Community-Based Health: Lessons from Rural Kenya

Written by Erica Petersen //

Waiting in Chicago O’hare Airport’s international terminal on the last day of May 2019, I had no idea what to expect of the upcoming ten weeks. My colleague-turned-friend from the Masters of Public Health program at the University of Illinois at Chicago (UIC) and I were both nervous and excited as we boarded our flight to Nairobi together. The two of us were headed to Maseno, Kenya, a small town on the west side of the country, to assist a local university in their efforts to conduct a Community Health Needs Assessment (CHNA). We were under the supervision of a professor from UIC who has been doing HIV prevention work in Kenya for over 20 years. He had fostered a relationship with two faculty members from Maseno University, and together, the five of us made up the leadership team for the impending project. 

CHNAs are a tool commonly used in the world of public health to capture a broad picture of the health status, and determine the needs and assets of a particular community. They are typically used as a tool to inform health programs and interventions that address the needs revealed by the assessment. In the US, they have become more prominent in recent years due to the Affordable Care Act mandate for non-profit hospitals. In Kenya, there is very limited publicly-available health data. As such, the Maseno University School of Public Health and Community Development, which frequently conducts field work in neighboring communities, hoped to collect baseline data regarding what issues were at play there. 

We had gone to Kenya with the goal of working with the university to conduct the preliminary work for data collection that would happen after our return to the US, but at the end our first team meeting, it was clear that the Maseno faculty wanted to hit the ground running and finish all data collection by the time we returned home. They set an ambitious timeline, and we went to work. 

Over the first month and a half, the leadership team wrote a research proposal detailing the study that was sent to the ethics review board for approval. Our assessment would include two household surveys — one for the head of household, and one for every woman of reproductive age — to be administered to a selection of homes in two communities bordering the university. We created the surveys and translated them into Swahili, as well as two local dialects (Luo and Luhya). Next, we defined the study areas, selected participants, recruited a team of public health students to administer the surveys, and held trainings on survey administration and study methodology. 

For this study, we utilized Kenya’s community-based health system. The country’s foundational level of healthcare consists of community health volunteers (CHVs) that conduct household visits to check in on people, provide basic health care, and refer patients to health facilities when necessary. CHVs know every person in their village, including where they live, what they do for a living, and who their family members are. The CHVs were an absolutely integral part of our project, and one of the aspects that made it so successful. They were able to escort us into the villages, introduce us to community members, and foster trust between the community members and our research team. I was really impressed with the grassroots-style, community-centered healthcare model that Kenya employs. Not only does Kenya have universal healthcare, but also utilizes community members as health workers and liaisons in the healthcare system to make sure patients do not slip through the cracks. Both of these practices might serve to address access issues and health disparities if implemented in the US. 

It is expected that anyone entering communities for programs or research engages in a community entry process. Our entire research team attended a community meeting with the village chief and community elders to ask for permission to conduct the study. We discussed the purposes of the study, what our questionnaires would entail, and the study methodology. After addressing any questions the chief and community members had, we were given the chief’s permission to enter the community and conduct the study. 

With three weeks left in Maseno, we were able to begin the data collection. My research partner and I went out into the field with the teams of Maseno students to help with logistical support, and to make sure the methodology was performed correctly, but the students were the sole administrators of the survey. All the students were local and spoke English, Swahili, and the community’s tribal language, so it was imperative that they were the ones conducting the surveys. 

While it was truly an incredible experience being able to meet so many community members and being welcomed into their homes, there was a certain level of discomfort in being present during the interviews. More often than not, when westerners come into rural villages in Kenya, they are conducting their own projects for their own benefit. Although this assessment was for Maseno University and was explained as such to the participants, my mere presence gave the connotation that this was a “Muzungu” (Swahili for white person) project. Even the students themselves had a hard time grappling with the fact that we were there to conduct Maseno University’s research and not vice versa. 

On the very last day of our time in Maseno, we finished entering the entirety of the data into a database that we had created ourselves. After roughly two months of intense work, we had fully planned, organized, and collected data for a CHNA. Back in the US, we are currently working hard to analyze the data and write a report of the findings for our Kenyan colleagues. 

Reflecting back on the time spent in Kenya, we accomplished more than any of us thought possible, while overcoming many challenges and learning a lot along the way. The work was a continuous practice in patience and perseverance. Our Kenyan colleagues were very busy with their own roles at the university, and were often unavailable to answer our questions. It tended to take longer to get responses and reach verdicts than we were used to, which was primarily a result of how overworked all of our Kenyan colleagues were. We quickly learned to allow space and time to our team members without letting our project grind to a halt. In order to press on with limited support, we had to teach ourselves many new skills, from GIS mapping to database creation. At times we felt like we were being thrown off the deep end, but with a little help from YouTube, and a lot of trial and error, there was nothing we couldn’t figure out. 

Flexibility was also an absolute necessity. Things frequently did not go according to plan and plans were constantly changing, so we had to roll with the punches and adapt to changes on the fly. As much as we meticulously prepared ahead of time, once we stepped out into the field things were always a little (or a lot) different than we anticipated. Whether it be that one of our community health volunteers didn’t show up, our maps of the study areas were inaccurate, or we were short on measurement tools, there was no day that went perfectly according to plan. It was certainly frustrating at times, but we quickly learned to expect the unexpected and deal with challenges as they arose.

Throughout the entire experience, I grappled with — and continue to grapple with — how to do ethical and equitable work in a global setting. It is surely a practice in challenging your own preconceived notions and western-centric view of the world. While I have mixed feelings about coming to low- and middle-income countries from a position of power and privilege to provide “aid,” our team worked hard to make the project as ethical and equitable as possible. Toward these ends, the surveys were created with input from Maseno University faculty, and administered by students who are community members themselves and speak the local languages, while we only provided managerial oversight as needed. 

In Kenya, higher education resources are spread too thin among many universities with overlapping programs and student populations, leading to inefficiency, less funding per institution, and fewer faculty members. As such, most faculty members are working at their absolute maximum capacity and wearing more hats than any one person should. To help reduce their burden, and maximize our usefulness, the team from UIC used the “train the trainer” model for this study. We worked with Maseno to put together all the materials and methodology needed to complete the CHNA, trained a team of student researchers, and assisted in conducting the study. Once we left, Maseno was well equipped to continue surveying additional communities. This extra expertise and increased capacity was instrumental in the completion of the project, and we were able to help Maseno faculty complete a project that they had wanted to do for many years in a much shorter period of time. For that I am extremely proud. 

Conducting ten weeks of community-based research in rural Kenya was a truly invaluable experience that was both challenging and incredibly fulfilling. I learned more than I thought possible, and gained a new family on the other side of the world. Being on a team with people who care so deeply about their communities and show such dedication and commitment, all while facing difficult work conditions and limited resources, was a lesson in humility that I will not soon forget.