Enoch Kalenga, 10, sleeps under a mosquito net at his home, in Kalemies Filtisaf neighborhood.UNICEF / Benoit Almeras-Martino, 2014.

SAVING LIVES WITHKEY PRACTICES

Promoting key family practices in the Tanganyika District (Katanga)

According to the 2013 Demographic and Health Survey conducted by the Congolese government, the Tanganyika distr ict shows some of the worst health and chi ld protection indicators in the whole Democratic Republ ic of the Congo.

In this northern distr ict of the Katanga province, only one in a hundred birth (0.9%) is properly registered in the Civi l Registry1. Five women out of six (84%) give birth outside health faci l i t ies2. Only one in eight chi ldren (13.8%) is appropriately vaccinated3.

Due to rel igious bel iefs or local rumours, famil ies refuse immunization, putt ing the l ives of the chi ldren at r isk.

These indicators tend to highl ight the broken l ink between state services, especial ly health faci l i t ies, and the local populat ion. 1 vs. 25% at national level (DHS 2013)2 DHS 2013.3 immunization against BCG, DTCoq (3 doses), Polio (4 doses), Measles.

Famil ies turn to other trusted players such as their rel igious leaders or inf luent persons in their immediate surroundings.

In order to encourage routine immunization and to promote the key family practices, UNICEF developed Communication For Development activit ies that involve the different strata of the targeted communit ies of Tanganyika.

CONTEXT

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Martha Nyota breastfeeds her son Kabange (5 months) in her home in Kalemie. Kabange was vaccinated thanks to the sensitization efforts of the Community Health Workers.

HEALTH FACILITIES PERSONNELroutinely promote the key family practices with pregnant women and young mothers attending antenatal and postnatal consultations.

SCHOOLS TEACHERS promote the key family practices with their pupils, particularly hand washing and the use of a long-lasting insecticide-treated net.

COMMUNITY HEALTH WORKERS AND COMMUNITY-BASED ORGANIZATIONSvisit families to identify issues and sensitize them about the key family practices

RELIGIOUS ORGANIZATIONS with a more intimate link with families are also engaged in the key family practices promotion. Preachers (imams, pastors, among others) often hold educational talks after the religious gatherings.

MEDIA broadcast short programs and phone-in talk shows about the promotion of the key family practices. These are broadcasted during local prime time (mostly before the news broadcast).

Within villages or neighborhoods, LISTENING CLUBS have been set up to facilitate discussions about the broadcasts.

Multiple stakeholders work with UNICEF to promote the key family practiceswithin the local communities.

DESIGN:HOW IT WORKS

These various stakeholders directly advocate the LOCAL, RELIGIOUS AND MORAL AUTHORITIES so they also convince their followers in adopting the key family practices.

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Before, I did not like immunization: it was said that the children were becoming sick, that they could have a fever, they could have anemia...

Martha Nyota quietly recites the long list of rumors about vaccination, while breastfeeding her baby boy against the wall of her house.

She also believed these rumors. When she became pregnant with twins, Kabange and Kyungu, she started receiving visits form Leonard Mabingo, one of the Community Health Workers of her neighborhood.

He visited me several times to give me advice says Martha about exclusive breastfeeding, about sleeping under a mosquito net, and also about immunization.

At first, I thought he was annoying. Yet he kept climbing the steep path leading to my house. I got used to his visits. He gave me vouchers to vaccinate my babies to the health center.

I also listened to a radio programme saying that immunization was necessary for children. Still I didnt want to go to the health center. The person who eventually convinced me was my mother.

Marthas mother, Elizabeth, is quietly sitting in the shade of the living room. I told Martha that the Community Health Worker came here too many times. No liar would make that kind of effort.

I also think that my grandchildren have the right to be immunized like every other child. When I was young, everyone agreed to vaccinate their children.

Eventually, Martha decided to go to the health center. Kabange and Kyungu got vaccinated, thanks to their grandmother persuasion and Leonard perseverance. Martha did not regret her decision.

Since then, I saw that the vaccines did not hurt my children she says. Now I try to talk to my neighbors myself to convince them that the rumors we hear are not true.

C O N V I N C I N G M A RT H A : T H E I M P O RTA N C E O F P E R S O N A L I N F LU E N C E

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In July 2014, an anthropological study was conducted in Tanganyika district to identify the main resistances to vaccination1.

3200 Community Health Workers and 144 nurses were trained on the key family practices

1155 community workers from five different religious groups have been trained on promoting the key family practices. Through their activities, they reach more than 124,000 families.

