The Impact of a Community Mobilization Project on Health-Related Knowledge and Practices in Cameroon

Published in the Journal of Community Health in 2001, this study analyses the impact of a Cameroonian community mobilisation project on reproductive health practices. The project was part of the much larger Family Health and AIDS in West and Central Africa programme, a multi-faceted programme to promote reproductive health and HIV/AIDS prevention. The present study focuses on the Njangi Community Mobilization project. By capitalising on the strength of existing "Njangis" (local community associations), the project sought the following objectives:

• Increase knowledge of family planning methods;
• Increase the use of modern family planning methods;
• Increase the use of condoms;
• Increase the use of oral rehydration salt to reduce infant morbidity and mortality caused due to diarrheal diseases; and
• Increase the utilisation of family planning and reproductive health services.

The Njangi project was implemented in two sites: Mbouda, a rural district in the western part of Cameroon, and Djoungolo, a highly populated, urban neighborhood within the capital, Yaounde. This study compared the effectiveness of community mobilisation strategies in an urban and a rural setting from 1997-1998. Theoretically, the Njangi project was built on the diffusion of innovation approach, relying on the ability of "change agents" to spread innovations (i.e., positive reproductive health knowledge and practice) to the wider community.

Evaluation/Research Methodologies:

The Njangi project was designed to be multi-tiered in training, project implementation, and monitoring. At the top tier was a Cameroon-based health non-governmental organisation (NGO), which, through working with other NGOs, was responsible for providing vision, guidance, training of mid-level supervisors, and overall supervision of the project. This NGO provided this direction to a set of mid-level supervisors who became in charge of training, communication and trouble-shooting, and recruitment and supervision of the community mobilisers. At the core of the Njangi project was a series of community-level activities carried out by the community mobilisers. Activities included: formal health presentations and the facilitation of health discussion group, music, theater, and dance for the public, parades, and health activities at local festivals and events. The mobilisers had the freedom to cover project issues in any way they deemed appropriate.

A baseline survey (n=803) and a follow-up survey (n=854) were administered to randomly selected men and women aged 15-49 years living in Mbouda and Djoungolo. Data were collected on: socio-demographic characteristics, programme exposure, perceptions about programme activities, family planning-related knowledge, attitudes and practices, membership of Njangis (community-based associations), use of health care services, perceptions about sexually transmitted infections and HIV/AIDS, and perceptions about treatment of diarrheal diseases. The results of the baseline survey were shared with community members in order to motivate their involvement in the community mobilisation effort. Bivariate analysis was used to show the actual gains in these knowledge and practices. In addition, logistic regression models were used to isolate the impact of community mobilisation exposure and to account for the influences of socio-demographic characteristics.

Key Findings/Impact:

1. The extent of exposure to the project among the population addressed

Programme exposure (measured by respondents' participation in one or more activities conducted by the community mobilisers) varied by location. Almost one third of the respondents in Mbouda (rural site) had direct exposure to the intervention, while only one tenth of those in Djoungolo (urban site) had direct exposure. The authors attribute the low exposure level in Djoungolo to problems related to the research design (incomplete overlap between the geographic area of implementation and the population addressed) and the project design (loss of motivation among mobilisers who faced inadequate presence of a qualified family planning service provider).

The data showed that the intervention reached not only members of Njangis but non-members as well. No difference was observed on the level of exposure between men and women in Djoungolo. In Mbouda, women were better exposed to the intervention. In both sites, family planning was by far the most popular service received by the respondents (60% among those reported exposure to the intervention), followed by STI counseling (26%), and oral rehydration therapy counseling and products (21%).

2. Impact on family planning knowledge and practices

The impact of the intervention on family planning knowledge and practice also showed different patterns between the two sites. In Djoungolo, knowledge about contraceptive method remained the same level between the baseline and the follow-up; and there was no change in knowledge between the respondents who were exposed to the intervention and those who were not. In Mbouda, knowledge about modern a contraceptive method had increased from 70% to 81% between the two periods among the population addressed. The modern contraceptive knowledge was highest (87%) among the Mbouda respondents who were exposed to the intervention, indicating positive impact of the community mobilisation strategy.

The two sites exhibited differences in terms of the impact of the community mobilisation on health practices. In Mbouda, 39% of women were using modern contraception at the baseline. After the intervention, the reported level of modern contraception use was 45.9% among women not exposed to the intervention, and 52.1% among women exposed to the intervention. In Djoungolo, too, women who were exposed to the intervention demonstrated a significantly higher contraceptive use level than those not exposed to the intervention. However, in terms of the contraceptive use among the entire population addressed in Djoungolo, there was no overall improvement between the two periods, suggesting a decrease in contraceptive usage among the Djoungolo women who were not exposed to the community mobilisation.

3. Impact on knowledge/perceptions about sexually transmitted infections (STIs) and HIV/AIDS

The community mobilisation had positive impact on the knowledge about STIs and HIV/AIDS among the Mbouda women who were exposed to the project. No project impacts were demonstrated for the Mbouda women not exposed to the community mobilisation, and women in Djoungolo (even among those who were exposed to the project).

The impact of the community mobilisation on perceptions about vulnerability to AIDS also varied between Mbouda and Djoungolo. In Djoungolo, the perception that they were at risk of AIDS did not change between the baseline and the follow-up. In Mbouda, exposure to the project was associated with more than a two-fold increase in the odds of perceiving oneself to be at risk of AIDS.

4. Impact on the use of health care services

Finally, the reported use of health care services during the twelve months prior to the follow-up survey increased from 55% to 67% in Mbouda and from 57% to 64% in Djoungolo. However, the impact was statistically attributable to the intervention only in Mbouda.

The authors highlight the following lessons from the Njangi project:

• Community mobilisation was an effective strategy for behaviour change in reproductive health practices.
• The mobilisation strategy was more effective when utilising existing indigenous associations.
• Sharing the baseline survey findings with the community members helped to motivate community members to take part in the project and to feel committed to the success of the project.
• The original project design envisioned close partnerships between the lead NGOs and other entities in the project steering committee, but, in reality, the lead NGO centralised control over project planning and implementation. Further efforts in designing more decentralised project management are called for.
• The community mobilisation strategy helped to instill sustainable reproductive health activities among the participated Njangis. Anecdotal evidence showed that many community mobilisers continued to provide pertinent health information to their fellow Njangi members and, in some cases, continued to facilitate health talks within their Njangis within their Njangis and other groups using community mobilisation techniques.