Project Proposal: Implementation of Religious Leader Training
and Patient Referral Pilot Projects
Laila Zomorodian M.D., University of Washington School of Medicine
Background
Strengthening Care Opportunities through Partnership in Ethiopia (SCOPE) is a joint effort among
the School of Global Health at the University of Washington, University Presbyterian Church in
Seattle, the Ethiopian Orthodox Church, and the University of Gondar. The SCOPE project began in
2009, with a goal of strengthening the relationship between the local faith and medical communities
to improve the lives of people living with HIV/AIDS in Gondar, Ethiopia. Through its outreach,
education, and training initiatives, SCOPE is working to expand community access to medical
resources and to encourage community participation in the fight against HIV/AIDS.
SCOPE trains local priests and religious women to reduce the stigma around HIV/AIDS and to link
community members with health services like HIV testing and care, and Prevention of Mother-toChild Transmission (PMTCT) of HIV.
Problem Definition
I.
Evidence
a. Evidence of necessity: In 2012, there were roughly 760,000 people living with HIV
in Ethiopia, a country home to a population of 96.6 million people, resulting in an
estimated prevalence of 1.3% [1, 2]. While this prevalence rate ranks number 34 in
the world the number of deaths attributed annually to HIV ranks eighth in the world
[2]. Furthermore, the prevalence of HIV in the North Gondar zone was most
recently estimated at more than twice the national rate. [3] UNAIDS data from 2013
reports that 55% of HIV+ pregnant women receive anti-retroviral medications for
the Prevention of Mother To Child Transmission. Though these numbers reflect
improvement over the past decade, in order to further improve these numbers,
access to HIV care and related medical care must be expanded.
b.
Propensity for success: Roughly 90% of the North Gondar population identifies as
Ethiopian Orthodox Christian. [3] Recent estimates report that Ethiopia had only
2,000 doctors, but boasts 500,000 Orthodox priests. [4] In recent years, efforts to
expand the healthcare workforce have contributed hundreds to thousands of new
physicians [5], but even with these changes, the number and presence of priests
continues to outnumber local physicians. SCOPE has shown modest success in
training these locally respected religious leaders to recruit patients to be linked with
appropriate HIV-related care. As this project continues to expand, so does the
breadth of the community reached by these religious leaders and by extension, their
access to the medical community and system.
c.
Proving success: Previous SCOPE projects have trained dozens of local priests to
serve as liaisons between members of their community and health services.
Religious leaders, namely, priests and religious women, are trained by local SCOPE
members employed within the Gondar medical community. Training covers
antenatal care (ANC), PMTCT, and emphasizes the importance of HIV testing in the
prevention and treatment of HIV. After training, the religious leaders recruit,
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counsel, and refer pregnant women in their communities to their local health center
for the appropriate health visit. The clinic site first piloted in 2013 showed a 20%
improvement in ANC clinic attendance following SCOPE intervention. The purpose
of the current project is to continue and expand the efforts of the pilot carried out in
the previous project.
II.
Sustainability
a. Short-term: In order to maintain momentum throughout and between projects,
SCOPE members design and follow a schedule for training, project implementation,
and evaluation. This plan is created by the US and Ethiopian SCOPE fellows, and
shared with the stakeholders and participants in the SCOPE project at steering
committee meetings, as well as in personal communication. It is also submitted to
the Executive Board for review, with the expectation of project updates and plan
revisions as necessary.
b.
Long-term: The longevity of a young organization requires more than just initial
success. SCOPE is run in tandem by a team based in Gondar, Ethiopia, as well as by a
team based in Seattle, Washington. SCOPE fellows are selected from both areas and
work in parallel on separate but related projects. In the absence of US SCOPE fellows
in Gondar, Ethiopian fellows continue to implement pilot programs and gather clinic
site data. They also sustain the relationship between SCOPE and many of its local
partners with updates on current projects and consistent communication.
Project Goal
The goal of this project is to implement pilot programs at two of the clinic sites in the North Gondar
region, which have previously been identified and/or piloted by SCOPE.
