Sharing health information with the urban poor

Bridging the health care information gap and creating free treatment in Lagos

Olatawura Ladipo-Ajayi, Lagos Community Manager

The lack of access to health care information, such as treatment options and preventative measures, as well as the dearth of affordable treatment relevant to the urban poor have been the focal points of the Lagos State Government's awareness programs. It has been ascertained that some of the health information issues arise due to insufficient communication channels, or the use of inappropriate channels for target audiences. For example, television commercials tend to be ineffective, as most urban poor do not have access to such devices, and general illiteracy levels are high. With information materials usually in English, the message is lost on the majority of the populace that need it.

In an effort to increase knowledge about health care, the state government devised an awareness program which includes campaigns in Local Government Areas (LGAs) of Lagos state, which are geared towards arming the poor with health care information for common ailments. The program's approach is to segment the market, focusing awareness efforts on each of the prominent ailments and targeting groups (students, women, etc.) with relevant information. Because it's a targeted campaign, information is provided in dialects common amongst the urban poor, such as "Pidgin English" and Yoruba. Radio jingles, print materials, and billboards are also used, since the radio is more readily available to the urban poor and billboards more visible. The State Ministry of Health often plans events that provide health care information, like a "health week," and informational visits in schools. Although information about reach is not readily provided, it seems that these various awareness programs are helping to ensure that health care options are made available to the public.

One of these programs includes the Eko Free Malaria Program. According to the State government, malaria is responsible for 70 percent of out-patient visits, 15 percent of hospital admissions, and 20 to 30 percent of deaths in children under five. The Eko Free Malaria Program is a free health program which disseminates information on treatment options and preventative measures. The program distributes free malaria drugs, and print information on preventative measures in local communities, schools, and facilities.

The State's breast cancer awareness program was established in response to increasing numbers of late-stage cancer patients reported at hospitals, due to lack of awareness and information on available treatment options. The program propagates information through educational lectures and the regular distribution of communication materials through grassroots mobilization efforts in Local Government Areas within the State and on a senatorial basis (Lagos West, Lagos East, etc.) and divisional basis (Agege, Ikorodu, etc.), ensuring a wider reach. The program also includes referrals to hospitals for screenings, wellness talks, and aggressive television and radio campaigns on cancer in relevant dialects and languages. This initiative also makes use of communal activities, like watching informational videos on breast self-examination, screenings, and counselling. Such sessions are also held with existing groups, like associations, churches, and societies. A total of 12,693 women have already benefited from the screening program.

The campaigns implemented by the current government are aimed at removing the barriers to information that exist amongst the urban poor, and at increasing awareness of health care options. The hope is that these efforts continue to yield fruit as more people take advantage of them, and a decrease in ailments is recorded.

Reaching out to MSM in slums

Katy Fentress, Nairobi Community Manager

On the 27th of May 2012, the Kenyan LGBT news agency Identity reported that two men were caught having sex in the night in Kayole, a north Nairobi slum. According to the article, the men were attacked and stoned. One of them got away, but the other succumbed to his injuries; his body was later found at a dumpsite near where he had been caught.

The incident highlights a difficult reality for Men who have Sex with Men (MSM) living in Nairobi slums. Sleeping in cramped quarters, with privacy a luxury that few can afford, and forced to conceal their sexual identity for fear of repercussions, MSM hide in the shadows and often lack access to the medical services the rest of the population enjoys.

Homosexuality is illegal in Kenya, and people caught in the act can face up to 14 years in jail. That said, Nairobi is one of the better places in the region for LGBT people to live their lives. There are few cases of people actually ending up in court, and a number of NGOs and community organisations work for gay rights, advocacy, and outreach.

In September 2011 the LGBT group Gay Kenya hosted the first Gay Film festival; an openly gay candidate almost ran in the recent elections, the country hosts LGBT awards and the media is open to some amount of debate on the issue - which is more that can be said about most of Kenya's neighbouring countries. Nevertheless, there remains the challenge of how to get important health information and services to gay men who do not have the benefit of being educated and computer literate.

According to a report by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR): "MSM in low- and middle-income countries are on average 19 times more likely to be infected with HIV than the general population". Ignorance as to how HIV is contracted is one of the main causes for such a high prevalence of infection.

In Kenya, the stigma attached to being open about one's sexual orientation extends to talking about sex in general. So in what way does essential health-related information for MSM find its way to the heart of the slums? How do men, some of whom may have come straight from the rural areas and know little about STI and HIV transmission, become informed?

"It is definitely a challenge," says Wyclif Abasi (not his real name), Health and Program Officer at Ishtar, an organisation that has been offering consultation and outreach to MSM in Kenya since 1997. "We cannot just walk into slums and distribute safe sex information, condoms and condom compatible lubricants to MSM... we would be putting ourselves at incredible risk; anyway, I doubt anyone would come forward for fear of being singled out."

