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Project Report PR-PK-lhw1-01

Pakistan

Evidence-led training and communication tools for

Lady Health Workers

Khalid Omer, Noor Ansari, Sharmila Mhatre and Neil Andersson

Evidence-led training and communication tools forLady Health Workers

in Sindh, Pakistan

Final technical report

K Omer, NM Ansari, S Mhatre and N Andersson in collaboration with the

National Programme for Family Planning and Primary Health CareGovernment of Sindh, Pakistan

August 2002

Evidence-led training and communication tools

in Pakistan

TABLE OF CONTENTS

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiList of acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vSummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Objectives of the project . . . . . . . . . . . . . . . . . . . . . . . . 2

METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Evidence of the impact of LHWs . . . . . . . . . . . . . . . . . 2Consultation with stakeholders . . . . . . . . . . . . . . . . . . . 3Designing the tools and training material . . . . . . . . . . . 4Training of LHWs in the use of the communication tools . . . . . . . . . . . . . . . . . . . . . . . . . . 5Implementation, supervision and monitoring . . . . . . . . 5The framework for the impact assessment . . . . . . . . . . 6Survey instruments for the impact assessment . . . . . . . 8Training and fieldwork for impact assessment . . . . . . . 9Data management and analysis . . . . . . . . . . . . . . . . . . . 9

RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Embroidery as a communication tool . . . . . . . . . . . . . 10Key findings of the impact assessment . . . . . . . . . . . . 11

Information base . . . . . . . . . . . . . . . . . . . . . . . . . 11Characteristics of the study population . . . . . . . 11LHWs’ visits and use of the communication tools . . . . . . . . . . . . . . . . . . . . 12LHW as one of the key health messengers . . . . 15Impact of LHWs using communication tools on health practices during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Reducing a heavy workload during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Stopping routine heavy work during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Breastfeeding practices . . . . . . . . . . . . . . . . . . . 22Colostrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Introduction of liquids and foods other than breast milk . . . . . . . . . . . . . . . . . . . . . . . . 25

Community views about the communication toolsWomen’s views . . . . . . . . . . . . . . . . . . . . . . . . . 27Men’s views . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Experience of supervisors and programme managers . . . . 32


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FUTURE POLICY IMPLICATIONS AND NEXT STEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

LIST OF TABLES

Table 1: Distribution of LHWs and population covered . . . . 9Table 2: Who told you to go for an antenatal checkup? . . . 15Table 3: For this pregnancy who told you to

reduce your routine heavy work? . . . . . . . . . . . . 15Table 4: Who told you that you should give

your child colostrum after birth? . . . . . . . . . . . . 15Table 5: Reasons for those who reduced routine

heavy work during pregnancy . . . . . . . . . . . . . . 19Table 6: Breastfeeding trends . . . . . . . . . . . . . . . . . . . . . . . 21Table 7: Reasons for giving colostrum . . . . . . . . . . . . . . . . 22Table 8: Reasons for not giving colostrum . . . . . . . . . . . . . 24

LIST OF FIGURES

Figure 1: Embroidery as a communication tool . . . . . . . . . 10Figure 2: Communication tool - risk of heavy work . . . . . . 11Figure 3: Comparison of key socioeconomic

indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Figure 4: LHWs’ visits during last pregnancy . . . . . . . . . . . 12

Box1: Information base for LHW impact assessment . . . . . 12

ANNEXES

Annex I: List of the participants of the provincial consultation forum . . . . . . . . . . . . . 39

Annex II: Provincial consultation forum of LHWs: summary . . . . . . . . . . . . . . . . . . . . . . . 40

Annex III: User’s manual for Lady Health Workers . . . . . . 44Annex IV: Field workers who participated in the

impact assessment . . . . . . . . . . . . . . . . . . . . . 52Annex V: CIET methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 53


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ACKNOWLEDGEMENTS

The active involvement of the lady health workers and their supervisorsfrom the participating communities during the design, pre-testing and fine-tuning of the evidence-based communication tools was the foundation ofthis study. We hope the experience and knowledge gained might serve intheir future career development.

We recognise also the contribution of the women visited in their homes,key informants and participants of focus groups who generously providedtheir valuable time, experiences and ideas in interviews and discussions.Without their participation this venture would not have been possible.

The National Programme for Family Planning and Primary Health Care(NPFP&PHC) team was the federal partner in this project. We are gratefulto Dr Zahid Larik, national coordinator for the NPFP&PHC, who providedpolicy-level support for the initiative. We also appreciate Dr AyoubSalayria, training specialist, and Dr Fauzia Aqeel, field programme officer,for their input and technical advice.

Special thanks go to the team of the NPFP&PHC at the ProvincialProgramme Implementation Unit of Sindh. The team worked with CIET inarranging and coordinating the field activities. Dr Husna Memon,provincial coordinator NPFP&PHC Sindh, provided additional wisdomand gave great support to the planning and implementation of the projectactivities. We gratefully recognise the valuable participation of DrsZulfikar Ali Gorar and Uzair Pirzada, field programme officers, and DrKhairuddin Shah, Dr Saqib Ali Sheikh, Dr Laila Rizvi and Ms Zahida,district and assistant district coordinators, from the participating districts.They worked closely with the CIET team during the design phase andassisted in the supervision and monitoring during the implementationperiod.

The Sindh Bureau of Statistics extended logistical support and space fortraining for the consultation forum and the field teams for the impactassessment. We also appreciate the support of Health Oriented PreventiveEducation (HOPE), which provided personnel to facilitate the initialconsultation forum in Hyderabad, and for the field teams for the impactassessment. We appreciate also the hard work and commitment of the twosupervisors and eight field workers.

This project was funded in part by the Canada Fund for local support,Canadian International Development Agency Programme Support Unit atthe Canadian High Commission. We would like to extend our appreciationto Ms Attiya Hidayat, Canada Fund Coordinator, Ms Rukhsana Rashid andMs Namoos Zaheer, who provided continuous support and interest inensuring the successful completion of the project.

March 2002


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LIST OF ACRONYMS

APC Assistant Provincial CoordinatorBoC Bond of CareDPIU District Planning & Implementation UnitDPC Deputy Provincial CoordinatorFPO Field Programme OfficerHOPE Health Oriented Preventive EducationLHW Lady Health WorkerLHWS Lady Health Workers’ SupervisorLHV Lady Health VisitorNPFP&PHC National Programme for Family Planning &

Primary Health CareNPIU National Programme Implementation UnitPC Provincial CoordinatorPPIU Provincial Programme Implementation UnitRHC Rural Health CentreVBW Village Based Worker


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SUMMARY

Over the last decade the Government of Pakistan and severalnon-governmental organisations have focused attention onimprovement in the health sector. One initiative to improveaccessibility to primary health care for women and children isthe National Programme for Family Planning and PrimaryHealth Care (NPFP& PHC). Under this programme, ladyhealth workers (LHWs) are recruited from local communities,especially in rural areas of the country, to provide services forfamily planning and primary health care.

A CIET study (1997-98) in Sindh, North West FrontierProvince (NWFP), Balochistan and Rawalpindi interviewedmore than 23,000 women. This showed differences in healthknowledge and practices between women in communitieswith LHWs and women in communities without LHWs. Thissuggested some success of the government programme, but italso identified potentially important entry points forimproving health care. It offered a basis to strengthen the roleof LHWs at household level and to enrich their interpersonaland professional skills by providing evidence-ledcommunication training and tools.

Many health communication tools are based on general healthevidence, and are not necessarily culturally tailored to thecommunities in which they are to be used. In many cases,‘experts’ develop training manuals and tools forcommunication, without involving the users or recipients inthe formulation. In this pilot project, however, thedevelopment of the ‘evidence-led’ (as opposed to ‘expert-led’) communication tools and the training in their use wasunique in that the development of the tools was based onevidence from the same communities in which the toolswould be used, and involved the LHWs working in thosecommunities.

LHWs were present in all 37 sentinel communities that madeup the sample for the first Sindh Bond of Care (BoC) cycle(1997-1998). A sub-sample of ten sentinel communitiesprovided intervention and controlsites for this pilot project. The communities where the LHWswere trained and were given the evidence-led communicationtools for use in their daily activities are referred to here as


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‘intervention communities’. Some other communities whichwere similar to the intervention communities but whereLHWs were not trained and did not have the evidence-ledcommunication tools are referred to here as ‘controlcommunities’.Eight rural communities covered three districts in Sindh(Karachi West, Karachi South and Hyderabad). Working withthe local supervisors and FPOs, the CIET team trained LHWsin the five intervention communities in the use of theevidence-based communication tools. In the controlcommunities, the tools were not introduced and the LHWswere not trained in the use of the evidence-based communication tools.

Objectives• To build on existing and further develop evidence-based

communication tools to be used by LHWs and guidingmaterial for training them on their use.

• To initiate and conduct an interactive process withLHWs and programme staff of the NPFP&PHC todevelop evidence-led training and communicationmaterial to complement the existing training programmein Sindh and increase the effectiveness of the work ofLHWs.

• To build the voice and experience of LHWs indeveloping the evidence-led training and communicationmaterial.

MethodsWith support from the national coordinator of theNPFP&PHC, the work was carried out in close collaborationwith the provincial team of the NPFP&PHC in Sindh.Scientific evidence-gathering and capacity-building the majorsteps included:• establishing the evidence of the impact of LHWs• stakeholder consultation• designing the tools and training materials• training of LHWs in the use of the communication tools• implementation, supervision and monitoring


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Embroidery as a communication tool - the risk of heavy work during pregnancy

• impact assessment • data management and analysisWith limited resources, this pilot project was implemented inthree districts of Sindh province: Karachi West, KarachiSouth and Hyderabad. The development of the evidence-ledcommunication tools and training was indigenous andreflected local culture. A stakeholder consultation resulted inthe idea of using a traditional Sindh cloth as the basis for thecommunication tool. From this consultation, the tool wasfurther developed by the provincial team and the LHWs inboth urban and rural communities.The draft tools were pilot-tested at household level. The finaltools and the manual were provided to the LHWs in formaltraining sessions. The Lady Health Workers’ Supervisors(LHWSs) also received training to monitor the LHWs in thefield. In total, 50 LHWs were trained in five communities inthree districts. Field programme officers (FPOs) of therespective districts were part of the provincial team for thedesign and development of the tools, and provided overallmonitoring support for the activity during the implementationphase. After ten months, an impact assessment was carried out thatincluded a household survey in intervention and control sites,gender-stratified focus groups and key informant interviews.

ResultsAfter consultation the final evidence-led communication toolthat was developed was embroidery on traditional Sindhmaterial, ajrak. There were three sets that depicted the healthpractices of antenatal checkups, the giving of colostrum andhaving a heavy workload during pregnancy, and the impacton child malnutrition of doing and not doing these things.Impact on motivation of the LHWsA woman in an intervention community was three and a halftimes more likely to be visited by an LHW during pregnancy,compared with a woman from a control community. Thiseffect increased to seven and a half times during the periodwhen the LHWs were trained to use the communication tools.In addition, the average woman who was shown the ajrak wastwice as likely to report that she received advice on targetedhealth-care practices by an LHW than from any other source,


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compared with a woman who was not shown the ajrak.

Measurable difference in targeted key health practicesA woman from an intervention community visited by anLHW during her pregnancy was eight times more likely tohave at least one antenatal checkup, compared with a womannot visited by an LHW from a control community. A womanshown the ajrak was:• 61% more likely to completely stop her routine heavy

work during pregnancy, compared with one who was notshown the tool. This practice was dependent largelyupon support from her family members.

• 60% more likely to feed her newborn baby breast milkas the first thing after birth, compared with a womanwho had no exposure to the communication tools.

• twice as likely not to introduce liquids other than breastmilk to the child before the age of four months,compared with a woman who was not shown the ajrak.

With respect to providing colostrum for newborns, comparingthe intervention communities with the control communitiesshowed that a woman from an intervention community was60% more likely to give colostrum to her newborn, comparedwith a woman living in a control community. The effect wasgreater in rural communities and those with lowersocioeconomic status. It was difficult to directly determinethe impact of the ajrak communication tool on this healthpractice. The relationship was confounded by the level of thewoman’s education, limiting interpretation of impact.

Community viewsThe reaction to the ajrak was positive. Women in the focusgroups were excited about the tools, and said they couldeasily relate to the pictures depicted. Most remarked that thetools helped improve their interaction with the LHW andfacilitated discussion. They said the pictures helped them toask questions. They thought that such a format could also behelpful to illiterate women, as the colourful and realisticpictures left an impression and stimulated them to askquestions. Suggestions for improvements included increasingthe frequency of use of the tools, and possibly showing thetools to other family members as a catalyst for discussion in


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the household. They also suggested similar tools forpregnancy and immunisation.Overall, men were also in favour of the tools, suggesting theiruse in a group setting. They indicated a need to createawareness among men so women could get adequate supportat home for appropriate healthy practices. This was especiallyso for antenatal care and workload during pregnancy, whereparticipants appreciated that often women were aware butcould not carry out these health practices due to lack ofsupport.Experience of supervisors and programme managers Onesuccess of this project referred to by the LHW programmemanagement team was the process by which thecommunication tools were developed. They regarded theexercise as a useful learning experience for programmemanagement, especially the FPOs, LHWSs and LHWs. Itbrought different levels of management closer to each other,with everyone feeling equally important. This in turndeveloped ownership of the activity and resulting tools. Todate, the LHWs had not used communication tools forinteraction at household level and had never been involved inthe development of programme initiatives. A similar processto develop future programme materials was stronglyrecommended by those involved.The supervision and monitoring of the communication toolsintegrated well with the ongoing routine monitoring of LHWsin the communities. Based on the experience shared by theLHWSs and FPOs, they did not have to invest much extratime in monitoring the tools. The use of the tools may indeedhave helped to focus the efforts of their supervision. TheLHWs with the tools evidently became more active.

