The Regional Advisory Information and Networking System (RAINS) Health Advocacy on Health Behavioural Change in Hot Spot Conflict Communities: A case study of Bawku Municipality, Ghana.

The Regional Advisory Information and Networking System (RAINS) Health Advocacy on Health Behavioural Change in Hot Spot Conflict Communities: A case study of Bawku Municipality, Ghana

Fuseini Ahmed Rabiu

Regional Advasory Information and Networking System, Ghana

DOI: https://dx.doi.org/10.47772/IJRISS.2025.914MG00108

Received: 02 June 2025; Accepted: 06 June 2025; Published: 14 July 2025

ABSTRACT

The research focuses on the RAINS health behavioural change intervention in hotspot, conflict-prone settings in Bawku Municipal. A qualitative approach served as a pathway to explore focus group discussions to facilitate an insightful discussion on the phenomenon in the five communities designated for the study through open-ended questions. A purposive sampling technique was adopted to identify five hot spot conflict communities for the study. Thematic analysis was embraced as the source of data analysis. The outcome of the article reveals an improvement in pregnant women and lactating mothers visiting child welfare centres regularly, improved awareness among men about the importance of providing balanced diets for their family, open defecation and malaria prevalence and improvement in the use of treated mosquito nets. On the contrary, movement restrictions, bans on motorbikes, gunshots, and Insecurity continue to tiptoe the work of RAINS in the Municipality. The recent spark of the conflict resulted in the displacement of people. The vacuum of the study is the inability to include statistical backing with a pre-baseline survey therefore, future studies should employ the mixed method to fill the missing gap

Keywords: Regional Advisory Information and Network Systems (RAINS), Accelerating Social and Behavioural Change (ASBC), Community Health Officers (CHOs), Community Health Management Committees (CHMC)

Rains Background

The Regional Advisory Information and Network Systems (RAINS) is a registered non-governmental organization in Ghana dedicated to advocating for the rights of marginalized communities. Established in 1993, RAINS has a longstanding commitment to enhancing the lives of disadvantaged groups. Collaborating with communities, government agencies, and civil society organizations, RAINS has been at the forefront of initiatives to promote girls’ education, combat child labour, and empower women and girls.

The Accelerating Social and Behavioural Change (ASBC) Activity, implemented by USAID and RAINS is an implementing partner, aims to promote and sustain healthy behaviours and practices across various public health domains. These include family planning and reproductive health, malaria prevention and treatment, maternal, newborn, and child health, community and household-level water, sanitation, and hygiene (WASH) practices, nutrition, and responding to public health emergencies such as COVID-19. RAINS is leading community mobilization and engagement efforts in four districts of the Upper East Region: Bawku West, Bawku Municipal, Garu, and Tempane. The project is responsible for achieving measurable behaviour change outcomes in these Zones of Influence (Rains, 2025)

LITERATURE REVIEW

The delivery of quality health services in hotspot conflict zones cannot be downplayed without championing health care delivery in the hands of Community Health Officers and Community Health Management Committees, aligning with Non-Governmental Organisations to enhance effective delivery   (Ahmed et al., 2023; Omam et al., 2023a; Rab et al., 2023)

 Countries that have recently experienced or are currently in conflict often see a decline in their health system infrastructure and a weakening of service delivery. Consequently, populations in Fragile, Conflict-Affected, and Post-Conflict States (FCAPCS) endure mass displacement and exposure to violent atrocities, heightening their vulnerability to infectious diseases (Rutherford & Saleh, 2019).  Moreover, a systematic review in Africa indicates that population displacement impedes effective healthcare provision. This challenge is compounded by barriers such as communication issues, geographical constraints, logistical difficulties, cultural differences, financial limitations, risks faced by health workers, and overall population insecurity.

Care provision in conflict-affected environments differs from ordinary service provision for numerous reasons. These include migration of the population into new locations with the related strain on existing health facilities, the shutdown of some health facilities, the additional burden of disease or injury due to war, and limitations of population or health worker movement owing to lockdowns or curfews.  Similar findings by (David et al., 2017) and   His peers suggest that low-intensity conflicts like insurgencies, counterinsurgencies, civil strife, terrorism, and communal riots have replaced large conventional battles worldwide. These conflicts often persist at low levels for extended periods, with occasional violent flare-ups. Such prolonged low-intensity conflicts lead to long-term displacement, cross-border migration, and trafficking. Affected populations frequently struggle to access existing healthcare services due to a lack of documentation, livelihood, and social capital. Public health issues such as nutrition, water, and sanitation are also severely impacted. Healthcare services are often suspended, withdrawn, or rendered inaccessible, creating a significant health burden, especially for displaced populations with heightened health needs. In these contexts, humanitarian organisations generally provide healthcare rather than the government due to the latter’s diminished capacity for health service delivery during wars (Omam et al., 2023a).

