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Using Dialogue Education to Sustainably Improve Child and Maternal Health in Bangladesh

Jan Disselkoen
Learning and Innovation Coordinator, CRWRC
GLP Certified Dialogue Education™ Teacher

In 2004, CRWRC applied for and received a grant from USAID for a five-year project in Bangladesh aimed to improve the health and rates of survival for children under the age of five and women of reproductive age.

Five years on, it is clear that including Dialogue Education™ as a integrated part of the project contributed to the success of its three strategies: improving partnerships between health facilities (and services) and the communities they serve, increasing appropriate and accessible care and information from community-based providers, and integrating promotion of key family practices critical for child health and nutrition.

In the two rural districts of Bangladesh where the project was located, access to skilled medical care is difficult. When the project began 79% of women delivered their babies without the assistance of skilled personnel. A key piece of the project strategy was to train traditional birth attendants (TTBAs) and community health volunteers (CHVs) as first-line health workers.

In order to save cost and ensure that volunteer training would continue to be locally available, CRWRC-Bangladesh sub-contracted with three local teaching institutions to conduct the training. The grant proposal included, as part of the budget, the costs of two GLP courses as well as the facilitation of designing the curriculum for volunteer training.

In March 2007, sixteen CRWRC-Bangladesh partner staff and staff from the three local training institutions participated in Learning to Listen Learning to Teach and Advanced Learning Design courses. GLP trainers Peter Noteboom and Jeanette Romkema co-facilitated the two courses with Kohima Daring, the CRWRC country team leader in Bangladesh. Following the training, Jeanette facilitated the development of nine lessons on various health topics including breast-feeding, nutrition, HIV and AIDS, pre-natal care, post-natal care and diarrhea management. The modules were translated into Bengali and field-tested before the teaching institutions began using them more widely.

Since the project began, these institutions have trained 300 Community Health Volunteers and 400 Trained Traditional Birth Attendants. During the final evaluation of the project in July 2009, staff at the teaching hospitals cited dialogue education as one of the main benefits of the program. LAMB hospital went so far as to revamp all of their training using the Dialogue Education approach. They subsequently received approval for their 21-day community birth attendant curriculum from the Bangladesh government.

The time spent together by CRWRC partner staff, community health volunteers, their supervisors and teaching hospital staff also helped cement relationships between the communities and health facilities, and thus contributed to the first objective of improving partnerships between health facilities (and services) and the communities they serve.

It became clear early in the project that effective training of community health care workers was also contributing to the achievement of the other two project strategies -- increasing appropriate and accessible care and information from community-based providers and integrating promotion of key family practices critical for child health and nutrition.

The first draft of the July 2009 final evaluation of the project states,

“An important unplanned achievement of CSP was that CRWRC sub-contracted the training of CHVs and TTBAs to indigenous training institutions. This provided an opportunity to provide training of trainers in Adult Dialogue Education and in using similar curricula. The TTBA curriculum was revised to make it more participatory and to provide a better overall learning experience. By working through existing training facilities rather than developing its own training system, CRWRC has achieved an impressively low cost per TTBA and CHV trained, and contributed to capacity-building of local institutions” (page 30).

The mid-term evaluation already noted a marked difference in TTBA capacity due to the training:

“It has been clear that the TTBAs have safer practices from observational follow-up as well as quantitative knowledge and skills-based follow up.”

At the end of five years, the project met nearly all of its quantitative objectives for increased child and maternal health. Most notable, the percentage of children in the two rural districts whose births were attended by skilled health personnel, including TTBAs, rose from under 21% to 95%!

Milon Tara was initially trained as a Community Health Volunteer (CHV). She was later chosen by CRWRC-partner SATHI as a supervisor of other CHVs talks.

The following citation from the final evaluation gives the perspective of one of the participants in CHV training:

Milon Tara is a mother, wife, and a Super CHV (Community Health Volunteer). In a society with numerous limitations for women, she, and several dozen other CHVs, have received additional training and responsibility to further promote good health in their communities.

With her willingness to work for others and good acceptance in the community, Milon was chosen to be trained as a CHV in her area of Mirpur. She received a 5-day training on primary health care followed by a 3-day refresher training from SATHI. Once she completed the training, she began teaching nutrition and health lessons to pregnant mothers and adolescent girls, and visited 15 to 20 households a week in order to make sure that mothers and children were well. Milon especially enjoyed monitoring children’s growth through child-weighing sessions and participating in national health observances such as the National Immunization Day (NID) and HIV/AIDS Day.

“When I first began working as a CHV, people were not interested in health lessons, but now they understand the importance of health and voluntarily come to the meetings to learn more. Mothers are extremely happy when they see their children growing, but tell me that they need to feed them more when their weight remains the same,” Milon told us with a smile of satisfaction on her face. “And pregnant mothers now ask for TTBAs (trained traditional birth attendant) instead of TBAs (traditional birth attendant) when they are expecting.”

As a CHV and supervisor of other CHVs, Milon has witnessed positive changes both within her community and her life.

From draft report of the Final Evaluation of the CRWRC Child Survival Project, Bangladesh, July 6, 2009.

Related Article: “From Praxis to Practitioners” by Will Story, CRWRC’s Child Survival and Health Technical Advisor on how the principles of Dialogue Education™ were applied to the Designing for Behavior Change workshop to strategically plan for behavior change in this project.

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