Developing Culturally-Oriented Strategies For Communicating Women's Health Issues: A Church-Based Intervention

GN Aja, EN Umahi, OI Allen-Alebiosu, 2011.
A licence to publish this material has been given to Education for Health:
http://www.educationforhealth.net/ 1

ORI GI NAL RE SE ARCH PAPE R
Developing Culturally-oriented Strategies for
Communicating Womens Health Issues: A
Church-based Intervention
GN Aja, EN Umahi, OI Allen-Alebiosu
Department of Public & Allied Health, Babcock University, Nigeria

Published: April 2011
Aja GN, Umahi EN, Allen-Alebiosu OI
Developing Culturally-oriented Strategies for Communicating Womens Health Issues: A Church-based Intervention
Education for Health, Volume 24, Issue 1, 2011
Available from: http://www.educationforhealth.net/

A B S T R A C T

Context: In developing countries, messages on maternal health are often developed and conveyed without due regard to the
literacy and cultural context of communities. Culturally-acceptable approaches are, however, necessary to increase awareness on
womens health issues, especially in cultures where oral tradition is important.
Objective: To describe the processes adopted to engage church-based women support groups to develop innovative culturally-
based strategies for communicating womens health matters.
Methods: We utilized an activity-oriented workgroup discussion methodology to engage 30 participants from 15 churches (two per
church) in a two-day workshop located in an urban community in southeast Nigeria. The recruitment process included initial visits
to 25 churches with an expression of interest form, followed by an invitation letter to the 15 churches that completed and returned
the form. Participants were female church leaders, 26 years of age and older, from different occupations and educational levels.
They attended a 16-hour (two-day) small group workshop, conducted in an adult-learning format.
Results: Six groups of five participants each used the Women and Health Learning Package (WHLP) to create and develop a
dialogue on adolescent health, a drama on violence against women, a song on nutrition and womens health, a story on use of
medicines by women, a quiz on cervical cancer and a poster on family planning. Thirteen of the 15 churches submitted a written
report of the workshop to their local churches one month after the workshop as well as a copy to the workshop facilitator. Of the 13
churches, three organized a workshop to increase awareness on womens health issues in their local churches within three months
of the workshop.

GN Aja, EN Umahi, OI Allen-Alebiosu, 2011. A licence to publish this material has been given to Education for Health:

Conclusion: Activity-oriented workshops can be a useful way of developing culturally- appropriate communication strategies for
increasing awareness on womens health issues among church-based women groups.

Keywords: Church, community-based education, Womens health, workshop

Context

Several attempts have been made to improve the health status of women
1
and to elicit global commitment to womens health
rights
2
. Despite these efforts, access to health information still remains a mirage to a vast number of people in developing
countries
3,4
. Health communication
5
, therefore, requires that health messages should be tailored
6
to suit local needs, especially in
Africa where oral tradition is common
7
.

To enhance teaching and learning in womens health, The Network: Towards Unity for Health (The Network: TUFH) Women and
Health Task Force (WHTF) in 2006 developed the Women and Health Learning Package as a free learning resource for use by
educators, health providers and health sciences students to increase awareness on womens health issues. Currently, the 14 learning
modules include the following topics: cervical cancer; contraceptive practices; female genital mutilation; gender and health;
internalization of domestic violence; menopause; men's involvement in promoting reproductive health; mother-to-child
transmission of HIV/AIDS; nutrition and women's health; safe motherhood; unwanted pregnancy and unsafe abortion; use of
medicines by women; violence against women; and adolescent health. To-date, the WHLP has been used to implement programs in
different cultural settings
8
.

Activity-based approaches
9
to improve the health status of the community
10
are necessary, particularly in Christian churches where
stories, songs, proverbs, illustrations, etc., are commonly used to convey pertinent spiritual messages - a legacy that can be
extended to health promotion. Christian churches are associated with local communities
11
, tend to reach a wide range of people
12

and seem to possess unique cultural assets
13
. Many studies show that churches are involved in disease prevention research
12
,
mammography promotion and screening
14,15
, breast cancer screening
16
and peer counseling
17
. Thus, churches can serve as avenues
for health promotion
18
and specifically for recruiting and training non-professionals for behavior change
19
.

There is a need to effectively engage church members to harness their vast potential to help improve womens health.
Consequently, the purpose of this paper is to describe the processes we used to engage church-based women group workshop
participants to develop culturally-oriented strategies for communicating womens health issues and to highlight some of the
challenges that resulted from the overall process.

The authors of this paper have had experience working with church groups in the area of HIV/AIDS, malaria, etc. Specifically, one
of the authors worked with churches to explicate perceived church-based needs and assets
20
and the importance churches attach to
the assets they have to prevent and control HIV/AIDS
21
. He is also the author of the WHLP module on Use of Medicines by
Women
22
.