Organizations in hotpot conflict areas use different healthcare strategies to reach affected communities. Findings show that healthcare models in conflict-affected communities include mobile clinics, outreach programs, home visits, health centers, and community-based services. Various actors, including national and international organizations, deliver primary healthcare, targeting internally displaced people and refugees. These services often focus on nutrition, mental health, and sexual and reproductive health. Some organizations employ an integrated service delivery model, while others provide vertical (stand-alone) services (Ahmed et al., 2023; Omam, Jarman, et al., 2023; Rab et al., 2023)

Although the evidence on using community-based models of care, such as community health workers in these settings, is limited, strategies to improve service delivery and access to services are needed. In conflict-affected settings, there may be opportunities to coordinate care or service delivery to meet the minimum standards for quality crises. Disease-specific programs and responses offer limited opportunities to prevent and treat other existing health conditions in difficult-to-reach populations in conflict-affected settings.The disadvantages of stand-alone interventions could be averted through integrating health services (Omam, Jarman, et al., 2023).

 McGowan et al. (2022) pronounced that integrated community case management witnessed significantly improved health outcomes. It should be considered a strategy to overcome access barriers in remote areas. A systematic review of multiple studies examining the role of community health worker (CHW)-based interventions in post-conflict settings across nineteen countries indicates that CHWs can effectively mitigate access barriers associated with healthcare in conflict-affected regions. Leveraging their proximity and social ties within communities, CHWs enhance healthcare by facilitating access, improving disease detection, and promoting better adherence to treatment

Findings indicate that the community health workers who integrate with local experts have strong ties or relationships and can signal any outbreak of communicable prevailing diseases and act faster to ameliorate than professional doctors (Lassi et al., 2015). Also, based on the findings of (Otieno-Odawa & Kaseje, 2014), trained community health workers (CHWs) from local communities can effectively gather dependable data, particularly concerning maternal and child health indicators. Consequently, their data collection efforts in rural and urban settings can be deemed reliable for community-based studies.

Yansaneh et al., (2014) found an increase in care-seeking behaviour of roughly 10% compared to no CHWs in the surrounding neighbourhood within the borders of Sierra Leone. The same results show the influence CHWs have on health-seeking behaviour and in what sense their sample representativeness will be better. “Churches positively impact care-seeking behaviour and improve access to the appropriate treatment of common childhood illnesses, especially in hard-to-reach and poor areas. Deploying Community Health Workers (CHWs) is one strategy to address the growing shortage of health professionals in low-income countries. By assuming tasks previously handled by health centers, CHWs can increase the number of care providers within communities (de Sousa et al., 2012; Lipp, 2011). Unlike medical facilities, CHWs are more accessible and localised. As community members, they can effectively navigate and overcome potential language and cultural barriers that may exist in healthcare settings (Kelly et al., 2001).

In Sierra Leone, the substantial efforts of community health volunteers led to a 105% increase in appropriate treatment for pneumonia and a 55% reduction in the use of Indigenous treatments for diarrhoea (Yansaneh et al., 2014). Furthermore, Volunteer Community Health Workers (CHWs) were recognised for reducing child mortality rates and enhancing healthcare-seeking behaviours for diarrhoea and fever/malaria following the implementation of a CHW program in rural Uganda (Brenner et al., 2011). Similarly, other findings conducted in Zambia attested that the implementation of Integrated Community Case Management (ICCM) by CHWs resulted in higher utilization of CHW services and reduced visits to health facilities for children with fever and non-severe pneumonia (Seidenberg et al., 2012).

