That one question I am always asked

It is on many occasions that friends and new people I meet ask me that one question- what is life in a refugee settlement like? Actually, some have modified the question to assess my expectations versus experience of the refugee communities. To be honest, I had a rough picture of the environment and general way of life in a refugee settlement until my current GHC fellowship placement in Kyangwali refugee settlement, Hoima district in Uganda. I could imagine thousands of barely dressed miserable people lining up at a UN food store for the next day’s meal. A long queue of patients at a small clinic or at a bore hole collecting water, the crowded run-down shelters- all these I pictured in my mind. But thanks to my organization’s (Action Africa Help- International) reports and publications I read before traveling to my work station. My opinion and expectations were further biased on my first trip to the settlement by the bumpy and muddy road network of 96 kilometers from Hoima town. My first morning in the settlement began the road map to my current experiences.

I won’t say this is a land of milk and honey but it is quite a peaceful and conducive place for work and settlement. The major economic activity is farming and you will not miss the maize, rice and beans plantations plus the vast vegetation cover. Business in farm produce is booming plus other ordinary shops and eating houses not forgetting the bars in the trading centers of the settlement. People are settled in fairly modest housing with some exceptions obviously. In fact, on any ordinary day, you will be able to meet friendly smartly dressed, healthy men, women and children. We have three health centers in the settlement and one out of the settlement but accessible by the refugees! There are various water sources, solar and generator power at the offices, staff residences and some other facilities. “That sounds like a modest living and working environment in my opinion-” is my usual response to the question after all the explanation.

Doesn’t my response to that question I am always asked seem to over shadow the concerns and inadequacies in this kind of environment? I make it a point to explain the missing bits. Health in the settlement is still a great challenge attributable to inadequate resources and supplies, low household incomes and various behavioural and social dynamics to mention but a few. It is not a rare occurrence for children to fall sick or die of preventable illnesses like malaria, anaemia, nutritional complications, diarrhea, worms and others. In fact my imagination of the long queues at the health centers and during health outreaches stands valid! Women and children continue to be more at risk and actually affected. Poverty still bites hard amidst gender-based violence, psychological trauma, HIV/AIDS, poor sanitation, environmental degradation, child headed and single parenthood families and others. 

The prevailing challenges and inadequacies are however not meant to underestimate the tireless efforts of the actors in Kyangwali refugee settlement and other similar environments. I have assessed data and information and heard stories that tell of how far worse Kyangwali settlement has come from to meet its current standards though much is still desired. It is at this brink that I show thumbs up to all humanitarian aid workers and all activists of health equity and social justice. I am indebted to GHC for making me realize and stand up for this cause. The journey is still long but we have to carry on. My biggest experience at the moment is that, “Every effort counts.”

Where is the missing link?

Apparently, malaria is the major disease burden in Kyangwali refugee settlement accounting for close to 50% of the morbidity. There have been various preventive and curative interventions that are widely implemented by Action Africa Help and other implementing partners- something that really raises hopes among health workers, sympathizers and some of the residents.

However, the reality is a bitter one that nearly rubbishes the efforts and time spent in the preventive approaches, specifically the supply of Insecticide treated mosquito bed nets. One of the facts that the refugees have come to learn with time is the “insect-cidal” effect of the chemicals these nets are treated with. As opposed to utilizing this “insect-cidal” effect by sleeping under them for the control of mosquito infestation, majority have adamantly used the mosquito nets as termite resistant building materials. The closer one gets to most of the grass thatched houses in the settlement, you notice strips of blue or white thick netted thread joining up reeds or sticks used for the superstructure and as well firmly fixing the grass thatched conical roof tops.  As though this is not enough, I saw animals tethered by twisted but netted blue and white ropes that clearly turned out to be mosquito nets. I was exasperated and sick of this unhealthy practice among people who indeed are in dire need of rescue for their lives. They are causing a great disservice to themselves, health service providers plus inhabiting and surrounding communities by averting the efforts towards a malaria free community. My worst scene had not come yet until I coincidently moved to the back yard of one of the houses that we visited during the intensive nutrition assessment exercise for the refugee settlement. A brand new mosquito bed net, without a single puncture was hanging over firmly fixed sticks forming a chicken pen that restrained 2 cocks and a hen just like one would use a wire mesh!

