Sep 30, 1993 - nursing and health care system factors were of secondary importance in ...... Kenya: African Medical and Research Foundation. Osei-Boateng ...
This report is presented as received by IDRC from project recipient(s). It has not been subjected to peer review or other review processes. This work is used with the permission of Judith Shamian. © 1993, Judith Shamian.
COMMUNITY PARTICIPATION,
PRIMARY HEALTH CARE AND
THE NURSE IN BOTSWANA
Principal
Investigators Ph.D. -- Canada Shamian, Judith —— Botswana
Investigators Jacqueline Bolway, Ph.D. -- Canada David Zakus, Ph.D. -- Canada
Catherine Walsh, )t.Bc.N., Research Assistant —— Canada Ntbabiseng Phaladze, B.N.Ed., Research coordinator —— Botswafla Notshedisi Babone, B.N.Ed., Research Assistant —— Botswana
This research project was funded by the International Development Research Centre Ottawa, Canada (Centre File 1 89-1037—01)
September 30, 1993
ARCHIV 96753
r DRC.Ub ABSTRACT
L
In
keeping with the direction put forward by the Declaration of Alma Ata in 1978, the Government of Botswana has recognized
that Community Participation and Primary Health Care are key strategies for the attainment of a healthier society in Botswana.
Policies and infrastructures are in place to promote Community Participation for Primary Health Care but the desired results have not been realized.
Although nurses have been accorded a
major responsibility for mobilizing communities to participate in Primary Health Care activities, to date there has been little research into the nurse's role or effectiveness in enhancing Community Participation for Primary Health Care. This report will describe a collaborative research project
between two multidisciplinary teams from the University of
Botswana and the University of Toronto, Canada which examined factors, perceptions, attitudes, and expectations that are
associated with Community Participation and Primary Health Care. The study was conducted in two rural and two urban communities in Botswana.
Data were collected using questionnaire, focus group,
and participant observation formats from convenience samples of
Household members (n=206), members of the District Health Team and Key Persons in community and national structures (n=32), and from all Nonwestern Healers (N=33), and all Nurses in the four communities.
The study found that several factors contributed to the
varying levels of Community Participation evident in the four communities. The most significant factors concerned the nature of the community and the empowerment of its members. Although nursing and health care system factors were of secondary importance in this study, this is not necessarily an inevitable situation. The study offers a model that could assist in
conceptualizing and guiding the enhancement of Community Participation for Primary Health. Care.
1
V1
1994
ACKNOWLEDGEMENTS
would
like to acknowledge the support and encouragement of a number of people in Canada and Botswana who assisted with this project. We are indebted to members of the International Development Research Centre (IDRC) in Ottawa, Canada, specifically to Dr. Duncan Pedersen, Jane MacDonald, Dr. Annette Stark, and Irene Lythall for their contribution to this project in its initial phases and on an ongoing basis. Without the financial support of IDRC, this research project would not have been possible. We gratefully acknowledge the contributions of Anne Rawley and Dr. Laurie Ferris to the development of the project and of Mary Lang, and Dr. Irmajean Bajnok of Toronto, Canada for their assistance with data analysis. A special thank you is extended to Valerie Jones in Toronto for her assistance with coordinating appointments and travel arrangements for members of the Canadian team. At the University of Toronto, we would like to thank Dr. Dorothy Pringle, Dean of the Faculty of Nursing, for her ongoing support and encouragement, as well as Vivien Hinds and Bryce Moroz for their financial management of the project. We would also like to thank all the participants in our study; the Household members, Nonwestern Healers, members of the District Health Team, Key Persons, and members of the focus groups for their keen participation. We want to extend a special thank you to all the nurses in the clinics for supporting us throughout the research period and for finding time to work with us in spite of their busy schedules. We would also like to acknowledge the University of Botswana for its approval of the project and for administration of the funds. A special thank you is extended to the Advisory Group in Botswana, particularly, Dr. Joan Reeves, Senior Lecturer, and Esther Seloilwe, Lecturer, in the Department of Nursing Education; Dr. Thabo Fako, Senior Lecturer, Sociology; Mmatsae Balosang, Head of Health Education; Pilate Khulumane, Head of the Research Unit--Ministry of Health; Mbulawa Mugabe, National Institute of Research and Documentation (Health Unit); and Phutego Knudsen, Acute Respiratory Infections. We
ii
TABLE OF CONTENTS
ABSTRACT ACKNOWLEDGEMENTS
.
CHAPTERI
.
.
.
ii iii 1
The Problem and Purpose
1
Political and Administrative Structure
2
National Health Policy
3
Literature Review
5
The Concept of Primary Health Care
5
Community Participation
7
Relevant Botswana Research
.
.
.
.
The Role of the Nurse
8 1].
Collaborative and Research Objectives
.
14
Collaborative Objectives
14
Research Objectives
15
CHAPTERII
16
Methods and Procedures
16
Sample
16
Setting
16
Phase I-—Preparation Instrument Development
.
17
.
17
Qualitative Methodology Phase II -- Data Collection Phase III —— Data Analysis
iii
19 .
20
.
20
CHAPTER III
21
Results
21
Community Profiles
21
Community
1
-
Rural
21
Community
2
-
Rural
23
Community
3
-
Urban
25
Community
4
-
Urban
26
Demographics
27
Primary Health Care
34
.
Research Objective
1
Community Participation Research Objective Role of the Nurse
.
34 39
2
39
3
45
.
Research Objective
Model of Community Participation for Primary Health Care
Research Objective
4
50 50
Summary
CHAPTER IV Discussion
54
Primary Health Care
54
Primary Health Care--Hindered Primary Health Care--Enhanced Community Participation Community Participation--Hindered Community Participation--Enhanced iv
Role of the Nurse
61
Role of the Nurse--Hindered
61
Role of the Nurse--Enhanced
63
Community Factors
64
History and Location
64
Community Integration
66
Employment and Income Opportunities
67
Leadership
68
Collective Activity
68
Nurse Factors
69
CHAPTER V Summary and Recortunendat ions
Summary Recommendations REFERENCES
75
APPENDICES
78
V
LIST OF APPENDICES
APPENDIX A
Annotated Bibliography of Coirimunity Participation in Primary Health Care (Botswana 1979—1990)
.
