO 30,000 DMOH
reduce Chlorine to
the every homes
number [Link] Marc CHPO - - Rain
of family h
deaths members in
due to 20 homes in
diarrheal the use of
diseases water
from 20 treatment
per [Link] 2 April Water 200,00 County Landscape
month to boreholes in engineer 0 treasury
15 per the
month community
by Dec [Link] Aug Water 90,000 KEWASC
2019 pit latrines in and O
30 sewerage
homesteads office
[Link] Dec Area 20,000 DMOH Stock out
ORS to nurse at KEMSA
children with
diarrhea
 Implementation framework
o Training – this include community based education to the CHVs
 o Resource mobilization – this includes local fund raising and proposal
writing
o Coordination of activities – this involves leadership and control of
activities
 Monitoring and evaluation plan
o Meeting schedule
o Creation of indicators
o Development simple reporting forms

Note:
 Develop partnership between Community members (CHVs), Ministry of
Health, KMTC and any institution that is relevant to the community project
 Establish a coordination mechanism which is led by the CHVs
 Align the work plan with the community strategic plan, county work plan,
sub county plan
 Cost the work plan according to capability of the community resources
 Mapping of available government and partner resources for the project
 Identify financial gap and assist the community to generate income
 Implementation of the plan, within the existing funding envelope
 Establishment of monitoring and evaluation framework

Unit 6. Planning and evaluating community health services

6.1 Introduction
 Planning – This is the process of arranging activities required to achieve
a desired goal. It is the first and foremost activity to achieve desired
results.
 Evaluation - is an assessment of something (a project/service or activity)
to determine its worth, fitness
  Community health services – essential health services that are
practiced or provided at individual, family and community levels. These
services aim at:
o Encourage, support and empower residents to be healthy, build
capacity for self-sufficiency, and improve the health and well-being
of the community.
o Promoting healthy choices through policy development, community
engagement, education and information sharing
o Protecting the health and well-being of the community
o Ensuring access to quality health and social services through
collaboration with individuals, families, institutions and available
resources in the community
o Providing culturally and ethnically sensitive services to the
community
o Engaging in on-going planning and evaluation in partnership with
the community
 Planning community health services – This is the process of
identifying community health needs and arranging essential health
activities that aim at empowering the community to be healthy. It
indicates what is to be done, when is it done, who will do it and how will it
be done.
 Evaluating community health services – It is also called community
health assessment. This is assessment of the essential health activities to
determine whether it has achieved its aim of empowering the community
to be healthy.
6.2. Objectives of planning and evaluating health services
 A planning cycle brings together all aspects of planning into a clear and
unified process. It helps to ensure that your plans are fully considered,
well focused, resilient, practical and cost-effective. The cycle includes:
o A situation analysis,
o Formulation of objectives,
o Selection of strategies,
o Development of an operational plan,
o Implementation and evaluation, which lead, in turn, to a new
situation analysis.
 The purposes of planning and evaluating community health services are:
o To increase the capacity of communities to plan, implement, and
evaluate comprehensive, community-based health programs
targeted toward priority health problems.
o It helps in identifying and good use of available resources in the
community in supporting the essential health activities
o Ensures a systematic implementation of activities
o It establishes a health working teams
o Defines key data to be collected and used
 o Set health targets, and design and evaluate interventions
o Identify and address priority health problems or special population
to be addressed

6.3. Community health cycle

 Also called community action cycle
 This is a methodology for engaging community leaders and members in a
process of community level advocacy and collective action for addressing
health issues.
 The cycle is summarized below:

6.4. Choosing priorities

 Most communities do not have the resources to address all of their health
problems and target groups at once.
 They must set priorities and plan to address some problems initially and
others over time.
 The following are steps to prioritize community health needs:
o Identify criteria for prioritization i.e.:
 Magnitude of the problem
 Severity of the problem
 Need among vulnerable population
 Community capacity and willingness to act on the issue
 Availability of resources to be used in addressing the issue
 Existing interventions that are focusing on the issue
  Whether the issue is a root cause of the other problems
 Trending health concerns in the community
 Ability to have measurable impact on the issue
o Assign preference scale (1-5) whereas 1 is the least and 5 is the
highest
o List all the community problems then assign the scores against
each problem
o Sum up the totals at the right side of the table to determine the
total value of each problem
o Problem with the highest score becomes the priority issue
6.5. Setting goals
 Goal setting involves establishing what one wants to achieve
 Setting goals helps people work towards their own objectives.
 Characteristics of a good goal:
o Specific - When setting goals, they should answer the highly
specific questions of who, what, where, when, and why.
o Measurable - In order for us to track our progress, goals should be
quantifiable.
o Attainable - It is important to evaluate your situation honestly and
recognize which goals are realistic, and which are a little far-
fetched.
o Relevant - Is this goal relevant to your life? Does this match my
needs?
o Time-related - Setting a "due date" to meet goals not only keeps
you on track, but it prevents pesky daily roadblocks from getting in
the way.
 Facts about goal setting include:
o Specific, realistic goals work best
o It takes time for a change to become an established habit
o Repeating a goal makes it stick
o Pleasing other people doesn't work
o Roadblocks don't mean failure
 How to write goals and objectives:
o Goals are broad, abstract statements of intent that help create a
vision of what you are striving to accomplish.
Example: Our goal is to reduce the number of premature deaths due to
heart disease in our community.
o Objectives are measurable, specific statements that lead toward
program goals and define what change the community will try to
achieve.
o Each objective should answer these questions:
o Who will receive the intervention?
o What health benefit should these persons receive?
o How much of that benefit should they receive?
o By when should it be achieved?
 For example:
 By 2020, the prevalence of smoking among county residents
aged 18 years and older will be reduced by 15% from 25% to
10%.
 By 2019, the rate of fatal injuries among county residents
caused by drinking and driving will be reduced by 15% from
7/1,000 to 5/1,000.
 Objectives are active, working tools and not merely academic exercises.
An objective:
o Specifies a single key result.
o Specifies a target date.
o Is specific and quantitative.
o Specifies what and when, not why and how.
o Is readily understandable to those involved.
o Is realistic, attainable, yet a challenge.
o Provides limits to expenditures of time and effort.
o Identifies criteria for evaluating achievement.
o Provides orientation to cooperating agencies in the community.
 Community health planning uses two types of objectives to clarify
community goals:
o Behavioral objectives - refer to those behavioral risk factors that
contribute to the cause of death in your community goals
o Intervention objectives - refer to the intervention activities you plan
to undertake
 The community goal is more general, the behavioral objectives are more
specific, and the intervention objectives the most specific.
Examples:
Community goal:
Our goal is to reduce the number of premature deaths due to heart
disease in our community.
Behavioral objectives:
• By 2000, the prevalence of county residents who smoke will be
reduced by 20%, from 32% to 25.6%.
• By 2000, the prevalence of physically inactive adults in our
county will be reduced by 15%, from 38% to 32%.
Intervention objectives:
• By January 2020, 20% of participants in a “Quit and Win”
smoking cessation contest will still be nonsmokers one year after
the contest (January 1994).
• By December 2019, the rate of onset of smoking among county
school students, grades 6-9, will be reduced by 20% from
158/1,000 to 128/1,000.
 • By August 2019, the county school board will set policy that
allows the community to use school playing fields for evening
and weekend recreational activities.
• By July 2020, 5 companies that employ 50 or more workers in
the community will provide access to programs that address
physical activity, good nutrition, and cessation of tobacco use.
6.6. Organization of community health services
 The following are steps in organizing a community health services:
Step I: Mobilizing the community - Mobilizing the community is an
ongoing process that starts in step I as a community organizes to begin
planning and continues throughout the process. During this step:
• The community to be addressed is defined,
• Participants are recruited from the community
• Partnerships are formed
• Demographic profile of the community is completed
Step II: Collecting and organizing data - Step II begins when the
community members form working groups to obtain and analyze data on
mortality, morbidity, community opinion, and behaviors. These data are
obtained from various sources, include quantitative data (e.g., vital
statistics and survey) and qualitative data (e.g., opinions of community
leaders).
Step III: Choosing health priorities - During this step, objectives
related to the health priorities are set. The health priorities to be
addressed initially are selected.
Step IV: Developing a comprehensive intervention plan - Using
information generated during steps II and III, the community group
chooses, designs, and conducts interventions during this step.
Step V. Build on existing services - In order to prevent duplication
and to integrate the existing services, the community group identifies and
assesses resources, policies, environmental measures, and programs
already focused on the risk behavior and to the target group.
Step VI: Evaluating plans - Evaluation is an important part of the
planning and implementation processes. It is ongoing and serves two
purposes: to monitor and assess progress during the five phases of
planning and to evaluate interventions. The community sets criteria for
determining success and identifies data to be collected.
 In each of these steps, community members are involved and are put to
take lead in order to ensure sustainability, ownership and accountability.
6.7. Selecting measures of success and outcome
 There are 4 essential key success measures that are all of great value.
The 4 essential key measures are:
o Financial viability - Example: profitability.
o Customer satisfaction - Example: performance on customer
satisfaction surveys.
 o Employee satisfaction - Example: performance on employee
satisfaction surveys.
o Contribution to society - Example: number of trees saved by
developing paperless processes.
 These measures are important because:
o Financial viability measures organizational survival and growth.
o Customer satisfaction is important because without happy
customers the organization will fail.
o Employee satisfaction is important because over the long term it is
impossible to have an organization with unhappy employees that
has happy customers
o Contribution to society (e.g., environment, ethics, safety, social
responsibility) is important because every organization needs more
than a simple profit motive to attract and retain the best talent and
to sustain itself over time. An organization in which greed is a core
value will ultimately devour itself.
 Outcome measures are long terms effects as a result of the outputs.
o Outcome measurement is a systematic way to assess the extent to
which a program has achieved its intended outcomes.
o It helps understand whether the program is effective or not.
o Outcome evaluations examine the results of a program (intended or
unintended) to determine the reasons why there are differences
between the outcomes and the program's stated goals and
objectives.
6.8. Evaluation of programs
 Community health evaluation is systematic assessment of how well a
program is working in a community and why.
 Through evaluation, the implementers of community health services can:
o Create more effective and efficient programs
o Make better management decisions
o Support new and innovative approaches and emerging practices
o Continuously improve existing programs
o Subsequently improve human health and the environment
 The following are the purposes of evaluation:
o Answer questions about projects, policies and programs, particularly
about their effectiveness and efficiency.
o Assess how well a program is working and why.
o Implementers can make better management decisions; support new
and innovative approaches and emerging practices; continuously
improve existing programs; and subsequently, improve human
health and the environment.
o Evaluations should help to draw conclusions about five main
aspects of the intervention:
  Relevance
 Effectiveness
 Efficiency - Finally, cost-benefit or cost-effectiveness analysis
assesses the efficiency of a program. Evaluators outline the
benefits and cost of the program for comparison. An efficient
program has a lower cost-benefit ratio.
 Impact
 Sustainability
 The following are types of program evaluations:
o Design - A design evaluation is conducted early in the planning stages
or implementation of a program. It helps to define the scope of a
program or project and to identify appropriate goals and objectives.
Design evaluations can also be used to pre-test ideas and strategies.
o Impact - An impact evaluation is a subset of an outcome evaluation. It
assesses the causal links between program activities and outcomes.
This is achieved by comparing the observed outcomes with an
estimate of what would have happened if the program had not existed
(e.g., would the water be swimmable if the program had not been
instituted).
o Cost-effectiveness - Cost-effectiveness evaluations identify program
benefits, outputs or outcomes and compare them with the internal and
external costs of the program. The impact evaluation determines the
causal effects of the program. This involves trying to measure if the
program has achieved its intended outcomes, i.e. program outcomes.
 Evaluation result is measured by indicators:
o Input indicators – are efforts or what you invest in an activity.
These can be resources e.g. money, personnel, time etc.
o Process indicators – are procedures, methods or steps followed
during implementation of an activity. A process evaluation assesses
whether a program or process is implemented as designed or
operating as intended and identifies opportunities for improvement.
Process evaluations often begin with an analysis of how a program
currently operates. Process evaluations may also assess whether
program activities and outputs conform to statutory and regulatory
requirements, policies, and program design or customer
expectations.
 Output indicators – are immediate outcome or results of an
activity

