Community health behaviours change as effects of an intervention to improve health facilities environment in Mali: a qualitative study

¹Faculty of Nursing, Laval University, Quebec, Canada, ²Institute for Interdisciplinary Training and Research in Health Sciences and Education, Burkina Faso, ³Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon, ⁴University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali, ⁵Faculty of Medicine, Université Laval, Quebec, Canada, ⁶Université de l´Ontario Français, Toronto, Canada

^&Corresponding author
Patrice Ngangue, Faculty of Nursing, Laval University, Quebec, Canada

Introduction    

Research indicates a strong relationship between water, hygiene, and sanitation (WASH) infrastructures and worldwide population health [1,2]. Without WASH, patients, healthcare workers, and communities are at risk of disease spread and infections [3]. Indeed, poor WASH conditions are related to greater incidences of diarrhea, other children's health problems, and poor maternal and perinatal health outcomes [4,5]. The Mother and Child Health Environment Improvement Project (BECEYA) supported the establishment of water, hygiene, and sanitation (WASH) and solar electrification infrastructure in Mali from 2015 to 2020. This intervention included community participation as part of its implementation process. Community participation (CP) refers to the conception of health as community ownership, thus implying the responsibility and investment of the community in actions that promote the health of each of its members [6,7].

Several studies have reported the numerous benefits of community involvement in implementing health-related programs and their positive impact on improving health [7,8]. Community engagement is central to the implementation and sustainability of health initiatives [7-9]. Although community participation is considered essential in providing comprehensive health services, many functional and operational challenges can prevent the effective participation of different community actors, especially in the African context [10,11]. The literature highlighted the expected effects of WASH interventions on the well-being of communities [12]. The relationship between community engagement and behaviour change resulting in community positive benefits and few adverse effects is also well known [13]. However, the results related explicitly to CP in implementing WASH interventions in sub-Saharan Africa, particularly Mali, must be better documented.

Hence, the interest in conducting the present study, which aims to answer the following research question: what are the effects of the BECEYA project associated with the CP in the Babala healthcare centers in the rural region of Kayes and Wayerma 2 and the urban area of Sikasso? The study aimed to document the combined effects of the BECEYA intervention and community participation on community health behaviour change in two regions of Mali.

Methods     

Research design and study sites: this is a qualitative exploratory study of the perceptions and experiences of community members after implementing the project. The study complies with COREQ standards. Qualitative research allows in-depth theme analysis without relying on many participants [14]. The community health center (CHC) of Wayerma 2 in the health district of Sikasso and the CHC of Babala in the health district of Kayes were selected according to the following selection criteria: 1) to be a CHC supported during Year 2 and Year 3 of the intervention; 2) to be a CHC that is geographically accessible; and 3) to be a CHC located in a safe area. All CHCs in the Segou region were excluded due to insecurity.

Study population and sampling: the community members selected for this study were members of the coordinating women's associations and members of the community health association (ASACO) in each selected CHC. The inclusion criteria for ASACO members were a man or woman from one of the chosen CHCs in the Sikasso or Kayes health district who voluntarily agreed to participate in the study. The inclusion criterion for women from the community was defined as follows: to be a woman involved in the consultation and implementation process of the intervention belonging to a women's association and accepted to participate in the present study. We opted for purposive sampling, targeting key informants to select participants for this study. This choice is justified because we want to approach the competent social actor [15]. The sample consisted of forty-four (44) eligible participants, considering the principle of data saturation. This depth of analysis is feasible with a small number of participants [16,17].

Data collection: the data were collected in January 2020. Data collection techniques used were individual semi-structured interviews with community leaders who are members of the community health association of the two healthcare centers (one woman and one man per CHC, i.e. n = 4), focus groups per health area concerned with women who are members of groups (10 per health area concerned, i.e. n = 20) as well as with the staff of the healthcare centers concerned (10 per healthcare center, i.e. n = 20). These data sources made it possible to ensure triangulation during data analysis [18]. The semi-structured individual interview guide and the interview guide for the focus groups were built based on a literature review. The data collection tools were pre-tested with staff and patients at the CHC of Bankoni in Bamako.