78
APPENDIX B
Focus Group Interview Guide
93
APPENDIX C
Household Questionnaire
95
APPENDIX D
District Health Team Questionnaire
APPENDIX E
Key Persons' Questionnaire
103
APPENDIX F
Nonwestern Healers Questionnaire
106
APPENDIX G
Nurse Questionnaire
108
APPENDIX H
Household Subjects' Indicators of Primary Health Care Collapsed into Mutually Exclusive Categories
113
Committees Which Exist in the Communities Collapsed into Mutually Exclusive Categories
115
APPENDIX
I
vi
.
.
.
.
.
100
CHAPTER
I
The Problem and Purpose
The Ministry of Health in Botswana, Africa, identified
Primary Health Care (PHC) as the first health priority for its sixth national development plan (Ministry of Finance and
Development Planning, 1985).
Within this plan, PHC was accorded
a central role in achieving "Health for All by the Year 2000"
(World Health Organization, 1978).
In addition,
Community
Participation was determined to be one of the major strategies in the attainment of Primary Health Care.
Although national
policies and structures have been implemented to foster Community Participation and Primary Health Care, the desired results have not been realized. Studies in Botswana have examined the role of the Village
Health Committee (VHC) and the Family Welfare Educator (FWE), both of whom were expected to be catalysts in promoting Community Participation (Knudsen, et al., 1988; Owuor-Omondi, Atiholang, Diseko, 1986; 1987).
Consistently, both studies found
insufficient involvement of the VHCs and the FWEs in promoting and attaining acceptable levels of Community Participation.
Nurses in Botswana form the main PHC cadre.
Nurses are
expected to provide leadership and supervision in curative, preventive, and health promotive activities.
They also are
expected to play a significant role in the development and ongoing work of both the VHC5 and FWE5. It is essential that the nurses' role is examined in a broad context in order to understand the contribution made by nurses to Community Participation and Primary Health Care. The overall aims of this study were to build on existing knowledge and further identify factors that could enhance or
hinder Primary Health Care and Community Participation,
and to
examine the Role of the Nurse in enhancing Community
Participation for Primary Health Care in Botswana. has both social and scientific relevance.
This research
From a social
perspective, the study has produced information on the Role of
2
the Nurse in Community Participation and Primary Health Care. This information will have significance for health care planning, It has policy making, nursing practice, and nursing education. also brought to light information about which community factors
are most likely to contribute to high and low levels of Community Participation for Primary Health Care. From a scientific perspective, a beginning step has been taken to understand the
concepts of Community Participation, Primary Health Care, and the Role of the Nurse in the Botswana context. New instruments for studying these concepts have been developed and these instruments can be tested in future research.
This report is the result of research collaboration between two multidisciplinary teams: one from the University of Botswana
and the other from the University of Toronto, Canada.
Funding
for this study was successfully obtained from the International
Development Research Centre in Ottawa, Canada in 1990 (Centre file # 89—1037—01) Political and Administrative Structure Botswana, formerly the Bechuanaland Protectorate, received
independence from Great Britain in 1966.
Its constitution
provides for a multiparty democracy and a society based upon non— racialism and freedom of speech, press, religion, and association. Traditional institutions and practices are
recognized by the government and incorporated throughout the national system. Botswana is noted for its democratic character and has suffered little internal or ethnic conflict. Since independence, there has been a move to decentralize
administrative authority and promote local participation and initiatives (Ministry of Finance and Development Planning, 1985). Botswana, a country about the size of France, is landlocked, semi—arid and located in the centre of Southern Africa. At independence it was, according to the World Bank, among the
poorest countries in the world, but the discovery of significant mineral deposits, particularly diamonds, has contributed to impressive economic growth. According to the World Bank's 1992
3
report (World Bank, 1992), Botswana has had the fastest growing In 1974, minerals economy in the world for the past 2 decades. replaced beef as the major source of export revenue, but
unemployment remains
significant problem.
a
The majority of the
population are dependent upon livestock and agricultural production, remittances from wage earners, and social welfare relief measures, many tied to recurrent droughts. Efficiently and equitably delivered aid prevented large-scale suffering but created some dependence on government relief. The drought exacerbated the already existing economic inequalities; possibly half the rural population still lives in absolute poverty and studies in the urban areas also indicate greatly skewed income
distributions (Ministry of Finance and Development Planning, 1985).
National Health Policy The Government of Botswana has adopted the World Health
Organization motto "Health for All by the Year 2000" (World Health Organization, 1978). Thus, the Government, through the
Ministry of Health, is committed to improving the physical, mental and social wellbeing of every Motswana by the year 2000. The Ministry of Health aims to: of all citizens;
country;
(a)
promote the personal health
improve environmental health within the
(b)
prevent and control the outbreak and spread of communicable disease within the country; (d) guard against the (c)
introduction of disease from outside the country; (e) provide effective treatment, using appropriate technology to those affected by disease; (f) advise, assist, and supervise local authorities in regard to matters affecting public health; (g)
promote and carry out research into the prevention and treatment of human diseases as well as the control and improvement of environmental health;
(h)
provide treatment and care for the
physically and mentally handicapped/disabled and assist their rehabilitation; and
(i)
develop health service related technical
and professional human resources (Ministry of Finance and
Development Planning, 1985, p.319).
4
Priority, within the context of the national health plan, has been given to Primary Health Care, personnel development,
planning and statistics, hospital services, technical support services, and management. Primary Health Care has been defined as the "essential health care made universally accessible to
individuals and families in the community by means acceptable to them, through their full participation at a cost that the
community and the country can afford" Development Planning, 1985, p.319).