Example of M&E plan

Goal: Improve health of the community in Huduma community
Objective Activity Indicators Means of
verification
To reduce [Link] # of homes supplied Household
the number Chlorine to every with chlorine survey
of deaths homes # of homes with
due to patients with diarrhea
diarrheal Household
diseases # of chlorines survey
from 20 per distributed per home
month to 15
per month Distribution list
by 2015 [Link] family # of homes covered Education
members in 20 with education on use program
homes in the use of of water treatment
water treatment # of family members
educated on use of
water treatment Education
report
# of educated family
members actually
treating water Home visit
[Link] 2 boreholes # of boreholes drilled Survey
in the community in the community
# of drilled boreholes
has water Survey

# of people fetching
water from the Survey
borehole daily
[Link] pit # of latrines Construction
latrines in 30 constructed report
homesteads # of homes with
latrines Household
survey
# of constructed
latrines are in use Household
survey
[Link] ORS to # or ORS sachets S11 form
children with provided
diarrhea # of children provided ORS register
with ORS
Unit 7. Practical session: Community diagnosis and planning of
community survey
7.1. Visit a community unit
 This refers to going to the community unit (preferably your partnership
project area)
 Agree with the community unit and KMTC to agree on the frequency of
visiting the unit
 Develop a visitation plan that is agreeable with the KMTC and the
community
 Develop a scope of work that includes:
o Objective of the visit
o What content do you have for the objective
o What key message do you have for the community unit
o What actions do you expect the CHVs to take

