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 Table of Contents  
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 61-67

Communication between community leaders and healthcare providers for maternal and child health in conflict region of Asia: A review article

School of Public Health, Dow University of Health Sciences, Karachi, Pakistan

Date of Web Publication12-Feb-2015

Correspondence Address:
Mubashir Zafar
School of Public Health, Dow University of Health Sciences, Karachi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-9019.151304

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Coordination between community leaders and healthcare providers for provision of maternal and child health (MNCH) in conflict areas is very important because community people are affected both physically and mentally due to conflict. Community leaders such as community chiefs, school teachers and church priests have very important role play in solving community health problems by proper arrangement of health facility from where community utilizes these services. In this paper, we report the number of scientific studies published from 2007 to 2011 about MNCH problem in conflict regions of world. Secondly, we study about the community leader role and communication with healthcare providers to solve the MNCH problem. Co-ordination between community leaders and healthcare providers to improving maternal and child health (MNCH), clinicians and health service utilization improve and protect population health. Overall, there is lack of published information about community leaders' role, i.e., accessibility, affordability and co-ordination with healthcare providers for the provision of MNCH services. We believe that high quality scientific approach must be taken in studies of MNCH with appropriate study design in order to obtain data and information regarding communication aspect between community leaders and healthcare professionals in MNCH programmes.

Keywords: Communication, conflict region, healthcare provider, maternal and child health

How to cite this article:
Zafar M. Communication between community leaders and healthcare providers for maternal and child health in conflict region of Asia: A review article. Int J Health Syst Disaster Manage 2015;3:61-7

How to cite this URL:
Zafar M. Communication between community leaders and healthcare providers for maternal and child health in conflict region of Asia: A review article. Int J Health Syst Disaster Manage [serial online] 2015 [cited 2022 May 20];3:61-7. Available from: https://www.ijhsdm.org/text.asp?2015/3/2/61/151304

  Introduction Top

Communication with community consists of participation, mobilization and empowerment. Participation has been used to indicate active or passive community involvement. [1] Mobilization consists of communities responding to directions given by professionals to improve their health. New concept of mobilization, health and development workers have begun to act as facilitators focusing on the process of health improvements as well as the outcomes. [1] In this approach, the facilitators support local communities to become actively involved in both activities and decisions making that affect their own health and in community health, either as a resource that can provide assets to address health problem or an agent of change that uses its own supportive and developmental capacities to address its need. The old style of community mobilization (for example, breastfeeding promotion, diarrhoea prevention and growth promotion, promotion of complementary feeding after 6 months of age. treatment of severe acute malnutrition and pneumonia prevention and treatment). [2],[3] Fewer studies have investigated the effectiveness of community mobilization interventions, either on their own or in combined packages with other interventions, where the community provides the resources and is the active agent of change. [3]

  Materials and Methods Top

To assess the role of community leaders and healthcare providers in communication for provision of MNCH in conflict region of Asia, we identified and counted all papers published between 2007 and 2011. The decision to start from 2007 was arbitrary and base on the idea of reviewing only recent data. We searched two databases that covered our topic of communication between community leaders and healthcare providers in MNCH in conflict regions: Google Scholar and Science Direct. To identify relevant literature, the key words used were 'communication between community leaders and healthcare providers in MNCH' with reference to different regions in the world in general especially conflict regions in particular. We found 55 articles in Science Direct and 11 articles in Google Scholar, included 22 and 45 are excluded out of 66, we finally select 9 article after data extraction form. We included all studies which were published between 2007 and 2011 and were in English language with particular focus on studies from conflict regions, published in journals, problem related to MNCH and dealing with communication between healthcare providers and community leaders. We excluded from our review, studies for health problems not related to MNCH, published before 2007, or not published in any recognized journal [Figure 1].
Figure 1: Selection of study n = number of articles

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Challenges of MNCH in developing countries

Approximately 530,000 women and 4 million newborn babies die every year globally because of complications related to pregnancy and childbirth, 6 million children die each year before reaching their fifth birthday, [2],[3],[4] almost all of these deaths occur in low-income countries. It can be prevented through the wide-scale implementation of interventions involved in promoting and implementing essential interventions. There is evidence available about various types of interventions used including communication for improvement of MNCH programmes in regions of conflict as discussed below.