(Ministry of Finance and It is anticipated that
individuals will integrate the concept of health into their way of life and not equate it with medical care; a commodity
dispensed by medical personnel and institutions. In order for PHC to make an impact on health, the people must be fully involved in their own health care at the community level. As such, people will identify the main health problems of the
community, as well as identifying and implementing solutions. The Government recognizes that support, in the form of health
education programs at the family and community level, will be
required from health workers, government departments, and extension teams. With the implementation of the Sixth National Development Plan (Ministry of Finance and Development Planning, 1985),
qualitative improvements were made at the community level to the existing health care system. Increasingly more health posts were staffed with Enroled Nurses within the limits of the Local Authorities' budgets. Radios and vehicles were provided in order to improve local residents' access to higher order facilities. Village Health Committees were strengthened and village-based health worker training continued so that communities could be more involved in the planning, implementation and monitoring of health care. This study represents an attempt to evaluate the effectiveness of implementation of the National Development Plan at the community level, particularly the role of nurses in
enhancing Community Participation for Primary Health Care.
5
Literature Review
A review of relevant literature will address the major variables of the study, Primary Health Care and Community Participation, both in general terms and in the context of Although there are descriptive reports
Botswana National Policy.
of nurses' involvement in PHC activities, to date there are no
research studies which examine the role of the nurse in encouraging Community Participation for Primary Health Care. An Annotated Bibliography of Botswana literature relevant to Community Participation and Primary Health Care was prepared by members of the Botswana research team and is appended to this report (Appendix A). The Concept of Primary Health Care The concept of Primary Health Care has arisen in the last 20
years in response to assessments of community health needs which demonstrated that large percentages of populations lacked access to appropriate health care.
Primary Health Care has occupied a
central position in the strategy for meeting health care needs in
many countries; most notably in the developing world, though many industrialized countries are now giving it more attention (Epp, 1986; and Vuori and Hastings,
1986; Zakus,
1988).
Central to PHC are the concepts of Community Participation,
universal coverage and accessibility, appropriate technologies, intersectoral collaboration, referral to more sophisticated levels of care, and the use of community based health workers. But of all its components, that of Community Participation is
proving particularly difficult to achieve. Conceptually, Primary Health Care is viewed in a very broad context. Strategically or operationally, though, this "essential health care" is to include any or all of the following components: (a) education concerning prevailing health problems and the methods of preventing and controlling them (especially concerning nutrition and hygiene);
(b)
promotion of food supply
and proper nutrition;
(c)
basic sanitation;
maternal and child health care, including
(d)
an adequate supply of safe water and
6
family planning, prenatal care, qualified birth attendance, care of newborns, and child growth monitoring;
(e)
immunization
prevention and control of locally endemic (vector—borne) diseases; (g) appropriate treatment of common diseases and injuries; and (h) the provision against the major infectious diseases;
of essential drugs.
(f)
To these rehabilitative services, mental
health care and the integration of proven traditional practices can also be added [World Health Organization (WHO), 1978). Primary Health Care in Botswana. For the Sixth National Development Plan (1985-1991) the
Botswana Ministry of Health adopted Primary Health Care as an essential strategy for improving health (Ministry of Finance and Development Planning, 1985). Through the Primary Health Care approach,
available health resources will be equitably
distributed among population groups. Thus, essential health care is to be accessible to all individuals and families in an acceptable and affordable manner, and with their full
participation and involvement, so that all people of the country would have the opportunity to attain a level of health permitting them to lead socially and economically productive lives. The Government of Botswana recognized that Primary Health
Care could not be attained by the Ministry of Health alone.
The
people of Botswana were expected to fully participate as partners in their own health care.
Primary Health Care was intended to be
community oriented, where communities and individuals took
responsibility for improving and maintaining health. Community Participation, was recognized as a key component of Primary Health Care and community members were to be included in identifying the main health problems and the possible solutions to those problems, as well as implementing the solutions. To attain Primary Health Care during the period of the Sixth
National Plan the Government of Botswana made organizational changes at both national and local levels.
These changes were
based on the belief that decentralization could bring better
health services to the people, and enhance communication and
7
Community Participation.
At the national level a Department of
Primary Health Care was established to integrate preventive, promotive, rehabilitative, and appropriate curative health care services and to promote the participation of community groups at all levels of the national health care system.
At the local level the Regional Health Teams were made
operational under the District/Town Councils and called District Health Teams.
While they were under the executive and
administrative control of the Councils, the Ministry of Health,
which maintained overall accountability for health in the country, continued to supervise,
assist and advise district
health services to ensure that Ministry policies were followed and acceptable standards of care were maintained. To support Primary Health Care and Community Participation at the community level the Ministry of Health, together
with the
Ministry of Local Government and Lands, put in place support structures to foster community involvement. These include: the Family Welfare Educator cadre, Village Health Committees, Village
Development Committees, Village and District Extension Teams, and District Development Committees. It also mounts educational programs like the Community Leaders Health Seminars.
All of
these are recognized as major factors in the attainment of
Community Participation and Primary Health Care during the Sixth National Development Plan (Owuor-Omondi, Atlholang, & Diseko, 1986;
1987)
Community Participation Community Participation in health may be defined as the process by which members of the community, either individually or collectively: (a) develop the capability to assume greater responsibility for assessing their own health needs and problems; (b)
plan and decide on solutions;
(c)
create and maintain
organizations in support of these efforts; and (d) evaluate the effects and bring about necessary adjustments in goals, targets and programs on an ongoing basis (Nuyens, 1981; Vuori, 1986; WHO, 1978).
The most fundamental dimension of Community Participation
8
is power and its distribution between citizens and their leaders
or political structures
(Windle and Cibulka,
1981).
The principle of Community Participation is one of the
cornerstones of the Primary Health Care strategy for achieving the goal of Health for All by the Year 2000 as enunciated by the Declaration of Alina—Ata (WHO, 1978), and of the various specific goals and targets set by many countries and by the international community collectively [Pan American Health Organization (PAHO), 1977; WHO,
1985].