The solution, says Abasi, comes in the form of informal networks through which information can be passed along and which hopefully reaches the most vulnerable of MSM: sex workers.

"MSM in slums have meeting points and develop support networks," Abasi tells us. "Through these and a combination of SMS messaging and peer education and other outreach activity, we aim to inform men about health-related issues."

Abasi explains that nightclubs are the main places where MSM meet, and that it is here that peer educators share important health-related knowledge and advise people to visit VCT (voluntary counselling and testing) centres. Ishtar has free drop-in centres where, he tells us, they offer free medication sponsored by the Liverpool VCT, SASA centres run by Ishtar in partnership with other local organizations.

When it comes to medical services, Nairobi boasts a number of centres that treat MSM without questions or stigmatization. According to Abasi, Kenyatta hospital (one of the main hospitals in the city) is one of these, a significant step in a country in which same sex relationships are technically illegal.

"As long as the criminalization of MSM continues to be prevalent," Abasi concludes, "it will remain an impediment towards successfully tackling the spread of HIV/AIDS in Nairobi and beyond. To get the message out, we need to be free to step up our advocacy and sensitization efforts and create more awareness amongst MSM and society at large."

Curing TB with new awareness campaigns

Carlin Carr, Mumbai Community Manager

Millions of people across the globe die of tuberculosis each year. Tragically, nearly all of these cases could have been cured. The public health threat hits hardest in the developing world, where 98 percent of TB deaths occur. Even short of death, the illness takes a massive toll, especially on the livelihoods of the poor: a TB patient loses three to four months of work, equivalent to 20-30 percent of a family's annual income, and is most prevalent among the "working age" group, ages 15-54. Perhaps most unfortunate is the fact that a cost-effective strategy, DOTS (Directly Observed Treatment, Short-course), has been available for years, yet its promise remains unfulfilled. In Mumbai, the government has gone so far as to make treatments available for free. Yet TB continues to affect the city's poor and vulnerable. For Mumbai's progressive program to have a greater impact, it will need to be accompanied by a comprehensive awareness campaign that targets not only the public, but care providers as well.

Public awareness campaigns

The most widely known public campaign against TB is on the back of Mumbai's ubiquitous rickshaws. Bumper stickers plastered across the back of thousands of the black-and-yellow three-wheelers declare: "Don't Spit! Spitting spreads TB!" and "TB is Curable. Use DOTS." However, the discovery of TB cases starts with making pharmacists more aware of the symptoms, detection processes, and free treatment options. An article in the Hindustan Times for World TB Day on March 24 said that infected persons will often visit a pharmacist and ask for cough medicine, not knowing that they could potentially have something much more serious. If pharmacists are not trained to detect potential TB cases, then patients will receive the wrong treatment, increasing their risk of spreading the disease (an untreated TB patient will infect, on average, 10 to 15 people per year) and putting the infected person at risk of death.

In a ground-breaking public-private partnership (PPP) program launched in 2006, the Indian Pharmaceutical Association (IPA) collaborated with local chemists in Mumbai under a program called Lilli MDR TB Partnership. The program trains chemists in detecting TB cases and referring patients to local clinics. The program is now being adopted by the Union Health Ministry's Central TB Division, elevating the initiative to the national level. In order to carry it out across Indian cities, the IPA has created a training manual for community pharmacists.

While the pharmacist awareness campaign has shown great promise, public awareness needs to be raised beyond what can be achieved with bumper stickers. Operation ASHA, a Delhi-based organization, uses local community members to raise awareness in their own communities, mostly slums in northern Indian cities. The organization runs clinics in community shops and temples and keeps them open for long hours. Most importantly, they recruit trusted community members to act as counselors, spreading messages about TB and walking patients through the treatment process.

Who's being left out?

Local engagement can be a very effective approach to working with communities at risk of TB. In addition to leading to more effective outreach, support services, and follow-up, communities "may also be able to influence national policy and help leverage more support for health systems and TB services," says a report on TB. While these on-the-ground systems work well in slums, they may still leave out the most marginalized populations, such as people living with HIV, drug users, or those in prison — all of whom face a high risk of TB. Given the highly contagious nature of TB, Mumbai's no-cost drug initiative can only work on a widespread level if all populations are targeted in the campaign. Otherwise, even programs with the best of intentions will continue to fall short.

Strategi sosialisasi hidup sehat dan bersih bagi masyarakat

Widya Anggraini, Jakarta Community Manager

Encouraging communities to engage in healthier habits is vital to creatating more livable cities. In Jakarta, a variety of different dissemination techniques exist, starting with the Ministry of Health's online "Clean and Healthy Living" campaign. Within the private sector, the "1000 Hygienic Toilets" and "21 Handwashing Days" initiatives both encourage hygiene and cleanliness habits in schools. Another important dissemination strategy is to empower existing local community health centers to reach out to the urban poor — for example, through movie screenings followed by a dialogue on effective health and hygiene practices.

