There are four main themes emerging from the results regarding HA experiences. The perceptions include; collaborative work experience, personal growth, community response of health animation and challenges with implementation.
Collaborative work experience
The HAs were generally pleased with their training and the progress of the work they carried out in the community “With the chief’s involvement it has made the work easy for us to engage with the community…people accepted our message” (IDI). They indicated that the workload was manageable, through hosting of two meetings a month, covering topics introduced in the training sessions, ‘People have been attending the meetings consistently…they show interest” (IDI). The HAs also expressed a keen interest in continuing the work independently in future as they were able to appreciate the benefits of such a programme in their community.
“As health animators we are happy with what we learn. We hope to continue this work even after the project has left. I urge [the project] to continue to teach us more so that we become experts at the end [of the program], and that we are able to run this [malaria workshop] on our own’ (FGD).
Support structures
The HAs considered the village chief an important part of the implementation process. Village Chiefs were involved in the selection of the HA and also supported the running of the workshops. “To call for a meeting we need to use the chief, without announcing through the chief people would not come to our meeting” (IDI). The Chief would be responsible for announcing the dates for community workshops and was present at some of the meetings, if unavailable, the chief would send a representative.
The HAs also worked together with government health workers, who took on a supervisory role in the community workshops. Their relationship to government health workers also created a system of accountability, where people visiting the clinic frequently with malaria were referred to attend community workshops in order to learn more about prevention of illness. The Government health workers also assisted in correcting the animator or reinforcing important messages at the community workshops, “the government [community health] workers help us where we get stuck in disseminating information” (FGD). Health talks held at health centres would disseminate information which tallied with lessons learned at the workshops. This gave the community more confidence in the message imparted by the HA in the community. The referrals from the health centres also increased the numbers of participants in the community workshops during the first year of running community workshops.
Personal motivation and growth
Health beliefs
The valuable benefit of the health animation training was the opportunity provided for the volunteers to personally internalise information and understand the real threat of malaria by understanding the main causes, as well as the importance of prevention and minimising the spread of infection within one community.
“The benefits of this job [community health animation] is that we are now aware of things that we did not know in the past. We now know the importance of rushing to the hospital when sick” (FGD).
“Before the project was introduced, when I had malaria, I would take medication up until I felt better. When my health improved, I would stop taking the medication. In a short time, I would get sick again. I would wonder why this happened…but now when I test for malaria and get medication, I complete the dose. I can go months now without getting sick” (FGD).
The HA felt they had to be convinced on the importance of changing their health behaviour, during their training, before carrying the message forward to the community. “A community health animator acts as a leader. If you do not lead by example, then it shows as though whatever you are promoting is of no benefit” (FGD). The HA leading by example, with people following the example, promoted change in health behaviour through the trust nurtured in this new relationship.
“Before we were made aware, when a person visits the hospital, they would get medication such as LA [Lumefantrine Artemether] and we would share it; if for example I get malaria I would take the medication without finishing it and give the rest to my friend when he gets sick. The project has made us realise that when we receive LA we ought to finish all of it…this shows a change in our lifestyle” (FGD).
Advocacy and peer influence
The general perception from respondents was that the influence of change would first begin with the HA before filtering into the community. The new information learned through the training changed their logic in understanding the disease, and therefore made them more aware of how best to change their behaviour to avoid infection and prioritise treatment.
“As an animator I am now knowledgeable of a few things I had not known [before]. Some people would deceive me by telling me that if I do hard backbreaking work I will get malaria, or if I get soaked in the rain then malaria follows. Since starting the health animation work, I have seen that it [previous advice] was a lie, malaria spreads with mosquitoes. I have also learnt that it’s not all mosquitoes that spread malaria” (FGD).
Through leading by example; adopting desired disease prevention and treatment health behaviour they were also able to appreciate the socio-economic benefits of minimising illness in the household.
“The benefits of animation work… from the training I received I am able to recognise what malaria is; how it starts and how it spreads and how I can personally avoid [infection]. It [health animation training] has helped me personally in my household with improving my life because of having less malaria, because I follow what I was taught…instead of wasting time at the hospital dealing with this disease” (FGD).
Their ability to influence their peers consequently assisted with dispelling false rumours of the origins of the disease, that perpetuate illness by promoting poor health seeking behaviour. The HA role helped the volunteers to lead by example in terms of managing malaria within their household.
Community participation
With the introduction of the community workshops, people were very eager to attend the meetings and appeared in large numbers proportional to the village population. From attending the workshops, community members were able to share what they learned with friends in their community, carrying the message along to those who were not attending the meetings. At times this also served as a way of encouraging others to participate in the workshops.