The Woleka clinic site is an existing project site where religious leader training and patient
recruitment has been done before. The Azezo clinic site is a new SCOPE site, where the same project
will be implemented, but for the first time. During this time, the University of Gondar fellow will also
run an additional project to assess the capacity of future clinic sites, including the Gabriel clinic.
Project Objectives and Activities
I.
Project Legality - Ethiopia requires programs to obtain legal authorization for any project
implemented in the country. In order to ensure that the project is sanctioned and to prevent
implementation delays, letters and documents should be obtained as soon as possible.
SCOPE has obtained a letter from the University of Gondar explaining the project and
sanctioning the project as authorized under Ethiopian law. This letter has been signed by
Ministry of Health officials and has been presented to the clinic sites.
a. Confirm that every clinic site has received the letter explaining the project.
b. Obtain an additional letter from the Woreda Health Center stating its support for the
priests and religious women conducting outreach. This letter should serve to
increase the legitimacy of these leaders, thereby extending their acceptance in the
community. This should be done as soon as the religious leaders have been chosen
in or by January 2015.
II.
Project Budget
a. Submit a budget plan to the SCOPE board. This should include payments to be made
to the participating health center, participating religious leaders, room rental for
training, and trainers leading the instruction.
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III.
Pre-Project Meetings
These meetings should occur within the first few weeks of the fellow’s arrival and will serve
to refresh partnerships, introduce new parties, and explain and review the project’s mission.
IV.
V.
a.
Meet with the North Gondar Archbishop to discuss the progress and current goal
project, and confirm his consent.
b.
Meet with head of each participating health center or clinic to discuss the project
and confirm their consent. Verbal consent has previously been obtained from every
clinic head and should be re-established prior to beginning the pilot projects.
c.
Meet with health center/clinic head nurse and ANC nurses to review and discuss the
project, their role, and any ideas or suggestions they may have.
d.
Obtain baseline ANC and PMTCT data from participating health center/clinic. The
most recent two years (20012-13) of this data have been collected. As clinic sites are
added to the SCOPE project, record whether/what data is recorded from individual
kebeles, and whether this data is from some or all kebeles in the catchment area.
e.
Confirm the willingness of the head of health center/clinic and ANC nurses to
document when a religious leader was responsible for encouraging a woman to
attend ANC. Explain the unique indicator on the referral card and obtain their
consent to accept and store these cards. Confirm stock and availability of these cards
prior to beginning.
Select Priest and Religious Women for Project Participation
a.
Partner with the North Gondar Diocese to select one priest and one religious woman
from each kebele, and provide the diocese with specific selection criteria. Should the
North Gondar Diocese have trouble identifying priests and religious women for
project participation, obtain the contact information for the head of the local
diocese. This should be completed within the first couple weeks of the fellow’s
arrival.
b.
In the case that the North Gondar Diocese is unable to obtain a priest and/or
religious woman from a specific kebele, put the diocese in contact with the Health
Extension Workers (HEWs) for each kebele. The HEWs should provide the names of
potential priests/religious women for approval by the Diocese.
i. The North Gondar Diocese should contact priests and religious women to
inform them of their selection, project goals, participation requirements,
and compensation to be provided.
ii. Obtain names, kebele of residence, and contact information for each
religious leader.
c.
Speak with each priest and religious woman independently to verify his or her
understanding of the project. Obtain verbal agreement for project participation.
Conduct Baseline Interviews
These interviews serve to establish a baseline of individual perspective and practices before
the intervention.
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a.
Conduct one-on-one semi-structured open-ended interviews with participating
religious leaders. These interviews should focus on their knowledge and
perspectives. Interviews can be transcribed or recorded, depending on IRB
approval. The proposed interview questions are provided in the Appendix.
VI.
Religious Leader Training Preparation
a. Establish location for training. Location should be easily accessible for participating
religious leaders as well as facilitators.
b. Confirm availability of training location with whoever is in charge.
c. Assign trainers to each training section.
d. Obtain slides or training documents for each trainer.
e. Confirm refreshments and meals as necessary.
f. Purchase notebooks and pens for each participating religious leaders. Extra
incentives (such as a bag and umbrella for outreach) can be provided as available
and desired.
