CRS/GHANA’S PRESENTATION

DANISH WATER FORUM & NETWORK FOR INTERNATIONAL HEALTH

WORKSHOP

SOGAKOPE

18 – 20 SEPTEMBER 2007

TOPIC:

CRS’ BEHAVIOR CHANGE STRATEGIES, SUCCESSES,

CHALLENGES AND LESSONS LEARNED

OVERVIEW OF CATHOLIC RELIEF SERVICES PROGRAMMING

History/Background of CRS’ Work in Ghana

• CRS has operated in Ghana since 1958 with the goal of improving the quality of life among the poor and the most vulnerable and helping victims of natural and man-made disasters. The choice of beneficiaries is based on the agency’s mandate to alleviate suffering and its commitment to work for the poorest of the poor. These are most often women and children in food insecure households in rural communities where the major income generating activities are rain-fed farming and small scale local based agro-processing.

History/Background of CRS’ Work in Ghana Cont.

To achieve its goal, CRS/Ghana acts as aservice and support agency for programsand projects, which are implemented by theCatholic Church, the Government of Ghanaand its various ministries, departments andagencies, and other religious and nonreligious and non-governmentalorganizations that pursue commondevelopment goals.

History/Background of CRS’ Work in Ghana Cont.

• CRS/Ghana has interventions and programs in several development sectors, including Education, Health, Water and Sanitation, HIV/AIDS, Safety Net Initiatives, Peace-Building and Conflict Transformation, and Agribusiness.

• The three regions in the northern most part of Ghana are cited in the Ghana Poverty Reduction Strategy II as the regions experiencing extreme poverty.

History/Background of CRS’ Work in Ghana Cont.

These are also the regions with the highest levels

of malnutrition and stunting among children,

highest child morbidity and mortality rates, lowest school

enrollment and completion rates, especially among girls,

highest adult illiteracy levels, and the regions with the most

recurrent cases of guinea worm and other water-borne

diseases. As such, in pursuit of CRS’ global determination

to reach out to the “poorest of the poor”, CRS/Ghana made

a just decision since 1987 to focus its limited resources in

the three northern regions, in all its 34 districts.

Programs/Interventions

• Working with local church ,government partners, and other NGOs, CRS/Ghana supports development through specific activities or programs as outlined below.

• School Feeding: provides hot meals for pre and primary school children and take home rations for girls to promote enrollment, attendance and retention of school aged pupils.

• School Health Education Program (SHEP): Recognizing the link between health and school attendance, SHEP promotes appropriate hygiene practices, teaches health education and provides children with deworming tablets twice yearly

Programs/Interventions (Con’t)

• Quality Education Improvement Program (QEIP): Improving educational attainment in target schools through improved quality of primary education using methods and activities that are proven to yield results.

• Water and Sanitation: Improving access to water and sanitation facilities for participating communities by providing technical and infrastructural support in addition to improving hygiene practices by training community based water and sanitation committees.

Programs/Interventions (Con’t)

• Agribusiness: Increasing incomes and yield for rural farmers producing selected crops by adding value and facilitating marketing linkages

• Peace Building: Supporting five satellite peace centers throughout Tamale Ecclesiastical Province with training and inputs to mediate and transform conflicts in selected communities.

• Leprosy Support: Providing targeted hospitals materials and support to improve the care of leprosy patients.

• Safety Net Initiatives (SNI): Providing food assistance to marginalized and vulnerable groups ( PLWHA, Orphanages, the Aged, physically challenged, visually impaired and learning disability institutions, etc)

• HIV/AIDS: providing care and support to PLWHAs

Programs/Interventions (Con’t)

• Health Sector: Child Survival: The Child Survival program relies on four key objectives namely:– Improving key household health and nutrition

behaviors among mothers of young children– Improving accessibility of health services to

rural communities– Improving quality of health services– Increasing utilization of health services

Programs/Interventions (Con’t)

• INAAM (INTERGRATED NUTRITION ACTION AGAINST MALNUTRITION)

This focuses on rehabilitating undernourished children by using quick impact and assets-based approaches at both the community and facility level. These approaches include: Focused Nutrition Intervention (FNI): Facility based treatment of severe child under-nutrition

Child Survival Assistance/Targeted Food and Education-Educational support and appropriate food inputsPositive Deviance (PD)/Hearth Approach-Assets based approach that utilizes community based resources to rehabilitate undernourished children. Central to the above stated programs is the fact that they all hinge on the behaviour attitude and situations of people.