Despite the efforts of Community Health Workers, Community Health Management Committees, and volunteers through integration with NGOs and government institutions, they are faced with challenges that hinder the progress of health delivery services in conflict zones

The study identified three key challenges faced by CHWs. Firstly, inadequate knowledge impacted service delivery, raising concerns about the quality of care provided. Due to inadequate logistics, CHWs often lacked sufficient training opportunities and could not apply new knowledge. CHWs find it challenging to do their jobs because they lack essential supplies, which include bicycles, hand gloves, Wellington boots, and first aid kits (Daniels et al., 2015). Secondly, insufficient infrastructural support, including inadequate accommodation, hindered their ability to reach and assist communities. CHWs, limited supplies, and inadequate transportation for women in labour. Thirdly, there were social barriers that hindered acceptance of CHWS’ services, influenced by local sociocultural beliefs, demographic factors such as the gender of CHWs, and clash between CHWs’ health schedules and community members’ daily routines (Dil et al., 2012; Olaniran et, 2022)

The report added that CHWs in all the study nations expressed dissatisfaction over how frequently the timing of home visits and community clinics interfered with the recipients’ regular schedules. CHWs also expressed dissatisfaction over their inability to undertake early-morning house visits due to their family duties  (Wijnker et al., 2015)

Contrary to the substantial efforts of governments and humanitarian organizations to reach hard-to-reach populations in conflict zones, interventions have followed mainly a bureaucratic path where medical professionals are considered the ultimate primary focus, often sidelining grassroots inclusion. Moreover, the decentralization of health services to local communities and community health workers (CHWs), complementing government initiatives, remains limited to a few countries (Rab et al., 2023; Stijntjes, 2015). For example, in Sub-Saharan Africa, Nigeria, Liberia, and other parts of Africa, including South Sudan and Congo, have embraced integrated health delivery models. However, scaling up healthcare in hard-to-reach conflict zones typically remains within governmental purview.

In Ghana, the literature predominantly highlights the involvement of CHW,s. Still,  overlooks the collaboration between Community Health Officers (CHO,s) and Community Health Management Committees (CHMC,s) to enhance effective healthcare delivery by supporting NGOs,s in conflict-prone communities. This paper uniquely explores the health behavioural change intervention approach of the Regional Advisory Information and Networking System (RAINS) project in promoting sustainable healthcare delivery in hot spot conflict zones at the Bawku Municipality.

METHODOLOGY

The research design provided an overall framework for the study, guiding its execution. Therefore, qualitative research methods were employed, using semi-structured interviews and focus group discussions. This approach allowed interviewees to ascertain the targeted population, which was the Community Health Officers and Community Health Management Committee, to answer open-ended questions. Key informants, including the field officer and the health director, were also interviewed to understand the phenomenon comprehensively. Additionally, RAINS documents were sorted as a referral for secondary data sources to validate the activities observed in the field.

Data Collection Method.

The clear objective of the study guided the researchers to employ a purposive sampling technique, focusing on community health officers and community health management committees in conflict zones within the Bawku Municipality. However, due to rain distractions, the research was conducted in five specific Chip Compounds within the communities of Wiidi, Hausa Zongo, Kpalwega, Buabula, and the Baribari CHPS zone, out of the nine communities. The researchers employed Focus Group Discussions with members of the Community Health Management Committees in the targeted CHPS zones. Each FGDs was made up 10 participants (five males and five females). In all, a total of fifty (50) participants were engaged for the FGDs.

Key informant interviews were also conducted with the CHPS zone heads, serving as interviewees, with a total of 5 participants being interviewed. This interview was primarily to collect data on facility-level indicators of interest to the research.  The data was collected by the principal M & E officer and his assistant. The two have extensive research and data collection skills, especially in qualitative research designs.

 Research Ethics

The researchers informed the RAINS project officer at the district level via email and phone calls. The project officer then communicated the purpose of the research to the CWHs and CHMC members. It was agreed that data collection would occur during their respective Child Welfare Centre days at a convenient time. Participants were allowed to review the questions beforehand. Additionally, the researcher emphasized that anyone who felt uncomfortable could choose to decline participation. Pseudonymization was employed to protect the identity of the interviewees in the process of presenting the given findings.

RESULTS

The strategies and activities at the community level were geared towards improving the general health-seeking behaviour of the communities. This was to cure the habit of community people resorting to self-medication when they felt ill. Data from the five (5) revealed an increase in health-seeking behaviour of communities. Health-seeking behaviour was observed to have improved by 34% in the above in five (5) CHPS zones.