Future policy implications and next stepThe participatory approach to the development of the toolshelped to build local capacities to such initiatives. It enhancedthe confidence, knowledge and skills of the LHWs and theirsupervisors. The process also helped to bring different levelsof management closer together and provided a catalyst forbringing forward innovative ideas from the field.Participants in this pilot project were keen to see this processand the tools integrated into the training curriculum for LHWsat a provincial and national level. They emphasised the


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importance of building local concepts to increaseacceptability of these tools and ownership. One way ofachieving this would be to involve the teams from provincialmanagement in each province in the same way as was done inSindh, and ensure that their inputs were incorporated. Theysuggested involving donors through the Federal Ministry ofHealth for the distribution and use of the tools on a widerscale.The results were shared at a provincial consultation todevelop an action plan to incorporate the lessons into thecurrent programme policies of the NPFP&PHC and possiblygo to scale provincially and nationally.


1 UNICEF data at http://ww.childline.org. WHO/UNICEF/UNFPA estimates for maternal mortality 1995.2 Community voice into planning initiative; cycle 3; The Bond of Care. Planning and Development Department, Govt of Sindh,NWFP, Balochistan, Rawalpindi, CIET, UNICEF, 1998-9.3 Community voice into planning initiative; cycle 2; Community Responses to Sanitation Risks. Planning and DevelopmentDepartment, Govt of Sindh, Balochistan, CIET, UNICEF, 1997-8.

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BACKGROUNDEvidence on the health care of women and children inPakistan is not encouraging. The latest statistics put thematernal mortality ratio at 200 deaths per 100,000 live births.This translates into a woman’s lifetime risk of maternalmortality at 1 in 801.One of the initiatives undertaken by the Government toimprove access to primary care for women and children is theNPFP&PHC. Under this programme, LHWs were recruitedfrom local communities, especially in rural areas. TheseLHWs were trained to work at community level to provideservices for family planning and primary health care. Theyhave been effective in promoting health education in theirrespective areas at household level, but concern has beenexpressed that coverage does not meet need, especially inrural communities.Better care of women during pregnancy has a demonstrablehealth impact on children. This link was documented inSindh, NWFP, Balochistan and Rawalpindi. Interviewing alittle over 23,000 women2, CIET identified actionable areasfor better care of women and, in turn, children. Theseincluded improved antenatal care and the prevention ofdomestic violence. The CIET cycle on community responsesto sanitation risks3 also provided evidence on important caringpractices related to health and hygiene for women andchildren. Recognising their important role in health care at householdlevel, interviews with LHWs were included in near-nationalresearch-communication cycles consisting of repeated,multiple fact-finding and results-communication phases. Thein-depth interviews drew out their experience, training andpractice patterns, and the management of delivery and type ofadvice given to pregnant women during their visits. This pilot project focuses on strengthening the training ofLHWs, based on the evidence produced by the large near-national surveys.


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Objectives of the project• To build on existing and further develop evidence-based

communication tools to be used by LHWs and guidingmaterial for training them on their use.

• To initiate and conduct an interactive process withLHWs and staff of the NPFP&PHC to develop evidence-led training and communication materials tocomplement the existing training in Sindh and increasethe effectiveness of the work of LHWs.

• To build the voice of LHWs in developing evidence-ledtraining and communication material.

METHODSThe approach to the evidence-based training included:• establishing evidence of the impact of LHWs• stakeholder consultation• designing the tools and training materials• training LHWs in the use of the communication tools• implementation, supervision and monitoring • impact assessment • data management and analysis

Evidence of the impact of LHWsThe BoC cycles established that better care of women duringpregnancy has an important health impact on children. Thecycle on community responses to sanitation risks alsoprovided evidence on care practices related to hygiene. LHWshad a demonstrable impact on the health of mothers andchildren on several issues:• child spacing and family planning• prevention of diarrhoea through hygiene education• infant feeding, including colostrum, exclusive

breastfeeding for the first four months and duration ofbreastfeeding

• child development milestones such as sitting. The effect of the LHWs was strongest among the moredisadvantaged groups of women – illiterate women, those


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Dr Husna Memon working with LHWs at the consultationforum. Photo: CIET/SMhatre

living in rural settings without their own source of income,and those living with physical or mental abuse. This may bebecause LHWs may be their only source of advice,information and health care. In communities where LHWsprovided services, more women reported dissatisfaction withantenatal services. This could indicate some degree ofempowerment of women exposed to LHWs, or that antenatalservices provided by LHWs need to be improved.Consultation with stakeholdersThe development of the evidence-based communication toolsbegan with a provincial one-day consultation with LHWs inHyderbad on 4 April 2000. This was organised with the Sindhtechnical committee of the NPFP&PHC. The seminar wasattended by the Provincial Programme Implementation Unit(PPIU), national and provincial coordinators of theprogramme, and LHWs (see Annex I for the list ofparticipants). The evidence from the CIET cycle provided thesubstrate for dialogue and an increased knowledge base forLHWs. Besides sharing the evidence, the seminar proved auseful opportunity to involve LHWs in developing their ownways or words to communicate the evidence to their clientsand initial brainstorming on design of the tools.This was done in two stages. In the first stage, facilitatedgroups discussed the evidence and participants consideredhow best to communicate the evidence. Groups agreed theyneeded targeted materials to convince people to makehealthier choices – consultations alone were not enough. Theysaid their clients expected some type of handout, medicines orother aids. They felt that if these were not given, people paidless attention to their advice. Suggestions for communicationaids included ideas such as handbills, posters, pamphlets andsome pictorial guides to explain to women about differenthealth topics.After the focus groups, participants met in a plenary sessionto demonstrate the use of a communication tool developedearlier by CIET for the BoC cycle. The tool consisted of aposter with pictures of risk factors supported in a woodenframe, with dolls on a wooden runway stand depictingchildren younger than three years of age, some of whom werenormal and some who were malnourished (low height forage). The purpose of the demonstration was to show howtools can facilitate the communication of evidence. To enableparticipants to have some hands-on experience with using


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LHWs in design groups discuss the evidence and thebest way to communicate it. Photo: CIET/SMhatre

tools, a few participants were asked to use the tool. Adiscussion then followed on the use of communication toolsand key aspects of their effectiveness. The LHWs then worked in small design groups to brainstormways to use evidence for communication. The group workincluded discussion of the tools, and words and phrases of keymessages to communicate evidence.In developing the evidence-led communication tools andtraining, the forum concluded that conventional methods werebest avoided and certain principles should apply to the design:• communication methods should be user-friendly so that

health messages conveyed by LHWs might be easilyunderstood by clients

• evidence-led communication tools should be indigenousand reflect local culture

• the design of the tools should be attractive, especially forLHWs and client women, to get instant attention throughinteraction

• the programme should be durable, long-lasting and cost-effective

Designing the tools and training materialThe design meeting supported a tool based on traditionalSindh cloth. Based on recommendations from the consultationforum, they developed tools and a training-scenarios manual(see Annex II for a summary report on the consultationforum). Three caring practices identified from the findings ofthe earlier cycles were incorporated as messages. Thesepractices had the greatest measurable impact on the healthpractices of the women and their children, all linked toLHWs’ daily activities. These included antenatal checkups;reducing heavy workloads during pregnancy; and feedingcolostrum as the first thing fed to the newborn.The development of the evidence-led communication toolsinvolved the provincial team of the NPFP&PHC and LHWs.A market search and consultation with local designers andhandicraft experts was also an important part of this process.Committee meetings then fine-tuned the tools. To ensureinput from the LHWs and to build their ownership, the teampre-tested the draft tools in five communities of three districtsin Sindh with the LHWs from these communities.


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Training of LHWs in the use of the communication toolsLHWs were present in all 37 sentinel communities that madeup the sample for the first Sindh BoC cycle (1997-1998). Asub-sample of ten sentinel communities provided interventionand control sites for this pilot project. Eight of the 10communities were rural, covering three districts in Sindh(Karachi West, Karachi South and Hyderabad)The pilot involved LHWs from a few communities, ratherthan all LHWs. The selection was based on recommendationsfrom the concerned FPOs and district coordinators to ensureregularity in the use of the tools and prevent dropout on thepart of LHWsSince the LHW programme could not move LHWs out oftheir communities, the training was conducted in thecommunities. Working with the local supervisors and FPOs,the CIET team trained LHWs in the five interventioncommunities in the use of the evidence-based communicationtools. This included an explanation of the tools andguidelines, and role modelling to practise the use of the tools,followed by field practice under supervision with the womenin their communities. In the control communities, the toolswere not introduced and the LHWs were not trained in the useof the evidence-based communication tools.LHWSs were involved in the training to increase theirunderstanding of the tools and their application. They alsoacted as resources during training to monitor the performanceof the LHWs during the field practice. The training helped inbuilding LHWs’ communication skills, and also their abilityto use the tools effectively and in an interactive manner. Atotal of 52 LHWs in five communities in the districts ofKarachi West, Karachi South and Hyderabad were trained, asshown in Table 1. After incorporating the lessons learnedfrom the pre-testing, the finalised tools were launched inJune-July 2000, for pilot use in five communities in threedistricts.Implementation, supervision and monitoringEach trained LHW was provided with a set of communicationtools and user guidelines. They were advised to use the toolsfor communicating relevant health messages generally to allwomen, but the focus was on women who either werepregnant or had recently delivered. Each LHW was providedwith a monitoring sheet in which they had to register all the


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pregnant women, along with the total number of visits theymade during their pregnancy. For each pregnant womanregistered, the LHWs were advised to visit her at least twiceevery month and use the tools for communication. To ensure proper use of the tools by the LHWs, a monitoringmechanism was established using the existing supervisorystructure of the LHW programme. At the field level theLHWSs, who were also involved in the whole processincluding training, were given the responsibility to providesupervisory support to the LHWs. Thus, as a part of theirroutine supervisory visits to these communities, they maderandom visits to the households in the catchment area of eachtrained LHW to check if the LHWs were using the tools.Also, they visited households with the LHWs to see if theLHW used the tools properly according to the guidelines. Ifthe guidelines were not followed or if LHWs faced anyproblem, the supervisors gave them on-the-spot feedback andadvice. As an aid to their supervisory activity, each LHWSwas provided with a supervisory checklist. A separate sheetwas maintained for each trained LHW.The next level of monitoring was established through themonthly meetings of LHWSs held at the district level. CIETcoordinators attended these meetings regularly during theproject-implementation phase. During these meetings, theLHWSs provided feedback on the progress of the activities intheir respective communities and discussed any problems thatthey were not able to rectify on their own. The respectivedistrict coordinators and the FPOs of the LHW programmealso attended these meetings. Based on the outcomes of thesemeetings, the CIET team, together with the FPOs and thedistrict coordinators, made visits to the communities tomonitor the project implementation.The framework for the impact assessmentIt is not enough to just develop evidence-led tools and trainLHWs in their use. Until and unless the effectiveness of thetools in terms of having an impact on the knowledge andpractices of mothers in these communities is scientificallyassessed, full-scale implementation cannot occur. Also, it iscrucial to document the experiences gained by those whohave been involved, particularly the field staff, includingLHWs, their immediate supervisors, the FPOs and the districtcoordinators, and also the views and suggestions of theprogramme management, for implications for a wider-scale


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implementation of the project activities. An importantcomponent of the overall initiative, therefore, was to assessthe impact of the use of the evidence-led communication toolsand training material in changing the health-care practicestargeted through the tools.The impact assessment was conducted at the end of April2001, giving a period of about 10 months during which theLHWs used the tools in their respective communities. Theimpact assessment had several elements:1. Review of existing data from the BoC cycle on the samecaring practices from the same communities. This provided auseful baseline for the impact assessment.2. A household survey conducted in the communities wherethe LHWs were trained and were given the evidence-ledcommunication tools for use in their daily activities(‘intervention communities’). During the survey, interviewswere conducted with women who either were pregnant or haddelivered during the previous three years from the date of thesurvey (end of April 2000). This helped to collect informationon key indicators that related to the key messages conveyedthrough these tools, not only on the pregnancies anddeliveries that occurred during the intervention phase in thesecommunities, but also about pregnancies and deliveries thatoccurred to the same women in these communities before theintervention phase, thus providing a useful comparison toevaluate the impact. 3. The information obtained from the intervention sites wasalso compared with that obtained through a similar householdsurvey conducted during the same period in some othercommunities which were similar to intervention communitiesbut where LHWs were not trained and did not have theevidence-led communication tools (‘control communities’).4. Key-informant interviews were conducted with theLHWSs, FPOs, district coordinators and the key-resourcepersons from the PPIU, to get their feedback and suggestionsfor future implications.5. Focus groups were conducted in each interventioncommunity with the women who had received exposure to theevidence-led communication tools and trained LHWs. Thishelped in getting their experience views of the usefulness ofthese tools for the work of the LHWs.


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Survey instruments for the impact assessmentDraft survey instruments were developed and finalised inconsultation with the PPIU. These instruments drew onvalidated and tested questions of previous surveys, includingthose used in the BoC cycle. The survey instruments – boththe household questionnaires and the focus-group formats –were translated into Urdu and Sindhi. They were thentranslated back into English to double-check the accuracy ofthe translations.Household questionnaire: Trained interviewers administeredthis to the eligible women in households in both theintervention and control communities. The survey collectedinformation on issues including:• household demographics and socioeconomic status• knowledge and practices about care during pregnancy,

especially reduction of workload and access to ofantenatal care

• child-care practices regarding breastfeeding, feeding ofcolostrum, early initiation and continuation ofbreastfeeding, and the timing of the introduction ofadditional liquids and foods to the child’s diet

• exposure to trained LHWs and communication toolsFocus-group discussion formats: Focus-group formats weredeveloped for the facilitator and recorder to conduct gender-stratified focus groups from the households that reportedvisits by the trained LHWs and exposure to the evidence-ledcommunication tools. During the focus groups’ exposure tothe tools, their experiences, opinions about the tools’strengths and weaknesses and suggestions for futureimplementation were discussed. Key-informant interviews: These were semi-structuredinterview guides that helped to get feedback and suggestionsfrom key-resource persons in provincial- and district-levelprogramme management, to assess the piloted process andmake suggestions for future implementation. The areascovered during the interviews included the opinion of theinterviewee about the tools, his or her experiences during theimplementation of the project activities, supervision andmonitoring, suggestions for improvement, and acceptabilityand means for mainstreaming the experiences from the pilotproject for provincial and national implementation.