Integration of health system

Community-based intervention consists of combination with social protection and intersectoral action in education, infrastructure and poverty reduction. Interventions need to be planned and implemented at the district level, which requires strengthening of district planning and management skills. Figure given below is providing a model of integration of primary healthcare particularly for MNCH [Figure 2] and [Figure 3].
Figure 2: Integrated care for both primary health and maternal, newborn, and child health at district and supporting processes

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Figure 3: Building blocks for maternal, newborn, and child health in emergency obstetric care. Adapted from reference 9

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Above figure shows that use of emergency obstetric care by integration of health system and communication between community leaders and healthcare provider. Community-based organization provide infrastructure like setup of facilities, supplies and equipment, provide human resource which take training from healthcare providers then team building for providing services, all these activities co-ordinated and monitoring and continue improvement process progress. [5],[6]

Conflict areas for provision of MNCH

In conflict areas settings, where resource scarcity, and logistical constraints prevail, provision of maternal health services within health centres and hospitals is unfeasible and alternative community based strategies are needed. In eastern Burma, such conditions necessitated implementation of the Mobile Obstetric Maternal Health Worker (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. [2] Maternal Health Workers (MHWs) are central to the MOM service delivery model because they are accessible to both the communities inside Burma and to outside project managers; they serve as key informants for the project. [2] Their insights can facilitate programme and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality are now creating a new challenge for developing countries and therefore imply need of managing the complex web of donor requirements putting these already fragile systems into more risk due to resource constraints. Community or client's trust in a programme or its workers incenses service use both negatively and positively, along with an individual's awareness of a service, is crucial in ensuring access. When building trust to develop a successful healthcare programme, all stakeholders (co-ordinators, providers, patients) should be involved in decisions, and two-way communication and solidarity emphasized. Case studies suggest that ownership and decision-making power for both project personnel and community members (e.g., ethnic leader input into programme design; misoprostol use for Trained birth Attendant (TBAs)), paralleled with material support from the MOM project (e.g., supplies), create a balanced community-based approach to healthcare that allows for pragmatic solidarity and challenges the burden of human rights violations and lack of facility-based healthcare in eastern Burma. [2]

Internal armed conflict has been continuing in Maguindanao province, southern Philippines. [3]

Maguindanao's internal armed conflict has involved mainly the government's armed forces and two groups, the Moro National Liberation Front (hereafter called the National Front) and Moro Islamic Liberation Front (hereafter called the Islamic Front). [3] Given the conflict setting, it is important that healthcare providers communicate with community-based organizations with relevant service delivery. It is important for them to know how and to what extent provision is affected by the armed conflict, and strategies have been used to reduce its effects. Committed to the psychosocial dimensions of peace and social development internationally, community and family service internationally (community based organization) seeks: a) To empower and equip uprooted people and others in exceptionally difficult circumstances to address and prevent social and health problems and b) to prevent children, women and men from being uprooted by promoting peace, respect for human rights and equitable distribution of resources, along with its family support workers. Community and family service international (CFSI), [3] their central office in Manila and does not have its own health centre, utilizes the office's medical and paramedical personnel for delivering antenatal, natal and post-natal services to its family beneficiaries. CFSI coordinates closely with the office's rural health units and has representatives from the office on its technical working group. Integrating service delivery with the community's broad life concerns is effective, neither the office nor its NGO partners have control over the inevitable disruptions to services and civilians' lives when military, rebel, political or clan conflicts result in head-on armed collision in community.

Nepal's population of 23 million is predominantly rural only 14% of the population lives in urban areas. [4] One of the most disadvantaged nations in South Asia, 42% of Nepal's population live below the poverty line. The recent conflict in Nepal has resulted in on going violence and civil unrest. [4] The maternal mortality ratio (MMR) remains high in Nepal and is one of the highest in South Asia. MMR range from of 549 to the UN estimate of 740 maternal deaths per 100,000live births. Government of Nepal started programme for maternal and child health by two project national safe motherhood programme and women right to life health project (WRLHP) funded by UNICEF. There are several strategies for improving MNCH (1) empowering women and communities with information on causes of maternal deaths, danger signs, and birth preparedness; (2) establishing revolving funds for travel to maternal health facilities and treatment; (3) developing emergency transport mechanisms (ambulance, stretchers) and referral systems and (4) training auxiliary nurse-midwives (ANMs) to provide delivery services and obstetric first aid at the community level, and to refer women with complications to healthcare facilities. The result show that low resources setting, low level of facilities available but increase level of quality and utilization of services can be achieved in during conflict region even short period of time. Advocacy is needed for to increase form doctors for the expanded role of nurses in emergency obstetric care. Partnership with community-based organization is critical role for delivering services to reducing maternal mortality [Table 1] and [Table 2]. [4]
Table 1: Studies regarding communication between healthcare providers and communities leaders for improvement of MNCH services

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Table 2: Data extraction form

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Impact of sexual violence and responsibilities of the healthcare system