Data analysis: immediate and complete transcription of the data collected from the semi-structured interviews and focus groups was carried out, followed by double coding involving two research team members using QDA Miner software. The inductive thematic analysis was carried out in five (5) steps: 1) reading and familiarisation with the data; 2) development of initial codes (codification); 3) search for themes; 4) review of potential themes; and 5) identification of categories of these themes. This thematic analysis identified recurring elements in the data collected and provided insights into the research objectives or problem [19].

Ethical considerations: to ensure compliance with ethical considerations, we had official approval from the Institutional Ethics Committee of the Faculties of Medicine and Odontostomatology of Mali, authorizations for data collection, and free, voluntary, and informed consent from all study participants. The anonymity and confidentiality of the data were also ensured.

Results     

Twenty women (10 per region and FG) and four community members (two women and two men per region) were interviewed. The participants' characteristics are available in Table 1 and Table 2. Positive effects associated with the intervention were highlighted at the individual, family, and community levels: 1) men's involvement in hygiene and family and community health; 2) adoption of good attitudes conducive to maternal care; 3) adoption of good hygiene practices; 4) empowerment of women; 5) improvement of the community health environment; 6) active involvement of external and internal community actors through financial and material support; 7) active involvement of community leaders.

Involvement of men in the family and community hygiene and health: a first community change is linked to the gender approach to health. Thus, women members of women's association coordination explain that men have begun to be more involved in activities relating to hygiene and health in the family and the community since implementing the intervention. For example, a member of the coordination of women's associations in Babala (case 4) notes, "Since BECEYA has been in place, women, as well as men, respect hygiene measures. People did not go to the CHC even when they were sick. After the arrival of BECEYA, we see more and more people coming to the health center. Men's involvement is also reflected in allowing their wives to travel to participate in awareness-raising activities, as reported by a Babala healthcare staff case 4): "there are changes because before, men did not accept their wives sensitizing or speaking in public. However, this has changed since the arrival of BECEYA. Today's women of Babala have gone to another village to raise awareness, even if some men accompany them because they have understood that this is a good thing".

Adoption of good attitudes toward maternal care: a second change brought about by BECEYA concerns the health decisions made by women regarding their pregnancy or childbirth. Since implementing the BECEYA project, fewer women have chosen to give birth at home. As a result, a member of the ASACO in Wayerma 2 (case 3) explains that "[...] Women are at ease because they come for their needs, no problem, they give birth, no problem, the water is there. [...]. It encourages women to come; that is it". A healthcare staff member (matron) at Babala (case 4) supported these statements by adding. "Thanks to the sensitization, women are doing more ANC now and coming to deliver at the healthcare center."

Adoption of proper and safe hygiene practices: community actors also identified that the community has started to adopt new hygiene practices to maintain a healthy environment, such as hand washing, proper use of toilets, or maintenance of toilets. Two members of ASACO speak out on this subject. An ASACO member of Babala (case #1) stated, "Thanks to the women, no one can enter the healthcare center without washing their hands. A member of women's associations in Wayerma 2 (case #6) explains the importance of compliance with instructions on attitudes to adopt at the healthcare centre: "Thanks to the awareness-raising, children no longer defecate in the open. The women have taken sanctions against all those who let their children defecate in the open". Another woman from Babala (case 4) explains that washing the toilet is now part of a regular maintenance routine. This allows women to ask their children to defecate in pots. In addition, the data collected reveals the community collaboration in adopting hygiene and sanitation rules in the village and the CHC. Thus, according to a member of the ASACO in Wayerma 2 (case #5). "The CHC is sanitized, and everyone arranges their belongings well. People respect the rules of sanitation. The same is true within the village, as "[...] the neighborhood is becoming cleaner and cleaner. Rubbish is no longer thrown away anarchically' (Female CFU member, Wayerma 2, case #6).