7.2 Observe the organization of health services at the community unit

 Observe the following:
o Dialogue processes used by the CHVs
o Processes of conducting meetings
o Ways in which the CHVs offer services
 Identify the following:
o Strength
o Opportunities
o Weaknesses
o Threats
 Provide the following:
o Technical support
o Social support
o Moral support
 Document your visitation outcomes
7.3. Data collection tools for community diagnosis
 The following are the main tools for conducting a community diagnosis
1) Interview schedule 4) Questionnaire
2) Focus group discussion guide 5) Notebook
3) Camera 6) Voice recorder
 The following are qualities or points to consider when designing
questionnaire for community diagnosis
 Open ended questions with probes
 Simple and brief questions
 Avoid closed questions
 Avoid leading questions
  Start with most easy questions
 Make personal questions last
 Each question to address one issue
 When writing the questions, keep the language very simple and
avoid ambiguity or double negations.
 Make questions specific
 Ask questions in a logical order
 Construct response categories carefully – let it not be too long
 Provide clear instructions or directions on the questions
 The following errors can lead to inaccuracy during community
diagnosis:
o Unclear objectives
o Questions not matching the objectives
o Questions are ambiguous
o Tool doesn’t provide adequate space for data entry
o Questions are not well numbered
7.4 Linkage between community unit and facility
 The following are linkages:
o Community Health Extension Workers
o Community Health Assistants
o Community Health Volunteers
 Other linkages are extension workers from relevant ministries
7.5 Community diagnosis
 Definitions of terms
o Community - a group of people who: 1) live in a defined
geographical area, 2) share common cultural values, norms and
identity, 3 and stays in a social structure according to relationships
o Diagnosis - identification and confirmation of a problem
o Assessment - evaluate progress, status, situation or measure
achievements or failures
o Need - something that is necessary for an organism to live a healthy
life. Needs are distinguished from wants in that, in the case of a
need, a deficiency causes a clear adverse outcome
o Community diagnosis
o refers to the identification and quantification of health problems
in a community with a purpose of defining those at risk or those
in need of health care
o a comprehensive assessment of health status of the community
in relation to its social, physical and biological environment
o According to WHO definition, it is a quantitative and qualitative
description of the health of people and the factors which
influence their health. It identifies problems, proposes areas for
improvement and stimulates action
 o Community needs assessment - A community needs assessment is
a regular collection, analysis and sharing information to identify the
strengths and resources available in the community to meet the
needs of children, youth, and families.
Note: Community diagnosis is also referred to as community needs
assessment
 Importance of Community diagnosis
o This is a foundation for improving and promoting the health of
community members
o It identifies factors that affect the health of a population
o Determine availability of resources within the community
o Define existing problems and analyses health status in the
community
o Determine trend of illnesses and injuries
o Assess attitudes toward community health services and issues
o Identify priorities and set goals to improve the health status
o It measures the needs of the population (both sick and well-people)
o Establish epidemiological baseline for measuring improvement over
time
o It acts as a data reference
o It provides overall picture of the community and their concerns
o It helps to access the group of underprivileged people
o Evaluate effectiveness and accessibility of quality of health services
o Helps in developing policies and plans that support individual and
community health efforts
o Mobilizes community partnership
o Provides information that inform, educate and empower people
about health issues