A number of countries have constitutionally
recognized the importance of community/public involvement in social policy development and decisions (Vuori and Hastings, 1986; PAHO, 1984)
In the course of its development, Community Participation
becomes: stages;
(a)
active when the people take part in its various conscious, when they fully understand the problems,
(b)
translate them into felt needs, and work to solve them; (c)
responsible, when they commit themselves and decide to move
ahead in full awareness of the consequences and their deliberate, when they express their voluntary
obligations;
(d)
resolve;
organized, when they perceive the need to pool their
(e)
efforts to attain the common objective; and
(f)
sustained, when
they band together permanently to solve the various problems of
their community (Fonaroff, 1983; Vuori and Hastings,
1986; and
Zakus and Hastings, 1988). Thus,
with so many problems and obstacles to confront, those
involved in promoting and developing Community Participation have an enormous task.
Whether they be doctors, nurses, supervisors,
community health workers, community promoters, or the actual participants themselves, they need to have in hand as many techniques as possible to solve these problems. This study sheds some light on these core issues for Botswana.
Relevant Botswana Research The Ministry of Health identified research priorities for
the six year span of the National Development Plan in order to
assist policy makers, planners, and developers by providing them
9
with objective data to guide the implementation of PHC. The research priorities included: (a) community involvement and structures, for example Village Health Committees and Family
Welfare Educators;
(b)
intersectoral coordination;
(c)
utilization patterns of health care and health facilities; staff utilization;
(e)
costing of Primary Health Care;
(d)
(f)
traditional health care; (g) research on specific groups and conditions; and (h) the role of non—governmental organizations (Ministry of Finance and Development Planning, 1985). In response to these research priorities, there have been
three major health care studies conducted in Botswana:
Continuous Household Integrated Programme Survey; National Health Status Evaluation Programme; and Family Health Survey.
(b) (c)
(a)
the
the the Botswana
All of these studies focused on evaluating
the implementation of the Primary Health Care system and on
identifying and developing indicators to monitor and evaluate the health of individuals as a result of the various health services. The National Health Status Evaluation Programme was a
multidisciplinary project involving the Botswana Government, the University of Botswana, the National Institute of Research, and the Norwegian Agency for Development.
The program comprised a
number of different studies all addressing specific areas. of these studies have major relevance to the proposed study:
Two (a)
the Village Health Committee Study (Owuor-Omondi, et aL, 1987), which assessed the committees as viable instruments of community mobilization for Primary Health Care, and (b) the Family Welfare
Educators Study (Knudsen, et al., 1988), which examined methods for improving the community focus of the Family Welfare Educator cadre.
The Village Health Committee Study.
The Village Health Committees (VHCs), comprised of volunteers, have an important role to play in fostering Community
Participation in accordance with Botswana's PHC policy (Ministry of Finance and Development Planning,
1985).
The Village Health
Committee study (Owuor-Omondi, et al., 1987) examined the role of
10
the VHC in community mobilization, established the extent to
which VHCs contribute to the implementation of PHC in Botswana, identified the reasons for active and inactive village health committees, and examined the relationship between the VHC and other individuals, committees, or sectors involved in development activities in the community.
Interviews were held with
members of various Village Health Committees.
The study used a
number of different quantitative and qualitative data collection methods, including questionnaires, focus group discussions, and key informant interviews with community leaders, members of
various committees and members of the extension teams. While it remained clear that VHCs were the key to community involvement in the implementation of PHC, a problem with role
ambiguity was identified among VHC members.
Fifty-five percent
of the participants indicated that they did nothing as a VHC
member during the previous week, and 37% of the study sample was found to have no plan of action for the next six months.
There
was a general lack of clarity as to who should supervise the
activities of the VHC and a perception among VHC members that the committees received little respect or support from the communities (Owuor-Omondi, et al., 1987). Family Welfare Educators' Study. Family Welfare Educators (FWE5) were the second group
charged with the responsibility of fostering Community Participation for Primary Health Care. FWEs form links between the community and the health care providers by motivating the
community toward the improving the health of individuals in families. They also assist the community to analyze the causes and find solutions to their problems and provide health and
health-related information during home and school visits, clinic sessions and community meetings. FWEs are expected to spend 50% of their time in the
community visiting households.
In a number of studies,
the FWE5
were consistently identified as being too clinic-based and insufficiently community-oriented (Bennett et al., 1980; Cook,
11
1973; Manyeneng, 1982; Owuor-Omondi et al.,
1986).
Similarly,
the Family Welfare Educator Study (Knudsen et al., 1988), found
that the FWEs spent less time working with the community than was expected.
Although responses to a national questionnaire
suggested a mean of 21.6 home visits per month were made per FWE, analysis of record books showed a mean of 8.8 visits per month, representing 13.5% of the FWE's monthly work time. Furthermore,
most home visits were in follow-up to problems identified in the clinic and not health promotive or illness preventive in nature. Some of the main conclusion of the FWE study were:
(a)
the
original role of the FWE as a motivator and an agent of
behavioural change was being taken over by increasing curative obligations;
(b)
"returning the FWE to the community" would
require the involvement of members of the community, supervisors and local health teams, members of the District Health Team,
training institutions like the National Health Institute, and most of all it would require a clear and firm policy from the
Ministry of Health and other related ministries; and (c) proper supervision was a critical tool for sustaining the morale of the FWE, and if properly structured could be an important medium for
continuing education.
The study ultimately proposed to increase
supervision of FWE5 by nurses, with day—to—day supervision becoming the responsibility of the clinic nurse. It was also deemed important to clarify the relationship between the nurse and the FWE as an integral part of promoting work in the community (Knudsen, et al., 1988). The Role of the Nurse Although nurses are the most numerous, and often the only health professionals available to underserved populations, their role in implementing Community Participation for Primary Health Care has not clearly been delineated. Council of Nurses'
(ICN)
In the International
statement on the role of nursing in PHC,
ICN has implied that nurses must shift their focus away from the idea of "doing f or" people to "working with" them to become more
self—reliant.
In addition, the focus must shift from the
12
curative model of health care to a health promotive, disease preventive framework with an emphasis on Community Participation (Krebs, 1983).
The PHC literature is rich with references to the key role
that nurses play in the attainment of Health For All by the Year 2000, however, to date there has been little research which
systematically analyzes and evaluates the nurses' role.