VII.
Project-Specific Referral Card Mark
Establish the consistent use of a mark or insignia to indicate that religious leaders have
referred a patient.
a. The clinic referral card used by HEWs will be distributed to priests. HEWs may also
maintain a supply of cards available to priests/religious women.
b. Ensure the project is specified on the referral card in order to differentiate it from
typical HEW referral cards.
c. Ensure that all clinic staff are able to identify the mark, in order to accurately track
numbers of women referred by priests/religious women.
VIII.
Priest Training
a. The trainings must be opened with a prayer. Identify a member of the diocese to
attend the training and bless the participation of religious leaders. This prayer must
take place before any other introductions.
b. Trainings should focus on HIV, ANC, PMTCT, assisted birth, strategies for conducting
outreach, and project roles. Structure the training to be interactive and allow room
for discussion and questions. See Appendix for sample training guide.
c. Request participants from past trainings to help for at least one day of the training
in order to promote buy-in and ownership.
d. Include at least 1 HEW from each participating kebele in at least one day of the
training in order to promote relationships between the religious leaders and health
workers.
e. Provide a pre-test and post-test to measure the trainings’ impact on knowledge and
perspectives. Offer “reading” assistance before participants begin the pre and post
test, as some participants may be illiterate. See Appendix for sample tests.
IX.
Identification of Pregnant Parishioners
a. Provide religious leaders with criteria for parishioner selection
b. Specify that religious leaders are responsible for identifying pregnant parishioners
through their own networks. They should not reply on names provided by HEWs, as
women identified by HEWs will likely already be integrated into the medical system
and have received some information regarding ANC and HIV.
c. Each priest/religious woman pair will identify 10 women per month to whom they
will conduct outreach.
d. Obtain list of names from each priest/religious woman pair at follow-up meetings.
X.
Conduct Baseline Interviews with Parishioners
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These interviews serve to establish a baseline for individual perspective and practices prior
to intervention.
a. Obtain contact information for Health Extension Workers (HEWs) from respective
Health Center or clinic. There should be two HEWs for every kebele.
b. Contact one HEW from each kebele. Explain the project and request their assistance
in meeting with pregnant parishioners.
c. Randomly select two pregnant women from each kebele. These names should be
taken from the list provided by the priest/religious woman pair.
d. Visit homes of selected pregnant parishioners with the assistance of the local HEW
and, if necessary, a translator. The HEW should introduce the SCOPE fellow, who
should in turn introduce the project and obtain verbal consent from the
participating woman.
e. Conduct baseline interviews with pregnant parishioners. All baseline interviews
must be completed before project implementation begins. Interviews can be
transcribed or recorded, depending on IRB approval.
XI.
Project Implementation
a. At the end of religious leader training, specify job roles and expectations of religious
leaders. Each priest and religious woman will be paired by kebele of residence. Each
pair must:
i. Identify 10 women every month. These women should have a “known
pregnancy” but NOT be currently utilizing ANC. These women should be
identified through the priests/religious women’s networks. They should not
obtain lists from HEWs.
ii. Visit each woman’s house twice a month.
1. During these visits they should discuss HIV and its transmission,
the importance of attending ANC and the number of visits an
expectant mother should have, the importance of having an HIV
test while pregnant and participating in PMTCT if they are HIV
sero-positive, and the woman’s birth plan.
2. If possible priests and religious women should talk to the husband
and explain the importance of supporting his wife in attending ANC
and saving money for an assisted birth.
3. If a woman or her spouse says no, inquire as to their reasons why.
Listen actively. Give the best possible answer and try to convince
them of the importance of ANC attendance.
4. If the woman or her spouse continues to say no, express
understanding and request to return another day to speak with
them.
5. At the end of each visit, priests/religious women should provide
the woman with a project referral card. They should direct the
pregnant woman to give this referral card to the ANC nurse at the
health center, and tell the nurse that a religious leader referred
them.