In summary: The purpose of community diagnosis is to: 1) Define existing

problem, 2) Determine available resources, 3) Set priorities for planning,
implementing and evaluating health actions
 What do we look for when conducting community diagnosis?
o Demographic characteristics – Population (Size, structure, density
and distribution)
o Vital statistics – Births, deaths
o Social characteristics – Values, beliefs, religions, lifestyle
o Physical environment – Settlements, roads, forests, water, air
o Safety - security
o Politics and government – leadership, gatekeepers, constitutions
o Health – morbidity, mortality, nutrition, hygiene, immunity
 Types of information in Community diagnosis
o The information collected in a community diagnosis is called
INDICATORS
o Characteristics of indicators:
  Valid - should actually measure what they are supposed to
measure
 Reliable – should be objective, i.e., the answers should be the
same if measured by different people in similar circumstances
 Sensitive - should be sensitive to changes in the situation
concerned
 Specific - should reflect changes only in the situation concerned
 Feasible - should have the ability to obtain data needed, and;
 Relevant - should contribute to the interest of people
o Indicators for community diagnosis can be classified as follows:
 Mortality indicators
 Morbidity indicators
 Disability rates
 Nutritional status indicators
 Health care delivery indicators
 Utilization rates
 Indicators of social and mental health
 Environmental indicators
 Socio-economic indicators
 Health policy indicators
 Indicators of quality of life
Table classifying indicators in community diagnosis
Mortality indicators are: Morbidity indicators are:
o Crude death rates o Incidence and prevalence
o Specific death rates: o Notification rates
age/disease o Attendance rates: out-patient
o Expectation of life clinics or health centers.
o Infant mortality rate o Admission and discharge rates
o Maternal mortality rate o Hospital stay duration rates
o Case Fatality rate
Disability indicators are: Nutritional indicators are:
o No. of days of restricted o Anthropometrics measurements
activity o Height of children at school
o Bed disability days entry
o Work/School loss days due to o Prevalence of low birth weight
disability o Clinical surveys: Anemia,
o Expectations of life free of Hypothyroidism, Night blindness
disabilities

Health care delivery indicators Utilization indicators are:

are: o Proportion of infants who are fully
o Doctor / Population ratio immunized in the 1st year of life
o Doctor / Nurse ratio i.e. Immunization coverage.
o Population / Bed ratio o Proportion of pregnant women
o Population / per health center who receive ANC
 o Hospital-Beds occupancy rate.
o Hospital-bed turnover ratio
Social/mental health indicators Environmental health indicators
are: are:
o Suicide & Homicide rates o Measures of Pollution
o Alcohol and drug abuse o The proportion of people having
access to safe water and
sanitation facilities
o Vectors density
Socio-economic indicators are: Health policy indicators are:
o Rate of population increase o Proportion of resources spent on
o Per capita income health services.
o Level of unemployment o Proportion of funds spent on
o Literacy rates - females health related activities.
o Family size o Proportion of total health
o Housing conditions e.g. No. of resources devoted to primary
persons per room health care

 Guiding Principles of Community diagnosis

o Community situated –Has practical relevance to the community
o Collaborative and partnership -community members and researchers
equitably share control of the research agenda through active and
reciprocal involvement in the research design, implementation and
dissemination.
o Knowledge and action-oriented -the process and results are useful to
community members in making positive social change and to promote
social equity.
o Recognizes community as a unit of identity
o Builds on strengths and resources within the community
o Involves long term commitment by all partners
 Techniques (methods or approaches) of Community diagnosis
1) Records review 3) Interview
2) Observation 4) Focus group discussion
Definition Advantages Disadvantages
1) Records This is extraction  Less expensive  Information may
review of information  Information is be of different
from existing readily available format
records. The  Information is  Limited only to
source documents permanent documented
can be health information
facility registers,  Existing data
patients records might have
etc. been bias
2) This is the process  Factual  Information may
Observatio of looking, information is be perceived
n listening and witnessed differently
 learning about  Physical  Not applicable
community needs verification of to people with
and problems information visual disability
3) Interview This is a process  Obtains detailed  Can be time-
that involves information consuming:
interviewer and about personal setting up,
interviewee. The feelings, interviewing,
interviewer asks perceptions and transcribing,
questions while opinions. analyzing,
the interviewee  Allows more feedback,
responds detailed reporting.
questions to be  Can be costly
asked  Different
 Achieve a high interviewers
response rate may understand
 Respondents' and transcribe
own words are interviews in
recorded different ways
4) Focus A process of  Useful to obtain  Can lead to
group gathering people detailed disagreements
discussion with similar information and irrelevant
background or about personal discussion
experiences and group which distracts
together to feelings, the main focus
discuss a specific perceptions and  Can be hard to
topic of interest opinions control and
 Saves time and manage
It is a form of money  Can be tricky to
qualitative compared to analyze
research that individual  Can be difficult
involves 6-8 interviews to encourage a
participants  Can provide a range of people
seated in broader range to participate
semicircular of information  Some
manner to discuss  Offers participants
questions about opportunity to may find a
their perceptions seek focus group
attitudes, beliefs, clarification situation
opinion or ideas.  Provide useful intimidating
material e.g.
There is always a quotes for
moderator and public relations
note taker publication and
presentations

 Steps in Community diagnosis

 o The steps of conducting a community diagnosis is categorized in to
three stages:
1) Exploration stage 3) Diagnosis stage
2) Data collection stage 4) Dissemination stage