Descriptive evidence suggests that nurses' education provides them with the administrative, coordinating, preventive, curative, and promotive background necessary to support and implement PHC. In addition, the nurses' work with the communities places them in
the unique position of being able to develop trusting
relationships with community leaders and thereby work with them to identify health problems and develop and implement solutions that are consistent with the cultural and health beliefs of the Nurses can also encourage Community Participation in health related issues through the dissemination of health community.
information, the teaching of health improvement skills and the
creation of supportive environments and self—help groups (Adebo, 1988;
Berland, 1991; Chamberlain
1991; Namate,
1992; Osei-Boateng,
&
Beckingham, 1987; McMurray, 1992).
Although nurses who had been educated in PHC expressed confidence in their ability to implement Community Participation (Ramalepe, 1988; Sishuba, 1989), throughout the literature nurses
consistently expressed dissatisfaction with the degree to which they could implement PHC.
Personnel shortages, role ambiguity,
the lack of clear direction in their job descriptions, lack of
support from superiors, job postings that give little consideration to the nurses' family integrity, all contribute to apathetic attitudes and a lack of job satisfaction, while serving to prevent the nurses from working with the communities as much as they feel they should (Adebo, 1988; Anderson, 1987;
Chamberlain
&
Beckingham, 1987; Ngcongco
&
Boateng, 1992; Spear, Oddi, Vor der Bruegge
Stark, &
1986; Osei-
Hamilton, 1990).
13
Nurses in Botswana are the most numerous health care workers in the country (Ngcongco
&
Stark,
Consequently nurses are
1986).
assigned to rural clinics and health posts in order to operationalize the government policy to bring Primary Health Care services to the communities.
In the course of the 1970s and
early 1980s it became clear that traditional nursing education did not adequately prepare the nurses for their key roles in
implementing PHC.
Nurses reported a lack of understanding of
community health nursing, specifically of the curative, preventive, and health promnotive aspects important to the implementation of PHC. Consequently, two post—basic nursing education programs, the Family Nurse Practitioner Program and the Community Health Nurse Program, were developed in order to increase the relevance of nursing education to the social and
health needs of the people. The first program prepared a cadre of Family Nurse
Practitioners (FNP5) from an existing pool of nurse-midwives to participate in activities aimed at improving health at the community level, particularly in the areas of maternal/child health and family planning (Ngcongco & Stark, 1986). Although the FNPs and their educational program were valued in Botswana and in other African countries (Ngcongco
&
Stark, 1986; Osei-
Boateng, 1992), their role in enhancing Community Participation
for PHC, particularly with respect to working with the
communities to identify health priorities and to develop and implement strategies to address those priorities, has not been evaluated. The second post—basic nursing program for Community Health Nurses (CHNs) was developed to strengthen the preventive and
health promnotive services in rural areas.
In a descriptive
study, Anderson (1987) examined the contribution made by CHNs
toward the goal of Health for All by the Year 2000.
The
CHNs reported that they derived pleasure from attending the
village committee meetings, making home visits, and working with the communities to develop and implement health programs. They
14
were largely satisfied with their community health education However, program and felt prepared to practice in the community. role confusion and ambiguity, especially with respect to job
descriptions and reporting structure, were particularly troublesome for the CHNS. Additionally, interpersonal conflicts, perceived lack of respect, and difficulty finding a balance between the curative and preventive aspects of their jobs contributed to the frustrations experienced by these nurses.
The
CHNs also expressed frustration with the posting system for nurses, specifically with posting recent graduates to remote
areas with little or no followup, posting CHNs in the hospital
setting where their community health work is impeded by demands for curative care, and posting nurses far from home and separated from husbands and children.
Similarly, Tapela
(1983), reported
nurses' negative attitudes toward working in remote areas. These
negative attitudes were attributed to poor working conditions in
remote areas and to the unfair, and often punitive, transfer system imposed upon the nurses.
In Tapela's study, marital
status was not found to have a significant effect on the nurses' attitudes.
Collaborative and Research Oblectives In spite of the abundance of descriptive literature, there is a paucity of research into the role of the nurse in Community
Participation for Primary Health Care. Major gaps exist in the literature to validate the role. The objectives of this study were derived to address these gaps. The specific objectives were as follows:
Collaborative Obj ectives 1. To provide an opportunity for research teams from Botswana and Canada to exchange information and expertise in health care research, and to work together in furthering health goals in Botswana. 2.
To enhance the research capabilities of the members of
the Botswana Team.
15
Research Obi ectives 1. To identify and validate factors, perceptions, attitudes, and expectations of Household members,
District Heath Team members, Key Persons, Nonwestern
Healers and Nurses that are associated with Primary Health Care in Botswana. 2.
To identify and validate factors, perceptions,
attitudes, and expectations of Household members,
District Heath Team members, Key Persons, Nonwestern Healers and Nurses that are associated with Community Participation in Botswana. 3.
To identify and validate factors, perceptions,
attitudes, and expectations of Household members,
District Heath Team members, Key Persons, Nonwestern Healers and Nurses about the role of the nurse in Community Participation for Primary Health Care in Botswana. 4.
To identify and model the factors that enhance or
hinder Community Participation for Primary Health Care in Botswana.
16
CHAPTER II Methods and Procedures This study was conducted in in Botswana,
2
rural and
2
urban communities
Southern Africa by a research team from the
University of Botswana in collaboration with a research team from the University of Toronto, Canada. The study combined qualitative and quantitative research methodologies, specifically focus groups, participant observation, semi—structured interviews, ethnographic community profiles, and questionnaire
administration. Sample The study had five target populations: representative
samples of (b)
(a)
Household members from four communities (fl=206);
members of the District Health Team
in community and national structures (d)
Nonwestern Healers (N=33); and
(e)
(c)
Key Persons
with all the Nurses (N=l4) in the four
communities. Setting Four communities were selected for the study, two rural and two urban. The criteria for rural community selection were size (small —
under two thousand), reputation among local health care
personnel for levels of Community Participation (high or low), and located within the same district so that the district policy
would remain constant. The urban communities were larger and also had a reputation for high or low levels of Community Participation. For the purposes of this study, communities with a high level of Community Participation were designated as "effective"; those with a low level of Community Participation were designated as "less effective". The communities were selected in March-April 1990 by the research team in conjunction with an advisory committee which was formed for the study.
