Evidence-based Information at the Community Level: How do we get it right?
"We seek simple, well-focused, understandable information, in small quantities, in a local context/language, and on a regular basis."
-- Community-level healthcare provider (and K4Health Needs Assessment/Net-Map participant)
As shown in our Knowledge for Health (K4Health) needs assessment and network mapping study in Ethiopia, family planning (FP) providers at the local level need tailored, contextual information to use in their daily work (Harlan et al, 2013). They may be bombarded with information about FP policy, research results, and clinical practice—or, on the flipside, they may lack these materials completely. Finding the right balance is a key element of what some refer to as “social knowledge management” (SKM). SKM puts people at the center of knowledge exchange, and focuses on a systematic approach to continual learning that improves health outcomes. SKM can help not only with national-level systems—such as web portals and other tools to connect those who have access to this technology—but it can rely on social exchange and networks to encourage learning and sharing at the community level.
Last week, I attended the International Conference on Family Planning in Addis Ababa, Ethiopia. Before the conference began, I was able to visit the Holeta Health Center and the Saadamoo Health Post, in the Oromia Region of Ethiopia. Each kebele (neighborhood) in Ethiopia has a health post that serves the community in family planning, HIV/AIDS, child health, sanitation, and more. Each health post employs two female Health Extension Workers (HEWs), who spend part of their time at the health post seeing patients, and the remainder visiting community members in their homes. The Health Extension Program—launched in 2003 by the government—has been instrumental in helping Ethiopia achieve phenomenal improvements in infant health and contraceptive prevalence over the past decade. Use of modern contraception has risen dramatically from 6% in 2000 to 27% in 2011. However, more remains to be done: The total fertility rate remains high at 4.8 children per woman (and is even higher in rural areas), and 25% of women have an unmet need for contraception (source: Central Statistical Agency and ICF International 2012).
After visiting the main Holeta Health Center—which includes a number of mid-level providers offering antenatal care, family planning, maternity care, infant care, immunizations, HIV testing and treatment, pharmaceuticals, and a host of other services—we visited the Saadamoo Health Post, which serves a rural community, and is located just a few kilometers from the main health center. When we arrived, the two HEWs described the care they provide at the community level. As they were demonstrating some of the materials that they use for counseling women and couples about their FP options, I asked them both the same question: “When a client asks you something you don’t know, where do you go to find the answer?”
- The first HEW pointed to the National Family Planning Guidelines, a Federal Ministry of Health document outlining the goals, strategies, and systems that guide the family planning program in Ethiopia. A relatively thin—yet densely-written—handbook, the main audience for this guide appears to be national-level stakeholders or those designing programs, not health care providers at the community level. Many questions this health extension workers receives are likely not in this document.
- When I asked the second HEW the same question, she pointed to a stack of papers in the main office of the health post—nearly a foot high—containing briefs on policy, research, service delivery, and other topics. Most were in English, some were in Amharic, and very few appeared to be in Oromo (the primary language spoken in Oromia). Sifting through this stack seemed to be a daunting task, especially for a busy health worker with a number of clients.
While the two health extension workers gave me two different answers, both responses point to a common problem among community health workers: When serving clients, health care workers often have the problem of either too much information, too little information, or not the right information.
Neither of the health extension workers in Saadamoo seemed to have access to tailored information for their needs as community health care providers. Health extension workers cover a wide range of topics—including FP—and they often need to answer very specific questions. Even the most thoroughly trained of these providers cannot answer every single question that comes her way. Furthermore, with new evidence and experiences being published daily, it is important that there is a process of continual learning and sharing in order to provide the best care and meet the individual needs of the clients they serve.
At the Holeta Health Center and the Saadamoo Health Post, I sensed that—despite the work that remains—the recent success of the family planning program has brought hope, promise, and a certain enthusiasm among health extension workers and community members alike. The presence of dedicated health extension workers presents an incredible opportunity for further improving family planning services at the community level. Using SKM principles, it is important to design materials that provide these workers with easy access to tailored, contextual, understandable information (including those in their primary language) so they can deliver optimal care to women, men, and children they serve.
Central Statistical Agency (Ethiopia) and ICF International (2012) Ethiopia Demographic and Health Survey 2011, Central Statistical Agency: Addis Ababa, Ethiopia; ICF International: Calverton, Maryland
Harlan, S.V., T.M. Sullivan and S.E. Hailegiorgis (2013) Mapping networks to improve knowledge exchange among family planning and reproductive health organizations in Ethiopia. Knowledge Management for Development Journal 9(2) (Forthcoming)