Chicken restrained by a mosquito net as a chicken house

Mosquito net used as building material

A grass thatched roof fixed with strips of mosquito nets

  

                                                                                                           

As I reflect on these observations that seem to be happening in many homes in the refugee settlement, I can’t stop asking myself what exactly the missing link is. Why would a pregnant mother, a recovered client or a vulnerable person who has received instructions and sensitizations on the value and usage of such an effective item go back home only to use it as a chicken house or a tether rope? Could it be that the health communication is not effective or that the paradigms in behavior change among such populations are rather complex?  

Participatory Learning: A case of the training of community health workers on Infant and Young Feeding Practices (IYFP) in Kyangwali refugee settlement

Training community health workers can turn out to be a sluggish and boring activity if participation of the trainees in under looked. This 3 day training (27^th to 29^th September) was a great experience to test how participatory learning can make training fun and much more beneficial to the trainees and the trainer.

At the end of the second day, we decided to introduce what we called “problem based learning”. This is a scenario where you formulate a problem statement close to real life encompassing the topics that you already discussed with the trainees. You then let them divide in groups and tackle the problem while jotting down the solutions and then pick a group member from them to present on behalf of the entire group.

Trainees tackling the scenario in their group

The group representative discussing their solution

Lessons drawn from the “problem based learning”:

The participants become more active and you will not see any of them dozing off be it after lunch hours.

It greatly imparts communication skills to the trainees

The trainees feel valued and thus will better own the training and its objectives

This makes the assessment of whether the trainees have understood the training content easier for the trainer.

Norms, beliefs and customs of the community are easily spelt out when one of the members is given opportunity to solve a scenario.

It creates opportunity for the trainer to build on local or available knowledge and skills of the community

It emphasizes creativity in problem solving

It creates opportunity for the facilitator to re-emphasize messages or to communicate what was forgotten or accidentally left out.

The training ended on a good note but more importantly, we were generally satisfied that the trainees had widely benefited and that they are capable of putting what they had learnt in appropriate practice. We concluded by asking them how we could improve the trainings and they listed a number of things that we too had identified along the way:

·         They demanded for the use of audio-visual training materials from which they will watch what the trainers are emphasizing as opposed to just imagining.

·         They demanded for some incentives that could motivate them to carry on with this voluntary role that they play in the community. Such include; T-shirts with health messages, gum boots, certificates etc.

·         They however pointed out that at times they are over ridden by various trainings and other roles by various implementing partners and therefore proper timing and prior communication are key in mobilizing them for the training.

From our own view, we noticed that the trainings will be much beneficial if other influential people capable of determining and promoting health in the community take part. We thus decided that during other trainings, we shall invite some community leaders to attend.

State of Environmental Health at Kagoma market

Our team of three dropped by at Kagoma market on a bright Wednesday afternoon for purposes of pre-testing one of the monitoring tools that was designed by UNHCR WASH department.

Kagoma market is most active on Sundays and is the largest market in Kyangwali Refugee Settlement with a capacity of over 100 traders/stalls and with a climax of over 300 clients on the market day. There is a tendered agent supposed to clean the market on Saturdays just before the market day and on Wednesdays. The market as well has a 2 stance VIP latrine that is meant to be used by the traders on the market days. We were also informed that the available water sources are quite distant from the market with an estimate of 1 kilometer away- a situation that makes it difficult for the market traders to access water.

It so turned out that the entire market premise was profusely littered with both biodegradable and non biodegradable materials. There were faeces around the latrine- a situation that could have been due to the locking of the latrine by the management on non market days and as well due to the poor sanitation and hygiene practices of the surrounding community. The latrine had a hand washing facility (tippy tap) that did not seem functional since some parts were missing.   Information from our informant was that on a typical market day, about 4 goats, 4 cows and 5 pigs are slaughtered, however on inspecting the premise; there was no sign of an abattoir. The slaughtering is done in the open space and indeed there were signs of indiscriminate disposal of the wastes from the slaughtered animals. The market space is bushy and this most likely breed vectors and poses potential occupational hazards to the traders.