“In the beginning we would hold our meetings in the community, we would include plays to encourage people to attend the meetings. Those that missed the first meeting would show up to the next. They would ask questions…this was because malaria was causing problems [for them] and they wanted to understand [the problem]” (FGD).
“When a person attends a meeting and learns the benefits of taking medication or going to the hospital, they would take the message to their friends in the community to tell them what they were taught at the workshop…their friends would ask when the next meeting was so that they hear the message for themselves” (FGD).
The HAs required some level of creativity to maintain interest in their audience, as well as to encourage attendance. They would use theatrical performances as a way of making the lessons interactive. During the training they were encouraged to recruit audience members to perform a candid skit after each lecture. This was meant to display context of the lesson to the audience and was also used as a way of assessing how well the audience had understood the key message.
“We would use drama, and choir to get people to attend the meetings and to participate. We would select people from within the community and give them roles in a play with guidance and a topic” (FGD).
The scenarios used relayed the message of making positive choices on health seeking behaviour. This was designed to allow people to understand the importance of making the right choice as well as the implications of wrong decisions with regards to disease prevention and treatment.
In some instances, there was distrust in the community on the intentions of the research activities within the community. There was very little understanding on the objectives and intentions of the MMP randomised control trial. The HA acted as their point of contact with the MMP as well as the source of information where necessary.
“We had community members who did not take part in the workshops. When the research started [enumeration], people were then able to see the connection between our work and the research project. That is when we noticed more people attending the meetings, once they realised, we are connected to the project” (FGD).
“The community had a problem with the people putting the stickers on the door…they did not trust them; they would say they had other intentions that they were not disclosing. But as health animators we were able to explain properly the intentions of the project. People were then willing to accept the project and were then looking forward to receiving bed nets” (FGD).
Implementation challenges
Community Engagement
In general, people showed interest in the community meetings. However, there were some factors that affected attendance. “As you know, at the moment there is a problem of famine, and although we get handouts, people rush for piece work in the gardens” (IDI). During times of hunger or planting season, people would prioritise their farms and getting food over attending a meeting. Funerals were also prioritised over community meetings.
“Other times very few people came, especially if the meetings coincided with other activities... For example, if we held a meeting on the day there was a football match, that meant that we shared the crowd and we would have fewer people attending,” (IDI).
At times the HAs struggled with relating their teachings to services in the health system. In as much as the community was willing to change behaviour, the barrier existed when the health system was failing to provide the services that would encourage the community to reinforce the positive health behaviour change.
“We taught them about not using medication without getting a malaria test. But the problem is that some clinics that we have in the community, the doctors give medication without giving a test to check whether the person has malaria or not. This is making people ask ‘I thought you told us that we should only get medication when we have been tested for malaria? Why is it that these clinics do not have the equipment to test for malaria? we are receiving malaria medication without being tested’, yes” (FGD).
The MMP community is set in a disaster-prone area with crippling poverty. This created some problems in the community’s understanding of research and the intentions of the workshop for malaria. People expected to be given donations or benefit with more tangible items other than knowledge. This attitude was a result of receiving handouts from charity and governmental organizations in times of disaster.
“Some of the people say, ‘the project is useless. Whatever you promised to happen has not been done, so now we cannot listen to anything you have to say’. The chief would announce our meetings and people would not come. We would get maybe three people, but we still teach them because we need to do our job” (FGD).
The community was set to receive bed nets as part of the universal coverage of LLINs for the control arm of the RCT intervention. Due to logistical delays, the nets had not been delivered for over 18 months from the proposed date. The delay affected the commitment of the community to consistently attend meetings.
“Despite the challenges, we still feel this project has benefited the community. Even though nets have not been distributed, there are people in the community that own nets but don’t use them. Some would hold on to their nets and not use them expecting to use nets from the project. We would explain to them that they should still use the nets because between now and when nets are distributed, they could get sick, and it will be a problem for them not the project. Those who understood would [start to] use them” (FGD).
Attendance
Attendance was substantial during inception and increased gradually the first year of implementation. However, during the second year of the program, the numbers declined, making it difficult for some HAs to maintain the meetings consistently. The community did start to experience participation fatigue with the community workshops.
“In the beginning things worked very well and people had accepted [the programme] well based on attendance, I felt the work was progressing well…Currently, as animators we feel the work is good, but the community are tired of hearing the same message being delivered to the same group of people” (IDI).