Methods

We organized a 16-hour (two-day) small group workshop, conducted in an adult-learning format, using the Women and Health
Learning Package (WHLP) developed by The Network: TUFH Women and Health Task Force as the information tool. During the
initial visits, the project team with 25 church leaders discussed details regarding the purpose of the workshop, description of the
steps for the development of culturally-oriented strategies for communicating womens health issues, confidentiality issues and
rights to withdraw at any time. Subsequently, this was discussed with the participants at the workshop. A written informed consent
was obtained from each participant at the workshop.

Six steps were used in the recruitment process:

Step 1: Dispatch of expression of interest forms. Based on previous work with 83 churches in the area
20,21
, 25 churches within the
city center, noted for active womens support groups, were contacted and visited by the project team with an expression of interest
form. This specified the purpose, date, time and location of the workshop. On the form, the head of the church was requested to
nominate two church women leaders to participate in a two-day workshop.

Of the 25 churches, 16 were orthodox (Anglican, Baptist, Catholic, Methodist and Seventh-Day Adventist) and nine were
indigenous (Christ Apostolic, Cherubin and Seraphin, Celestial, Deeper Life, Assemblies of God, Evangelical Church of West
Africa and Pentecostal ministries and fellowships). To ensure that a diverse number of churches were represented at the workshop,
churches were revisited and reminded a few days before the scheduled date to submit their expression of interest form signed by
the church leader. Of the 15 churches that responded and agreed to participate, eight were from orthodox and seven from
indigenous church groups. A total of 30 women leaders participated (two each from the 15 churches) to maximize the chances that
they would extend the workshop lessons to local church members. Information on each participants age, education and occupation
was collected using the registration sheet.

Step 2: Dispatch of invitation letters. Upon receipt of the expression of interest form, an invitation letter specifying the date, venue
and incentives for participation (free lunch and transport subsidy) was sent directly to the women through their church leaders.

Step 3: Talk shop. On Day 1 of the workshop, the 14 WHLP modules were presented by an experienced facilitator (an author of one of the
modules) and extensively discussed by the participants. During the discussion, participants mainly focused on six modules (adolescent health,
violence against women, nutrition, proper use of medicine, cervical cancer and safe motherhood-family planning) that they thought addressed
their concerns and/or the concerns of family and fellow church members. Participants also helped identify six communication methods they
considered useful for sharing the six identified modules with local church audiences.

To prepare for the Day 2 task, we requested participants to form six groups of five each. Joining a group depended on an
individuals interest in one of the six modules and on the condition that no two individuals from one church joined the same group.
The arrangement was intended to ensure diversity within and between the groups. Individuals who had interest in more than one
module were encouraged to join only one group since they would have the opportunity of contributing their ideas during the
feedback session. The list of members was submitted to the project team by each of the groups and was verified to ensure that
members from the same church were in different groups. To avoid bias in the allocation of the communication methods, the
participants requested the project team to randomly allocate the six communication methods to the six groups by ballot (however, a
group may have chosen to use more than one method where necessary - for example, drama and song).


On a final note for the day, the groups were reminded to reflect on the key activity-based question: 'How can the topic, identified
by the groups from the WHLP modules, be communicated to a local church audience using one or a combination of dialogue,
drama, storytelling, quiz, song and poster?'

Step 4: Workshop. On Day 2, each group used the morning session to discuss, develop, rehearse and present their topics. Each
group selected a moderator to guide the discussion and a scribe to take notes on the process of presentation development. This
lasted for about three hours after which all the six groups reconvened for the first presentation, followed by a feedback session. The
feedback questions were, 'What aspects of the topic were well emphasized by the group?' and 'What aspects of the topics needed to
have been well emphasized by the group?' The feedback mechanism was designed to gain input from other group members,
particularly participants who would have liked to join more than one group. An additional 15 minutes were allotted to the groups to
make necessary revisions or modifications based on the feedback before the final presentation. The final presentation lasted for
90 minutes, or about 15 minutes for each group.

Step 5: Next Steps. During the final session, we requested each of the groups to come up with a plan on how they intended to
disseminate the lessons learnt from the workshop to their local churches.

Step 6: Workshop evaluation. The project team used a one-page questionnaire to evaluate participants satisfaction with the two-
day workshop. Items on the questionnaire were scored on a scale of 1 (Not Sure) to 5 (Strongly Agree). Provision was made for
additional comments.

Results

Overall, 30 participants representing various Christian womens groups including Anglican, Baptist, Presbyterian, Assemblies of God,
Catholic, Seventh-Day Adventists and other ministries and fellowships participated. Table 1 indicates that the participants were aged 26 years
and older, from varied occupations (teaching, trading, pharmacy, nursing/midwifery) and from different educational levels (primary,
secondary, university and nursing/midwifery education).