The
following communities were selected for the study. Community
1 is a
rural community situated in the Bobonong
subdistrict of the Central district. census, Community
1
According to the 1981
had a population of 1,470 but it is now
17
believed to be larger. Community 1 had a reputation for a high level of Community Participation. Community 2 is the second rural community. It is situated on the fringes of the Kalahari desert in the Central District.
The 1981 census lists 542 inhabitants but since that time great
efforts have been made on the part of government to settle people
from outlying areas into the village so that the 1981 estimate is
now surely very low.
Community
2
has a reputation for a low
level of Community Participation.
Community
3,
is a
pen-urban township of Lobatse with an
estimated population of 9,139, according to a 1989 census. Community
3
is known for a low level of Community Participation.
The community originally selected as the urban community with a reputation for a high level of Community Participation was
unavailable to us at the time of the study. as Community 4,
a
Therefore, we chose,
suburb of the nation's capital, Gaborone.
1990 estimated population of Community
4
The
Community
was 12,098.
4
was selected for the study because of its proximity and easy access to a number of facilities such as schools and clinics. The town was built to meet specific building and sanitation standards.
Although these factors may contribute to better
levels of Primary Health Care, we recognize that our results may have been biased because of our choice of Community
4
as a study
site.
Phase I--Preparation
Preparation for the study began in April 1990 with hiring of staff and purchasing of equipment. Two members of the Canadian
team assisted the Botswana team in instrument development and provided education regarding ethnographic data collection techniques. Instrument Development questionnaire Development. The research instruments were developed in the following stages:
(a)
Instruments from previous health care and community
studies in Botswana were examined for ideas, concepts, and
18
structure.
(b)
In April 1990 the research team conducted three
focus groups to identify concepts and to develop items for the
questionnaires.
Two focus groups were held with community
members and clinic staff at clinics in pen—urban villages of Gaborone.
These were designed to elicit community views on
Primary Health Care, Community Participation, and nurses (Appendix B). One focus group was held at the University of Botswana with senior nursing education students to refine concepts and obtain Setswana phraseology and ideas surrounding the study factors and variables. (c) Concepts, factors, and
variables were identified, discussed and refined at a series of advisory committee meetings.
(d)
The Botswana team in
consultation with the Canadian team drafted the Household Questionnaire (Appendix C). Six domains of inquiry were included: (i) socio-deinographic profile, (ii) knowledge of Primary Health Care, (iv)
(iii)
Community Participation,
community perceptions of nurse-community relations,
of health facilities, and (vi) Household observations.
(v)
use
This
questionnaire was examined thoroughly and refined at an advisory committee meeting. (e) Following the drafting of the Household Questionnaire, questionnaires with corresponding categories of
questions (where appropriate) were designed for (i) District Health Team members (Appendix D); (ii) Key Persons (Appendix E); (iii) Nonwestern Healers (Appendix F); and (iv) Nurses (Appendix G). (f) All questionnaires were examined at length and refined by the research team and the advisory committee. Members of the Canadian team were in continuous communication with the Botswana team during the questionnaire refinement process. Pre-testing of the questionnaires was conducted in June 1990 at villages near Gaborone. (h) In July 1990, during the early stages of data collection, the questionnaires were further (g)
refined so that the generic questions on different categories of
questionnaires would correspond to a greater degree. The questionnaires included open—ended questions; some of which had
19
mutually exclusive responses, and others had multiple, non—mutually exclusive responses. Qualitative Methodology The study employed qualitative research methods at the study design and instrument development stage and at the data collection stage.
The first stage of qualitative research was
carried out in the form of focus groups conducted in Gaborone and These, described above in the in neighbouring villages. instrument development section, contributed to the design of the study by facilitating hypothesis generation, concept generation, and the identification and definition of factors, variables, and
appropriate subjects for the instruments.
Data collection,
both
qualitative and survey, was carried out in the four communities through early July to early September 1990 and again in March and April 1991. The second period of research consisted only of ethnographic research. During data collection the researchers resided in the communities in order to immerse themselves in the local culture.
The qualitative research methods of participant
observation, semi—structured and open—ended interviews, and focus groups were utilized.
Fieldnotes based an participant
observation were taken daily during the data collection period and lengthy answers were entered on the open—ended sections of the interview and focus group forms. The data has been analyzed in three stages:
before the second round of ethnographic research the fieldnotes and interviews were examined, some summarized,
(a)
and gaps in information were noted so that they could
be addressed in the second round of research.
Recurrent themes
in the fieldnotes and interviews were also identified.
(b)
After
the second stage of ethnographic research the frequencies of the questionnaire responses were examined in detail and any
observations regarding anomalies, variations between communities, recurrent themes or points of significance of the answers were noted for all categories of the questionnaires.
At this time the
researchers drafted community profiles of the four communities. The profiles included sketches of the community and physical
20
infrastructure, socio—economic situation, political organization,
history; and they described the communities' health facilities and their patterns of utilization. These two exercises enabled
much of the qualitative information obtained to be brought together and presented in
a
concise and coherent form.
(c)
The
results of the quantitative data were examined in light of the qualitative.
The qualitative data served as a corrective for the
quantitative and served to deepen, expand, and to help explain the quantitative data. Phase II —— Data Collection
The study was conducted in in Botswana.
2
rural and
2
urban communities
Data were collected via instrument, participant
observation, and focus group methodologies in July, August, and September, 1990. Prior to data collection, content and face
validity of the structured interviews and the questionnaires were established by administering the instrument to groups similar to those in the study. Phase III —— Data Analysis
The majority of the data were coded by the research
coordinator from the Botswana team under supervision of the Canadian team during a 1990.
9
week visit to Canada in the late fall of
Data entry and subsequent collapsing of data codes was
undertaken in Canada during the spring and summer of 1991 with further collapsing and recoding occurring in the winter of 1991/92. Data were analyzed using the SPSS-PC statistical package in the summer of 1992. Quantitative data were analyzed using descriptive statistics in association with cross tabulations and Chi Square analysis of the major variables across groups and
across communities.