4 Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst1959;22:719-748.

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Table 1Distribution of LHWs and population covered

District LHWstrained

Populationcovered*

Karachi West 8 8000Karachi South 20 20000Hyderabad 8 8000Hyderabad 10 10000Hyderabad 6 6000

52 52000*Source: PPIU, Sindh: showing estimatedpopulation covered by LHWs.

Training and fieldwork for the impact assessmentTwo field teams were recruited to conduct the field work, onefor the communities in Karachi and another for thecommunities in Hyderabad. Each team consisted of fourfemale interviewers and one female supervisor. Efforts weremade to involve individuals who had participated in previousCIET cycles in Sindh. A two-day training workshop wasorganised in Karachi to train the field teams on field methods,instrument administration and quality-control issues. Thetraining included explanation of the instruments, discussion,role plays and field testing. The Sindh Bureau of Statisticsprovided the venue and other logistical support for thetraining. Data collection was completed in one week,including the household survey, focus groups and most of thekey-informant interviews. Each community was covered inone day. CIET coordinators supervised data collection,staying with the field teams all the time during data collectionto ensure the quality. They also conducted the key-informantinterviews and facilitated the male focus-group discussions.Data management and analysisDouble data entry took place in Karachi using the EpiInfosoftware package. After using the validate programme inEpiInfo to remove keystroke errors, the data were furthercleaned for logical errors. Analysis involved frequencies and major contrasts in the datato assess the impact, using defined quantitative indicators andtaking into account the potential confounding effects of age,sex of respondent, education, residential area and otherfactors. Qualitative information from the focus groups and keyinformants enriched the findings from the household survey inthe final report. Analysis used the EpiInfo software packagefor basic descriptive frequencies and uni-variate analysis ofassociations, with the strength of associations tested using theMantel-Haenszel4 procedure and stratification to examineconfounding and effect-modification. Contrasts reported asodds ratios and confidence intervals (CI) were those ofCornfield. Heterogeneity between strata was tested using theprocedure of Woolf.


5 Ajrak is the local Sindhi name for the cloth used in the communication tools.

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Figure 1Embroidery as a communication tool - evidence oncolostrum and malnutrition

RESULTS

Embroidery as a communication tool

One challenge for developing a communication tool was tocommunicate safe health behaviour to non-literate people. Thetool needed to be something that was simple but would make astrong impression on the women.

The final product for the communication tool was embroideryon traditional Sindh material, ajrak5. It pictorially depictedmaternal practices such as attending or not attending antenatalcheckups, doing or not doing heavy work during pregnancy,and giving colostrum after birth or not, with the child’s healthrisks displayed below.

In Figure 1, one quadrant depicts a woman after delivery notgiving colostrum. Six of the ten children under that quadrantare clearly malnourished and four are healthy. Under theopposite picture, depicting a woman giving her newborncolostrum, five of the ten children are clearly malnourishedand the other five are healthy. The LHW would show thesepanels to her clients in an interactive manner, getting themother to identify what is going on in the pictures and at thesame time facilitating dialogue on the issue. From the pictures,the woman was led to understand that giving a newborncolostrum does not guarantee that the child will be wellnourished and healthy, but that it reduces the child’s risk ofmalnourishment.

To convince a woman to practise healthy behaviour, such asgiving a newborn colostrum, the LHW discusses with awoman any difficulty she might face or what others’ views areon the first milk. To go for antenatal checkups, for example,the discussion may include when and how she would go. Thewoman is also ensured of support by the LHW if she requiresit. The LHW concludes with the following message to thewoman:


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Figure 2Communication tool demonstrating the risk ofheavy work during pregnancy

Box 1: Information base for impact assessment

Inter* Control** Number of households visited 500 469Population covered 4391 3,452Number of women interviewed 529 541Female focus groups 5 - Male focus groups 5 - Key-informant interviews 10*Inter=intervention communities **Control=control communities

Figure 3Key socioeconomic indicators (n= 469 - 506)

“Now you know that not going for antenatal checkupshas a negative impact on your health and thenourishment of the child. What ways can you make sureyou can go for antenatal checkups at least three timesduring your pregnancy?”

Figure 2 shows similar embroidery panels produced to exhibitthe risk of a heavy workload during pregnancy.

All the evidence-based communication tools wereaccompanied by training workshops and a user’s manualtranslated into both Urdu and Sindhi (Annex III).

Key findings of the impact assessment

Information base

A total of 969 households was visited as part of the impact-assessment phase of this project (see Box 1), with almostequal proportion in intervention and control communities(52% in intervention communities, 48% in controlcommunities). From these households, 1,070 interviews wereconducted with women who reported to either have beenpregnant and/or have delivered during the preceding threeyears, the proportion being slightly higher from the controlcommunities. Qualitative information was also collated from10 gender-stratified focus groups, five with men and fivewith women in the intervention communities, and 10 key-informant interviews with the LHW programmemanagement, including LHWSs, FPOs, district coordinatorsand members of the PPIU.

Characteristics of the study population

Figure 3 compares the socioeconomic conditions of the twogroups of communities. The main parameters were the numberof people and rooms within the household, education levels ofthe women and their spouses, and household economyassessed based on the type of occupation of the spouse and the


6 OR 1.37, 95% CI 1.06-1.77; 49% (245/506) of women had some formal education in intervention communities, compared with41% (206/507) of women in control communities.7 OR 1.32, 95% CI 1.02-1.72; 63% (315/503) of women in intervention communities reported that their spouses had middle- orhigh-income occupations, compared with 56% (282/505) of women in control communities.8 OR 1.62, 95% CI 1.15-2.30; 20% (102/504) of women in intervention communities reported to have their own source ofincome, compared with 14% (68/503) of women in control communities.

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Figure 4 LHWs’ visits during last pregnancy

woman herself having a source of income.

These socioeconomic indicators revealed the interventioncommunities to be slightly better off than the controlcommunities. A woman from an intervention community, forexample, was 37% more likely to have some formaleducation, compared with a woman from a controlcommunity6. Based on the nature of occupation of the spouse,a woman from an intervention community was 32% morelikely to report that her spouse had a middle- or high-incomeoccupation, compared with a woman from a controlcommunity7. A woman from an intervention community wasmore likely to report that she had her own source of income,compared with a woman from a control community8.

There were some differences, such as the proportion ofhouseholds with four or fewer people per room and educationof the spouse, that could be explained by chance. Therefore,the effect of these factors was ruled out while comparing thecaring practices of the women in the two groups ofcommunities for assessing the impact of the use of thecommunication tools.

LHWs’ visits and use of the communication tools

For 7 out of 10 reported pregnancies, women reported havinghad a visit from an LHW (Figure 4). The average woman inthe intervention communities was significantly more likely tohave been visited by an LHW during her pregnancy than one


9 OR 3.60, 95% CI: 2.69-4.83; 82% (470/570) of pregnant women in intervention communities reported to have been visited byan LHW, compared with 54% (297/553) of pregnant women in control communities.10 OR 7.65 95% CI: 4.65-12.63; during the intervention phase, for 287/315 pregnancies in intervention communities, womenreported tohave been visited by an LHW, compared with 30/227 in control communities.11 OR 5.71, 95% CI: 3.60-9.08; among rural women, for 274/307 pregnancies in intervention communities, women reported tohave been visited by LHW, compared with 160/270 in control communities.12 OR 7.17, 95% CI: 4.20-12.31; among women living in households having more than four persons per room, for 172/196pregnancies in intervention communities, women reported to have been visited by an LHW, compared with 109/218 in controlcommunities.

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in a control community9.

The training of LHWs and the use of the communication toolsseemed to have a positive impact on the LHWs’ performance.To measure if there was a greater impact on the LHWs’performance during the intervention phase, the pregnancieswere categorised into those that took place during the CIETintervention phase and those reported before this period. Thiswas done from responses to the question on the timing of thewomen’s last pregnancy. During the intervention phase, awoman in an intervention community was seven times morelikely to have been visited by an LHW during her pregnancythan was a woman from a control community10. One possibleexplanation for this improved performance by LHWs could bean increase in their interest and enthusiasm due to their activeinvolvement in the project. Another explanation is that theadditional monitoring and supervision by the LHWSs, theFPOs and the CIET team during the intervention phase couldhave caused the LHWs to work better in the interventioncommunities.

This effect of more frequent visits by the LHWs in theintervention communities was also stronger in certainsubgroups. For example:• among those living in a rural community, a woman in an

intervention community was five and a half times morelikely to have been visited by an LHW, compared with awoman in a control community11.

• among those living in a household with more than fourpersons per room, a woman living in an interventioncommunity was seven times more likely to have beenvisited by an LHW, compared with one living in acontrol community12.

• among women who had some formal education, a


13 OR 5.94, 95% CI: 3.80-9.32; among women with some formal education, for 244/284 pregnancies in interventioncommunities, women reported to have been visited by an LHW, compared with 116/229 in control communities.14 OR 5.21, 95% CI: 3.53-7.70; among women whose spouses had some formal education, for 317/367 pregnancies inintervention communities, women reported to have been visited by an LHW, compared with 180/328 in control communities.15 OR 7.83, 95% CI: 4.66-13.20; among women whose spouses had education up to matric or higher, for 189/220 pregnancies inintervention communities, women reported to have been visited by an LHW, compared with 74/169 in control communities.

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woman living in an intervention community was almostsix times more likely to be visited by an LHW, comparedwith a woman living in a control community13. A similartrend was observed for women whose spouses had someformal education – among such women, one living in anintervention community was five times more likely to bevisited by an LHW, compared with one living in acontrol community14. The effect was stronger for womenwhose spouses had more education in interventioncommunities15.

Some 63% (298/470) of women in the interventioncommunities reported to have seen the ajrak communicationtools presented by LHWs. Of these women, 97% (289/297)found the communication tools useful in understanding theadvice.


in Pakistan 15

Table 2 Who told you to go for anantenatal checkup?

Who suggestedto go for

checkup?

All 10 sites(n=1,116)

No-one 303 (27%)LHW 335 (30%)Doctors 128 (12%)Relatives/friends 181 (16%)Knew herself 159 (14%)Others (nurse,TBA, NGO)

10 (0.9%)

Table 3For this pregnancy, who told you toreduce your routine heavy work?

Who told to reduceheavy work?

All 10 sites(n=1,115)

No-one 342 (31%)LHW 311 (28%)Doctors 157 (14%)Relatives/friends 252 (23%)Knew herself 45 (4%)Others (nurse, TBA,NGO)

8 (0.7%)

Table 4Who told you that you should give yourchild colostrum after birth?

Who told to givecolostrum to the

baby

All 10 sites(n=891)

No-one 238 (27%)LHW 195 (22%)Doctor 298 (33%)Relatives/friends 75 (8%)Knew herself 33 (4%)TBA 34 (4%)Others(TV/books/NGO/nurse)

18 (2%)

LHWs as one of the key health messengers

The evidence from the BoC cycles provided strong evidencethat LHWs were a good source of advice on certain health-care practices. This conclusion was maintained in the impactassessment, demonstrating a stronger effect in certainsubgroups. The evidence-led communication tools furtherpromoted the role of the LHW as a key health messenger.

Advice for antenatal checkupsLHWs were identified as the most common source of adviceon antenatal checkups, followed by relatives/friends, thewomen themselves, doctors and other health workers (Table2). At the same time, 27% (303/1,116) of the women did notreceive any advice about going for antenatal checkups.

Advice for reducing routine heavy work during pregnancyFor 3 out of 10 pregnancies (311/1,115), respondents wereadvised to reduce their routine heavy work by an LHW. Thenext most common sources of advice were relatives or friends,followed by doctors. For 3 out of 10 (342/1,115) pregnancies,women reported that no-one advised them (Table 3).

Advice to give colostrumDoctors were the leading source of advice on giving colostrumto newborns, followed by LHWs. Relatives and friends forthis practice were not as strong messengers as for the otherhealth practices. Some 27% reported that no-one advisedthem on this practice.

The evidence-led communication tools proved to increase thepositive impact of LHWs being the messengers of these healthpractices. A woman living in an intervention community wastwo times more likely to report that an LHW had advised heron targeted health-care practices than any other source,


16 OR 2.27, 95% CI:1..67-3.07; for 274/509 pregnancies in intervention communities, women reported that they were advised byan LHW on health-care practices, compared with 136/479 in control communities.17 OR 4.99, 95% CI: 3.12-8.00; among women living in households with more than four persons per room, for 118/180pregnancies in intervention communities, women reported that they were advised by an LHW on health-care practices, comparedwith 53/192 in control communities.18 OR 5.07, 95% CI: 3.21-8.03; among women having some formal education, for 142/257 pregnancies in interventioncommunities, women reported that they were advised by an LHW on health-care practices, compared with 38/194 in controlcommunities.19 OR 7.16, 95% CI: 4.08-12.64; among women whose spouses had completed 10th grade or higher, for 112/197 pregnancies inintervention communities, women reported that they were advised by an LHW on health-care practices, compared with 23/148 incontrol communities.20 OR 8.37, 95% CI: 4.62-15.26; among women who received help for heavy work during pregnancy by relatives or friends otherthan in-laws, for 113/157 pregnancies in intervention communities, women reported that they were advised by an LHW onhealth-care practices, compared with 27/115 in control communities.21 OR 3.46, 95% CI: 2.41-4.98; among women who gave colostrum to their babies, for 175/349 pregnancies in interventioncommunities, women reported that they were advised by an LHW on health-care practices, compared with 66/293 in controlcommunities.