Exploration stage
o This stage is also called initiation stage.
o It involves the following steps:
1) Formation of a committee or a working group to coordinate
community diagnosis
2) Involvement of different stakeholders and sectors in the
committee
 Education sector
 Agriculture
 Health
3) Identify the scope and objectives of community diagnosis
 The objectives must be SMART
 Scope is the extent in which you want community
diagnosis to address
4) Identify budget and resources
5) Develop and pretest the tools (questionnaire, interview schedule,
FGD guide)
 Refer to qualities of a good tool and develop the
questionnaire
 Pretest the tool to identify and correct questions that might
not be clear
 Pretesting is administering the tool in a small population
before the actual survey
6) Determine the sample size:
 Sampling is the process of giving every individual in a
population an equal chance to be included in the survey
 A sample is a small unit of a population taken to represent
the entire population
 Sampling can be:
 Simple random - Every member of a population has
equal chance of being selected [i.e. pulling names
out of a basket]. It is time consuming when used in
large populations
 Systematic - Sample members from a larger
population are selected according to a random
starting point but with a fixed, periodic interval. This
interval, called the sampling interval or Nth item, is
calculated by dividing the population size by the
desired sample size [e.g. if the total population is
1000 and you desire a sample size of 50, divide 1000
by 50 to get 20. The 20 becomes Nth item. So decide
 randomly the starting item, then select the sample
after every 20 items]
 Stratified - Divide the target population into
important sub categories based on homogeneous
characteristics. Select members in proportion that
they occur in the population [e.g. a population of
1000 is composed of Teachers, Farmers, Lawyers
and Beggars]. Each composition becomes a stratum.
It ensures that all relevant strata of the population
are represented in the sample.
 Multistage - This is a sampling which involves
dividing the population into groups (or clusters). [e.g.
is you want to do a study in one village, list all the
counties in Kenya then randomly select one county.
List all the sub counties in the selected county then
randomly select on sub county. List all the locations
in the selected sub county then randomly select one
location. List all sub locations in the selected location
then randomly select one sub location. List all the
villages in the selected sub location then randomly
select one village.] The village now become the
sample.
 Cluster - Various segments of a population are
treated as clusters and members of each cluster are
selected randomly. Clusters may be families within a
society, markets within a county, colleges within a
province. Each cluster doesn’t need to be
homogeneous
 Snowball – one subject recruits the other
 Biased sample means a sample has some favors on a
particular subject
 The following are causes of biasness:
 Unrepresentative sample - Bias often occurs when
the survey sample does not accurately represent the
population. It is also called selection bias.
 Under coverage - occurs when some members of
the population are inadequately represented in the
sample
 Nonresponse bias - Sometimes, individuals chosen
for the sample are unwilling or unable to participate
in the survey.
 Voluntary response bias - Voluntary response bias
occurs when sample members are self-selected
volunteers, as in voluntary samples
 Measurement Error - A poor measurement process
can also lead to bias
  Response bias - refers to the bias that results from
problems in the response process. Some examples of
response bias are given below:
o Leading questions - The wording of the
question may be loaded in some way to unduly
favor one response over another.
o Social desirability - Most people like to
present themselves in a favorable light, so they
will be reluctant to admit to unsavory attitudes
or illegal activities in a survey, particularly if
survey results are not confidential. Instead,
their responses may be biased toward what
they believe is socially desirable.
 Biased sample can be eliminated by applying random
sampling procedures
 Response rate refers to the number of people who
answered the survey divided by the number of people in
the sample. It is also called completion rate or return rate.
It is usually expressed in form of percentage
 The following are ways of increasing response rate:
 Offering an incentive to the participant, for example,
you can offer a gift, the chance of winning something
in a lottery, a donation to charity, or a point’s
accumulation system where participant can save up
points that can be exchanged for gifts.
 Promising to share the results with your participants.
7) Identify enumerators and train them on the tools for community
diagnosis
8) Plan for the community diagnosis and make schedule for field
work
9) Communicate to community leaders or gatekeepers before going
to the field
Data collection stage
 This is the stage for actual data collection in the field
 It involves the following steps:
1) Apply appropriate methods of data collection such as:
 Administering the questionnaires
 Self-administering means the respondents fill the
questionnaire themselves
 Interviewing means you fill the questionnaire as the
respondent respond
 Conduct FGD sessions
 Involves 6-8 participants seated in semi-circular manner
 Has moderator and note taker
 Observations
 Extraction of information from existing records
 Taking pictures
2) Present data for easy understanding by using:
  Tables
 Graphs
 Charts