The problem of declining attendance was largely due to the repetitive nature of the lessons or lack of new information in the second year, community members felt that they had assimilated the information well the first time and saw no need to be reminded or take the time to attend the workshops. The decreasing attendance forced the HAs to deviate from their prescribed engagement and communication methods. They would resort to some level of coaxing for participation, by promoting the idea of bed net distribution as an incentive to participate in the research. This would later lead to a coerced attendance of workshops.
“we would encourage them to attend the meetings. When they realised the link we had with the project we would explain to say that if they wanted to participate in the project, to receive the net, then that process would start here [attending workshops]. If they do not attend the workshop, then they would not participate in the research and would then not receive the net” (FGD).
“When we have problems with some communities, we sit down to discuss how we can approach that community…we are being creative and coming up with new ideas on how to approach people, at times raise money to give them a little entertainment so that we entice them to the meetings…there are challenges but with this program people can change [their behaviour]” (FGD).
With delays in implementing the net distribution, this coercion resulted in a drop in attendance of workshops as whatever was perceived as promised was not delivered to the community. As a result, the community felt there was no benefit in attending the workshops or engaging with the health messages delivered.
“At the start of our programme, we as health animators, would receive respect [from the community]. We would talk and people would listen. But now people are not willing to listen. They say that in the beginning they felt the project started off strong, but now it is weak, and they wonder why. We are not receiving respect…we need new ideas, to bring something different to the people so that they feel it’s a new thing so that they come back [to attend meetings], because right now we have lost them” (FGD).
“The strategy we are using now is that when the chief calls for a meeting, we take advantage of it. We tell them that we would like to give talks…the chief would say that when he is done with his meeting, we can then address the people. This is working, and this is the system we are now using. But if we tell the chief to call an independent meeting for our workshop in the community the people would say ‘that meeting is useless, a project with no benefits’ so we are being insulted for the work” (FGD).
Volunteerism
In terms of commitment to working as an animator, the concept of volunteerism was difficult to accept and manage in this rural and indigent context. The role of the animator was still understood as a type of formal employment, one that specifically doesn’t pay, “They say when you plant a tree, for it to live it must be watered. I think it would be good if this project had a way of engaging us frequently to keep us confident” (FDG 003 CHA). The cost of foregoing labour, especially for subsistence farmers, to run animation workshops, came at a significant cost to the household. This was most evident during the cultivating season as it limited what time they were able to dedicate to their role of generating income within their household.
“The activities of [animation] work and household work can be challenging when trying to manage time…it can be a problem because we do not get anything for it. It seems to be slowing us down a bit. Because we do not get trained frequently, we may forget we are animators” (FGD).
HAs were also mocked for taking on ‘employment’ without remuneration, it was seen to some of their friends as a waste of time that could be spent making money for the family. “The challenge with this job is that we work with no pay. We work without receiving anything because it’s voluntary” (FGD). At times this came with the consequence of the loss of respect from their peers in the community which also impacted the efficiency of their work for imparting knowledge to the community.
“We are told that we are leaving productive jobs to do something with no [financial] benefit ‘the time you are spending here, we are spending in the field farming’…Because we opted to do the work, we still continue to do it” (FGD).
Most of the animators expressed their concern on the loss of income and suggested some form of payment, however minimal, to cover the cost of foregoing labour for their households.
“As a woman it presents some challenges, I have to tell my husband that I am going to work so he will be alone working in the field. At times he will tell me the days are too many and I am not contributing much to the home. I do apologise and continue doing the [animation] work” (FGD).
The limitation on income at times created the situation where animators were forced to migrate to seek employment, which meant they were unable to run workshops in the community, “at times we feel it’s better to go across to Mozambique to do some piecemeal work instead of running workshops…we feel neglected” (FGD). At the start of the program they did admit to accepting the role and understood the nature of voluntary work. However, they assumed that they would be trained frequently. The frequent training would mean access to a monetary allowance for attending the training. It was assumed this would be the alternative source of income if they would be foregoing labour dedicated to other modes of generating income.
“Our friends are in small projects where they get a budget [money] and they say ‘oh well you are an animator’ and we would not be given other roles [in community work]. It’s a big problem…We are not paid; we are struggling to pay fees…the man of the house alone cannot do everything. Maybe in future they [the project] can consider that” (FGD).
When the opportunity for monetary allowances was not available to them, they were forced to seek employment elsewhere or find alternatives for income generation. This meant the running of workshops was inconsistent and at times incomplete. This situation forced them to falsify reports; a requirement for them to maintain their role as a HA.
“We go to Mozambique for work and not run the workshops. When they ask us for reports [from workshops] we can write false reports. This is because we are not monitored or supported adequately” (FGD).