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compared with a woman living in a control community16. Theeffect was stronger among the following groups of women:• those living in households with more than four persons

per room – among such women, one living in anintervention community was almost five times morelikely to report that an LHW advised her than one livingin a control community17.

• women having some formal education – a woman livingin an intervention community was five times more likelyto report that an LHW advised her than one living in acontrol community18.

• women whose spouses had completed 10th grade (matric)or higher – a woman living in an intervention communitywas seven times more likely to report that an LHWadvised her than one living in a control community19.

• women who received help with their routine heavy workduring pregnancy from relatives or friends other thantheir in-laws, including the husband – a woman living inan intervention community was eight times more likelyto report that an LHW advised her than one living in acontrol community20.

• women who gave colostrum – a woman living in anintervention community was three and half times morelikely to report that an LHW advised her than one livingin a control community21.

More direct evidence of the impact of the communicationtools came from the comparison of women who reported to


22 OR 2.15, 95% CI: 1.50-3.08; for 189/262 pregnancies among those women whom LHWs showed the ajrak tools, womenreported that an LHW advised them on targeted health-care practices, compared with 211/425 pregnancies among those womenwhom LHWs did not show the tools.23 OR 4.42, 95% CI: 2.64-7.45; among women with some formal education, for 103/137 pregnancies among those women whomLHWs showed the ajrak tools, women reported that an LHW advised them on targeted health-care practices, compared with76/187 pregnancies among those whom LHWs did not show the tools.24 OR 4.62, 95% CI: 2.54-8.44; among women with spouses having education up to 10th grade or higher, for 84/112 pregnanciesamong those women whom LHWs showed the ajrak tools, women reported that an LHW advised them on targeted health-carepractices, compared with 50/127 pregnancies among those whom LHWs did not show the tools.25 OR 4.05, 95% CI: 2.54-6.50; among those who reported to have three or more checkups during their pregnancies, for 127/164pregnancies among those women whom LHWs showed the ajrak tools, women reported that an LHW advised them on targetedhealth-care practices, compared with 116/253 pregnancies among those whom LHWs did not show the tools.26 OR 3.86, 95% CI: 2.20-6.80; among those who reduced their routine heavy workload before the seventh month of pregnancy,for 102/127 pregnancies among those women whom LHWs showed the ajrak tools, women reported that an LHW advised themon targeted health-care practices, compared with 93/181 pregnancies among those whom LHWs did not show the tools.

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have been shown the embroidered ajrak communication tools,compared with those who were not. A woman who was shownthe ajrak communication tools was twice as likely to reportthat she received advice on targeted health-care practices byan LHW than any other source, compared with a woman whowas not shown the ajrak tools22.

The impact of the ajrak tools on women receiving advice fromLHWs on key health-care practices was stronger in certainsubgroups:• among women who had some formal education, a

woman who was shown the ajrak tools was four timesmore likely to report that she received advice from anLHW, compared with a woman who was not shown thetools23.

• among women whose spouses had education up to 10th

grade (matric) or higher, a woman who was shown theajrak tools was four and half times more likely to reportthat she received advice from an LHW24.

• among women who had three or more antenatalcheckups, a woman who was shown the ajrak tools wasfour times more likely to report that an LHW advisedher25.

• among women who reduced their routine heavy workbefore the seventh month of pregnancy, a woman whowas shown the ajrak tools was three and half times morelikely to report that an LHW advised her26.

• among women who reported to give colostrum to theirbabies, a woman who was shown the ajrak tools was two


27 OR 2.81, 95% CI: 1.86-4.24; among women who gave colostrum to their babies, for 119/181 pregnancies among those womenwhom LHWs showed the ajrak tools, women reported that an LHW advised them on targeted health-care practices, comparedwith 114/281 pregnancies among those whom LHWs did not show the tools.28 OR 3.59 95% CI: 2.62-4.97; 645/818 of those visited by LHWs had at least one antenatal checkup, compared with 122/303 ofthose not visited by LHWs.29 OR: 8.35, 95% CI: 5.02-13.94; among women from intervention communities, 410/455 of those visited by LHWs had at leastone antenatal checkup, compared with 60/115 of those not visited by LHWs.

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and a half times more likely to report that an LHWadvised her27.

Impact of LHWs using communication tools on healthpractices during pregnancy

Antenatal checkupsFor two-thirds of the reported pregnancies (73%, 818/1,123),women said they had gone for at least one antenatal checkup.For 7 out of 10 pregnancies (557/811), women reported tohave had three or more antenatal checkups.

Visits made by LHWs during pregnancy did motivate womento have antenatal checkups. A woman visited by an LHWduring her pregnancy was three and half times more likely tohave at least one antenatal checkup, compared with a womannot visited by an LHW during her pregnancy28.

The effect was more pronounced in intervention communities,where a woman visited by an LHW was eight times morelikely to have antenatal checkups, compared with a woman notvisited by an LHW29.

Comparison of women exposed to the ajrak tools with thosewho reported not to did not yield a significant difference interms of going for antenatal checkups that could not beexplained by chance (OR 1.43, 95% CI: 0.92-2.21). Perhapsmore time is needed to bring a significant impact in thispractice.

Reasons for going or not going for antenatal checkupsThe three main reasons reported by women for having


30 OR 1.48, 95% CI: 1.01-2.16; 239/310 of women advised by an LHW reduced their heavy work at any point in time duringpregnancy, compared with 471/799 of women advised by others or none.

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antenatal checkups included:• antenatal checkups were good for a mother and the baby

(43%, 343/806)• “as per routine or for registration of delivery” (30%;

240/806)• had a health problem during pregnancy (23%, 188/806).

The main reasons for not going for antenatal checkupsincluded:• not necessary (63%, 180/286)• “not in the culture to go for antenatal checkups” (14%,

40/286)• not having enough money (10%, 31/286)• not aware or were not told (6%, 19/286)• health centre was too far away (2%, 5/286).

Among those who had antenatal checkups during their lastpregnancy, 63% (535/852) of women reported to be verysatisfied, 31% (261/852) were “somewhat” satisfied and 7%(56/852) reported to be “not at all satisfied”.

Reducing a heavy workload during pregnancy

During one-third of the reported pregnancies (36%,405/1114), women did not reduce their routine heavy work.For those who reported to reduce their routine heavy work,69% (491/709) of respondents reduced it before the start of theseventh month of their pregnancy.

Advice from LHWs can make a difference. A woman whowas advised by an LHW to reduce her routine heavy workduring pregnancy was 48% more likely to do so30 and 73%more likely to reduce it before the start of the seventh monthof pregnancy, compared with a woman who was not advised

Table 5Reasons for those who reduced routineheavy work during pregnancy

Why did you reduceheavy work?

All 10 sites(n=682)

Better for mother/baby 409 (60%)Prevent problem duringpregnancy

36 (5%)

Due to health problemduring pregnancy

160 (23%)

Advised by someone 21 (3%)No heavy work at home 32 (5%)No reason given 24 (4%)


31 OR 1.58, 95% CI: 1.15-2.16; 169/305 of women advised by an LHW to reduce their heavy work before the start of the seventhmonth of pregnancy reported to have done so, compared with 266/797 of women advised by others or no-one.32 OR 6.05, 95% CI: 4.59-7.98; 564/709 women who were helped by someone during their pregnancy with their routine heavywork reported to reduce their heavy workload, compared with 144/399 pregnancies among women who were not helped.33 OR 10.31, 95% CI: 6.70-15.90; among rural women, 315/388 who were helped by someone during their pregnancy with theirroutine heavy work reported to reduce their heavy workload, compared with 54/183 pregnancies among women who were nothelped.34 OR 10.11, 95% CI: 6.29-16.30; among women from a low-income group, 233/286 who were helped by someone during theirpregnancy with their routine heavy work reported to reduce their heavy workload, compared with 50/165 pregnancies amongwomen who were not helped.35 OR 9.92, 95% CI: 6.87-14.34; among women who had at least one antenatal checkup, 476/572 who were helped by someoneduring their pregnancy with their routine heavy work reported to reduce their heavy workload, compared with 78/234pregnancies among women who were not helped.

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by anyone or advised by some other person31. No differencebetween the intervention and control communities, andbetween those women who were exposed to the tools andthose who were not exposed to them, could be found in termsof reducing heavy workload. Both sets of analyses wereconfounded by family, friends or servants helping the woman.

The most widely stated reason for reducing a routine heavyworkload during pregnancy was that it was good for themother and the baby. The second most common reason wasthe recognition of health problems. Other reasons are listed inTable 5.

The main reason reported for not reducing a routine heavyworkload during pregnancy was because they had no-one tohelp them at home (42%, 149/355). This was closely followedby women perceiving a heavy workload during pregnancy asnot harmful (41%, 145/355). The third most common reasonfor not reducing their workload was that women said it wasnot their custom (11%, 40/355).

Having help with work can make a difference. When a womangot help with her routine heavy work during pregnancy, shewas six times more likely to reduce her routine heavy workduring pregnancy32. The effect was stronger among ruralwomen (10 times)33, women from a low-income group basedon occupation of the husband (10 times)34 and women whohad at least one antenatal checkup during pregnancy (almost10 times)35.


36 OR 1.61, 95% CI: 1.10-2.35; among women whom LHWs showed the ajrak tool, 189/295 completely stopped their routineheavy workload during pregnancy, compared with 235/465 of pregnancies among women not shown the tool.37 OR 3.46, 95% CI: 2.58-4.64; 479/709 women who were helped by someone during their pregnancy with their routine heavywork reported to stop their routine heavy work at any point in time during pregnancy, compared with 131/399 pregnanciesamong women who were not helped. 38 OR 10.71, 95% CI: 4.53-26.04; among women having their own source of income, 80/124 who were helped by someoneduring their pregnancy with their routine heavy work reported to stop their routine heavy work at any point in time duringpregnancy, compared with 9/62 pregnancies among women who were not helped.39 OR 6.94, 95% CI: 4.43-10.93; among rural women, 236/384 who were helped by someone during their pregnancy with theirroutine heavy work reported to stop their routine heavy work at any point in time during pregnancy, compared with 34/182pregnancies among women who were not helped.40 OR 8.02, 95% CI: 4.45-14.55; among women whose spouses had an education of less than 10th grade, 130/192 who werehelped by someone during their pregnancy with their routine heavy work reported to stop their routine heavy work at any pointin time during pregnancy, compared with 23/111 pregnancies among women who were not helped. 41 OR 7.49, 95% CI: 5.19-10.83; among women who had at least one antenatal checkup, 403/574 who were helped by someoneduring their pregnancy with their routine heavy work reported to stop their routine heavy work at any point in time duringpregnancy, compared with 56/234 pregnancies among women who were not helped.

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Stopping routine heavy work during pregnancy

A little more than half (55%, 614/1,113) of the womenreported a complete stop of routine heavy work during theirpregnancies. However, for the majority of these pregnancies(67%, 410/614), women stopped their heavy work after thestart of the seventh month of their pregnancy.

The communication tools did make a difference in this healthpractice. A woman who was shown an ajrak tool was 61%more likely to completely stop her routine heavy work duringpregnancy, compared with a woman who was not shown anajrak tool36. This practice was dependent largely upon supportfrom the woman’s family members.

When a woman got help with her routine heavy work duringpregnancy, she was three and half times more likely tocompletely stop her routine heavy work at some point duringher pregnancy, compared with a woman whom no-onehelped37. The effect was more pronounced among women whohad their own source of income38, rural women (almost seventimes)39, women whose spouses had an education of less than10th grade (eight times)40 and women who had at least oneantenatal checkup during pregnancy (seven and half times)41.


42 OR 3.46, 95% CI: 2.07-5.78; 166/708 women who were helped by someone during their pregnancy with their routine heavywork reported to completely stop their routine heavy work before the start of the seventh month of pregnancy, compared with23/399 pregnancies mong women who were not helped. 43 OR 1.88, 95% CI: 1.29-2.74; 139/193 of the babies whose mothers received advice on colostrum from an LHW received breastmilk as the first thing fed after birth, compared with 392/695 of the babies whose mothers received the same advice from anyother source.44 OR 6.25, 95% CI: 2.49-16.69; among women living in urban communities, 53/59 of the babies whose mothers received adviceon colostrum from an LHW received breast milk as the first thing fed after birth, compared with 243/415 of the babies whosemothers received the same advice from any other source.45 OR 2.76, 95% CI: 1.68-4.54; among those who had three or more antenatal checkups, 102/131 of the babies whose mothersreceived advice on colostrum from an LHW received breast milk as the first thing fed after birth, compared with 190/339 of thebabies whose mothers received advice from any other source.

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Table 6Breastfeeding trends

Breastfeedingtrends

Intervention sites ControlsitesBaseline

(BoC)Current

Proportion ofbabies breastfed

99%(669/674)

99%(437/442)

99%(448/453)

Breast milk as firstthing fed after birth

24%(158/668)

58%(254/440)

61%(278/456)

Breastfeedinginitiated within anhour after birth

33%(217/654)

36%(158/437)

40%(180/448)

Breastfeedinginitiated within 24hours after birth

84%(549/654)

87%(380/437)

82%(370/448)

Having help can also increase the probability of a womanstopping her routine heavy work before the start of the seventhmonth. Such a woman is three and half times more likely tocompletely stop her routine heavy work before the seventh

month of pregnancy, compared with a woman whomno-one helped42.

Who helped with routine workAlmost one half (49%, 351/715) of the women reportedthat their mother-in-law or sister-in-law helped themwith their routine heavy work during pregnancy. Only9% (66/715) of the women reported that their husbandshelped them with their routine heavy work duringpregnancy.

Breastfeeding practicesSome 99% of the women reported to have initiatedbreastfeeding upon delivery. Table 6 shows the initiation ratescomparing breastfeeding practices in the interventioncommunities, the control communities and the BoC cycle.