Why CRS Employs Behaviour Change Strategies in its programs

CRS merely facilitates a process to aid thecommunities/beneficiaries to change their attitudes orbehaviours towards a particular action or inaction, whichwhen not checked might generate into situations thatnegatively affects one or more sectors of their lives.These will then further exasperate an already decliningstatus of wellbeing. Thus cardinal to the successfulimplementation of all these programs is the effectiveparticipation of partners and beneficiaries in acceptedbehaviour change strategies aimed at improving anidentified negative, harmful and sometimes lifethreatening situation.

CRS’ BEHAVIOUR CHANGE COMMUNICATION (BCC) STRATEGIES

• In the context of CRS’ work, we describe BCC as the development of interventions that best empower target groups to identify problems, evolve solutions and mobilize resources and skills to address the problems.

• In the design of BCC strategies, CRS is guided by the Academy for Educational Development’s (AED’s) BEHAVE Framework. BEHAVE employs easy-to-use tools based on principles of behavioral science to make four strategic decisions:

BCC Strategies (Con’t)- BEHAVE Model

• Who the primary target groups are that should be reached with BCC

• What actions should be taken to change behaviour• what the psychosocial, structural, or other

determinants and factors are that make the most difference in the target group’s choice to act

• What strategies will be effective in addressing those determinants and factors?

Selection of BCC Strategy

Once a BCC strategy is determined, it is further scrutinized and categorized into the following 3 main categories:

• Instruction: This is communication designed to improve skills e.g. how to wash hands, or brush teeth, how to prevent guinea worm infection, how to breast feed exclusively

• Advocacy: Communication for removing environmental constraints e.g. socio-cultural factors or norms that affect hygiene promotion and education, exclusive breast feeding, high taxes that make mosquito nets too expensive for people to buy.

• Promotion/Counseling: -Communication designed to change ideational factors e.g. knowledge, attitudes (belief & values), perceived risks, social influence, emotions etc.

CRS’ BCC Strategies

The key BCC strategies/activities most frequently employed are:• INSTRUCTION - Communication designed to improve skills e.g. how

to wash hands properly with soap, - Hygiene and sanitation education

– Nutrition education– Environmental education– Sensitization – Demonstration– Development and use of Health guides and other teaching/learning

materials– Wall/pocket calendars– Posters– Child to child

CRS’ BCC Strategies (Con’t)

• ADVOCACY - Communication for removing environmental constrait • - Community sensitization and meetings• - Trainings• - Health Talks • - Radio Broadcast• - Drama• - Focus group discussions using appreciative inquiry-

best practices.• - Handouts• - Incentives-wheel barrows, hand washing containers• - Child to child methodologies

CRS’ BCC Strategies (Con’t)

Promotion/counseling -Communication designed to change ideational factors e.g. knowledge, attitudes etc.

• Drama, role play

• Quiz Competitions

• Health campaigns

• Health walks/circle of assessment

• Games

• Posters

Principles Guiding BCC

Participatory Hygiene and Transformation Tools (PHAST): knowledge and tools from PHAST methodologies are adapted for various BCC strategies across all sectors in the development of relevant and appropriate target strategies.

Appreciative Inquiry: Recognizing that beneficiaries have a lot of potential and a assets CRS usually employs AI to build on these local-based assets in the development of appropriate BCC strategies.

Regular review/Assessment meeetings: BCC strategies are constantly reviewed to ascertain its relevance, impacts and acceptance by beneficiaries. These reviews and assessments are usually conducted with expert consultants in BCC and behavioural science.

Principles Guiding BCC (Con’t)

• Partnership/Collaborations: For continuity and sustainability CRS and partners (GES/GHS/Community) has put in place structures to make its BCC strategies more effective. Some structures established within beneficiary communities include:

• School Health Clubs• Community School Health Management Committee• Community food Management Committees• Mothers Clubs• Watsan Committees• Community Volunteers attached to outreach clinics• Regional and district GES/CRS Partner supervisors

Partnership/Collaboration (Con’t)

In addition to these CRS-established structures, CRS also works with already government established structures such as SMC/PTAs, Regional and District SHEP coordinators, Environmental officers, District water and Sanitation Teams (DWSTs), Community Health Nurses, District Health Management Teams (DHMT) Assemblypersons, area Council /unit Committee members, chiefs, religious leaders magazias and other community leaders.