Such situations intrigued us to caution the food safety status and envisage the potential of sanitation related outbreaks. This was a vivid illustration of the poor performance of the market management authority. We then tried to dig into the drivers for community collective efforts as far as improving public health and the role of governance (social accountability) in the process of achieving improved health. It is until the community recognizes the importance of improved sanitation and understands that it is their collective responsibility, and then there will be increased prioritization and demand for improved services. Why should an agent who collects some fees from the traders fail to perform his duties of managing the market as expected?

There is thus dire need to stem up interventions that will protect and promote the health of this community.

The food demonstration at Nguruwe Village

After some hours of delay rising from the failure to mobilize for transportation to the venue for the planned activity, we finally managed to set off at around 11.30 am. The 3 manned team was equipped with buckets, saucepans, a bag of charcoal, plastic plates, cutlery and of course food items including: dry fish, tomatoes, sweet potatoes, pumpkins, cabbages, milk,  matooke, soya peas, eggs, avocados, meat, ground nut paste and many other items like you would anticipate to find in a “rich” kitchen.

Food demonstrations are some of the practical interventions in place under the nutrition program that are reached out to the communities on a monthly routine with the aim of imparting knowledge and skills especially to the women (who in most cases look after the young ones and prepare meals at home) on proper food preparation procedures and proper diet compositions.

The open space that is a trading center was our site for the day’s activity much as there were barely any women at the time we arrived. The few women that included a community health worker began work by offloading the items from the van and thereafter washing the utensils. In no time, the lighting of the charcoal stoves was in progress and some women were already fetching water from a nearby water source. The number of the participants was rather giving no hopes at the moment though we were latter informed by one of the women that more members would be soon returning from the gardens. The peeling of the matooke and sweet potatoes kicked off the food preparation and on a good note it was by collective efforts. Lawrence; the nutritionist had earlier informed me that one of the motivations was that excess food is used for the demonstrations so that the active participants eat at the end of the activity.

With the unsatisfactory child nutrition status in the settlement, it necessitated the demonstrations of the preparation of nutritious meals for under 5s especially those above 6 months of age. The cooking thus kicked off with three dishes that were branded “Ekitobero”- fit for such an age group. One of the “ekitobero” dishes comprised smashed fish mixed with ground nut paste, flour and some water which the nutritionist was steamed for close to 45 minutes. The other comprised chopped matooke mixed with locally minced meat, ground nut paste and water that were as well steamed for about an hour. The third dish was a mixture of cow milk, sugar and eggs that was as well steamed for a shorter period of time. The availability of such foods in the community was appreciated by the participants to whom key messages concerning careful and separate preparation of food for under 5s, use of steaming as a preparation method and observing personal hygiene were emphasized. As time went by, more women were all over the place with many coming along with their children. Only a few Congolese refugees were part of the bigger crowd that was composed of Sudanese refugees. Other dishes were demonstrated including; extracting milk from soya peas, preparation of beef stew, preparation of the nutritious pumpkin sauce, rice preparation and preparation of vegetable -ground nuts -fish mixture. Many other health practices such as hygiene, fruit dieting, adequate infant and young child feeding were emphasized. The day long activity concluded with assembling the dishes that had been prepared and reminding the participants of the ingredients and value of each. The bigger excitement swept across the crowd when the time to taste and feast on what they learnt to cook just as the clock ticked to our departure time of 6.00 pm.  

Major challenges and gaps for the food demonstration exercise:

. Poor time management rising from inadequate transport facilitation from the office

. Poor community mobilization probably due to wrong timing (villagers being in the gardens) or due to abrupt changes in program by the nutrition department

. Lack of ideal work station/shelter during the activities causes discomfort due to heat from the sun or even rainfall disruption

. Under staffed department of nutrition faces a great challenge in executing its duties.

. Keeping the participants focused and present for the entire activity is difficult thus disrupting effective communication process.

Solutions to the challenges/gaps:

. There is need for improvement in planning and prioritization of nutrition activities by the organization as nutrition plays an equally important role in health promotion and better livelihoods.

. There is need for improved communication and motivation of the community mobilizers for better mobilization services and feedback purposes

. Improvising a tauplin for the nutrition department is a solution for such day long activities for purposes of creating shelter from harsh weather that could also help to keep the participants comfortable thus present for most of demonstration duration.