A baby whose mother received advice from an LHW onfeeding colostrum to a newborn was 88% more likely toreceive breast milk as the first thing fed after birth, comparedwith a baby whose mother received the same advice fromanother source43.

The effect was stronger among urban women (six times)44,those who had three or more antenatal checkups duringpregnancy (almost three times)45, those who had help from


46 OR 2.95, 95% CI:1.65-5.33; among those who were helped by in-laws with routine heavy work during pregnancy, 119/238 ofthe babies whose mothers received advice on colostrum from an LHW received breast milk as the first thing fed after birth,compared with 65/187 of the babies whose mothers received advice from any other source.47 OR 2.34, 95% CI: 1.58-3.4; among those who did not initiate breastfeeding within half an hour of delivery, 119/167 of thebabies whose mothers received advice on colostrum by an LHW received breast milk as the first thing fed after birth, comparedwith 305/593 of the babies whose mothers received the same advice from any other source.48 OR 1.60, 95% CI: 1.10-2.43; 145/204 of the babies whose mothers were shown the ajrak communication tools received breastmilk as the first thing fed after birth, compared with 223/384 of the babies whose mothers were not shown the tools.49 OR 3.16, 95% CI: 1.66-6.05; among women who were helped with routine heavy work during pregnancy by their in-laws,64/84 of the babies whose mothers were shown the ajrak communication tools received breast milk as the first thing fed afterbirth, compared with 73/145 of the babies whose mothers were not shown the tools.50 OR 3.95, 95% CI: 1.62-9.80; among those who introduced liquids other than breast milk to the baby after four months of age,58/69 of the babies whose mothers were shown the ajrak communication tools received breast milk as the first thing fed afterbirth, compared with 36/63 of the babies whose mothers were not shown the tools.

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Table 7Reasons for giving colostrum

Reason Interven-tion sites(n=348)

Controlsites

(n=291)

All (10 sites)(n=639)

Good forbaby

214 (62%)

185(64%)

399(62%)

Advised bysomeone

105(30%)

93(32%)

198(31%)

Child washungry/crying

14(4%)

4(1%)

18(3%)

Ownwill/culture

5(1%)

2(1%)

7(1%)

their in-laws for their routine heavy work during pregnancy(three times)46 and those who did not initiate breastfeedingwithin half an hour of delivery47.

A woman who had exposure to the ajrak communicationtools was 60% more likely to feed her newborn baby breastmilk as the first thing after birth, compared with a womanwho had no exposure to the communication tools48. Theeffect seems to be associated with other caring practices formothers and children within the family. Thus, the effectwas more pronounced among women who had help fromtheir in-laws, including the husband, with their routineheavy work during pregnancy (three times more likely)49

and those who introduced liquids other than breast milk tothe baby after four months of age (almost four times morelikely)50.


51 OR 1.74, 95% CI:1.15-2.63; 463/589 of the babies whose mothers reported to have been visited by an LHW during pregnancyreceived colostrum, compared with 184/308 of the babies whose mothers reported not to have had a visit from an LHW.52 OR 4.13, 95% CI: 2.38-7.18; among women living in intervention communities, 301/356 of the babies whose mothers reportedto have been visited by an LHW during pregnancy received colostrum, compared with 49/86 of the babies whose mothersreported not to have had a visit from an LHW.53 OR 3.84, 95% CI: 2.32-6.35; among women whose spouses did not have any formal education, 160/207 of the babies whosemothers reported to have been visited by an LHW during pregnancy received colostrum, compared with 63/134 of the babieswhose mothers reported not to have had a visit from an LHW.54 OR 3.76, 95% CI: 2.27-6.25; among women from low-income groups, 183/236 of the babies whose mothers reported to havebeen visited by an LHW during pregnancy received colostrum, compared with 56/117 of the babies whose mothers reported notto have had a visit from an LHW.55 OR 4.60, 95% CI: 2.82-7.52; among women who gave things other than breast milk to the child as the first thing fed afterbirth, 138/218 of the babies whose mothers reported to have been visited by an LHW during pregnancy received colostrum,compared with 39/143 of the babies whose mothers reported to not have had a visit from an LHW.56 OR 3.00, 95% CI: 2.14-4.21; among women who did not initiate breastfeeding within half an hour after delivery, 398/514 ofthe babies whose mothers reported to have been visited by an LHW during pregnancy received colostrum, compared with136/255 of the babies whose mothers reported to not have had a visit from an LHW.57 OR 1.60, 95% CI:1.17-2.18; 350/442 of the women living in intervention communities gave colostrum to their babies,compared with 297/455 of those living in control communities.

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Table 8Reasons for not giving colostrum

Reasons Interven-tionsites

(n=90)

Controlsites

(n=152)

All (10sites)

(n=242)

Not good forbaby

32(36%)

37(24%)

69(29%)

Dirty milk 16(18%)

77(51%)

93(38%)

Stopped bysomeone

12(13%)

11(7%)

23(10%)

Didn’t knowbenefit

9(10%)

2(1%)

11(5%)

Feedingproblem

11(13%)

3(2%)

15(6%)

Illness ofnewborn/mother

3(3%)

9(6%)

12(5%)

Ownwill/culture

3(3%)

2(1%)

5(2%)

No reasongiven

3(3%)

11(7%)

14(6%)

Colostrum

Some 72% (649/897) of mothers reported to feed theirnewborn colostrum. Tables 7 and 8 give the reasons whywomen gave or did not give colostrum to their newborn. In theimpact assessment a strong relationship was found between

LHW activities and the practice of giving colostrum to thechild. A baby whose mother reported to have been visitedby an LHW during pregnancy was 74% more likely toreceive colostrum, compared with a baby whose motherreported that she was not visited by an LHW51. The effectwas stronger among women living in interventioncommunities (four times more likely)52, those whosespouses had no formal education (almost four times morelikely)53, those from low-income groups (almost fourtimes more likely)54, those who gave their babies thingsother than breast milk as the first thing fed to the childafter birth (four and half times more likely)55 and thosewho did not initiate breastfeeding within half an hour ofdelivery (three times more likely)56.

Comparing the intervention communities with the controlcommunities showed that a woman from an interventioncommunity was 60% more likely to give colostrum to her

baby, compared with a woman living in a controlcommunity57. The effect was more pronounced with womenwho had visits from an LHW (almost two and half times more


58 OR: 2.40, 95% CI: 1.57-3.67; among women visited by LHWs, 301/356 of the women living in intervention communities gavecolostrum to their babies, compared with 162/233 of those living in control communities.59 OR: 4.80, 95% CI: 2.08-11.19; among women having their own source of income, 74/90 of the women living in interventioncommunities gave colostrum to their babies, compared with 26/53 of those living in control communities.60 OR: 4.42, 95% CI: 2.84-6.89; among women living in rural communities, 168/222 of the women living in interventioncommunities gave colostrum to their babies, compared with 81/196 of those living in control communities.61 OR: 3.21, 95% CI: 1.53-6.80; among women with less than 10th-grade education, 112/127 of the women living in interventioncommunities gave colostrum to their babies, compared with 72/103 of those living in control communities.62 OR: 3.66, 95% CI: 2.16-6.24; among women from low-income groups, 130/158 of the women living in interventioncommunities gave colostrum to their babies, compared with 109/195 of those living in control communities.63 OR: 4.59, 95% CI: 1.78-12.04; among women advised by an LHW to give colostrum, 117/126 of the women living inintervention communities gave colostrum to their babies, compared with 51/69 of those living in control communities.64 OR: 4.93, 95% CI: 1.68-14.83; among women who introduced foods other than breast milk to their babies before the age offour months, 20/30 of the women living in intervention communities gave colostrum to their babies, compared with 15/52 ofthose living in control communities.65 OR 1.50, 95% CI:1.02-2.20; 120/439 women living in intervention communities did not introduce liquids other than breastmilk to the child before the age of four months, compared with 84/453 of those living in control communities.

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likely)58, among women who had their own source of income(almost five times more likely)59, those living in ruralcommunities (almost five and half times more likely)60, andthose with an education of less than 10th grade (three timesmore likely)61. The effect was also stronger among womenfrom a low-income group (three and half times more likely)62,those who were directly advised by an LHW to give thecolostrum (four and half times more likely)63 and those whointroduced foods other than breast milk to their babies beforethe age of four months (almost five times more likely)64.

An impact as a result of exposure to the ajrak communicationtools was not possible to determine. The relationship wasconfounded by the level of the woman’s education. Possibly,such changes require more time. However, through educationwomen may start questioning such myths as “dirty milk”.

Introduction of liquids and foods other than breast milk

The communication tools provided an opportunity to discussother health practices, such as breastfeeding. Exclusivebreastfeeding up to the age of four months is a highlyrecommended practice to prevent morbidity as well asmortality. A woman from an intervention community was50% more likely not to introduce liquids other than breastmilk to the child before the age of four months, compared witha woman from a control community65. The effect was strongeramong women who added foods other than breast milk to the


66 OR 2.17, 95% CI: 1.39-3.40; among women who added foods other than breast milk to their child’s diet before six months ofage, 68/332 of women living in intervention communities did not introduce liquids other than breast milk to the child before theage of four months, compared with 40/377 of those living in control communities.67 OR 2.29, 95% CI: 1.46-3.60; 70/205 women who were shown the ajrak tools did not introduce liquids other than breast milk tothe child’s diet before the age of four months, compared with 63/382 women who were not shown the tools. 68 OR 9.92, 95% CI: 3.29-31.08; among women having a grade-10 education or above, 20/39 women who were shown the ajraktools did not introduce liquids other than breast milk to the child’s diet before the age of four months, compared with 7/73women who were not shown the tools.69 OR 3.09, 95% CI: 1.77-5.40; among women with educated spouses (primary or above), 46/132 women who were shown theajrak tools did not introduce liquids other than breast milk to the child’s diet before the age of four months, compared with32/217 women who were not shown the tools.70 OR 4.21, 95% CI: 2.37-7.49; among women who were “very satisfied” with their antenatal care, 45/121 women who wereshown the ajrak tools did not introduce liquids other than breast milk to the child’s diet before the age of four months, comparedwith 29/235 women who were not shown the tools.71 OR 3.53, 95% CI: 2.09-5.95; among women who gave breast milk as the first thing fed to their newborn, 58/143 women whowere shown the ajrak tools did not introduce liquids other than breast milk to the child’s diet before the age of four months,compared with 36/222 women who were not shown the tools.

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child’s diet before six months of age (more than twice aslikely)66.

A woman who was shown the ajrak communication tools wastwice as likely not to introduce liquids other than breast milkto the child before the age of four months, compared with awoman who was not shown the tools67. The effect wasstronger among women having education up to matric (10thgrade) or above (almost 10 times more likely)68, amongwomen who had spouses educated at primary level or above(three times more likely)69, among women who were “verysatisfied” with the antenatal care that was available duringtheir pregnancy (more than four times more likely)70, andthose who gave breast milk as the first thing fed to the childafter birth (three and half times more likely)71.


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“It would be sheer negligence on the part of women if they do not act upon themessages that they receive from thesepictures.”

Women’s focus groupMissan, Hyderabad

“After seeing these tools, one can surely saythat with the help of such tools any woman couldeasily understand about any health problem andits causes during the course of pregnancy.”

Women’s focus groupTando Jam, Hyderabad

Community views of the communication tools

An important aspect of the development of the evidence-ledcommunication tools was the participatory process. Fromanalysis and design to the impact assessment, stakeholderswere involved. This built capacity and ownership and led tothe development of a communication tools that wereindigenous to the province.

As part of the impact assessment, focus groups were held withwomen and men to get qualitative feedback on theirexperience with the communication tools and for suggestionson improvement.

Women’s views

Most of the women in the focus groups were very excitedabout the tools. Their reaction was immediate upon seeing thetools, commenting that they were very attractive and striking.They saw the pictures as beautiful and providing messagesabout pregnancy. Some said that after seeing the ajrak tools,they realised that it was a way to improve their health. Theycould easily relate the pictures to their daily life and themessages were very clear.

The pictures identified the reasons why a child could behealthy or weak. Some women’s first thoughts were that theirown children should not be so weak. Individual women in twofocus groups mentioned that at the very first look at the ajrak,they thought that these were children from the same woman.However, subsequent discussion with LHWs clarified themessage. Some descriptions under these pictures weresuggested to make them clearer.

The women found the tools very helpful in understanding thekey concepts in relation to their own health, as well as that oftheir children. During pregnancy this would be effectivebecause many women think they are fine during pregnancyand are not aware of the risks. The tools clearly showed thedifference between healthy and harmful practices duringpregnancy and after childbirth. The link between practices


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“We knew these things before but afterseeing these pictures we understood veryclearly that if a pregnant woman lifts someheavy weight it would have a bad effecton the baby’s health.”

Women’s focus groupQasba Colony, Karachi West

“When I saw the picture, the firstimpression that came to my mind was thatit related to pregnancy. As such, I felt quiteeasy about talking and asking questionsabout it.”

Women’s focus groupAgra Taj, Karachi South

“The making of these pictures is such thatafter seeing them, we immediately start talkingabout pregnancy. These pictures themselvesinvite us to have a discussion on this topic.”

Women’s focus group Qasba Colony, Karachi West

“My youngest child is healthier than thetwo elder ones and I was also healthyduring pregnancy because I had seenthese pictures and acted on them.”

Women’s focus groupTando Jam, Hyderabad

such as having antenatal checkups, reducing a heavy workloadduring pregnancy and breastfeeding the child immediatelyafter birth rather than giving anything else, and the health ofboth mother and child, was very clear.

Many women shared their own experiences during the focusgroups after seeing the tools. They pointed out that as a resultof seeing the tools became very particular about their regularmedical checkups during pregnancy to ensure that they hadhealthy children. Some mentioned that previously they wouldcontinue with their heavy work during pregnancy but that theywould now avoid it. The illustrated contrast between healthyand malnourished children was effective, as every womanwished that she would bear healthy children.

