Communities are heterogeneous: some groups are more marginalized than others because of socio-cultural, gender, religion, socio-economic status, ethnicity, age, political and other factors. These can have damaging consequences for health and access to services. For these reasons, public health research and implementation of services should be community-centered to reach all community members.
REACHOUT, a five-year implementation research project (2013-2017) funded by the European Union, was engaged with two large service delivery organisations. The project used a community-centric model to improve health by increasing the use of services for safe pregnancy terminations by poor women and adolescents living in informal slum settlements. Despite the availability of legal, safe pregnancy termination services, Dhaka city has many private and informal sector care providers to which younger and older women are frequently referred or diverted toward unsafe services.
REACHOUT engaged community women, adolescents, and female community health workers (CHWs) to identify key barriers to accessing safe services. These key barriers were found to include: weak referrals, uncertainty about where to go for safe terminations, and a lack of comprehensive information given by CHWs. Through intensive engagement with community and women, the project produced many changes in the model of the program service delivery. For instance, referral cards were redesigned to include Identification Numbers so that CHWs could track adolescent and women’s use of safe clinics. CHWs could also immediately follow up with any females who had dropped out and would encourage them to access quality facilities. Married adolescent women and older women in the communities demanded clearer information on available service options and the risks of delayed termination. Communication Information Kits were developed and CHWs working closely with communities and conducting home visits shared the information with women. Local, context-driven solutions were developed based on young and older women’s critical feedback and recommendations. A longitudinal evaluation found a marked overall improvement in referrals, with an increase of 17.4% of women using safe clinics.
This intervention illustrates that a community engagement-based approach can be responsive and effective and that it can promote health and wellbeing among marginalized groups, particularly vulnerable women.