3) Ensure accurate recording of the information
Diagnosis stage
 Analyze and interpret data
 Here are some practical tips on data analysis and presentation:
o Statistical information is best presented as rates or ratios for
comparison
o Trends and projections are useful for monitoring changes over a
time period for future planning
o Community data can be compared with other districts or the whole
population
 Diagnosis of the community is reached from conclusions drawn from the
data analysis (higher bars for positive indicator shows no problem
whereas higher bars for negative indicators shows a health problem.
 The analysis should preferably comprise three areas:
o Health status of the community
o Determinants of health in the community
o Resources for healthy community development
Dissemination stage
 Provide feedback to the community
o This can be through community gathering
o Let the community own the findings
 Document the report of the community diagnosis
o Title – the title should indicate the activity, place, date and name of
writer
o Purpose – this is the reason and objective why the diagnosis was
conducted
o Method – the procedures and steps followed during community
diagnosis
o Findings – Results of the diagnosis
o Conclusion – Final statement about the findings
o Recommendation – Actions to be carried out to address the
problems
 Develop action plan
o Use Participatory Rural Appraisal (PRA) to identify priority problems
and ways of addressing them
o PRA is a process that incorporate knowledge and opinions of rural
people in planning and managing community programs
o The following are principles of PRA
 Participation
 Flexibility
 Teamwork
 Systematic
o The following are techniques of PRA
 Diagramming:
  Transect walk - Transects are observatory walks to
study the natural resources, topography, indigenous
technology, soils and vegetation, farming practices,
problems and opportunities. These are done with a
group of villagers-either following a particular course,
cross country or covering the area.
 Seasonal calendar - Seasonal Diagrams can be used
for obtaining seasonal patterns of rainfall, employment,
income/expenditure, diseases, livestock, production,
workforce availability, crop pattern etc
 Venn diagram - It is used to depict key institutions,
organizations and individuals and their relationship with
the local community or others. Key players in decision
making are shown. On the Venn diagram each
institution is represented by a circle. The size of the
circle represents the importance, significance or power
of that institutions.
 Daily routine chart - It is used to identify daily routine
pattern of either gender in a particular [Link] helps in
analyzing work type and distribution of workloads
throughout the day, for comparative analysis between
different individuals’ daily schedules. It helps:
o To identify the gender roles.
o To document the timings of the activities.
o For discussion of new activities and their
implications for time use.
o For discussing time of meetings and training
sessions
o To illustrate mobility and periods spent away from
home.
 Flow diagram - Flow diagrams discover and analyze
impacts and linkages. Current situations, constraints,
problems and opportunities can be discussed as the
effects of specific problems or interventions.
 Mapping - Maps are used to identify the comparative
location and importance of different resources with in
an area. They can examine a great breadth of subject
matter, and allow for a range of different types of maps
to be produced for one area, or for comparative analysis
by different groups with in the same area.
 Interviewing
 Structured or semi structured questionnaire can be used
to carry out individual or group interviews
 It can be used to find out people’s feelings about the
health status
  Preference ranking
 A community may have many issues that they need to
address.
 Preference ranking will enable them select the most
important issue to address
o Matrix ranking – It priorities issues at hand
o Wealth ranking - This is a method of making the
community categorize poverty and wealth. The
following questions may be used: Who is
perceived to be poor? Who is perceived to be
wealthy?
 Mapping and modelling
 The making of maps that depicts conditions and
environment of the area is called mapping.
 It increases the knowhow of the natives about their
surrounding and the physical features of the area.
o Social maps – Consists of household information
such as population density, social classes, land
use etc.
o Resource maps – Shows resources of the area
like soil, water, minerals etc.
o Topical maps – Contains information about
physical features of the area, crops grown in the
area, population and infrastructure facilities
present in the area.
o Hazard maps - Showing areas that can be
affected by hazards.
 Implementation of interventions
o Develop a simple action plan that shows:
 What is to be done?
 Where should it be done?
 Who should do it?
 When should it be done?
 How will it be done?
 How much will it cost?
o Develop a simple evaluation plan that gives answers to the
following:
 Am I doing it correctly as planned?
 What shows that I have succeeded of failed?
 How will I know that I have succeeded of failed?
 Roles of households and communities
What is the roles of the following in community diagnosis? (Group work)
o Individual
o Family
o Institutions
 o Leaders
 Evaluation of Community Diagnosis
o It is advisable to carry out evaluation after completing the community
diagnosis.
o The following are the importance of evaluating community diagnosis
process:
 Identification of what diagnostic approaches that worked best