6. Priests/religious women should record in their SCOPE notebook
the name each woman they saw, whom they spoke during the visit,
the date on which the visit took place, and any challenges they
encountered.
iii. Attend bi-weekly meetings with the project implementation team for the
first 2 months, followed by monthly meetings for the following 4 months,
and bi-monthly meetings for 6 additional months. An appropriate schedule
for recurring meetings will be decided after 12 months of implementation.
Each meeting date and time should be set at the previous meeting so as to
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ensure that every participant has information about when they are next
expected to meet. Include HEWs, clinic staff, a diocese representative and
Univ. of Gondar implementation team in these meetings.
iv. These meetings should include focus groups discussing experiences
conducting outreach, challenges encountered, and responses of the women
and their families. They may serve as opportunities for strategic planning
and for religious leaders to share stories and examples of what did and did
not work during their outreach.
v. Emphasize that these meetings are mandatory, and that compensation will
be deducted accordingly by absence.
Deliverables
All deliverables will be finalized and submitted in the final project report upon return from Ethiopia
in May or June 2015. Documents intended to inform the next board meeting will be completed prior
to that meeting.
Project Scope and Approach
The essential components of this project are implementation and evaluation. A final report will serve
as the assessment of the project that is carried out between January and May 2015. The data
incorporated in the report will consist of interviews conducted with project participants as well as
the numerical data collected by clinics prior to and continuing through the project implementation.
Ethical Issues
The University of Washington Human Subjects Division determined that this project does not fall
under the definition of “research” under section 45 CFR 46.102(d) and therefore does not require
review by the IRB. This project is intended for internal use by SCOPE to evaluate current programs
and inform strategic decision-making. Project participants will consist of volunteer partners who
participate in interviews that gauge their perceptions of SCOPE and its projects. Data will not be
collected for external use.
To limit the risk of negative outcomes, the interviewer will prevent potential discomfort of interview
subjects by stating the goal of each interview and clearly communicating how responses will be used.
Interviews are designed to capture attitudes about SCOPE and gauge the effectiveness of training and
other ongoing project components.
Constraints
Likely barriers to project implementation include the following:
I.
Language: Ethiopian SCOPE project leaders will lead training of religious leaders. Entry
and exit interviews of religious leaders, parishioners, and other participants will be
conducted with the use of a translator, and accuracy of the data will be dependent on
this translation.
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II.
Time: the SCOPE project relies on volunteer participation and is therefore subject to the
availability and scheduling constraints of those religious leaders and University of
Gondar staff who have chosen to participate.
III.
Availability of in-country officials: SCOPE’s work involves connecting the local
medical and faith communities and the leaders and officials therein. These people must
often be consulted and/or consented prior to project initiation.
Measurement
I.
II.
III.
IV.
V.
Collect most recent health center data on ANC, PMTCT, and attended births.
Conduct entry interviews with religious leaders following their selection.
Conduct entry and follow-up exit interviews with pregnant parishioners.
Analyze interviews using open coding.
Compare pre- and post-tests from priest training sessions.
Timeline
A timeline for this project is included in the Appendix.
References
1.
2.
3.
4.
5.
Country Progress Report on the HIV Response.
http://www.unaids.org/sites/default/files/country/documents/ETH_narrative_report_201
4.pdf
The World Factbook: Ethiopia. https://www.cia.gov/library/publications/the-worldfactbook/geos/et.html
Robinson, Emily and Getahun Asres. Improving Health in Ethiopia Through Partnerships
with the Church. Sept 9 2014. http://www.capitalcommentary.org/scope/improving-healthethiopia-through-partnerships-church
Savage, Kristen. Soul Fathers As Health Educators: A Pilot Project to Improve Uptake of
Antenatal Care and Prevention of Mother-to-Child Transmission Services at the Woleka
Health Center in Gondar, Ethiopia. Community-Oriented Public Health Practice (COPHP)
Program, University of Washington. January 2014.
IRIN Africa: News. ETHIOPIA: Surge of doctors to strengthen health system. Aug 14 2012.
http://www.irinnews.org/report/96101/ethiopia-surge-of-doctors-to-strengthen-healthsystem
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