The findings reported in this paper are broadly categorised into two major themes namely facilitators and barriers to the implementation of the WGs interventions. On the one hand, facilitating factors include community readiness to adopt the interventions, the role of community leaders, stakeholders’ engagement and support of the local health systems. On the other hand, constraining factors include unfavourable physical environment, victimization of the WGs and family-related challenges.
Community-related Factors that Facilitated the Implementation of WGs Interventions
Community readiness to adopt the interventions
During the implementation of the interventions, community members’ showed satisfactory readiness to adopt the strategies implemented by the WGs. One of the factors that triggered the community readiness to adopt the interventions included active participation during the sensitisation meetings. During these meetings, community members were sensitised on the importance of attending ANC within the first trimester, completing four or more ANC visits, use of family planning methods and avoiding home delivery, among others. During the sensitisation meetings, community members had the opportunity to ask, get clarification and probe more about ANC from WG members as illustrated by one respondent:
Whenever we conducted sensitisation meetings, community members were always willing to attend. In fact, there were a few instances when the attendance was poor but this was due to other factors, especially unfavourable weather. In these meetings, participants were curious about raising so many maternal related issues. They went further telling us that they wished this intervention would have taken place many years back (IDI with WGs members in KDC).
Another reason for community readiness was the direct support provided by the WG members to pregnant women who needed help. This increased community confidence and trust of WGs hence they adopted the implemented interventions. WGs provided material support such as sugar, cooking oil, soaps, flour as well as escorting pregnant women who needed facility assistance. During the FGDs participants explained how this touched community members as narrated by one participant.
At first, community members were sceptical of our works; they thought we were not serious enough. But having witnessed our support to pregnant women and searching for malnourished children in the village their confidence in us increased. Afterwards, it was the community members themselves who used to direct us to pregnant women whom they thought needed our assistance (FGD with WG, in KDC).
Participants also revealed that following the implementation of the interventions, pregnant women were keen to complete four or more ANC visits, and even their spouses were supportive. It was evident that some community members who had myths on contraceptive started using family planning methods. Hospital deliveries had also increased because of the increased sensitisation and home visits as affirmed by one health care worker:
Community members have embraced this programme and have adopted the interventions. Since this intervention started, we have seen women from the communities coming to the health facility to inquire about different family planning options. They even come along with their partners. Our records also show that deliveries at this facility have increased (IDI with health worker in MDC).
Additionally, the fact that community members participated during the first stage of implementing the interventions by selecting WGs, supervisors increased the sense of ownership of the programme. They had confidence in the among implementers of the interventions because they participated in selecting them. As a result, health education messages on the importance of utilisation of ANC services disseminated by the WGs were easily accepted by the community.
The role of community leaders
The WG members frequently cited the support of community leaders in the implementation of the interventions. These included the elected and appointed leaders who formed the VMT especially, the Village Executive Officers (VEOs), the Village Chairpersons (VCs) and hamlet chairpersons. These leaders were actively involved throughout the implementation phases and Community leaders played different roles including (i) introducing WGs to the community members during the sensitisation meetings; (ii) organising meetings in their areas of jurisdiction for WG members to deliver their ANC messages, (iii) providing moral and material support such as space to hold their meetings and items to facilitate their work such as reams of papers and pens (iv) prioritising ANC issues and integrating them in the village development plans; (v) recognising and appreciating WGs implemented activities; (vii) providing security to WGs especially when visiting pregnant women at night and (viii) introducing WGs to the neighbouring village leaders where they wished to extend the implementation of the interventions. Some respondents narrated:
Our village leaders accorded us all assistance that we needed. Whenever we went to their offices or called them on phone, they were quite ready to help us. Our local leaders especially the VEOs would even provide us with security in case we wanted to check on pregnant women at night (IDI with MCs, in MDC).
The IRT member added:
Community leaders were important during the implementation of the interventions. Given the fact that we involved them from the beginning of the interventions; it was very easy for them to support the implementation of the interventions (IDI with IRT).