In addition to the impact of the messages, the tools also had aneffect on improving the interaction between the mothers andthe LHWs. The women explained how the pictures helpedthem to ask questions and discuss the issues with the LHWs.They were of the view that with the help of these pictures,even illiterate women could understand the messages. Theylinked this to the colourfulness of the pictures and the clearrepresentation of reality.

Some women said that when LHWs talk to them, often theyare unable to discuss and probe, but that when they saw thesetools, questions automatically came to mind. The tools helpedthem to understand the message quickly in comparison withthe verbal explanations given by the LHWs. The womenexpressed that the pictures could not be ignored and left animpression in their minds. After identifying the weak andhealthy children, questions could then easily be asked. Womenin some communities even said that it helped those who wereshy. They no longer hesitated to discuss their pregnancy andasked “bold” questions.

Although the frequency with which the LHWs used the toolsvaried in different communities, women in all groups agreedthat showing the tools repeatedly during pregnancy would beuseful. By seeing the tools repeatedly, they would gain agreater understanding of the health practices. At the sametime, some women said that the pictures were so clear that


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“I was pregnant when I saw these picturesand only then I came to know that I mustfeed the baby with my own first milkimmediately after pregnancy.”

Women’s focus group Agra Taj, Karachi South

seeing them once was enough to understand the message.However, it is always useful to use the tools as a reminder tomake sure that a long-term change in these health-carepractices is established.

Women were asked if the evidence-led communication toolscould be used in a group setting. There was unanimousagreement that the tool needed to be used in one-to-oneinteractions. However, a mixed response was obtained aboutthe use of these tools in a group setting. Those who insisted onone-to-one use gave reasons of mobility restrictions of womenand the importance of concentrating on the messages andbeing able to discuss the issues openly without otherslistening.

Those who advocated for group use thought this would enableexposure to more women, increase women’s interest andallow women to hear each other’s views. Some of themmentioned that some women were very busy with theirhousehold chores and thus it was difficult for them to payattention when the LHW visited. For these women, a groupactivity would be more effective, enabling them time toconcentrate.

Women expressed preference for the ajrak tools comparedwith other tools, such as flip charts. However, they suggestedsome other methods for conveying health messages:television, newspaper, video films, drama and large charts forgroup meetings.

Women were asked to comment on the presentation of thetools. They were satisfied but did suggest that they should alsobe shown to other family members, especially elderly ladies,who could then discuss them with younger women in theirfamily. Some of them re-emphasised that the tools should beshown repeatedly to women during pregnancy.

When asked for suggestions for improving the design of thetools, such as material, cloth, colours and pictures, most of thewomen said that there was no need for change. Some,however, offered specific suggestions:


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“It is a clear model and shows comparisonof good and wrong practices. It is a modelfor better understanding wherever shown.”

Men’s focus group Tando Jam

• there should be a clearer distinction between the healthyand the weak children. They suggested that the healthychildren should not be illustrated wearing red, whichindicates a danger sign. Also, they should be larger insize compared to the weaker children

• the general outlook of the pictures may need to beadapted for a rural setting. For the heavy workloadscenario, there should be some greenery in thebackground, which is very typical of a rural setting

• there should be both rural and urban scenes• changes could be made to the dress style• other tools on other health issues, such as pregnancy

testing and immunisation, should be developed.

Given family-planning issues, some women in urbancommunities of Karachi suggested that there should be onlyone child in each picture. For example, there should be apicture of a weak child along with the picture of the womanwho is doing hard work during pregnancy, while a picture of ahealthy child should be shown along with the picture of thewoman who is performing some light work.

Men’s views

With the exception of one or two participants, most of themen were not knowledgeable about the ajrak tools, as thetools were targeted at women. Those who knew about thetools mentioned that they seemed to be helpful andcommented that messages given verbally were not as wellunderstood as those illustrated with pictures.

When asked about the appropriateness of the tools, men werein favour of them, indicating that they would help women tounderstand about health-care practices during pregnancy andfor their children. They thought that the “charming”embroidery would facilitate in delivering the health messages.The women would take interest in them and would easily beable to understand the messages. They commented on how theembroidery work done on the ajrak with different colours


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“Verbal advice is like dream, whereasthese pictures are reality. All this is infront of them. They can visualise what isgood and what is bad.”

Men’s focus group Tando Jam

would be attractive to women, as would the different coloursmarking the healthy and unhealthy children. They did suggestthat some explanation from the LHW would be required toensure that the correct message was conveyed. The picturesgave a good visual comparison of benefits and risks.

An interesting observation made during group discussions inrural and urban settings was the fact that in urbancommunities men were more inclined towards conventionalpaper and card tools, along with some written description.Thus participants from urban communities in Karachisuggested that instead of cloth and embroidery, printed

pictures on paper or card should be used, which would have abetter visual impact. In one of the urban groups, participantspointed out that there was not much difference in the numberof weaker children in the two comparative situations. Theysaid that this minimal difference might be misleading, andthus the women might argue that there was not much benefitto carrying out the positive health practice.

In all of the groups, there were always participants who wereof the view that the tools were effective and did not requireany change in the design or material. A few participants inurban settings suggested that printed instead of embroiderypictures would be better, while some others said that somewritten description with each picture would make themessages easier to understand.

In contrast to the women, most of the participants in the men’sgroups agreed that showing the tools in groups would be moreuseful than in one-to-one meetings. In a group there would bemore interaction, debate and discussion. Women would beable to listen to other women’s views. Group meetings wouldalso save time. There were a few who preferred the one-to-oneinteraction, saying it was a better way to discuss andcommunicate on such issues because it provided some privacyand confidentiality.

When asked about using such tools with men, participantsagreed on the need to create awareness among men so that thewomen could get adequate support at home for appropriatehealth practices. This was especially the case for antenatal


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care and workload, as the men recognised that often womenmay be aware of these health practices but could not carrythem out due to a lack of support. They considered that thesame tools could be used effectively with men to explain thesemessages to them. The majority of them suggested using thesame method of presentation but some were of the view that itmay be more useful for men in groups or communitymeetings. In one community, some participants indicated thattalking with men, and especially youngsters, on these issuesmay not be culturally appropriate. Other possible methods to convey the messages as suggestedby the men’s focus groups included: group meetings anddiscussions, showing short video films, booklets, pamphletsand calendar-type charts with pictures. In one ruralcommunity the use of tablecloths and other household itemswas suggested, used for decoration and either embroidered,painted or printed with such health messages.

Other suggestions included:• for women, printing health messages on ghee and oil

tins, match boxes and tea packs, and dupatts (scarves)and hand fans

• for men, printing the messages on handkerchiefs, pensand caps

• printing the messages on rilhi (another Sindhi cloth), butin a bigger size so that it could be hung on a wall

A few suggested that kitchen items such as vegetables or fruitscould be used for comparison while having a discussion withthe women. Fruits or vegetables that are in bad conditioncould be indicative of bad health, while those that are freshand good could be used as a symbol of good health, and thereasons could then be discussed.

In one community the men acknowledged that the householdenvironment did not provide support for women to reducetheir workload during pregnancy. Men were usually out of thehouse from morning until evening, leaving women with nohelp. Until this situation changed, it would be difficult for


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“The process of development for these tools hasbeen very encouraging to the LHWs. They feltthat they are important, and their views can alsobe useful for making decisions for theprogramme. It has boosted their confidence.”

Dr Husna Memon Provincial Coordinator

Sindh, NPFP&PHC

“In communities where these tools have beenintroduced, they have become an identity forthe LHWs, as they are recognised as theladies who show the chart. It has given thema distinction.”

FPO Karachi South

“The process of involving the LHWs andthe communities in design and pre-testinghas made the tool more effective, as wellas acceptable to women and LHWs.”

Assistant LHW district coordinator Karachi South“Seeing is better than hearing. When

women see these tools, they betterunderstand the issue.”

Dr Husna Memon, Provincial Coordinator

Sindh, NPFP&PHC

women to follow the advice even if they understood theimportance of it.

Experience of supervisors and programme managers

As a part of the impact assessment, key-informant interviewswere conducted with the LHW programme management team.The team included provincial and deputy provincialcoordinators, FPOs, district coordinators and LHWSs from thethree participating districts.

One of the mandates of the NPFP&PHC is to provide servicesto the unserved population, establish communication withthese communities and share information and services onbasic family planning and primary health care.Communication is central to the role of the NPFP&PHC.Before the introduction of the evidence-led training and thedevelopment of the ajrak communication tools, the LHWs hadnever been involved in developing any curriculum orcommunication tools and had never used any mobilecommunication tools/aids for interpersonal communication athousehold level. The only aid used was in the form of wallcharts that were hung at the health clinics. The health-education cell of the Federal Ministry of Health developedthese charts on topics such as diarrhoea, oral rehydration salt,acute respiratory-tract infection (ARI), immunisation, dangersigns during pregnancy, anaemia and nutrition. The LHWprogramme management was not involved in the design ordevelopment of these charts.

The team found the process of the development of the ajrakcommunication tools an extremely useful learning experience

for the programme management, especially the FPOs,LHSs and LHWs themselves, who were encouraged toactively participate and give their views during the designand pre-testing. This facilitated their capacity-building ingenerating ideas, increased their knowledge base andcommunication skills, and provided them withconfidence. Their involvement was critical in ensuring

that the tools were acceptable to the communities, developinga sense of ownership between the LHWs and their supervisors,who keenly used these tools in the field. Members


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“The tools are so attractive andeffective that I used them myself,besides supervising LHWs to talkdirectly with the women in my owncommunity.”

LHS Missan, Hyderabad

“The process gave importance to ourviews and suggestions, which does nothappen usually, and we are reallyhappy about it.”

LHS Tando Jam

recommended that a similar process should be used to developfuture programme materials.

All the team members indicated that the tools proved effectivein communicating the desired message to the women. Thiswas because the tools were pictorial, they were developed in aconsultative process with input from a number of people whohad relevant field experience, they were properly tested beforeuse and they were based on strong evidence. Also, the toolswere easy to use and appealing to both LHWs and women inthe communities.

No difficulties were mentioned regarding the use of thesetools. The FPOs and district coordinators were satisfied withthe way LHWs used the tools. They emphasised that they didnot require any extra time to invest in monitoring, as itintegrated well with their routine activities. The LHWSsmentioned that they had to spend some extra time, rangingfrom 10 to 15 minutes per household, to monitor the use ofthe tools. However, they attributed this mainly to the extradiscussion generated around the use of the tools.

Most of the FPOs and LHWSs shared the view that moreinput from the CIET team would have helped with themonitoring process. They suggested more frequent meetings

between the CIET team and the LHSs, coupled with fieldvisits to directly observe the way the LHWs were using thetools. This would help with a two-way feedback and enhancequality during implementation.

When asked how the implementation of the tools could belinked to the existing training curriculum, all the respondentssaid that there should not be any problems, as all the conceptsrelayed through the tools were already part of the curriculum.Currently LHWs are being trained and advised tocommunicate on these health-practice concepts, although onlyverbally. In fact, many were of the opinion that these toolswould serve the purpose of being supportive material fortraining, as they would also help the LHWs themselves tolearn these concepts better.

All the respondents were very keen to scale the


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implementation of the tools to the provincial level. In addition,they suggested developing similar tools on other issues, suchas diarrhoea, ARI, nutrition, family planning, essentialobstetric care and community mobilisation. When asked aboutthe possibility of scaling the initiative to the national level,they were supportive and indicated that other provinces wouldbenefit from such an approach. However, they emphasisedthat it would be extremely important to build in local designconcepts to ensure acceptability and ownership of the tools.This could be achieved only by involving the teams fromprovincial management in each province in the same way thatwas done in Sindh and ensuring that their inputs wereincorporated.

Respondents indicated that the effectiveness of the ajrak clothas the basic medium would be appreciated in all of theprovinces and could result in the same effectiveness. Theavailability of financial resources, maintaining the quality oftraining and supervision, and local cultural taboos were someof the important challenges identified by the respondents for awider implementation of the activity. In addition, a strongpolicy commitment and advocacy on the part of the provincialand national programme implementation units to push forscaling up the activities would be required. Involvement ofdonors through the Federal Ministry of Health for thedistribution and use of the tools on a wider scale wassuggested.

Some FPOs also suggested that testing the tools in some othercommunities, and in a relatively larger and more diversecatchment area, may be useful, before finally deciding onimplementation at the provincial and/or national level. Toensure the quality of training and supervision, the extensionshould be gradual, with addition of new areas and LHWs overa defined period. There was definite interest expressed by theprovincial coordinator and her team to extend all possiblesupport for a follow-up and further extension of the activity.


in Pakistan 36

FUTURE POLICY IMPLICATIONS AND NEXT STEP

The joint venture of the NPFP&PHC and CIET has proved tobe a useful learning experience. The participatory approachand the process of involving all the stakeholders in thedevelopment of the tools have been effective and appreciatedat all levels of management. The process helped build localcapacities and confidence to take on such initiatives. Itespecially enhanced the confidence, knowledge and skills ofgrassroots workers such as LHWs and their supervisors toparticipate in such activities and bring innovative ideas fromthe field. The process also helped bring different levels ofmanagement closer to each other, where everyone felt equallyimportant. This in turn has aided in developing an ownershipof the activity and resulted in indigenous tools. All those whowere involved strongly recommended that a similar approachbe used while conducting such activities in the future.

Communication of key health-care practices forms a majorpart of an LHW’s activity. However, until now LHWs havebeen doing this verbally, without using any supportivecommunication materials. This project has for the first timeattempted to equip LHWs with an aid that facilitates theircommunication with women. From the impact assessment it isclear that the ajrak communication tools have been effectivein communicating the evidence-based messages to the womenthrough LHWs, and that they have had a beneficial impact onsome if not all of the targeted practices. Given that the timefrom design to assessment was considerably short (10months), it is possible that a stronger effect could be expectedif LHWs continued to use the tools over a longer period andon a larger population. It may therefore be useful, and wasrecommended by the provincial programme managementteam, to widen the scope of the project and include morecommunities in different districts and provinces.