Impact/Achievement of BCC

PERCENTAGE OF PUPILS WHO DEMONSTRATE AND PRACTICE APPROPRIATE HYGIENE BEHAVIOUR

Baseline 2003

2006 (Target)

2006 (Achieved)

42.8% 47.8% 79%

Percentage of pupils in program schools

who consume de-worming medication twice per yearBaseline 2003 Target 2006 Achieved 2006

0 85 86

Increase in Enrolment and Attendance

Indicator Baseline

2006

Target

2006

Achieved

2006

# of Girls enrolled in program Schools

44,388 48,827 53,700

# of Pupils enrolled in Program schools (boys &girls)

150,145 157,650 171,240

% increase in attendance of pupils (boys & girls)

24.6 50 59.3

Increase in Enrolment and Attendance

Indicator Baseline

2006

Target

2006

Achieved

2006

% increase in girls’ attendance 24.5 55 83

% of teachers in program schools effectively planning their lessons

78.0 - 97.0

% of teachers in program schools using pupil-focused instructional practices

19.7 - 62.4

Nutritional Status of Children under 5 years

STUNTING DISTRICT BASELINE2004 MID-TERM 2006

Moderate Lawra 19.6% 11.2%

Severe Lawra 7.6% 3.7%

Moderate East Mamprusi 21.8% 19.7%

Severe East Mamprusi 16.7% 7.4%

Moderate Saboba 25.3% 15.4%

Severe Saboba 18.9% 7.7%

Moderate Bongo 24.8% 15.9%

Severe Bongo 11.8% 9.3%

Moderate Wa 20.9% 8.5%

Severe Wa 20.3% 16.9%

Water & Latrine Provision

Facility 2005 2006 2007

Boreholes 4 6 8

HH Latrines

140 510 600

Usage of Household Latrines

Year # of

Communities

Household Latrines

Family

Size

2005 7 70 420

2006 13 494 2,964

2007 19 500 3,000

SUCCESS STORIES

• 1. Adaboya School/community: The School Health Club action plan had contribution of shea nuts as an activity. All children willingly contributed and money used to purchase 10 cartoons of soap and the rest used to buy shares in the Bongo Community Bank

• 2. Feo SHEP Club constructed a urinal whilst community provided coaltar for painting. School Health Clubs engaging in income generating ventures like basket/hat weaving to support SHEP activities

SUCCESS STORIES (Con’t)

• 3. SHEP Club members asking for land from opinion leaders for farming purposes to sustain the program

• 4. SHEP teachers integrating the program into capitation grants by adding provision of soap to their School Performance Improvement Plan

• 5. As a result of effective animation, the communities of Langbinsi and Namangu in the East Mamprusi district have evolved a good maintenance strategy ( by employing young girls who keep registers of money collected on water fetched) by collecting token amount of money on each bucket of water collected and saving it at the bank to yield profit. Use of the money to purchase spare parts for maintenance

SUCCESS STORIES (Con’t)

• 6. A Community Health Volunteer through her active involvement in CRS health program by working with nurses and keeping of good records, finally gained admission into the Nursing school

• 7. Mothers (lactating and pregnant) attend clinics regularly even though food incentives given has ceased

• 8. Mothers of malnourished children are learning from mothers of well-nourished children how to combine locally available food commodities to ensure that their children grow strong and healthy

CHALLENGES

• Post –intervention assessment• Dissemination of information to the larger

community• Target and coverage (scope)• Ineffective coordination among stakeholders

(NGOs and District assemblies)• Volunteerism fatigue (motivation, migration, etc)• Lack of clear-cut policy directives e.g. SHEP• Enforcement of bye-laws• Inadequate funding

LESSONS LEARNED

• Collaboration /consultation with key partners helps in synchronizing activities

• For greater impact and success involves direct beneficiaries in programme planning information and assessment.

• Capacity-building is a key tool• Behaviour change is a process – it takes time to see the

impact• Hardware and Software leads to total behaviour change

(improved health)• Total coverage enhances behaviour change• “A good cloth sells itself”. Here good work promotes itself

•THANK YOU FOR YOUR ATTENTION!!