Table 2 shows the application of the communication methods (dialogue, drama, song, storytelling, quiz and poster) by the groups to womens
health issues.

The feedback session elicited important discussion and contributed to the revision and repackaging of the presentations. For instance, the
dialogue on adolescent health was revised to include thoughts around how HIV/AIDS can be prevented, rather than focusing solely on the
devastating effects of the disease. The drama on violence against women, which focused on physical violence, was expanded to include other
forms of violence such as verbal abuse, often not considered as serious in this cultural setting. The song on nutrition and womens health was
repackaged to include the importance of drinking clean water. A song on the importance of hospital care was added to the story on proper use
of medicinal drugs. Questions on where to go for cervical cancer screening were included on the cervical cancer quiz. The poster on family
planning was revised to include the drawing of a male figure as a major stakeholder in the family planning process.

At the workshop, participants developed an action plan. Table 3 shows the action plans, including how participants were going to
take what was learned and apply it in their local churches.


Table 1: Demographics of participants in a church-based workshop

n=30 %
Age (in years)
26 30
31 40
41 50
51+
Educational level
Primary
Secondary
University
Other (Nursing and Midwifery Education)
Occupation
Teacher
Trader
Pharmacist
Nurse/Midwife
Retired

6
15
7
2

5
15
7
3

13
10
2
3
2

20
50
23
7

17
50
23
10

43
33
7
10
7

Table 2: Summary of groups, Women and Health Learning Package (WHLP) modules, communication method(s) and
application of communication strategy

Group WHLP
Module
Communicatio
n Method
Application
1 Adolescent
Health
Dialogue Focused on sex and HIV/AIDS and conveyed important lessons on abstinence,
faithfulness, voluntary counselling and testing and Christian support. The dialogue
involved two good friends: one was against indiscriminate sexual relationships while the
other was in favour of a free life until she was confronted with the realities of
HIV/AIDS. Then she remembered the discussions she had had with her friend on the
devastating effects of HIV/AIDS and how it can be avoided.
2 Violence
against
Women
Drama Portrayed forms of sexual abuse (a husband insisted on sexual pleasure even when it was
not convenient for the women), physical abuse (beating, kicking and hitting) and verbal
abuse (insults, name-calling and unreasonable demands). The group strongly highlighted
one of the root causes of family violence in the Nigerian setting, which is undue demand
from mother-in-laws for a boy-child in the family. The drama ended with a song, on the
note that the time has passed when women were regarded as nothing
3 Nutrition and
Womens
Health
Song and
Storytelling
Emphasized that balanced diet (protein, carbohydrates, fats and oil, vitamins and
minerals and water) helps protect against diseases and provides fresh blood leading to
good antenatal and postnatal health, energy and vitality.
4 Use of
Medicine by
Women
Story Portrayed a poor widow who could not afford to take her child to the hospital because
she had no access to the health center due to lack of money and transportation. She relied
on a fraud village doctor who prescribed too many drugs at affordable cost. The illness
got worse and the child was eventually rushed to the hospital where he got well. While
the song emphasized the importance of hospital care, the need for improvement on the
social determinants of health was also strongly highlighted.
5 Cervical
Cancer
Quiz The twelve questions centered on the causes and prevention of cervical cancer. The
questions generated further discussions and questions within the groups, particularly
during the feedback session.
6 Safe
Motherhood
Poster Illustrated the danger of having more children than one can care for and how this can
enhance poverty and disease. The take-home message was that family planning improves
the quality of life of the mother, children and family.


Table 3: Groups action plans, including how they were going to take what was learned and apply it in their churches

Group Action Plan Specific Activity
1 Feedback to church leaders
Awareness raising
Present workshop report
Request for time slot during church worship for womens health programs
Discuss issues related to abstinence, faithfulness, and condom use with youth leaders in the
church
Awareness raising
Catch Them Young Program: A special ministry for young girls in the church to help them
learn basic family life skills such as cooking, sewing, home gardening, etc.
Train youth as womens health counselors
Awareness raising
Work with church leaders to run more health programs in the church
Identify women mentors in the church and community to support young girls
Awareness raising
Mentoring program for youths in the church
Workshop on use of medicine by women to create awareness
Awareness raising
Cervical cancer awareness workshop for church members
Awareness raising
Work with church members who are health professionals to promote womens health matters

A month after the workshop, participants from 13 of the 15 churches reported submitting a written report of the workshop to their
local churches and a copy to the workshop facilitator. The report indicated that the workshop was timely, relevant and should be
extended to other local churches.

