Process
The trigger stories generated interest and stimulated participants to think of actions that could be implemented in their households and community. At the end of the discussions, participants from all settings were able to recognise that preventing COVID-19 spread is important and they identified it as a worthwhile collective goal to achieve. Discussions facilitated the process of identifying, prioritising and analysing the determinants and planning intervention. These brainstorming sessions were also helpful in identifying potential challenges or difficulties and measures to minimise these, before implementing the actions within the community.
Three simple tools namely the ‘Corona Calendar’, ‘Well-being Calendar’ and ‘Happiness Calendar’ were used for monitoring and evaluating the progress of the implemented actions. Participants developed the ‘Corona Calendar’ creatively using agreed criteria and colour codes. The ‘Well-being Calendar’ and ‘Happiness Calendar were tools previously used in other settings, for different HP interventions. Family members marked these calendars daily and monitored whether each individual adhered to those precautions or not, and motivated those who do not follow the criteria to comply. For example, participants from Trincomalee used following criteria and the colour code for the ‘Corona Calendar’ to represent the risk of exposure:
- Red if any family member went out unsafely. Orange for rest of the family members on that day.
- Pink for all the family members if any external person (a neighbour or a relative) visited the household.
- Green for all the family members if none of them went out and if no one visited the house.
(CM 01 – excerpts from diary notes)
The ‘Corona Calendar’ is a tool to assess COVID-19 transmission risk in each household. This calendar assessed the risk of infection gaining entry into their house each time a family member or a visitor entered the house without adhering to safety precautions.
‘Going out from home and having visitors were the two main risk factors. Corona calendar was an important tool, because, family members started monitoring the days they had to go out; they reduced going out and unnecessary visits.’ (CM 01)
The ‘Well-being Calendar’ was used to assess the overall health and well-being of family members during the lock-down period. Participants assessed the family well-being in terms of level of adherence to healthy practices of each individual. For example, following behaviours or safety measures were assessed by the families in Trincomalee:
- Washing hands frequently with soap or a disinfectant?
- Drinking boiled water?
- Covering face when coughing, sneezing and not spitting everywhere?
- Washing food items and other goods brought from outside?
- Following safety measures when leaving the home for work and also at work place?
- Disinfecting the watch, mobile phone, belt and shoes properly after coming home? (CM 01, excerpts from diary notes)
People in Monaragala district used different criteria:
- Following the safety precautions properly- Happy face
- Following the safety precautions moderately - Normal face
- Not following the safety precautions- Sad face
- More than two family members go out frequently and not following safety precautions; high risk- Sad face (CM 02, excerpts from diary notes)
The ‘Happiness calendar’ assessed the emotional well-being of each individual in terms of feeling happy, sad or angry, on a daily basis. People used colours and emojis of faces to represent the respective emotions:
- Red colour – Angry face
- Yellow colour – sad face
- Green colour – happy face (CM 02, excerpts from diary notes)
CM were able to lead the intervention with minimal guidance of PI. Participants in all four settings engaged actively. The interest and engagement of families were higher in the other three communities when compared to Trincomalee, perhaps because those communities had previously been sensitised through previous HP interventions. CM were able to train other active community members without PI’s involvement and obtain their support to expand the group size and engagement. At the end of five months, a total of 638 families involved themselves actively in the process. Two groups initiated the process from family level while other two initiated it at the community level. Table 2 illustrates the participant engagement during the intervention. Tables 3 and 4 illustrate the progress of interventions in each setting.
Outcomes
Outcomes can be described under two themes: (1) preventing infection gaining entry and (2) caring for and supporting vulnerable and economically disadvantaged families and families that may have to undergo quarantine.
1.Preventing infection gaining entry
All the community groups were able to identify the severity of the problem, behaviours and lifestyles that increased the COVID transmission risk and ways to prevent spread. They realised the negative impacts of being infected with COVID or being potential carriers.
‘Arranged a discussion at MOH office with permission. Seven mothers from six GN divisions participated. We discussed about safety measures and importance of improving family wellbeing during this period.’ (CM 02)
‘Mothers were worried that many family members tend to go out when the curfew is lifted. They took measures to reduce it.’ (P 02)
Perceptions on hindered day-to-day lives, obstacles to be faced such as quarantine procedures and possible death if infected with COVID motivated all the groups to collectively create COVID free homes and/ or communities.
‘Every family arranged a water tap or a water basin in front of their houses for hand washing’ (CM 01, Diary notes)
‘We limited visitors. Corona Calendars showed the increased risk on the days we had visitors.’ (P 01)
The groups led by CM 01 and CM 04 identified that risk of transmission is high when purchasing goods from local vendors and they took measured to minimise that risk.