UNICEF developed a partnership with 12 local radio stations. They adapted their schedule to broadcast short programs about the key family practices. Nearly 2,000 shows have been broadcasted through theses channels. 29 listening clubs have been set up to disseminate the content of the broadcasts. In the district of

1 Main resistances lie in (i) religious beliefs (56.7 %), (ii) fear of suspected secondary effects (39.3 %), immunization being associated to poisoning (31%), fear that the vaccine can provoke anemia (28.6%), lack of trust in the health facilities personnel (27.9%) and inadequate organization of the immunization campaign (18.9%).

Tanganyika, one in three women and one in two men listen to the radio at least once a week according to the Demographic and Health Survey.

12 Child Reporters conduct advocacy with local authorities in order to promote the key family practices and the Childrens Rights throughout Tanganyika. They also participate in weekly radio and TV broadcasts with UNICEF media partners.

8 Community-Based Organizations were trained on promoting the key family practices in the district of Tanganyika.

The proportion of children who were not vaccinated due to the refusal of their parents / guardians decreased from 11 to 6 per cent in october 20132.

2 World Health Organization routine data.

Tanganyika Health District has developed a voucher system to encourage families to vaccinate their children.

Each Community Health Worker (CHW) distributes immunization vouchers in his neighborhood or village.

The voucher is given to the Health Center when the child gets vaccinated.

Thus the health centers can easily follow respect of the immunization schedule of every child.

Community Health Workers can also focus on families who do not vaccinate their children (since they didnt bring their vouchers back).

If there are more than three different families identified in the same street, Community Health Worker can organize a public information session.

Since December 2013, the coupons were able to recover 10,257 children who had not previously been vaccinated.

INNOVATING WITH IMMUNIZATION VOUCHERS

DELIVER: WHAT HAS BEEN ACHIEVED

Immunization vouchers used in April 2014 at Kalemies Clinique Niche Health Center.

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MULTIPLE SENSITIZATION CHANNELSThe promotion of the key family practices through a variety of channels is widely regarded as one of the factors faci l i tat ing their adoption. As for immunization, the repetit ion of the messages from different sources overcame resistances.

TRUSTED SOURCES OF INFORMATIONThe most effective communication channel is the home visit, conducted by trusted people in the targeted neighborhood or vi l lage, such as the Community Health Workers.

Sponsorship was also developed to encourage famil ies to promote the key family practices among their neighbors (see box on the r ight).

PERSONAL INFLUENCEAn inf luential person is also necessary in order to convey and reinforce the promotion of the key family practices. This person can serve as a role model for the famil ies.

Community-based organisations have developed a sponsorship approach to promote the key family practices.

In the Majengo area, the Congolese Red Cross has set up a Mothers Club to facilitate the adoption of the key family practices in families. Noella Mokonta tells how she incorporated this very open club.

I often saw the members of the Mothers Club in the neighborhood. They came here to give us advice on how to have healthy children. I wanted to be part of it to help my own neighbors.

I already knew the key practices - good hygiene, wash hands, breastfeed in the first six months of life, sleep under a net, to vaccinate, register the newborns at the Civil Registry... When I joined the Mothers Club, I was trained; I learnt how to share my knowledge with others.

Noellas house is like a model house: she uses it to educate her neighbors. She shows them her hand washing station (made with a single basin and a bucket), and the mosquito nets that cover all the beds.

Noellas activities make her children proud. Joseph especially likes how she helps the other families getting a better life. Bibiche, her daughter, sees her mother as an example that will inspire me for the years to come.

NOLLA, NEIGHBOR AND ROLE MODELDISCOVER: WHAT IS WORKING

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EXTENDING THE PROMOTION OF THE KEY FAMILY PRACTICESOne of the main chal lenges is the access to remote areas due to the lack of security and resources. The scarce number of state structures cal ls for mobi le health and civi l registry services.

In order to reduce the number of missed famil ies, NEW COMMUNITY HEALTH WORKERS ARE NEEDED to t ighten the coverage of neighborhoods and vi l lages.

INCREASED DIALOGUE BETWEEN COMMUNITY STAKEHOLDERSInteractions between community actors are needed to reinforce the coordination of the key family practices promotion messages and the use of health faci l i t ies.

MONITORING OF THE FAMILIES COMPLIANCE TO THE KEY FAMILY PRACTICESBetter monitor ing is needed to prove the adoption of the key family practices among famil ies, which is hindered by economic poverty.

DREAM: VISION FOR THE FUTURE

My dream is to see people take ownership of our work, so they know how to improve their

own health.

- Wasso Walonga, Community Health WorkerKalenga Mission Village

What I like most is the trust that the community showed me after I

gave them advice.I became a member of the family

for many people

- Adnive Singini, member of a religious community-based organization in Kalemie.

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A 6-months old girl is getting vaccinated at Kalemies Undugu Health Center.UNICEF / Benoit Almeras-Martino, 2014.