The introduction of evidence-led communication tools hasalso improved the overall performance of LHWs in terms ofthe regularity and frequency of their visits to their clients. Ithas improved their knowledge base and communication skillsand has provided them with an effective interactivemechanism to convince their clients to improve health-carepractices. LHWs were more focussed in terms of the messages


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“I strongly recommend to expand the scopeof implementation of this activity atprovincial as well as national level. Also,similar tools should be developed for otherissue, such as diarrhoea, low birth weightand essential obstetric care. The PPIU ismore than willing to provide all the help thatis necessary.”

Dr Husna MemonProvincial Coordinator

Sindh, NPFP&PHC

to be conveyed and, as mentioned by one LHS, “tended toforget less about what they were supposed to communicate”. The introduction and inclusion of the use of thesecommunication tools by LHWs as a part of their routineactivities may therefore have a positive effect on the overallperformance of the LHW programme.

The supervision and monitoring of the communication toolsintegrated well with ongoing routine monitoring. Based on theexperience shared by the LHWSs and FPOs, they did not haveto invest too much extra time in monitoring the tools. In fact,the use of the tools in the field helped to focus the efforts oftheir supervision. The LHWs became more vigilant and active.Using these tools in the field may have helped instrengthening the supervision and monitoring of the fieldactivities of the programme.

Experiences and findings from the project are to be shared inthe near future in a provincial consultation forum jointlyorganised by the PPIU and CIET, involving programmemanagers, policy makers and supporting agencies such asdonors. It is hoped that the forum will help to identify anaction plan to incorporate the lessons learned into the currentprogramme policies of the NPFP&PHC and be a catalyst fortaking this pilot project to scale nationally.


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ANNEXES


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Annex I

List of the participants of the provincial consultation forum

1. Dr Zahid Larik, national coordinator NPFP&PHC, Pakistan2. Dr Husna Memon, PC NPFP&PHC, Sindh3. Dr Akram Nizamani, DPC NPFP&PHC, Sindh4. Dr Gortan Das, provincial training focal point NPFP&PHC, Sindh5. Dr Zulfiqar Ali Gorar, FPO NPFP&PHC, Sindh6. Dr Khairuddin Shah, district coordinator NPFP&PHC, Hyderabad district7. Ms Salma Ahmed, LHS RHC Misson Waddi, Tando Allahyar, Hyderabad (rural)8. Ms Koshela Kor, LHW, Tando Jam, Hyderabad (urban)9. Ms Nusrat Rehman, LHW, Tando Jam, Hyderabad (urban)10. Ms Shakeela Naz, LHW, Tando Jam, Hyderabad (urban)11. Ms Shamim Bano, LHW, Tando Jam, Hyderabad (urban)12. Ms Naila Khatoon, LHW, Tando Jam, Hyderabad (urban)13. Ms Naila Perveen, LHW, Qasimabad, Hyderabad (urban)14. Ms Shamim Bano, LHW, Misson Waddi, Tando Allahyar, Hyderabad (rural)15. Ms Nusrat Shaheen, LHW G.O.R, Hyderabad, (urban)16. Ms Shahida Shah, LHW, G.O.R., Hyderabad, (urban)17. Ms Lubna Akhtar, LHW, G.O.R., Hyderabad, (urban)18. Ms Niamat Ali Shah, LHW, Misson Waddi, Tando Allahyar, Hyderabad (rural)19. Ms Shahida Sangi, LHW, Qasimabad, Hyderabad (urban)20. Ms Hameeda Hakim Ali, VBW, Qazi Noor Mohammad Laghari, Hyderabad (rural)21. Ms Nasreen Rehman, VBW, Sangar Chang, Hyderabad (rural)22. Ms Fouzia Ghaffar, VBW, Haji Hakim, Hyderabad (rural)23. Ms Rizwana Rehman, VBW, Khairo Talpur, Hyderabad (rural)24. Ms Shamim Bhatti, VBW, New Hala, Hyderabad (rural)25. Ms Lal Khatoon, VBW, Old Hala, Hyderabad (rural)26. Ms Naseem Ashraf, VBW, Karan Khan Shoro, Hyderabad (rural)27. Ms Fouzia Bhatti, VBW, Sukhpur, Hyderabad (rural)28. Ms Safeena Khatoon, VBW, Hyderabad (rural)29. Ms Perveen Bughio, VBW, Nachani, Hyderabad (rural)


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30. Ms Naheed Azra, LHV, HOPE Karachi31. Ms Bilqees Jehan, social organiser HOPE Karachi32. Ms Sabeen Ahmed, social organiser HOPE Karachi33. Dr Sharmila Mhatre, programme manager, CIETpakistan34. Dr Khalid Omer, PC, Sindh, CIETpakistan35. Mr Noor Muhammad Ansari, PC, Baluchistan, CIETpakistan


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Annex II

Provincial consultation forum of LHWs

Summary: Provincial consultation forum with the National Programme for Family Planning andPrimary Health Care (April 8, 2000)

To facilitate the involvement of the provincial team for the NPFP&PHC, a provincialconsultative forum was held in Hyderabad, at the Directorate of Health Services Sindh office.The objectives of the forum were to share and discuss evidence obtained from the BoC surveyrelated to the impact of LHWs in communities of Sindh and initiate an interactive process withLHWs and programme staff of LHWs to develop evidence-led training and communicationmaterial to complement the existing training programme in Sindh and increase the effectivenessof the work of LHWs.

Initial contact and meetings with Dr Zahid Larik, national coordinator of the LHW programme,Dr Ayoub Salayria, training specialist, and Dr Fauzia Aqeel, FPO, provided an opportunity toshare the conceptual framework of the proposed project, to learn more about the project and toget feedback on it. Following this, a number of coordination meetings were held with Dr HusnaMemon, PC for NPFP&PHC, and her team. With their commitment and support, a technicalsteering committee was formed to facilitate the project activities. The same helped in organisingthe forum. A meeting was also held with Ms Rukhsana Saleem, the secretary health department,Sindh, to ensure involvement at the highest level.

Participants in the forum included Dr Zahid Larik, Dr Husna Memon, the PPIU team, includingdeputy and assistant provincial coordinators, selected FPOs, the LHWs’ district coordinator fromHyderabad, LHSs, LHWs themselves and village-based family-planning workers (VBWs). Inpreparation for the forum, three facilitators from HOPE who had previously worked on CIETcycles were retrained specifically for facilitating the focus groups and design sessions at theforum. The office of the Sindh Bureau of Statistics, which has been a strong partner in previousCIET cycles in Sindh, also helped by providing space to conduct training for the facilitators.

At the start of the workshop a baseline assessment was done to ascertain LHWs’ knowledge andpractices about their work and responsibilities. Most of the participants (9 LHWs and 5 VBWs)had been working in their respective designation for four years or more. All the LHWs andVBWs were very clear and specific about breast milk as being the first thing to be fed tonewborns. However, knowledge of exclusive breast feeding for the first four months was not asconsistent.

Except for one LHW and two VBWs, all indicated that they conduct antenatal care for pregnant


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women in their communities. However, VBWs were only paying visits to pregnant women,without any physical checkup or screening for danger signs. All the LHWs, on the other hand,mentioned that they check for danger signs and a majority (8/11) indicated that they do physicalcheckups. Responding to the question on advice about a reduction of workload duringpregnancy, a majority of both the workers indicated that they did discuss this issue with theirclients. There was, however, a mixed response on advising to completely stop work. Both LHWsand VBWs seemed well aware of the issue of domestic violence against women, as a majority ofthem reported to discuss this issue with their clients.

Evidence relevant to the practice of LHWs from the BoC cycle was presented with somediscussion. This process really provided encouragement to the LHWs as it highlighted the impactof the LHWs’ work.

In order to get some in-depth information about the perceptions and knowledge on some keyissues related to their work, focus-group discussions were held with the participants. For this,LHWs and VBWs were evenly divided into two groups. All the participating LHWs and VBWsindicated that they conducted antenatal care for pregnant women in their communities. However,discussion revealed that there was a possibility that some of the LHWs might not be conductingthe full scope of antenatal-care activities. Some of the LHWs indicated that some LHWs onlygive advice on issues such as nutrition and vaccination, then refer the women for formalcheckups to the health facility rather the conducting physical checkups themselves. Othersindicated that in some areas LHWs may not be as mobile as in other areas, so they tended to stayat home and did not visit women. The discussion indicated that the participating LHWs werevery clear about their scope of practice around antenatal care. However, due to some minordifferences in the activities performed by LHWs in their respective communities, some of theLHWs may have doubts about identifying what they do as proper “antenatal care”.

Participants in both the groups agreed that domestic violence is a universal problem and exists inalmost all of the communities, though the intensity varies from community to community. Withincreasing awareness, they believe that the situation is improving. Most of them attributed theviolence to poverty, especially in situations where the husband is unemployed and the wife has towork to earn for the family. Some also mentioned illiteracy as a cause. They recommended thatmeasures for poverty alleviation and improving literacy, especially among females, need to beimplemented as long-term measures. The role of husbands and community leaders was alsoidentified as important to prevent or resolve such cases. In terms of their role in addressing thisissue, all the participants reported that they were already talking to women, as well as theirhusbands and other family members, and trying to resolve the issue.

All the participants agreed that at the field level when they try to convince people to practisehealthier habits, motivation or counselling alone was not enough, as their clients expected themto provide, with the advice, medicines or other supplies. Some LHWs mentioned that they wantto learn vaccination and use of injectable medicines for family planning, as their clients are


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motivated but they cannot get to the health facility. Suggestions for communication aids includedideas such as handbills, posters, pamphlets and some pictorial guides to explain to women aboutdifferent health topics. They were of the view that it would be helpful if the materials could beleft behind for the families.

Once the two groups were finished, all participants were brought together in a plenary session todemonstrate the use of the communication tools. A communication tool developed earlier byCIET for the BoC cycle was used in the demonstration. The tool consists of a poster withpictures of risk factors supported in a wooden frame, with dolls on a wooden runway standdepicting children younger than three years of age, some of whom are normal and somemalnourished (low height for age). The purpose of the demonstration was to show how tools canfacilitate the communication of evidence. To enable participants to gain a fuller appreciation ofthe tool, a few participants were asked to present the tool to the forum. After each participant hadmade her presentation, some tips were given, which were taken into consideration for thesubsequent presentations with the communication tools.

Participants later worked in small design groups to brainstorm and discuss ways and means touse evidence for communication. The scope of the group work included discussion on the natureof the tools and key messages (words and phrases) that can help to communicate the evidence.During these groups the PC, DPC, APC, provincial focal point for training of LHWs, FPO forHyderabad and Karachi West districts, district coordinator and assistant district coordinator ofHyderabad district remained present and actively participated. The LHWs also took keen interestand provided their inputs. Different ideas and alternatives were discussed towards developingevidence-led communication means and tools. Besides home visits, other ways ofcommunication that were suggested included community meetings and gatherings, and the use ofmass media such as television and radio. For the development of the messages, participantsemphasised using words that are easily understood by the mothers in their local language. Themessage should include the benefits of having a good caring practice as well as harms from notpractising it.

Participants started with some conventional methods, such as pictorial charts, booklets, postersand calendars with pictures. However, with further discussion it was believed and agreed uponthat there is a need to try something different. The tools should relate to the local culture andtraditions, so that women and mothers do not feel as if something from “outside” is beingimposed on them. One of the groups came up with the unique idea of using a piece of local cloth,which is very popular, and adorning it with pictures, using local home-based techniques ofembroidery and small dolls made of cloth and some stiff material such as cardboard. Theparticipants suggested taking two or three options for communication tools and then pre-testingthe material in the field to see which works and which does not. Based on the results from pre-testing, the tools that worked the best could be chosen and distributed to LHWs for continuoususe in the field. All the LHWs agreed that they would use such material if provided, as it wouldimprove the impact of their work.


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The forum also provided a useful opportunity for Dr Larik to interact closely with the LHWs onsome of their concerns and problems. He once again mentioned commitment from theNPFP&PHC for this initiative.

The forum concluded with remarks from the PC and a joint vote of thanks from the NPFP&PHCand CIET teams to the LHWs and VBWs. At the end of the forum participants evaluated theprocess very highly, especially the opportunity to interact with all the levels of management,discuss information and provide inputs on an equal basis for improvement. All participants ratedthe forum as a useful exercise.


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Annex III

User’s Manual (Evidence-led communication tools guidelines)For Lady Health Workers

BackgroundThe situation of health in Pakistan, especially for women and children, is not encouraging.During the last decade, both Government and civil society have focused their attention onbringing improvement to the health sector. In this regard, one of the major initiatives by theGovernment of Pakistan is the National Programme for Family Planning and Primary HealthCare (NPFP&PHC). Under this programme, Lady Health Workers (LHWs) are recruited fromlocal communities, especially in rural areas of the country. These LHWs are trained to work atcommunity level to provide services for family planning and primary health care. They havebeen effective in promoting health education in their respective areas at household level.

During 1997-98 CIET, an international non-governmental organisation, conducted countrywidesurveys on mother and child care. Besides identifying key interventions for improvement in thecare, the findings of the study also revealed a difference in the knowledge and practices ofprimary health care in communities with LHWs compared with those communities withoutLHWs. This in turn has resulted in improvement in general health-care practices for children,especially in rural areas.