‘We started using a bowl to exchange money without touching them when buying goods, especially the home deliveries. Some exposed the money to bright sunlight before putting them back in to their pockets and later disinfected the bowl.’ (P 01)
‘Risk of spreading COVID was high when people gather at the drinking water filter. We kept a bowl there so that villagers could put money when buying drinking water. Displayed a notice with instructions, ‘Put your money into the bowl’. (CM 04, Diary notes)
Participants in all community settings developed and adopted various forms of ‘Corona Calendars’, to assess COVID-19 transmission risk. Two groups developed ‘Well-being Calendars’ to assess their health and well-being. They modified the calendars from time to time, with more indicators.
2.Caring for and supporting each other
Three communities took collective actions to care for and support economically disadvantaged families and any families that may have to undergo quarantine.
‘We grew vegetables and kept the extra harvest in front of our houses. We planted vegetables along road sides allowing those who needed to pluck them for free.’ (P 03)
‘Ten mothers collected food items [such as rice and lentils] from those who were willing to donate and distributed these among those who were under home quarantine.’ (CM 03)
‘We looked after the two quarantined families… Kept water bottles and groceries at their gates regularly.’ (CM 04, Diary notes)
Some communities took measures to care for the elderly, people with NCDs and took actions to protect vulnerable groups such as smokers or alcohol users. There was an active involvement and engagement of children in these activities.
‘Elders and people with NCDs were at risk. We didn’t let them to go out unnecessarily.’ (P 05)
Communities, other than in Trincomalee (CM 01), took action to stop selling cigarettes in their village shops. CM 02 and her group conducted poster campaigns to prevent smoking in their community.
‘We pasted posters at public places… in front of shops. We received both positive and negative responses from villagers and shop owners. Towards the end of [1st month] posters were pasted in front of 19 shops in the area.’ (CM 02)
As a result of these community actions there was a reduction in smoking, alcohol consumption and incidents of family disputes or domestic violence.
‘At the end of five months, twenty village men quit smoking, twenty men stopped using alcohol and over thirty were trying to reduce smoking and alcohol consumption.’ (CM 03, Diary Notes)
‘During this time government ordered to close alcohol bars. Most fathers did not take alcohol and therefore, mothers and children were happy. There was no quarreling.’ (P 03)
‘Fathers were at home, playing with children. They were happy.’ (CM 02)
Some communities were able to identify at least one place that could be used as a basic community-led centre to care for infected individuals, those identified as potential carriers or recovered persons who are still subject to home quarantine.
‘There is an abandoned house. Owners live [far away from village]. We spoke to them and got their permission to use that house as a [potential] quarantine centre.’ [CM 03]
‘We could find either a common place or a house that could be used as a quarantine centre.’ (P 04)
Impact
The impact can be described under two themes: (1) overcoming stigma, fear and undue anxiety regarding COVID and (2) lifestyle changes leading to healthier behaviours.
- Overcoming stigma, fear and undue anxiety
Findings indicate a reduction of stigma towards infected people, as well as COVID suspects and those who were undergoing quarantine.
‘Some families were suspected as COVID-19 carriers and asked to self-quarantine. They were cornered at the beginning. But later we started caring for them. I am not afraid of corona patients now as I know how to protect myself while caring for them as well.’ (P 04)
People in all four communities reported that ‘fear, stress and anxiety caused by COVID-19 was reduced’, they ‘felt more confident’ and ‘happier about handling potential problems and risks’ when they were better informed and learned about the subject.
‘I was very afraid at the beginning because I heard on the news that many people died in other countries. But now, I have much less anxiety, because I know well about safety measures to be taken.’ (P 01)
‘We now know well how to be protected when going out of home and when somebody arrives in our home.’ (CM 01)
- Lifestyle changes leading to healthier behaviours
Findings indicate many lifestyle changes leading to healthier behaviours and changing of thinking patterns and attitudes as a result of adherence to actions introduced during the intervention.
‘Our children now wash their hands with soap and water before meals and after using the toilet, which they didn’t do earlier.’ (P 05)
Other illnesses such as common cold, asthma and diarrhoea among children were reported less as a result of healthy habits such as frequent hand washing and wearing face masks.
‘Now our children don’t get diarrhoea or flu as they used to get. Perhaps because they wash hands so often and wear masks. We could save lots of money spent for doctor visits and medication.’ (P 04)
Some communities collectively took actions for smoking cessation, and reducing tobacco and alcohol consumption in the village in future also. People also considered about their psychological well-being and developed measures to assess their mental health during the lockdown period. As a result, child care, family happiness and well-being increased and incidents of family disputes and intimate partner violence were reduced as a whole. CM2 and her group measured family happiness using a ‘Happiness Calendar’ and incidences that led to increased family happiness during the lockdown period:
‘We started marking the happiness calendar. It was so useful to note everyday moods of our family members and family issues.’ (P 02)
‘…Family disputes were reduced as a result.’ (P 03)
A majority reported that they felt ‘united’, ‘in more control’ and ‘had more power’ when working towards a common goal. Through this intervention the participants could establish relationships built on trust, mutual sharing of knowledge, and bring together the wider community to achieve a common goal ensuring cultural sensitivity and sustainability. Table 5 shows the overall behaviour and attitude changes in each community as a result of our intervention.