Weekly Health Activities

(CHO’s monthly report )

The participants revealed they had witnessed a profound change since implementing the capacity-building activity. Though they still face some complex challenges, a community member has testified that they have seen improvement in their health and the community. When CHMC members and the CHWs were confronted with their current situation, these were what they had to say;

A health officer confessed, ‘When I first reported, attendance at the CHPS compound was minimal. Many pregnant and lactating mothers were not using the facility. On Child Welfare Centre days, we recorded very few attendees and even faced discouragement in our efforts. However, after RAINS implemented an advocacy program and appointed CHMC members as community health advocates, I am pleased to report that attendance has significantly increased.

Monica, labelled as a CHMC member, could not hide her joy and expressed that,

“I remember when our husbands weren’t providing enough, and we didn’t have enough to eat, greatly affecting our diets. However, thanks to consistent advocacy through community gatherings, home visits, and religious leaders’ involvement, most of our husbands now understand what a balanced diet means to us and the babies. In my home, for example, my husband now ensures that everyone eats a balanced diet, even with the little we have.

A senior citizen testified, ‘There is something I’m particularly proud of about this program. In the past, mosquito nets were used to fence our farms. But thanks to the efforts of the CHMC members, we’ve come to understand that mosquito nets are meant to protect our children and us, the mothers, from illness. My husband even suggested that there should be a mass distribution because the benefits are greater than we initially anticipated.’

CHMC members stipulated, ‘ I can confidently say there has been improvement in addressing malaria and open defecation. ‘ Our community didn’t realise that stagnant water could lead to mosquito breeding and that open defecation, littering, and inability to clean our surroundings regularly contributed to the spread of malaria. However, with consistent capacity building and implementing what we learn, we are gradually seeing positive changes.

However, within the Bawku communities, the notable challenge identified was associated with restriction on movement due to the conflict. According to a CHMC member, the conflict situation could potentially disrupt their activities.

A CHMC member called Musah vehemently said,’ The ban on motorbikes has imposed movement restrictions.  Due to the remote location of our communities, we had to patronize tricycles popularly known as the “yellow yellow” to work or even organise people for meetings and to meet as a group.  In a situation where conflict sparks, no one comes for vaccination, negatively affecting our work and health outcomes.

Mercy,  a CHO, also chipped in and added,  ‘When pregnant women are 8 to 9 months old, they need to meet them, but the continuous sound of gunshots discourage these women from visiting the health center when it happens; I don’t have any choice but to stay indoors for my life”.

 Another healthcare worker voiced her concerns, explaining that “Movement restrictions have caused more harm than good. The vaccines are at Mognori, but I cannot go for them daily due to the ban on motorbikes. Consequently, I must mobilise caregivers on specific dates to give them their vaccines. This leads to some children missing out or delaying some essential vaccines.”

In addition, most of the CHMC members in conflict-prone communities pronounced their source of livelihood is affected by the conflict and has contributed to children dropping out of school”.

CHMC member Mariam from Hausa Zongo CHPS confirmed that “As for some of us, we are caged in the middle of the two tribes, Mamprusis and the Kusasis. whenever shootings begin, we can not go out to any place, not to mention visiting the facility. Sadly, some of our people have taken sides in the conflicts which is adversely affecting all of us.  I pray this conflict stops for us to return to our normal life.”

Abu, who was one of the Baubula Community Health Committee members, shared that Buabula is one of the hotspots for the conflict. A day before the research team came to visit the community, there was an exchange of gunshots in the community, and calm was restored on the day of the visit with some arrests made in the community.

A key informant could not hesitate to present his case and elaborated that;

I don’t even know what to say. The conflict is causing unnecessary expenses for RAINS. One stark example is that we used to have training in Bawku here. Still, we are compelled to have it on neutral ground like Bawku, and what worsens the situation is the lack of trust between the two tribes. Hence had to hire someone else to handle the food, or else the party would not eat the food with a suspicion that they might poison it. CHOs and CHMCs also mentioned some other challenges they encountered with some community members concerning behaviour change communication. They reported that community members have a lot of misconceptions about exclusive breastfeeding and family planning, leading to the low practice of the desired behaviour.

The CHMC members in the Buabula community passionately expressed that, “In this community, our mothers or the senior citizens tell us to give the children water because the CHO officers are telling us is not true and even they were also given water when they were children. Ignore them. It is not easy to change their ways. We will not relent until this mindset is eradicated.”