Effective participation of stakeholders was mentioned by the participants as an important aspect that facilitated the adoption of the interventions. It was revealed that stakeholders were fully engaged through different series of workshops and review meetings that were held during the implementation of the interventions. In most of the meetings and workshops, the participants included; district health personnel, ward and village leaders, elders, religious and traditional leaders and health care workers. During the workshops the stakeholders and WG members shared various problems, proposed interventions and reported success as well as the challenges they encountered in their respective communities. Stakeholders who attended these workshops got the opportunity to provide their opinions on the strategies and implementations process. In addition, these workshops served as the forum for health care workers to engage the community members and jointly refine the proposed strategies to improve ANC services in the health facilities as illustrated by one respondent:
Our participation during the implementation of the interventions is commendable. It helped to understand what WGs we were doing in the community. After being convinced by their activities as in charge of the facility, I used to ask my fellow staff to join them during sensitisation meetings so as to elaborate some issues that needed professional know-how (IDI with health worker, in MDC).
Having witnessed the roles that WGs were playing through the series of meetings and workshops, community and religious leaders joined the implementers to educate the community members in the church congregations as reported by one respondent:
IMCHA was one of the blessings for our village. I used to participate in several review meetings where we were informed of the good work that WGs were doing in our communities. Thus. I frequently preach during church congregations the significance of ANC services for our mothers and children during church congregations(IDI with CG, in MDC).
The views from the participants explain how crucial the engagement of stakeholders was during the implementation of WGs interventions was very crucial as it enabled most of the community members to know the implemented interventions in their areas of jurisdiction. Apart from providing technical knowledge during the meetings, stakeholders also served as the mouthpiece of sensitising community members on the need to utilise ANC services. The engagement, community stakeholder engagement was acknowledged by the IRT who mentioned that this was very pivotal for establishing supporting mechanisms that encouraged, advised and helped the WGs during the interventions.
Support of local health systems
It was revealed from the findings that the success of the WGs interventions relied upon the support of the local health systems. Participants reported that health workers were actively involved in different stages during the implementation of the interventions. Effective participation of health workers in the workshops enabled them not only understand strategies that were implemented by the WGs to improve ANC services but also to become part of the implementation process as expressed by one respondent.
We worked closely with health workers; and in the facilities and this made our work persuasive. For instance, whenever we referred pregnant women to the facility for more information, health workers would attend to them very well. Similarly, whenever we invited them to attend our community sensitisation meetings, they would come and help us in clarifying some of the health issues (IDI with WGS in KDC).
This revelation was affirmed by health workers who concluded that it would be difficult for WGs to accomplish their mission without their participation:
We are the one who received clients who were sensitized by the WGs. And in most cases, we used to attend sensitisation meetings that were held at the village level and clarified several ANC issues that were technical such family planning issues (IDI with WGS in KDC).
The, community health workers who were also Women Group Supervisors (WGSs) in this programme, were actively involved in the implementation of the interventions. Their roles were among others to supervise all activities implemented by WGs, and liaising with health workers and village leaders to ensure that all envisioned activities were implemented. They also organised sensitisation meetings, strategised the process of visiting pregnant women at households and arranged with religious leaders to visit churches. WG members also received support from Health Facility Governing Committee (HFGC) members who also participated in the training, workshops and meetings. Apart from participating in sensitizing community members on the importance of ANC, these leaders served as a bridge between the community, implementers of the interventions and health facilities.
Factors that Constrained the Implementation of WGs Interventions
Participants complained that unfavourable weather the topographic nature of the villages and the long distances from communities to health facilities hindered the implementation of the interventions. It was revealed, for instance, that heavy rains from December to May halted the implementation of most of the strategised activities. Several sensitisation meetings were postponed, while a few that were held attracted few community members and implementers of the interventions. The most affected intervention villages, were Igowole, Ibatu, Kasanga, Ihomasa, Kibengu and Usokami in Mufindi District, and Ng’uruhe, Isuka, Winome, Ukumbi, Mlafu villages in Kilolo District as illustrated by one respondent:
Rains were a hindrance to our efforts in sensitising the community on the use of ANC services. We used to hold public meetings in open spaces but when it rained, we had to postpone them. Attendance by community members in these meetings during the peak of the rainy season was also poor. In several occasions, we postponed the meetings in the middle as rains continued. In some months, it rained consecutively for the whole week and thus disrupted our work plan (FGD with WGS, in MDC).
This view was supported by some village leaders as exemplified by one respondent:
….In our villages, especially from January to April, it rains consecutively. During this period, getting adequate attendance in public meetings is always challenging(IDI with Village leader in MDC).
