The Volunteer Community Mobilizer: Promotion of ANC Attendance, Uptake of PMTCT Services

Programme focus: The focus is on the primary participants - PW - to propel and catalyse them into not just going for the first ANC but also to always complete the full schedule of ANC attendance and undertake consequential follow-up actions, such as when testing positive for HIV (then following up on the full regime of counsel and treatment). In addition, attention is focused on the secondary and tertiary participants by way of activities and information that are designed to propel them to influence positively contiguous PW into adopting positive pregnancy practices such as ANC attendance.

C4D objectives: The initiative was designed to pull every pregnant woman to start and complete ANC attendance and, in the process, access the full range of PMTCT services applicable, ANC being regarded as the entry point into utilisation of PMTCT services.

C4D strategies and approaches: The strategic approach for engaging the secondary and tertiary participants will be to engage them within the context of their group affiliations, rather than individually. There is evidence that group dynamics, including norms, rules, and conventions will often override individual judgments as determinants for action. Finally, in order to create a broad spectrum of individuals and groups advocating for ANC attendance in communities, emphasis is placed on building alliances with the social networks that pervade community life in Anaocha (in Anambra State) and Vandeikya (in Benue State) local government areas (LGAs), as well as the forum of community governance structures.

More specifically, according to UNICEF: "There are several communication theories and approaches in use in PMTCT programmes in Sub-Saharan Africa that have contributed to improvements in this area: Communication for Development using ACADA model (assessment, communication analysis, design and action); Behaviour Change Communication (BCC); Information, Education and Communication (IEC); Community-oriented approach to behaviour change; Target education messages, Interpersonal Communication (IPC) and Communication for Social Change....A community-based approach articulated within a comprehensive communication for development intervention which relies on key inter-related approaches (advocacy; communication for behavior and social change and social mobilization) is a viable avenue to pursue in order to increase PMTCT services uptake and address underlying and root causes that hamper communities (and women in particular) from fully benefiting from the latest health science findings and available services in order to ensure a HIV-free generation. It is also fundamental to work at different levels, from individuals to communities and societies, involving different stakeholders (socio-ecological perspective), with a focus on creating a supportive environment for sustainable behavior change. The international development community recognizes the importance of social change communication over and above individual behavior change only strategies. Community ownership and engagement can further support the PMTCT agenda."

In this context, The Volunteer Community Mobilizer: Promotion of ANC Attendance, Uptake of PMTCT Services has created linkages between health facilities, community volunteers, and the local government.

UNICEF advocated for designation and appointment of an LGA PMTCT Focal Person in all the 23 LGAs. The state was supported to identify, train, and equip 1,181 community-based mobilisers called Demand Creators (DCs). For sustainability, integration, and leveraging, the DCs were drawn from existing community mobilisation structures of the Polio Eradication Initiative (PEI), Agricultural Extension, and Malaria Role Model caregivers under the Roll Back Malaria programme. Other volunteers (volunteer community mobilisers, or VCMs) were selected from local governments or wards where the above structures do not exist. The selection process of the VCMs for each of the LGAs consisted of two basic steps. Firstly, at a forum with community-based organisations (CBOs) and social networks from communities in the LGA, they were requested to go back to their communities and ask for volunteers who should be literate and reasonably mature in age. The CBOs/social networks went back to their communities, got the volunteers, and sent the list to the LGA Chief Orientation and Mobilization Officer, who collated for all the communities within the LGA and sent the LGA list to the State Officer in charge of the project. Secondly, the volunteers were subsequently invited to the LGA orientation and training for VCMs, which was held before they were formally requested to commence their duties as VCMs within their communities. The majority of the volunteers were female.

The training consisted of a basic orientation on Facts for Life (FFL), which is a communication and mobilisation programme/resource that provides messages and information for mothers, fathers, other family members, and caregivers and communities to use in changing behaviours and practices that can save and protect the lives of children and help them grow and develop to their full potential. The goal was to provide the volunteers with a broad holistic overview of the key issues of child and maternal survival, focusing in more details on ANC attendance. The syllabus comprised essentially what had been stated in FFL, linking the content to local contexts and circumstances, e.g., by alluding to popular local songs that expressed issues of pregnancy and child bearing. Each of the volunteers was given a copy of FFL with the hope that this could empower them to be able to hold good conversations on these issues with other community members, particularly PW. The operational part of the training comprised developing their skills in information gathering, recording, and collation in relation to the issue of ANC attendance by PW. They were given a notebook to record basic demographic information about the PW they identified and talked with, as well as a data sheet to use in collating the information in their notebook. These data were to be discussed, once fieldwork began, at a monthly review meeting with all of the mobilisers in an LGA along with the officers in charge of the primary health facility to which the PW are referred.

The volunteers, the majority of whom were women and from the communities, easily knew and could identify their fellow community members who were visibly pregnant and could reach them in their households. There were no reported challenges of access to the homes of the pregnant women in the two LGAs of Anaocha and Vandeikya. A core element of the training provided to the VCMs was IPC techniques. They were expected to apply the techniques in their engagement with pregnant women and members of their households.

Motivation and commitment were maintained with the mobilisers through: giving them aprons and reflective jackets as a means of identification, reimbursing their transport cost to the LGA review meetings, and providing refreshment to them during the meetings. No additional stipend was paid to the VCMs.

Expected C4D outcomes:

• By end 2014, 75% of PW in Anaocha and Vandeikya LGAs are reached and they go for available ANC services in their communities.
• By end 2014, the percentage of PW going for ANC increases from the current level of 53.5% to 75% in Vandeikya LGA of Benue State.
• By end 2014, the percentage of PW going for ANC increases from the current level of 30.8% to 75% in Anaocha LGA of Anambra State.