Perilaku hidup sehat dan bersih di kota besar seperti Jakarta memang belum sepenuhnya menjadi kebiasaan. Orang masih suka membuang sampah disembarang tempati, mencuci di sungai, makan makanan tidak sehat, buang air besar di sungai dan perilaku tidak sehat lainnya yang cenderung mengundang penyakit dan mengotori lingkungan. Contohnya adalah kebersihan sanitasi yang kurang terutama di daerah-daerah miskin. Jumlah penduduk yang terus bertambah tidak diiringi dengan tersedianya sanitasi yang memadai mengakibatkan munculnya beragam penyakit seperti diare, disentri, hepatitis A dan lain sebagainya. Untuk itu perilaku hidup sehat dan bersih harus secara terus menerus disosialisasikan kepada masyarakat.

Perilaku Hidup Bersih dan Sehat pada dasarnya merupakan gerakan bersama sebagai upaya pemberdayaan anggota rumah tangga agar sadar, mau dan mampu berperilaku hidup sehat, dengan demikian anggota keluarga menjadi sehat dan masyarakat bisa hidup lebih tertib dan terjaga lingkungannya. Advokasi hidup sehat telah dilakukan oleh pemerintah melalui Kementerian Kesehatan Republik Indonesia secara online untuk memudahkan masyarakt mengakses apa dan bagaimana untuk hidup sehat.

Pihak swasta juga juga dengan aktif melaksanakan sosialisasi pola hidup bersih dan sehat seperti yang ditunjukkan oleh Pt. Unilever Indonesia melalui dicanangkannya Gerakan 1000 Toilet Higienis di sekolah-sekolah termasuk di Jakarta. Gerakan ini berawal dari keprihatian melihat kondisi toilet yang kotor dan masih rendahnya kesadaran untuk menjaga kebersihan toilet. Program edukasi dan sosialisasi toilet sehat ini juga memberikan Training untuk guru, siswa dan orangtua akan pentingnya hidup sehat. Selain itu, juga diberikan booklet dan komik edukasi agar memudahkan anak mencerna pesan menjaga hidup sehat dan kebersihan toilet dalam buku tersebut. Pt Unilever juga mengadvokasi murid dan komunitas sekolah melalui Gerakan 21 Hari Cuci Tangan dengan harapan mereka akan terbiasa mencuci tangan menggunakan sabun sebelum dan sesudah makan serta setelah dari toilet sebagai langkah preventif mencegah masuknya kuman. Dilakukan selama 21 hari sebab mencuci tangan harus dilakukan secara terus-menerus untuk menciptakan kebiasaan. Minggu pertama adalah masa pengenalan dan informasi, minggu kedua adalah menciptakan kesadaran dan minggu ketiga adalah masa pembentukan kebiasaan.

Salah satu metode yang juga efektif untuk meningkatkan jangkauan sosialisasi dan advokasi hidup sehat adalah dengan memberdayakan puskesmas yang merupakan ujung tombak pelayanan kesehatan masyarakat yang terpadu dan menyeluruh. Akses dan tarif puskesmas yang terjangkau menjadi pilihan utama bagi penduduk miskin Jakarta. Dengan jaringan puskesmas yang tersedia di setiap kecamatan dan Puskesmas Pembantu (Pustu) di setiap desa serta keberadaan Puskesmas Keliling, Pondok Bersalin Desa dan Posyandu maka pada dasarnya untuk menjangkau masyarakat miskin kota dalam hal sosialisasi hidup sehat adalah bukan perkara sulit. Hingga kini jumlah puskesmas di DKI Jakarta mencapai 340 dan posyandu sebanyak 4.237 pos. Potensi besar ini harus dimanfaatkan seperti yang dilakukan oleh Posyandu Melati di Mampang Prapatan, Jakarta Selatan bersama Tim Penggerak Pemberdayaan Kesejahteraan Keluarga (TP PKK) DKI Jakarta. Kegiatan edukasi dan sosialisasi diramaikan oleh para artis pemeran film Tanah Air Beta, hal ini sesuai dengan tema Gebyar Posyandu Tanah Air Beta Bersih dan Sehat. Pemutaran film dilanjutkan dengan sosialisasi dan dialog langsung oleh para pemeran film tersebut kepada sekitar 300 pengunjung. Kegiatan penyuluhan menggunakan metode audio visual dirasakan cukup efektif dan diharapkan kegiatan tersebut dapat direplikasi oleh posyandu maupun puskesmas lain di wilayah Jakarta. Puskesmas Melati juga secara aktif mendatangi masyarakat secara periodik untuk memberikan penyuluhan, kunjungan dan pembinaan kesehatan lingkungan masyarakat.