versus those never worked
 It provides answers to the following questions:
 Did the diagnosis reveal the hidden problem in the
community?
 Was the process interfered with by biasness?
 Were there missing responses in the questionnaires?
 Was the correct sample size used?
 What is the accuracy level of the responses?
 What can be improved in future diagnosis processes?
7.6. Plan a community survey
 Definitions of terms
o A survey - is defined as a brief interview or discussion with individuals
about a specific topic
o Community survey - is a way of asking group or community
members what they see as the most important needs of that group or
community.
o Questionnaire - is a research instrument consisting of a series
of questions for the purpose of gathering information from
respondents.
o Evaluation - is a systematic collection of information to determine
status of achievement, progress, effectiveness, effects , outcome and
impact
 The following are reasons for carrying out a survey:
o Gather information about residents, their opinion, attitude and
knowledge
o Measuring behaviors and population characteristics
o Solicit community reaction to policies, proposals and solutions
o Assessing effectiveness of program, facilities and services
o Make community aware of problems and their effects
o Provide opportunity for communities to influence public decisions
 When can you do a community survey?
o When your program is just starting out
o When there is doubt as to what the most important needs are
o When your group members disagree on point among themselves
o When you need donor funding
o When the community asks you to do it
o When you want to be sure of community support for whatever you
choose to do
 Types of Surveys
o Questionnaire survey
 There is no direct contact between the researcher and the
respondents
 The questionnaires can be mailed, self-administered or group
administered
o Interview survey
 There is direct contact between the researcher and the respondents
 These can be through personal interviews, telephone interviews or
FGD
o Cross-sectional survey
 Collects information from a sample that has been drawn from a
fixed population
 Information is collected at one point of time
 It collects information such as community needs, attitude and
practice, program evaluation
o Longitudinal survey
 Data is collected at two or more times
 There are 3 types of longitudinal surveys:
o Trend – trends in same population over time
o Cohort – changes in a group by common characteristics
o Panel – changes in same population over time
 Process of conducting a community survey
o Good surveys start with clear theory, then the translation of theory into
sensible survey questions, pre-testing and revision of questions,
development and pre-testing of the survey instrument, sampling, data
gathering, and, finally, data analysis.
o The processes are:
 Define the purpose of the survey
 Decide on your goals and objectives
 Get answers to the following questions:
o What outcome do you expect from the survey?
o What will you know after you have conducted the
survey?
o Do you have a particular audience in mind?
 Identify the participants
 Decide on the participants who represent the entire
population
 Define the inclusion and exclusion criteria to help you get the
most required participants
 Design the methodology for conducting the survey
 Decide on procedures for the survey i.e. self-administered
questionnaire or interview
 Decide on which questions to ask
  Decide on the structure of questions (open questions, closed
questions, matrix table questions, and single- or multi-
response questions)
 Develop the tool and pretest them
 Decide on the number of people you will survey (sample size)
 Consider the following points when constructing a survey tool
 Open ended questions with probes
 Simple and brief questions
 Avoid closed questions
 Avoid leading questions
 Start with most easy questions
 Make personal questions last
 Each question to address one issue
 When writing the questions, keep the language very
simple and avoid ambiguity or double negations.
 Make questions specific
 Ask questions in a logical order
 Construct response categories carefully – let it not be
too long
 Provide clear and sufficient instructions or directions
including reasons for the survey
 Note the following errors that may lead to inaccuracy when
constructing a survey tool
 Unclear objectives
 Questions not matching the survey objectives
 Questions are ambiguous
 Tool doesn’t provide adequate space for data entry
 Questions are not well numbered

 Identify the participants

 Decide on who you want to participate in the data collection
(enumerators)
 Invite the enumerators and train them on the tools
 Assign them responsibilities
 Schedule the survey
 Agree on the number of days the survey will take
 Decide on the starting date
 Ensure the survey is completed within the specified time
 Conduct field work
 Distribute survey forms. As they are returned, track the number
completed.
 Gather your responses by collecting the data
 Analyze the results
 Analyze your date according to your objectives
 There are several software packages available for data analysis
(Epi-info, SPSS, SAS, STATA, RA)
  Present the analyzed report in Narratives, Graphs, Charts,
Tables or Pictures
 Write a report
 Write a report explaining your findings
 A successful survey will provide the answers to the questions
you had
 Use proper report writing layout:
 Make a brief summary (abstract) of the report
 Abstract- provides a one paged summary of the survey report
in terms of:
o Title, authors particulars and introduction
o Methodology
o Key findings
o Recommendations