Within three months following the workshop, three of the 13 churches reported organizing a similar seminar in their local churches
on specific topics: cervical cancer; adolescent health; and use of medicines by women. Local participants in each of the three
locations used storytelling, drama and songs to convey important lessons on cervical cancer, adolescent health and use of
medicines by women respectively.

In terms of workshop evaluation, all 30 participants strongly agreed that group discussion matched with priority health problems,
was consistent with the specified topics, involved all as active participants, promoted participant-to-participant interaction, was not
dominated by the facilitator and concluded with satisfactory solutions in the final session. Additional comments included: 'the
workshop should be extended to men to help them understand that women need special care'; 'two days are not enough for this type
of workshop'; and 'organize a national womens health communication competition.' There were several commendations to the
project team for 'such a fun way of sharing health information.'

Discussion

Workshops can be very useful for training and instruction in womens health development. Group methods were adapted
9
to bring
about meaningful change and innovation in knowledge translation
23
, especially in resource-limited settings. For instance,
dialogue
24
is used in public health discussions
9
to engage the participants to respond to the content being learned
25
, and drama
helps to explore issues, create and stimulate discussions and connect people with real life issues
26,27
. In our workshop, each
scenario presented in the drama provoked discussion on ways of preventing violence against women.


Song and storytelling are effective ways of communicating health messages in local communities
7
and are usually thought-
provoking. In our workshop, the need and importance of good maternal and child nutrition was conveyed eloquently in a song
using the local language. Another group used storytelling and dancing to promote rational use of medicine, suggesting that a
combination of one or more communication strategies is practicable.

Quizzes can be an innovative way of promoting critical thinking
28
and were used to elicit in-depth discussion on cervical cancer.
Another group presented and discussed family planning issues using a poster. Poster-based interventions have been used to
promote healthy behaviors in other studies
29
.

Overall, our study showcases unique processes to engage church-based women groups to develop strategic ways of communicating
womens health issues. The activity-based workgroup discussion used the WHLP as the key resource material. The topics may
have helped participants to focus and reflect on the health problems affecting them and women in general (the participants were
middle-aged married women), thereby, enabling workshop participants to react and act on those issues by developing appropriate
strategies for sharing them. The content of the dialogue, drama, song, storytelling, quiz and poster may have been influenced by
individual experiences. The feedback mechanism employed at the end of the first group presentation helped to enhance active
participation, expand the discussion and harvest more input from the participants that led to the revision or repackaging of the
group presentations. The action plan submitted by the participants served as the template for measuring progress. As mentioned,
participants from 87% of the churches (13 of 15) submitted a written report of the workshop to their churches. Participants from
the three churches that reported organizing at least one similar workshop in their local churches three months after the workshop
were invited to help facilitate a similar workshop in the southwestern and northern parts of Nigeria (funded by Global Health
Through Education, Training and Service - GHETS). The key criteria for selecting the three facilitators included the number of
activities carried out in their local churches after the initial workshop and willingness to participate.

Workshop evaluations revealed that the processes were overall successful, but with some limitations. Heads of churches were
responsible for deciding who represented their churches at the workshop so perhaps relationship issues among leaders and
members influenced the selection of participants. For example, women leaders who did not always support the views of their
pastors/priests may have been less likely to have been selected to participate. Problems associated with travel between churches
included car breakdowns and heavy traffic (since this was in a commercial city) which led to cancellation and rescheduling of
prearranged meetings. Difficulty in meeting heads of churches resulted in repeated visits and more expenses. The period of the
workshop may have coincided with the time churches who could not participate had weeklong evangelistic programs.

Not all the participants reported having implemented any program in their various churches. Perhaps, some did organize programs
but were unable to report them to us. A more intensive follow-up plan is needed to see how those church groups that have
organized and reported their programs can help support other participants from other churches to become so engaged.

Despite the observed limitations, this project showcased the ingenuity of church-based women in developing culturally appropriate
tools needed to increase awareness on womens health issues. It demonstrated that church leaders are important assets in
mobilizing members for social/community action, and the diversity of the churches that participated in the workshop was a major
strength. It was also a great success that three of the women who participated in the initial workshop went on to facilitate two
similar interstate workshops in other parts of the country.


Conclusion

Four essential components may be required to effectively engage church-based women groups to develop culturally-relevant
strategies for communicating womens health issues: a recruitment process that involves church leaders in selecting participants;
activity-oriented focus workgroup discussion (using the WHLP as the key resource material) to keep participants engaged on
task(s); a feedback mechanism for quality improvement; and an action plan that defines the next steps. However, more workshops
are needed to ascertain the applicability of these processes in diverse settings.

Acknowledgement

The workshop was funded through a mini-grant awarded by the Global Health Through Education, Training and Service (GHETS).

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