The evidence from this study by CIET, entitled The Bond of Care, provided the basis to takesome measures to strengthen the role of LHWs at household level. Specifically, it provided theopportunity to build the communication skills of the LHWs and enhance their effectiveness incommunicating health messages to mothers through the development of evidence-ledcommunication training and tools. CIET, by working closely with the Sindh provincial teams ofthe NPFP&PHC, has been providing technical assistance to develop evidence-led communicationtools that are an aid to the LHWs for their routine activities. Initially, the initiative is beingpiloted in three districts of Sindh province. To develop the evidence-led communication trainingand tools, conventional methods were avoided and a more interactive and participatory strategywas followed. The points considered to evolve the new evidence-led communication toolsincluded: < the communication methods should be user-friendly so that the health messages conveyed

by LHWs are easily understandable for women< the evidence-led communication tools should be indigenous and reflect local culture< the design of the tools should be attractive to LHWs and their clients, evoking their

attention< the tools should be durable or long-lasting< the tools should be cost-effective


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Complete the usual process of greetings (salams) with the woman beforepresenting the communication tools.

Do not start explaining about the tools, but rather convey your message or adviceby asking selected questions. This initiates the woman to start thinking aboutthese issues and sparks interest.

Working with the provincial team of the NPFP&PHC and LHWs, the evidence-ledcommunication tools were developed. This started with a consultation session and design focusgroups, followed by several smaller group discussions. Starting with the evidence, everysubsequent step systematically involved the voices of the LHWs, down to the types of threads tobe used in the resulting communication tools. Women in the communities were also involved inthe development during the piloting of the tools.

How to use the evidence-led communication tools

A. The introduction

The evidence-led communication tools have been developed to strengthen the interaction by LHWs athousehold level. For effective communication and to make full, effective use of the communication tools, itis critical that the following guidelines are followed.

For example, you can initiate the discussion with the following introductory sentences.

Asalam-o-Alaikum. How are you doing?

Today I want to discuss with you care during pregnancy and child health. A survey has identified keyfindings about mother and child care. We have tried to sketch out these findings using local embroidery.

B. Health message # 1: Antenatal checkup

Take out the cloth tool, but display only the pictures of the children at the bottom of the cloth. Usingthe questions 1 to 3 below, discuss the embroidered pictures. The questions are like prompts to helpthe woman identify for herself the differences among the illustrated children. (Clearly explain that allthe children are of the same age.)


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Keep discussing the pictures, using these questions, until thewoman identifies the correct numbers of weak and healthy childrenin both the groups. After this, proceed with the next questions.

Encourage the woman to identify that the picture shows awoman going for an antenatal checkup.

Picture: 2

(ten children under situation ‘no antenatalcheckup’)

Picture: 1

(ten children under situation ‘antenatal checkup’)

Question 1: Though all these children are of same age, what difference do you see between them?(Askfor both the groups of children.)

Question 2: Can you count the healthy and weak/malnourished children in both the groups? (Ask bypointing at both the groups of children.)

Question 3: In which group do you notice more weak/malnourished children?

Yes! Among the ten children in the picture on your right, four are weak/malnourished and six are healthy.In the other group, five are weak/malnourished and five are healthy. Though all these children are of thesame age, there is a visible difference in their health status. Let’s see why this is so.

Exhibit the upper part of the cloth and use questions 4 to 7.

Picture: 4

(no antenatal checkup)

Picture: 3

(antenatal checkup)

Point at picture 3 and ask:

Question 4:What is the situation shown in this picture?

Question 5: Can you tell why this woman is having a checkup?


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Keep discussing until the woman herself identifies that one of the picturesshows a pregnant woman going for an antenatal checkup, whereas theother shows the woman not going.

Picture: 5

Whole chart

Get the woman to make the link between the higher number of malnourishedchildren and the mother who does not go for antenatal care.

If the woman has gone for antenatal checkups, then encourage the woman. If sheis not going for antenatal checkups, than remind her of the risk of not going forantenatal checkups by pointing at the picture.

Yes, you’re right. This is a pregnant woman and she is with a lady doctor for her antenatal checkup.

Point at picture 4 and ask:

Question 6:What is the situation shown in this picture?

Question 7:What is the difference in the two situations (pictures 3 and 4)?

Unfold the whole communication tool and, using questions 8 to 10, help the woman to make the linkbetween the practice of going or not going for antenatal checkups and the impact of this on a child’shealth.

Question 8: Can you tell me which of these practices is more likely to increase the risk of havingmalnourished children?

Question 9: So, which of these practices would you prefer to follow?

Question 10: How many antenatal checkups have you had so far?

As you can see, not going for antenatal checkups increases the risk of having a malnourished child. Betterhealth for both mother and child can be ensured by having antenatal checkups.

To fully convince the woman to go for antenatal checkups, discuss the following points:


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Keep discussing these questions until the womanidentifies the correct number of weak and healthychildren in both the groups. After this, proceed with thenext questions.

• Any difficulties she faces going for antenatal checkups.

• When and how she would go for antenatal checkups.

• Remind her of your help if she feels she would benefit from the support of an LHW to be ableto go for checkups.

Conclude your discussion on this message in these words:

Now that you know about the negative impact on your child as a result of not going for antenatalcheckups, what are some of the ways you think you can make sure you can go for antenatal checkups atleast three times during your pregnancy?

C. Health message # 2: Heavy workload during pregnancy

Display only the pictures of the children at the bottom. Discuss the picture using questions 1 to 3 below.(Clearly explain that all the children are of the same age.)

Picture: 2

(ten children under situation ‘heavy work load’)

Picture: 1

(ten children under situation ‘reduced heavy workload’)

Question 1: Though all these children are of same age, what difference can you see in them?(Ask forboth the groups of children.)

Question 2: Can you count the healthy and weak/malnourished children in each group? (Ask bypointing at both the groups of children.)

Question 3: In which group are there more malnourished children?

Yes! Among the ten children in the picture on your right, four are weak/malnourished and six are healthy.In the other group, five are weak/malnourished and five are healthy. Though all these children are of thesame age, there is a visible difference in their health status. Let’s see why this is so.

Now show the upper part of the cloth, showing the different workload situations during pregnancy. Usequestions 4 to 8 below to discuss this with the woman.


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Encourage the woman to identify that women can havedifferent workload conditions during their pregnancy.

Keep discussing until the woman identifies that:– the women shown in the pictures are pregnant– one of the pregnant women is doing heavy work– the other pregnant woman has reduced her heavyworkload

Picture: 4

(Heavy work load during pregnancy)

Picture: 3

(Reduced heavy work load during pregnancy)

Point at pictures 3 and 4 and ask:

Question 4:What is this woman doing? (Ask for both the pictures.)

Question 5:What is the health condition of the women shown in these pictures? (This is for the woman toidentify the pregnancy status of the women depicted in the pictures.)

Question 6:On both sides a pregnant woman is shown doing something. What is the difference in the twosituations?

Question 7:Which of the pregnant women is doing heavy work?

Question 8:Which of the pregnant women is doing less heavy work?

Explain by pointing at the pictures.

Yes! As you have said, one of the pictures represents a woman who has reduced her heavy workloadduring pregnancy. The other picture represents a pregnant woman who has not reduced her heavyworkload. Let’s see how these practices of pregnant women have an impact on the health of theirchildren.

Display the whole cloth and discuss it with the woman using questions 9 to 11.


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Picture: 5

Whole cloth

While asking questions 12 to 14, encourage the woman to thinkabout reducing her heavy workload during pregnancy and discusshow she can do this. If necessary, also convince other familymembers to help her reduce her heavy workload.


Question 10: Can you tell me which of these practices is more likely to increase the risk of havingmalnourished children? (Point at both the pictures.)

Question 11: So, which of these practices would you prefer to follow?

Then, once again, emphasise the following message:

As you can see, reducing heavy work during pregnancy is very important. If you do not reduce your heavywork during pregnancy, your child will be at a higher risk of malnourishment.

Conclude your discussion on this message by asking the following questions:

Question 12: How would you ensure that you reduce your heavy workload?

Question 13: Who can help you?

Question 14: In your view, how can other pregnant women in your community reduce their heavyworkload?

D. Health message # 3: First thing fed to the newborn and colostrum

If you are explaining this health message to the same woman with whom you have discussed previousmessages in the same sitting, start as follows:

So far, we have discussed antenatal care. For better care during pregnancy, it is critical that you shouldgo for antenatal checkups and reduce your heavy workload. These practices have a positive impact on thenourishment of your child. Let’s now discuss childbirth and care.


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Keep discussing the question until the woman identifies the correctnumbers of weak and healthy children in both the groups. Afterthis, proceed with the next questions.

If you are explaining this health message in a separate sitting, or only this message is to be discussed,start as follows after the introductory conversation:

Display only the pictures of the children at the bottom of the cloth. Use questions 1 to 3. (Once again,clearly explain that all the children are of same age.)

Picture: 2

(ten children under situation ‘other things fedafter birth’)

Picture: 1

(ten children under situation ‘colostrum fed afterbirth’)

Question 1: Though all these children are of same age, what difference can you see in them?

(Ask for both groups of children.)

Question 2: Can you count the healthy and weak/malnourished children in both the groups? (Ask bypointing at both the groups of children.)


Yes! Among the ten children in the picture on your right, five are weak/stunted and five are healthy. Inthe other group, six are weak/stunted and four are healthy. Though all these children are of the sameage, there is a visible difference in their health status. Let’s see why this is so.

Now show only the upper part of the cloth, illustrating feeding practice of the newborn. Discuss this usingquestions 4 to 6.

Picture: 4

(Other things fed to new born after birth)

Picture: 3

(Colostrum fed as first thing after birth)

Point at pictures 3 and 4 and ask:

Question 4:What do these pictures tell us? (Ask for both the pictures.)

Question 5:Where is the newborn in these pictures? (Ask for both the pictures.)


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Encourage the woman to identify that in one picture thenewborn is being fed colostrum as the first thing, whereas inthe other picture something else is being fed to the newborn.

Picture: 5

Question 6: What is the difference in the two situations?

Now display the whole cloth and discuss it using questions 7 and 8.

Question 7: Can you tellme which ofthese practicesis more likelyto cause risk of having malnourished children? (Point at both the pictures.)

As shown in the pictures, in some households the babies are not fed colostrum after birth. They are givensomething else, which can increase their risk of being malnourished.

Question 8: So, what would you prefer to feed your baby after birth?

Your opinion is right: newborns should be fed colostrum just after birth. Also, it is important that a babyshould only be breastfed (exclusively) for the first four months.

Conclude your whole discussion with following words:

Today we discussed antenatal checkups, reducing heavy workload during pregnancy, first feedingnewborns colostrum and exclusively breastfeeding for the first four months. I hope you have understoodthe benefits of these practices and would choose the better practices for you and your child.

Looking forward to see you again

Thank you very much.


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Annex IV

Field workers who participated in the impact assessment

We would like to acknowledge the hard work and commitment of the following field workersinvolved in the impact assessment:

Karachi teamKhalid Omer, team coordinatorRukhsana Shaheen, supervisorRubina KausarRubina SaeedSaimaAsma

Hyderabad teamNoor Muhammad Ansari, team coordinatorGharnata Tabassum, SupervisorAmna KhanBushra GhauriNasreen NigarSadaf Jokhio


72CIET (Community Information and Epidemiological Technologies) is an international group of non-profit NGOs, academicinstitutes and charities dedicated to building the community voice into planning. 73 Andersson N. Evidence-based planning: the philosophy and methods of sentinel community surveillance.CIETinternational/EDI World Bank: Washington, 1996.74Andersson N. Impact, Coverage and Costs: An operational framework for monitoring child survival emerging from twoUNICEF projects in Central America. September. 198575Andersson N, Martinez E, Cerrato F, Morales E and Ledogar RJ. The Use of Community-Based Data in Health Planning inMexico and Central America. Health Policy and Planning 1989;4(3):197-206. 76 Arostegui J. Los Sitios Centinela en Managua, Nicaragua. UNICEF, Managua, 1992.77 McTyre L. Assessment and analysis of progress towards National Plan of Action goals in Mozambique, UNICEF, 199378 Munroe L. Sentinel Community Surveillance in Zimbabwe, Evaluation News, UNICEF, Sept. 1993

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Features of CIETmethods

‘ Data collected from cluster sites, selected to be representative of a district, a region or a country. ‘ Repeated cyclical process, each cycle including planning and instrument design, data collection, data

analysis and interpretation, and communication of results.‘ Each cycle focuses on a particular area or problem, not trying to collect data on a wide range of

problems.‘ Quantitative data from household questionnaires combined with qualitative data from focus groups,

key informant interviews and institutional reviews from the same communities (that is, the data arecoterminous) allow a better understanding of the quantitative data. This combined analysis is calledmesoanalysis.

‘ Data analysis is not only in terms of indicators (for example, rate of childhood measles) but also interms of risk (for example, the risk of measles in an unvaccinated child compared with a vaccinatedchild).

‘ Analysis gives results in a form that assists planning at household, community, district and nationallevels.

‘ The same sites are revisited in subsequent cycles of data collection, allowing easy estimation ofchanges over time or as a result of intervention.

‘ Each cycle of data collection and analysis requires a communication strategy to get the information tothose who need it for planning.

‘ Transfer of skills of data collection, analysis and communication over a number of cycles is an explicitaim.

Annex V

CIET methodsThe CIETmethods72 was originally conceived to build capacities while producing accurate,detailed and actionable data rapidly and at low cost73,74. Ordinarily, the focus is on the use ofepidemiological data in local or national planning75. This may be at the level of a municipality, acity76, a state, a number of provinces77 or an entire country78. The approach permits community-based fact-finding through a reiterative process, addressing one set of issues at a time. CIETmethods is a cross-designof qualitative and quantitative techniques that permits a holistic picture of – and locally designed solutionsto – a particular problem. It is a cost-effective way to collect community data, presenting them in anappropriate form for planning at local, regional and national levels. CIETmethods has been used incommunity surveys in many countries and specifically in Service Delivery Surveys in a number of


79 CIETinternational and World Bank EDI. Service delivery surveys: applying the sentinel community surveillance methodology.Country overviews. EDI/World Bank, 1997.

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different countries79. Some of the key features of the methods are shown in the box..

evidence-led training and communication tools for lady ... · evidence-led training and...

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