21
CHAPTER
III
Results The results of this study will be presented in relation to the main concepts of Primary Health Care, Community Participation and the Role of the Nurse.
In addition,
community profiles and
demographic data will be presented for each target group. Comparisons were made across groups and within groups according to the following distinctions: "rural" (Communities 1 and 2) versus "urban" (Communities
3
and 4), and "effective",
communities perceived to have a high level of Community Participation and Primary Health Care, (Communities 1 and
4)
versus "less effective", those perceived to have a low level of Community Participation and Primary Health Care (Communities 2 and 3).
Again, it should be noted that Community
4
was selected
on the basis of reports by clinic staff of good Community
Participation.
During the period of investigation, it became
evident that the so-called good participation was based on ad hoc
activities such as participating in "World Health Day" and other activities organized by clinic staff and not necessarily by
members of the community. Community Profiles Four communities were selected for the study, two rural and two urban. A brief profile of each of the study communities will follow.
Community 1 - Rural Community 1, situated in the Bobonong subdistrict of the Central District had, according to the 1981 census, a population Most residents of of 1,470. It is now believed to be larger. Community 1 are Babirwa and the village is striking for its ethnic homogeneity.
Housing in Community
bungalows to simple mud huts. dramatically.
1
ranges from elaborate
Similarly income levels range
Housing plots tend to be large by Botswana
standards, most are fenced, and the village is notable for its
sense of orderliness and cleanliness.
Most residents are
involved in livestock and agricultural production, although the
22
area has been severely drought stricken, and many work outside the village in formal sector employment.
The nearby industrial
town of Selibe Phikwe is a common place of employment. The Community
1
Kgotla is active and the village's one
telephone, a public coin machine, is situated near it. a
There is
primary school and there are several shops in the village.
Although a remote village, several politically prominent Batswana have homes in Community
1
including the current Ambassador to the
United Nations and the Permanent Secretary to the Office of the President. Community 1 is close to the borders of South Africa and Zimbabwe and most Babirwa have kin in these countries which
enabled them to take advantage of the better educational
opportunities that existed in those countries in the early part These educational opportunities have of this century. contributed to the ability of Community
1
residents to obtain key
positions in Botswana. Furthermore, they learned from the white farmers in the Tuli Block to improve their cattle and to carry out small irrigation schemes. There are four wards in the
village which vary in their levels of political activity.
Within
the village political power tends to be concentrated within a few
families whose members hold many key positions. Community 1 emerged as a village in the 1920's following a
political struggle between the Babirwa and the ruling Bamangwato. The Bamangwato gave the Tuli Block to the British South Africa Company; the resident Babirwa were "relocated". In 1921, the
Babirwa hired a Johannesburg lawyer to defend their land rights. Although they failed technically in their land claim, using British law against the local powers was an extremely innovative move and the case remains, to a large extent, their moral victory.
This process of politicization has contributed to the
high levels of Community Participation evident in Community
1
today.
A healthpost was established in 1973 and in 1985 the
current clinic opened. The clinic grounds are well maintained, well fenced, and lovely vegetable and flower gardens enhance
23
their appearance. The clinic is staffed by two Registered Nurses (RNs),
one Enroled Nurse (EN), two Family Welfare Educators The clinic has four rooms
(FWEs), and three non-medical staff.
and a covered open space in the middle where patients congregate and other activities such as child weighing and education
sessions occur. relief foods.
A storage facility has been built for drought Of great concern to residents and clinic staff are
the poor roads connecting Community
1
to larger centres; in the
rainy season it is often impossible to get emergency patients out of the village.
For this reason the residents stressed the great
need for a maternity unit as part of the clinic.
Village Health Committee (VHC)
Community l's
is vibrant and active.
It follows
a classic participatory model in which problems are recognized,
solutions identified, and then implemented. is predominantly,
The committee itself
but not exclusively, composed of women and
represents a cross section of the village in terms of ward, education level, and income level. The VHC and clinic staff
maintain a collegial relationship and work well together. Community 2 - Rural Community 2, on the fringes of the Kalahari desert in the Central District, lies 43 kilometres west of Shoshong, the nineteenth century capital of the powerful Ngwato chiefdoin. The 1981 census lists 542 inhabitants but since then the community has grown as a result of efforts on the part of government to settle people from outlying areas into the village. Community
2
is primarily composed of Bakgalagadi and secondarily of Basarwa
peoples.
Both are former subject peoples of the Bamangwato and
although their servile status officially ended in the first half of this century prejudice against them by other Batswana remains
Within the community the Bakgalagadi top the ethnic hierarchy. Farming and livestock production are the predominant a reality.
economic activities, although some villagers have employment outside the village.
Very few employment opportunities exist in
the village and various forms of government relief are important for many villagers,
especially the Basarwa.
24
Community
2
is a remote community, connected by a sand road
The
to Shoshong with no public transportation between the two.
few public facilities there have largely been built within the last decade in what was a sparsely populated corner of the village. Kgotla,
These facilities include a healthpost, a school,
administrative building, borehole and standpipe,
nursery school which remains virtually unused.
and a
Community
2
residents have been accustomed to living in dispersed settlements but the government has been encouraging them to concentrate more in the new village centre.
The residential shift and increase in
government presence has been accompanied by a shift in the locus of political power; the chieftainship moved from one family group The Basarwa have been especially encouraged to another in 1984. to settle in the village in the last decade and forgo their
semi-nomadic lifestyle. Drought relief and other forms of government aid have provided a powerful incentive to the Basarwa to relocate. This has fostered dependence amongst the Basarwa, many of whom say that since they moved for the government, the government must now see to their needs. Community
2,
like most Kalahari villages is a large,
sparsely populated community; many people live permanently at their lands kilometres away from the new village centre.
The
compounds are large and far apart from each other. Most houses are traditional thatch huts. The dispersed settlement pattern, the remoteness of the community, the late arrival of schools and other form of infrastructure, and the history of political subordination, has contributed to the low levels of Community
Participation now evident in Community 2. Community 2 residents are keen farmers and this is reflected in the fact that the farmers committee appears the most active and has constructed long drift fences to separate arable from pasture land. The Community
2
healthpost is composed of a consulting room,
a dispensary, a small kitchen, and an open space used as a
waiting room, dressing and injection area, and child welfare unit.