Women's empowerment effectiveness: this study highlighted strengthening the effectiveness of women's power to act. Thus, implementing the intervention has enabled the community to perceive women as agents of change. Not only did the intervention's activities immediately call on the help of women to raise awareness of the effects of good hygiene practices on health, but these women also took advantage of the opportunity to initiate and encourage behavioural change within their community. For example, a member of the women's association from Wayerma 2 (case #6) states, "Women have become clean. When women are clean, the whole community will become clean. The role of women is also directly recognized by important community members. For example, the ASACO member in Babala (case 2) confirms that "women do the awareness raising and the animation, we often have parties, and we invite everyone."

Furthermore, activities implemented by BECEYA have allowed the development of a sense of belonging and mutual support among the women in the community. Thus, when "[...] the women of the neighborhood see the office members at work, all the women concerned mobilize". (Female ACF member from Babala, case 4). Finally, the sensitization carried out by women has enabled the community to establish a link between health and hygiene, as mentioned by a member of ASACO in Babala (case #1). "The women of the coordination do sensitization on hygiene and the promotion of the health center, during marriage and baptism ceremonies in the village. Through this, the population has understood what health and BECEYA are all about.

Discussion     

Our study aimed to document the combined effects of the intervention and community participation on health behaviour change in communities in two regions of Mali. Four main themes corresponding to changes in the community emerged from the analysis: 1) men's involvement in family and community hygiene and health; 2) adoption of good behaviours towards maternal care; 3) adoption of good hygiene practices; and 4) women empowerment. These themes describe how community participation can be effective in changing health behaviours. They are supported by statements from the respondents, in which the majority shared a positive view about its effects on health.

Although there can be many barriers to the effective involvement of males in family and community health, it appears to have more significant benefits [20]. Our study suggests that adopting a gender approach that puts men at the forefront during the implementation of community health activities can be highly beneficial because not only will they not be left behind, but they will also contribute to a better involvement of women [21]. A systematic review published in 2015 found that men's involvement in family health activities improved the utilization of the services offered to women and resulted in better outcomes [22]. Maternal health represents one of the essential health services provided to women. However, several communities in the developing world usually need better indicators when it comes to maternal healthcare [23]. One of the reasons for this is that women are sometimes reluctant to adopt acceptable behaviours about their maternal care, probably because they are usually considered beneficiaries in all the existing maternal health programs [24]. Although we found that involving women in these programs can allow them to improve their knowledge and adopt good behaviours extensively, it can sometimes be culturally and economically challenging to achieve such a task [25].

Research conducted in Pakistan reported that socio-economic and socio-cultural practices could create constraints among women seeking maternal care [26]. Therefore, addressing them represents the first step in improving the healthcare status of mothers and children. Several factors can interfere with adopting safe hygiene practices within communities, including knowledge, attitudes, and practices from community members, infrastructure availability, and education [27]. One of our study's findings suggests that ensuring the community has ownership of health programs being implemented, especially those related to water hygiene and sanitation (WASH), can lead to improved habits from community members, resulting in the adoption of good hygienic practices. Therefore, adjusting these programs to enhance community participation and ensure better outcomes is essential.

Following their implication in implementing health programs, we reported positive effects on behaviour modification among community members. In addition, several studies have also previously described the importance of community contribution in improving specific health indicators [6-8,12]. Therefore, identifying the strategies that can be put in place to achieve and sustainably maintain improved health behaviours can help several health systems in the developing world to address issues better.

Conclusion     

This study aimed to document the combined effects of the intervention and community participation on health behaviour change in communities in two regions of Mali. Several positive effects were described, which integrate gender issues and encompass different health topics. The study highlighted the importance of community participation in implementing interventions that aim to change behaviour and living conditions at the community level. Understanding how to sustain improved health behaviours among community members is critical for a better resolution of health problems in Africa.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Patrice Ngangue and Katherine Robert. Data collection: Patrice Ngangue, Katherine Robert and Birama Apho Ly. Data analysis and interpretation: Patrice Ngangue and Katherine Robert. Manuscript drafting: Abibata Barro and Douglas Mbang Massom. Manuscript revision: Patrice Ngangue, Birama Apho Ly and Leonel Philibert. Guarantor of the study: Patrice Ngangue. All the authors have read and agreed to the final manuscript.

Tables     

Table 1: characteristics of members of the community Health Association in each selected community health center

Table 2: characteristics of members of the coordinating women's association

References