ESPAÑOL

ENGLISH

PORTUGUÊS

ENGLISH

How cell phones save babies

By Pahima Ahmed, Kalpana Maharajan, and Shalu Sebastian, Dhaka Community Managers

প্রায় ৩.৪ মিলিয়ন নগরবাসী অস্বাস্থ্যকর বস্তিতে বসবাস করে যারা সঠিক স্বাস্থ্য সেবা সম্পর্কে জানে না। বস্তিবাসীরা বিশেষ করে প্রসূতি মা এবং শিশুরা সবচেয়ে জন্ডিস এবং নিউওমনিয়ার স্বীকার। মা ও শিশুর সঠিক ও নিরাপদ স্বাস্থ্যসেবা প্রদান করার লক্ষ্য নিয়ে মোবাইল সার্ভিসের মাধ্যমে “আপনজন” নামের একটি এনজিও কাজ করে যাচ্ছে। “আপনজন” দক্ষিণ এশিয়ার সর্বপ্রথম “এম স্বাস্থ্যসার্ভিস” যা ২০১২ সালের ডিসেম্বরে বাংলাদেশের রাজধানী ঢাকাতে প্রতিষ্ঠিত হয়। মাতৃমৃত্যু হার হ্রাসকরণ এবং শিশুদের স্বাস্থ্যসেবা নিশ্চিত করার জন্য মোবাইলে ক্ষুদেবার্তা এবং কণ্ঠবার্তার মাধ্যমে গর্ভবতী, প্রসূতি, এবং শিশুদের স্বাস্থ্যসেবা প্রদান করেছে এই প্রকল্পটি। “আপনজন” প্রকল্পে মূলত তথ্য ও প্রযুক্তির ব্যবহারের মাধ্যমে নগরবাসীকে স্বাস্থ্যবার্তা পৌছে দিচ্ছে। এছাড়াও “আপনজন” স্বাস্থ্য বিষয়ক পরামর্শের মধ্য দিয়ে তার গ্রাহকদেরকে উন্নত মানের স্বাস্থ্যসেবা প্রদান করছে।

Asha Rani, a 24-year-old mother of two living in the Vashantek slum, says that she used to have no idea about how to raise a healthy child. She did not know about immunization schedules, nutritional recomendations, or common pediatric illnesses that can be handled at home. This was her level of knowledge about health care before she came across the Aponjon service ("the close or dear one" in Bangla), a mobile health service in Bangladesh.

But now she exclaims, "I know that I should keep my daughter on my shoulder for a few minutes after she receives breast milk. She doesn't vomit anymore and I am so relieved..."

Like Asha Rani, approximately 3.4 million urban poor live in Dhaka's unhygienic slums, which generally lack proper health care facilities. The slum dwellers, especially expectant and new mothers and their newborn babies, are alarmingly vulnerable to life-threatening diseases like jaundice and pneumonia. However, this vulnerability can be reduced at household level if slum residents get information on safe motherhood and child health care. This is where the Aponjon service comes in.

The Aponjon program, launched in December 2012 in Dhaka, is the first ever nationwide mobile health service in South Asia. It disseminates maternal and child health care information through pre-programmed mobile texting and voicemail services to expectant and new mothers (primary subscribers) and their guardians (secondary subscribers). The messages use international standard guidelines and are reviewed by national and international experts on a regular basis. Once they register, primary subscribers receive two contextual messages a week (related to the mother's pregnancy stage and child birth) until the child is one year old; secondary subscribers receive one message a week. The information ranges from the importance of direct eye contact between a child and the mother while interacting, to the importance of exclusive breast feeding in the first six months of the child's life. Telecommunications operators like Grameenphone, Banglalink, Robi, and Airtel help provide mothers and guardians with this service throughout Bangladesh, and Aponjon has reached more than 40,000 subscribers. The service aims to reach 2 million mothers by 2015. The program is subsidized and therefore affordable, costing only BDT 2 (excluding VAT) per message, and registration is free by SMS or phone call.

The Aponjon project has become successful in utilizing ICT to disseminate health messages to the urban poor. The principal reason behind its success is that it provides useful information that can be implemented at household level. Secondly, it sends health care messages not only to pregnant women and new mothers, but also to husbands and family members, thereby making guardians aware of measures to help raise a healthy child. Thirdly, the Aponjon project disseminates health messages to subscribers via pre-programmed voice messages if they are illiterate or uncomfortable with SMS.

It must be noted, however, that the Aponjon service currently fails to reach the poor who cannot afford mobile phones. The program is indeed trying to expand its services to the poorest by collaborating with a government-run Union Information and Service Center (UISC). The UISC acts as a drop-in center where the poor can receive information about maternal and child health care. In addition, Aponjon plans to add a medical counseling line in order to help subscribers via telephone.