The healthpost is small, fenced, and its general condition
25
has improved since a General Duty Assistant (GDA) was hired in It is staffed by an FWE, an EN who started in December of 1990. the last few years, a GDA, and in the early 1990's the healthpost
got its first vehicle.
Community 3 - Urban Community 3, a township of Lobatse, was originally a squatter settlement settled willy-filly by Africans who were restricted from living in the European parts of Lobatse.
In 1989
Community 3's population was 9,139. Community 3 has a customary court, two primary schools, and many shops and bottle stores. Related to its rapid and unplanned growth Community 3 has had a reputation for social disorganization and disruption.
It is now
being decongested and efforts are being made to improve its
sanitation facilities and general living conditions. Community
3
residents have formal sector employment,
Some and some
live in fine large brick homes, but most parts of the community
are very poor and a large proportion of women depend upon selling
home brew from their homes.
problem in Community 3. Lobatse was founded as
Alcoholism is cited as a major a
village by refugees of the Difaqane
wars of the early nineteenth century.
It urbanized as a result
of many factors which include: a railroad built in 1897
connecting South Africa to Southern Rhodesia, now Zimbabwe, which made Lobatse one of its stops; white South African farmers established farming blocks nearby in the early twentieth century; mining prospectors came in the early twentieth century; in the 1930's a dairy and cold storage facility was built; and in 1952 a
Although services such as schools and medical facilities were developed in Lobatse during the colonial period, Africans often had restricted access
proper abattoir was built (Africa's largest).
to these.
Schools were opened in Community
its first clinic opened in 1963.
3
in the 1950's and
About half of Community 3's
population is Bangwaketse reflecting its proximity to the Ngwaketse area; the other residents are from other parts of Botswana and South Africa.
Community 3's population is dependent
26
upon formal sector employment, more significantly on informal sector employment, and while some residents retain links to the rural areas, many do not due to the long history of urbanization.
There are two large clinics in Community 3 with large staffs who provide a variety of services. There is no hospital. The clinics are utilized extensively but, according to informants,
little medical staff-community interaction occurs outside the Different committees exist such as the VHC, the
facilities.
Village Development Committee (VDC), and the Parent Teacher Association (PTA), but community involvement is low. The most active community members are those employed in the formal sector.
Community
4
-
Community
Urban 4
is a "suburb" community of the nation's capital,
Gaborone, the world's fastest growing urban community with a
population now of approximately 130,000. The 1990 estimated Gaborone was founded in population of Community 4 was 12,098. 1963 in preparation for the country's independence in 1966. Prior to that Botswana was administered from Mafikeng which is in South Africa.
Community
4
is a "planned" community which was
established in 1980 to accommodate the rapid growth of the country's capital. Housing in It has grown rapidly since then. Community 4 ranges from low to high cost and income levels range significantly as well. Gaborone is on the rail line and is now well connected to other parts of Botswana by a good road network. Community 4 is ethnically mixed, all residents are new to the area, and most maintain links with the rural areas.
Related to
the newness of the community is the fact that the population is relatively young and most elderly people remain in the rural
Amenities such electricity, telephone, and transport are readily available for a fee in Community 4. There are many primary schools and a secondary school. Community 4 residents areas.
depend on formal and informal sector employment and remain
economically linked to the rural areas with transfers going in both directions.
27
Being a new urban community, Community an active committee network.
4
has not developed
Residents display some cynicism
about community involvement and expect the government to provide
services such as refuse collection which they argue exist in other parts of the city. 4
The researchers observed that Community
was less tidy than the other urban community.
Community
4
residents were also more insistent than others that they should be paid for community service. This, in all likelihood, reflects both the fact of their greater dependence on formal sector employment than rural residents and the newness of the community. The Community
4
clinic, opened in 1990,
Botswana standards and includes
a
is a large one by
maternity wing.
There are
fifteen staff members including a nursing sister, an RN midwife, an EN midwife, an EN, 4 FWE's, and several non—medical personnel.
Nonetheless the clinic is very busy, the seating in the waiting room cannot accommodate all patients, and two to five hour waits are not uncommon. Demographics
Demographic data will be described in relation to the five target populations; Household members, District Health Team members, Key Persons, Nonwestern Healers, and Nurses.
Household The Household sample consisted of a total of 206 community from members, n=53 from Community 1, from Community 2, Community 3, and from Community 4. Subjects ranged in age
from 19 to 83 years, with a mean age of 41 years.
Seventy—two
percent of the subjects were between 20 and 49 years of age. There was no statistical difference between the four communities for the age variable.
Eighty three percent of the subjects were female.
Forty—one percent of subjects were married, 30.6% were single. The proportion of married subjects living in the two effective
communities was greater than in the less effective communities, and was similarly greater in the rural communities.
28
Nine subjects did not have children but the remainder had
between
1
and 20 children.
living children.
Most subjects
(77.6%) had less than
6
While families tended to be larger in the rural
communities, the infant mortality rate was also significantly
higher in the rural settings
(y 17.36,
7,
p=0.02).
In
Community
1,
36% of subjects had deceased children, and in
Community
2,
28% of subjects had deceased children in comparison
with 27% for Community
3
and 13% for Community 4.
interesting to note that although Community
1
It is
was perceived to be
an effective community where both Primary Health Care and
Community Participation are present, it had the highest rate of infant mortality. This may be a reflection of the age of the community, its relative stability, and the fact that Community 1 residents were without access to a health clinic until 1985. low rate of infant mortality for Community
4
The
is in part
attributable to the newness of the community and the fact that its population is young relative to the other communities.
The majority of subjects (94%) were members of various
Batswana ethnic groups, while the remainder were from other
African ethnic groups.
All subjects spoke the Setswana language,
3.4% could speak other African languages, and 10.2% could speak
non—African languages.
Significantly more rural subjects were
born in the research village than urban subjects (y 32.76, p