Addressing participation: The forum of the CBOs/social networks provided an opportunity for dialogue among the communities, within and among themselves and with government representatives and development partners. The strategy of the interaction was to make an evidence-based presentation showing why the LGA was chosen for the project. According to UNICEF, participants at the meeting saw clearly why ANC was considered a problem in their LGA. This then opened the conversations on what to do to move out of the problem and generally improve the situation of ANC attendance by PW in the LGA. Eventually, CBOs/social networks from the same communities came together to develop a community plan of action, detailing specific activities they would undertake to improve ANC attendance by PW from their community.

This approach was based on UNICEF's conviction: "It has been well documented that social networks are indeed social capitals; assets that programmes can have recourse to in order to achieve results in communities. Social networks are the nerve-centres of social interaction and social influence in communities. Most community members, as many of the behaviour and social change literature have highlighted look up to social networks for informational and endorsement purposes. Social networks manifest in many communities as associations or groups, such as women associations, men associations, youth associations, age grades, commodity groups, etc. They are thus points of influence and in themselves can become active mobilizers of their communities for change. They can become efficacious change agents in a diversity of programmatic areas.

They can become very useful in promoting ANC attendance by pregnant women, delivery at health facilities, male involvement in the care of pregnant women, etc. To effectively play the aforementioned roles, they need some level of orientation on the situation, challenges and prospects of ANC attendance by pregnant women in their communities. They need to be motivated and exhorted to promote the practice of ANC attendance by pregnant women in their communities. All the mapped CBOs and social networks in a community develop an action plan for promoting ANC attendance by pregnant women in their community.

Officials of the mapped CBOs and social networks identify and enlist a corps of volunteer mobilizers. These in turn to follow up pregnant women and their households on ANC attendance, including completion of the full schedule of ANC visits. The VCM [volunteer community mobilisers] operate in an assigned section of the community, linked to a health facility. They map their areas to enable identifying and linking up with women of the area who are pregnant."

Tools: As indicated above, tools included those to be used in work by the VCMs to give them some identity and recognition as well equipment for group learning, counselling, and edutainment on maternal and child health. These include bags, tee-shirts, notebooks, and a reporting template, as well as solar TVs to be used at group settings - particularly at health facilities linked to the communities. The other supplies needed included digital cameras for documentation at the community level and megaphones to build the capacities of the focus communities for convening groups and networks and making public announcements.

Combination of communication platforms: In addition to the actions of the VCMs and the forum of community-based organisations (CBOs)/social network - activities which are ongoing during the life of the programme - additional activities, which are reinforcing and complementing combine communication platforms, such as: speaking/address sessions at meetings of women's groups (faith-based and communal groups and networks) in communities within the LGAs and meetings of traditional rulers from communities in the LGAs, in addition to focused indigenous ANC-oriented radio language programmes for 13 weeks in Benue and Anambra states and two periodic radio campaigns on ANC attendance and uptake. There were also community-based creative events/competitions for mothers of children under the age of five in Anaocha and Vandeikya LGAs and the development and production of personalised audio and visual communication materials.

HIV/AIDS, Children, Education.

Specific results, impact, and methods for evaluation: The built-in activity mechanisms for monitoring are the periodic review meetings at the health facility and LGA levels. The basic output indicators that will be monitored at the level of C4D include:

• # of PW talked to by the VCMs;
• # of home visits to PW made by the VCMs;
• # of CBOs/social networks participating in mobilising PW;
• # of community leaders enlisted in promoting ANC attendance.

The outcome indicator is ANC attendance rate. Comparing ANC coverage from the period of January-April 2014 to the period of January-April 2005, new ANC attendance rose from 68% in 2012 to about 87% by 2014. Over 70% of the ANC attendees received HIV counselling and testing (National Health Management Information System (NHMIS), 2014). Furthermore,

• In the LGA Ogbaru, the number rose from 1,882 to 2,868.
• In the LGA Oyi, the number rose from 166 to 995.
• In the LGA Anambra West, the number dropped from 172 to 118.
• In the LGA Ihiala, the number rose from 1,098 to 1,192.
• In the LGA Nnewi South, the number rose from 276 to 868.

At the level of the state, the expectation is that the demand creation initiatives will now be fully integrated into the standing issues for deliberation of the technical working group (TWG) of UNICEF.

Lessons learned:

1. "[C]ommunity mobilizers can work with enthusiasm and passion, producing planned results as in the case of these VCMs, without having first been paid financial incentives, a situation seemingly unattainable given the history of polio eradication campaigns in Nigeria."
2. "[T]he step-by-step approach in the implementation of the VCM initiative, beginning with the wider social structure and networks in the communities, allowing to identify and nominate the volunteers, improved community identification, sense of ownership and participation of community leadership in the project."
3. "[E]ven though the project started with an immediate emphasis on ANC attendance and uptake of PMTCT services, we have now come to learn of the longitudinal character of the VCM initiative as a single volunteer can follow a woman through pregnancy and then continue with child thereafter up to completion routine immunization, early childhood education and even start of formal schooling by age five."

Recommendations for scaling up and replication: In process is a scaling up of the initiative from 20 to 200 communities. Plans are underway to scale up in other very high-risk communities for PMTCT in 2016. Mobilisers will follow a woman through pregnancy and then continue with her child thereafter, up to completion of routine immunisation, early childhood education, and the start of formal schooling by age five. "The big challenge in the attempt to scale up will be the capacity of the IPs [implementing partners] in the states to meet up with the provision of inputs required for service delivery at the health facilities activated for delivery of ANC and PMTCT services. The huge gaps often noticed between ANC and HCT and HCT and ARV often are results of the weaknesses in the availability of inputs for service delivery. However, many of the IPs in Anambra and Benue have expressed strong commitments towards ensuring adequate availability of service delivery inputs, particularly test kits."