. More support staff will be beneficial for better service delivery in the nutrition department.

.  More creativity through increased active participation of the participants will help to increase their presence for the bigger part of the activities.

Nutrition Outreach in Kagoma Village

By 10.00 am, we had arrived at Kagoma village center and the empty market was visible a few yards away. We quickly had to locate our work station that was an open space under a tree. All the necessities had been readily  packed prior to the departure and these included;  the Vitamin A tablets, Albendazole deworming tablets, Vitaglobin supplementary syrup, vaccines, Hb testing equipment, weighing scale, MAUC tapes and other such materials. It was however more likely that the consumables would not be enough to satisfy the community demand during that outreach. A number of different services were to be reached out to Kagoma community in this single event so as to maximize available resources. Immunization for under 5 years children, Growth monitoring, deworming, Hb tests (anaemia screening), Nutrition education and nutrition supplementation were some of the planned activities for this outreach. There was just 3 staff to carry out all these tasks!

The turn up was impressive much as it begun with just crowds of children most without their caretakers who had gone to the gardens. I helped with the administering of Vitamin A and deworming tablets together with Rachael who is a Congolese refugee nursing assistant. She as well immunized the children that had not previously been immunized and then recorded this in their Child Health Cards. Her multi-lingual capability together with Oris; the assistant nutritionist, were very helpful. Oris did the screening of malnourished children by taking their Mid Upper Arm Circumference (MAUC) and weighing of babies using the weighing scale for growth monitoring purpose.  Latter, I helped Mr. Nyende; the nutritionist, with recording the Hb readings from the Hemocue machine. I loved the child friendly design of the microtainers that were used to prick the children’s fingers without much resistance. We decided to give the vitaglobin supplement to those children that had Hb levels less than 10Hb/g/dl since the syrup bottles were really few. Caretakers of the children that were anaemic or were malnourished according to weight measurements and MAUC were cautioned on the feeding practices especially for their children and some were referred to the Health Centers for Supplementary or Therapeutic Feeding care. By midday, the number of clients had nearly tripled and the whole place was crowded though with some on-lookers as well. The mothers were readily availing their children for the services and within no time, there was a long queue for the anemia screening. The fact that the consumables were inadequate was soon realized when only some of the clients on the queue managed to access anaemia screening services, vitaglobin syrup and Vitamin A tablets by 2 o’clock. 214 children received Vitamin A and 255 were dewormed. Over 80 clients were screened for anaemia were majority were below 12Hb/g/dl. The outreach ended by around that time with crowds scattering off and a few mothers breaking into smaller caucuses chatting about their own affairs.

Challenges and gaps identified during the nutrition outreach:

. Inadequate mobilization of the community for the outreach

.inadequate consumables and other necessities for the outreach

.Absence of caretakers for some of the children hindered health communication, referral and instructions for example on prescription for the vitaglobin syrup.

.Some mothers who do not report with the Child Health Cards complicate recording and monitoring processes.

.There was inconsistence of Hb results from the Hemocue Machine for the same blood sample in some cases. (An example was when the blood for the same blood sample, the machine measured 3.1Hb/g/dl and 11.0Hb/g/dl the second time).

. The follow-up system for the malnourished and anaemic clients identified during the outreaches is either weak or inexistent.

.The community seems to lack adequate information of nutrition and related issues.

Suggestions to solve the challenges and bridge the gaps:

    . Mobilization should be done some time prior to the outreach date. The community leaders/workers should be greatly involved in this work and consulted on the community dynamics especially concerning timing/seasonality and involvement of caretakers.

.More lobbying for supply of consumables for the outreach services could be realized through documentation. This will reveal the magnitude of the problems and thus justify the dire need for more supplies.

.There is need for routine calibration of the equipment to ensure that the results obtained are consistent. However, this as well calls for refreshers on the mode of operation through reading of the manufacturers’ instructions prior to usage by the operators.

.A stronger referral and follow-up system has to be observed or established especially for the screened cases. However, more information on the value of follow-up by the clients and on services available should be regularly passed unto the communities.

. The nutrition education/sensitizations and food preparation demonstrations should be improved and increased.