In addition, heavy rains disrupted community infrastructure and the means of transport within the villages were highly affected. As a result it became difficult to walk or even drive within the village or move from one household to another during the rainy season because of slippery roads, heavy mud as well as wet and narrow footpaths. Participants complained that during the rainy season transport costs became so high as many roads were impassable. At the same time, not all WGs had fare to reach particular hamlets to attend sensitisation meetings since they were located very far; which significantly affected the interventions.
Mistreatment by Community Members
Findings in this sub-theme revealed that in some households which WGs visited, they were not jovially received, and instead, they were rebuked such that some of them were about to despair while carrying on with the interventions. It was revealed that some pregnant women and their partners were of the view that the WGs wanted to scout their private life. The situation worsened when WGs visited some households at night after receiving information from community members that some pregnant women had not attended ANC. In order to reduce some risks, WGs asked village leaders to offer them security while executing such tasks during the sundown. A few WG members reported that in some households they were even intimidated, especially during the early stage of implementing the interventions when village members were not yet fully aware of the roles of the WGs in their villages. This was mentioned in the FGDs held with women group members as listed in Table 3.
Embarassing Statements during Home Visits.
√ How did you come to know that I am pregnant?
√ You better leave my home, I have nothing to tell you.
√ I will deal with whoever told you that I am pregnant.
√ I don’t know why you ask me such private questions.
√ If anything bad happens to me you will be liable.
√ Make your story very short; I have other businesses to attend to. After all, what you are saying is not new to me.
√ My daughter is not pregnant unless you have come for other issues.
√ My husband is not here, I cannot listen to what you are talking about. You should come next time when he is present.
√ Give us the money that you are given instead of tormenting us with your questions.
√ I am old enough to know my responsibility when pregnant, you are still too young to advise me.
Source: Field Data (2019)
Family-related Challenges among the Implementers
Families of the implementers of the interventions were stated to have constrained the performance of the interventions as well. It was revealed that not all families approved their family members to actively participate in the implementation of the interventions. For instance, married WG members faced the challenges of convincing their partners to continue implementing the interventions. Findings revealed diverse intriguing issues that surfaced among family members who disapproved their partners to participate in the interventions. Some male partners were also reported to demand their wives to withdraw from the project as it was wastage of time. Respondents reported that women in Kilolo and Mufindi districts are the ones who fully engage in productive activities like cultivation, thus spending more time implementing interventions could have affected food security at the family level. During the FGDs, one participant had this to say:
…At times I failed to tell my husband where I was going. This is because he was not supportive of the interventions we were implementing. I knew the risk of telling him where I was going daily since I knew his reaction” (IDI with WG, in MDC).
Secondly, some members complained of lack of payment for the WGs efforts. Findings revealed that during the period when women were selected to join WGs, their family members relaxed hoping that it was a kind of income-generating activity, only to find out that their partners were merely volunteering. According to the participants, their partners were not happy having heard that there would be no payments for the tasks they were performing, as elaborated by one respondent:
My partner always wanted to know the amount of money I was paid. No matter how often I told him that we were not paid, he never understood. You know, when you spend such a long time walking all over the village and come back home very tired with nothing in the pocket, very few partners will understand why you keep committed to the intervention (IDI with WG, in MDC).
Thirdly, some male partners complained that WGs were not taking care of their families as they spent more time implementing the interventions. Some WG members used to meet twice a week for visiting households. In most cases, sensitisation meetings were conducted in the evening and thus WG members who lived far from the hamlets where meetings were conducted arrived home very late as narrated by one respondent:
I Often, I arrived home late because I had to walk a long distance from my home to the meeting venue. I would get back home late after meetings and I often found my little children asleep. This most often annoyed my husband (IDI with WG, in MDC).
Lastly, some WG members reported that family members were worried that WGs were draining more family resources for the intervention than it was anticipated. In some cases, WGs had to incur transport costs when attending sensitisation meetings, and also bought stationeries and drinking water during the meetings. Moreover, some more funds were needed to buy uniforms like Vitenge (local print fabric) and helping pregnant women who needed assistance as illustrated by one respondent:
It is true that at first when we were selected to join WGs, our partners were contented that we would bring food home; to the contrary, we took food away. This is what contributed to discontentment in our families and they did not want to hear anything regarding the interventions. At times, we did not even inform our household members about where we were going to avoid escalating the conflicts (FGD with WG, in KDC).