During chronic conflict across the globe make it imperative to draw attention to its health consequences, particularly the violation of women's reproductive and sexual rights. Effects of sexual violence resemble those seen in other situations of conflict; including the physical as well as the psychological and social effects of rapes on the victims, their families and the community. Women experience trauma in reproductive organs, deaths in childbirth, miscarriages and difficulties giving birth, a rise in and dangers of illegal abortions, sexually transmitted infections, possibly leading to human immunodeficiency virus (HIV) infection because of tears in genital tissues and the resultant bleeding, especially due to gang-rape. Indian state of Gujarat where communal violence occurred, number of women raped, reporter Taslima reporting this way: [5],[6],[7]]

'I have interviewed more than 100 women, 55 of whom were gang-raped. There are many more that I know who have not recorded their testimonies as the community did not want me to talk to them because many were unmarried. Each woman you speak to would tell you another eight to ten cases who were gang-raped in front of her. So the number of gang-rapes goes much higher'. [5],[6],[7],[8]

Number of steps must be taken first by the state to ensure that health services are available, accessible, acceptable and are of high quality, where there is greatest need among vulnerable populations, orphans, widows, unaccompanied girls and women from separated families.

Secondly, non-discrimination has to be demonstrated by health personnel. Third, healthcare providers need to acknowledge that they have an important role to play in the context of conflict and social unrest. Fourthly, when the state fails to discharge its obligations to respect, protect and fulfill the right to healthcare of its citizens and is the perpetrator of violence, as in the case of Gujarat, the role of humanitarian agencies becomes all the more important to ensure availability, accessibility, acceptability and quality of health services. [9]

Community mental disorder in conflict region of world

During tension, violence and instability which lead to community displacement which affect mental health of community, traditional healing method might not work and must communicate with community to overcome this problem. Changes in the social and economic environment, accelerated by the conflict, appear to have had an adverse impact on mental health, both in terms of access to services and as a consequence of stress and social disruptions. From 1998 to 2003, [5] the Solomon Islands experienced a period of armed conflict known locally as the 'tensions', occurring primarily on the island of Guadalcanal where the capital, Honiara, is located. Most of people displaced their homes and mental disorder burden increase; [5] people commonly contact their mental health problem to traditional healer which is not working. In result of conflict, people increase economic hardship, social dysfunction and distress, women are concerned about their security and told that their memory were free before conflict; after that memory are fear. Government start health programme with private organization and contact with community leaders was facilitated through the provincial health service, the church and a local faith-based NGO that had a strong presence in the area. [5] Local leaders include chief of village, church priest, school teacher, women group leader, trauma support worker; they co-ordinate their effort to solve community mental health problem by communication with healthcare providers to help vulnerable population. [6],[7]

  Discussion Top

The studies summarized here provide an overview of recent evaluations of MNCH services in conflict region of Asia. Clinical/Psychiatric approaches for intervention to improve the MNCH services. The published literature contains less information on formal evaluations of interventions that would be considered more broadly psychosocial by the definition presented earlier. This author's work on exploring the psychosocial aspects of emergency education programme for mother and children displaced by the Chechen war is one example of an initial effort at evaluating a more classically psychosocial programme; however, many more in depth evaluations of these sorts of programmes are needed in the future. Ultimately, a mix of qualitative and quantitative methods could lead to a much more complex understanding of the effectiveness of such programmes in field settings.

Certainly, a number of important next steps remain in the process of building an evidence base on psychiatric and psychosocial interventions for mother and children affected by war. Without question, we need more rigorously designed evaluations of both psychosocial and psychiatric/clinical interventions across a number of diverse contexts and cultural groups. In order to do this, we require more concentrated efforts to ensure the reliability and validity of cross cultural MNCH health measurement. Achieving valid and rigorous cross cultural MNCH health measurement will always be a challenge, but can be greatly improved by combining qualitative and quantitative methodologies. By learning about local priorities and local idioms of distress for the mental health issues facing mother and children, interventions may be direct problem areas and aspects of functioning that are relevant and prioritized by affected communities.

In order to build an evidence base, we require specificity in the identification of problem areas targeted by both psychosocial and psychiatric approaches. Such precision will ensure that treatment protocols are designed with clear targets in mind and that appropriate outcomes are assessed given the nature of the intervention being evaluated. We need to consider building programmes of research in a phased approach, beginning first with developing sound, locally valid measures, then piloting locally appropriate interventions, then testing them using rigorous designs, with the best of these being the randomised controlled trial (RCT). In order to ensure fidelity to treatment models and encourage the dissemination of evidence-based treatments, applied research can help to ensure that interventions are manual and well-defined so that they can again be adapted and tested in new settings. As demonstrated by this summary, there are only a handful of studies that assess intervention effectiveness using rigorous designs. The highest standard of evidence, the RCT, is still very uncommon in this work. However, using waiting list control designs can be highly ethical and often matched with the natural roll out of interventions while contributing to the knowledge base. Going forward, applied research must aim to ensure unbiased/randomised assignments of study participants to treatment protocols and the use of control groups.

