Increase in Institutional Delivery and Child Immunisation Coverage through an Appreciative Inquiry-based Community Dialogue Intervention in Afghanistan

"The appreciative inquiry-based community dialogue intervention considerably increased institutional delivery and child immunisation coverage, even in a hard-to-reach province in Afghanistan."

Evidence suggests that demand-side barriers may be as critical as supply factors in preventing individuals from utilising healthcare services such as immunisation. Afghanistan Demographic and Health Survey (AfDHS) results indicate that only 46% of children aged 12-23 months were fully immunised in 2015; the percentage was even lower in Kandahar province, which is regarded as a hard-to-reach province. A community dialogue intervention with an appreciative inquiry approach was undertaken to improve child immunisation coverage, as well as institutional delivery, in Kandahar. This study aimed to evaluate the intervention's effectiveness.

The term "community dialogue" (CD) refers to the process of people or groups exchanging information in an interactive and participatory manner to reach a shared understanding and agreement on addressing specific issues. The CD approach is based on Paulo Freire's work, according to which group members can engage in critical thinking, challenge assumptions, and develop new visions through dialogue. The CD approach also acknowledges a community's capacity to solve its problems, seeks out local expertise and diversity, and uses several processes that facilitate analysis, empowerment, and sharing alongside other participatory learning and action approaches.

CD aims to mobilise community dwellers to take necessary actions towards institutional delivery and take their children for routine immunisation to health facilities. An appreciative inquiry (AI) approach was used during the CD. The AI approach involves mobilising local communities and resources and fostering ownership of the health programme by focusing on existing strengths and accomplishments rather than analysing and criticising unmet goals. This strength-based management tool is intended to assist people in seeing themselves as change catalysts, after which they take on more responsibilities owing to their increased motivation; they require less external assistance, supervision, and monitoring to achieve their goals.

The CD involved the following phases:

1. Pre-dialogue phase: The researchers engaged with provincial authorities and those able to support the programme at the district level, holding advocacy meetings to seek support for the successful implementation of the intervention. In addition, an introductory meeting was held with community influencers such as community elders and religious scholars to establish trust, credibility, and ownership.
2. Dialogue phase: All community dwellers were invited to a specified location at a predetermined time and date to conduct the CD sessions. Considering the cultural context, dialogue sessions were conducted with male and female community residents separately. The sessions began with recitation of some verses from the Holy Quran. The event facilitator/s then asked the participants about their overall achievements and pride in life - in particular, success stories in the health area. Each achievement, such as child vaccination, could be shared with others. These achievements were appreciated, and the participants were complimented for their actions. Finally, all participants made a commitment to undertake similar actions, to fully immunise their children, and to accompany pregnant women to health facilities for antenatal, delivery, and postnatal care visits.
3. Post-dialogue phase: House-to-house visits were conducted by the CD project staff and community health workers (CHWs) with at least one visit in each quarter to assess child immunisation and care for pregnant women. The post-dialogue phase was adopted from a human-centred design to identify and address obstacles to using healthcare services at each step throughout the caregiver's journey to health and immunisation. If a vaccine-eligible child had not yet been vaccinated or a pregnant woman had not visited a health facility for antenatal care or had no intention to give birth at a health facility, then - considering the caregiver journey steps as outlined in Figure 2 of the paper - reasons were sought, all necessary advice was provided, and actions were taken.

Study participants were selected from the Panjwai (intervention) and Dand (non-intervention) districts of Kandahar Province. In the intervention district, participants received CD and routine care, whereas in the non-intervention district, participants only received routine care. During this routine care, maternal and child healthcare services, including maternity and child immunisation services, were provided in both districts. The researchers conducted the baseline survey in October 2018 and the follow-up survey in November 2019 in both districts. The researchers analysed age, sex, place of birth, and confirmed immunisation coverage data concerning 1,046 and 927 under-5 children pre- and post-interventions, respectively. Changes in institutional delivery and confirmed immunisation status were evaluated using net intervention effect and difference-in-difference (DID) analysis.

Selected findings:

• Full immunisation coverage among children aged 12-23 months and 24-35 months significantly increased from 26.4% to 76.9% (p < 0.001) and from 40.0% to 78.6% (p < 0.001), respectively, in the intervention district, whereas coverage significantly decreased in the non-intervention district. The net intervention effects were 59.1% and 44.8% for children aged 12-23 months and 24-35 months, respectively. The DID analysis also revealed significant differences in outcomes after intervention at follow-up.
• The results concerning antigen-specific immunisation coverage indicated a significant increase in immunisation coverage in the intervention district.
• There was a significant improvement of 17.3% points in the institutional delivery rate, from 66.3% at baseline to 83.6% at follow-up (p = 0.016) in the intervention district. However, the institutional delivery rate in the non-intervention district significantly decreased by 24.6% points, from 71.3% at baseline to 46.7% at follow-up (p < 0.001). Overall, the net intervention effect on the institutional delivery rate was 41.9% higher in the intervention district.

Reflecting on the findings, the researchers note that previous systematic reviews have revealed the effectiveness of community-based health education and CHWs' interventions on increased uptake of childhood immunisation. Contrary to those types of interventions, during CD, community dwellers are encouraged to make independent decisions to improve their health by fostering more active participation. This CD intervention was based on evidence that communities have the ability to think and act for themselves and have the capacity to change. The intervention employed facilitated conversations to evoke community strength, increase self-awareness, and stimulate self-confidence and action. The CD project staff supported the community on its path to take ownership of issues relevant to childbirth in a health facility, child immunisation, and their solutions.

Implications for policy and practice:

• A dedicated, feasible, and paid community-based health promotion workforce should be established to bridge the gap between the health system and local communities, to continually work with families, and to encourage the utilisation of health services and the adoption of healthy lifestyles and behaviours.
• Comprehensive and integrated community-based health promotion interventions comprised of multiple approaches must be deployed to target more than one health outcomes for one or several programmes in an efficient manner rather than several individual health promotion interventions targeting individual health programme outcomes.

In conclusion: "Various barriers against healthcare services utilisation can be tackled through integrated community-based health promotion interventions."