Research to date indicates that high quality MNCH services are possible in low resource and war affected settings, as are formal trials of these interventions. In advancing our research on MNCH health interventions for war affected mother and child, more advanced stages of a phased approach to this research can begin to catalogue treatment moderators such as subgroups for whom interventions are more or less effective, as well as identifying the mediators, 'active ingredients', or therapeutic change.

In summary, the greatest strength lies not in forcing an artificial divide between psychosocial and psychological approaches but in combining them to effect better outcomes for assessing and improving the mental health of war affected children. To do this, services must be integrated across sectors. Mental health is not to be separated from overall health. As our research in Ingushetia demonstrated, education systems present one example of a critical partner for working with children in that setting. Psychosocial interventions of this sort must be designed ecologically to leverage other aspects of the social ecology (i.e., community and family level protective processes). We are now in an era of sophistication such that 'child mental health programmes' must still consider the place of families and caregivers in the treatment outcomes being sought. It is often the case that interventions for child mental health need to also community leaders and health professionals.

In terms of future research that is needed, there is a great deal of opportunity to combine both qualitative and quantitative approaches to advance this field. Ultimately, research proceeding along the phased approach described earlier, beginning first with valid and reliable measures, then conducting feasibility and pilot studies of locally feasible and relevant interventions, could inform both psychiatric and psychosocial approaches. Both of these can be combined and tested using increasingly sophisticated designs (eventually RCTs where possible). In this effort, collaborations between implementation organizations (NGOs) and health professionals are compelling in order to ensure scientific neutrality. The examples of research presented here provide several models for how such collaborations can be conducted. These and other efforts to improve the evidence base on interventions are essential for advancing high quality and ethical care for mother and children affected by war.

  Conclusion Top

Women and children face the greatest burden in the conflict region. In this domain, various humanitarian emergencies are characterized by social disruption, armed conflict, population displacement, collapse of public health infrastructure and food shortages. Humanitarian assistance for refugees and internally displaced populations requires particular attention to the common issues affecting morbidity and mortality in women and infants. Gender-based violence and reproductive health concerns are discussed within the context of populations affected by conflict and forced migration. Recommendations for community healthcare providers and health professional engaging in care for women and children in conflict situation and their mutual role help out MNCH services.

  Acknowledgement Top

I acknowledge all my teachers, colleague and staff who contributed to the study.

  References Top

Lee AC, Lawn JE, Cousens S, Kumar V, Osrin D, Bhutta ZA, et al. Linking families and facilities for care at birth: What works to avert intrapartum-related deaths?. Int J Gynecol Obstet 2009;107:S65-85, S86-8.  Back to cited text no. 1
Teela KC, Mullany LC, Lee CI, Poh E, Paw P, Masenior N, et al. Community-based delivery of maternal care in conflict-affected areas of eastern Burma: Perspectives from lay maternal health workers. Soc Sci Med 2009;68:1332-40.  Back to cited text no. 2
Lee RB. Delivering maternal health care services in an internal conflict setting in Maguindanao, Philippines. Reprod Health Matters 2008;16:65-74.  Back to cited text no. 3
Morrison J, Thapa R, Hartley S, Osrin D, Manandhar M, Tumbahangphe K, et al. Understanding how women′s groups improve maternal and newborn health in Makwanpur, Nepal: A qualitative study. Int Health 2010;2:25-35.  Back to cited text no. 4
Khanna R. Communal violence in Gujarat, India: Impact of sexual violence and responsibilities of the health care system. Reprod Health Matters 2008;16:142-52.  Back to cited text no. 5
van Olphen J, Freudenberg N, Fortin P, Galea S. Community reentry: Perceptions of people with substance use problems returning home from New York City jails. J Urban Health 2006;83:372-81.  Back to cited text no. 6
Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done? Int J Gynecol Obstet 2009;107:S5-18, S19.  Back to cited text no. 7
Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: Patterns, prevention, and potential. Lancet 2007;369:1220-31.  Back to cited text no. 8
Khan MM, Van den Heuvel W. The impact of political context upon the health policy process in Pakistan. Public Health 2007;121:278-86.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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