Family planning is noted as a big challenge in Muslim-dominated communities, which the assembly members of the community attest as the following line of action to sensitise the community.

Osman, one of the vibrant members, complained, “Some of us are of the view that when we practice family planning, it means we cannot give birth again or have a limited number of children. Also, we have the misconception that Islam encourages us to give birth to many children as many as we can”

In some communities, some women openly expressed, “Hmm, because the health facility is a public place, whenever you visit, your husband may become suspicious and ask questions, thinking you are there for family planning. Sometimes, we visit distant health facilities or wait until the evening when we go to fetch water, and then we secretly sneak in for family planning.”

The Community health officers across the various facilities gravely complained about the inadequate family Planning commodities.  This is what one CHO member had to say.

The assemblyman, who was a CHMC member, emotionally expressed, “Previously, before the conflict, our clinic was highly patronized, but now things look devastating. It will surprise you that there are not enough beds to accommodate patients. When a pregnant woman is in critical condition, there is no vehicle to convey the person to the Bawku hospital. We use motor king, or sometimes the patient has to find their means. I’m worried.”

A health officer also added, “The facility lacks an adequate supply of essential family planning commodities such as implants, pills, Jadelle, injectables, condoms, and Norplant. Also, basic medicine for malaria is not often available, and we have to write for them to buy it, but because of the current situation, where will they even get money to buy it? The shortage of drugs is impairing health delivery and making our services difficult and stressful. Our facility sometimes faces the challenge of consumables such as  cotton and disposal gloves.”

CHMC and the CHOs revealed that meeting schedules conflict with community members’ daily activities, leading to low turnout or lateness. Again, some community members allege that CHMC members receive payment for their work.

When asked about the issue, a passionate member pointed out, “Politicians have spoiled the community members as they always throw monies to the community members when embarking on any intervention, and such people think we are being paid for the voluntary service we are offering to save people from falling sick, contracting diseases, or even dying.

“Also, you see most people engaged in their business, so when you call for a meeting, they want to finish whatever they are doing before responding because they know they are not getting money from the meeting. At times, we have to go door to door to call them. We are sometimes compelled to visit the churches and mosques to talk to the people about our activities. It’s okay; everything will change. We hope so.”

DISCUSSIONS OF FINDINGS

Improvement In Attendance

The collaboration between Community Health Workers (CHWs) and Community Health Management Committees (CHMCs) led to a notable increase in pregnant women and lactating mothers’ attendance during child welfare centers days. The effective dissemination of information by CHMC members, working closely with CHWs, deepened the community’s understanding of the importance of regular visits to these centers. This partnership has significantly improved attendance rates, as reflected in recent records. These findings are aligned with those of Otieno-Odawa and Kaseje (2014), who observed that trained CHWs from local communities, when working collaboratively with community members, can effectively collect reliable data, particularly on maternal and child health indicators and enhance health outcomes and positive attitudinal Change towards diet.

The advocacy health program improved attendance and became a wake-up call in the male-dominated community. A striking revelation was that most men owned the farm animals in their households, and their wives could only consume eggs or meat with their husbands’ permission. In some cases, women would serve their husbands the entire portion of meat while they ate only raw carbohydrates. However, thanks to the persistent efforts of the advocacy team, many Community Health Management Committee (CHMC) members have reported a shift in attitudes. More husbands are now developing positive views on nutrition, leading to an increased focus on ensuring that pregnant women and lactating mothers consume a balanced diet to improve their health. Similarly, these findings implied the findings of (Brenner et al., (2011) and)  and) andOmam et al., (2023), expressed that Volunteer Community Health Workers (CHWs) were recognized for reducing child mortality rates and enhancing healthcare-seeking behaviours for diarrhoea and fever/malaria following the implementation of a CHW program in rural Uganda.

Benefit of Malaria Sensitization

The study found that the behavioral initiative program was instrumental in eradicating malaria in the catchment areas. Initially, many community members misused treated mosquito nets, opting to use them as farm fencing to keep animals out rather than for their intended purpose. Additionally, controlling malaria outbreaks proved difficult due to widespread open defecation, stagnant water, and littered environments, which contributed to the spread of the disease. However, continuous capacity-building efforts by Community Health Management Committees (CHMC) and Community Health Workers (CHWs) through home visits, community gatherings, and outreach to churches and mosques have significantly reduced the spread of malaria and open defecation. As a result of these efforts, community members have started constructing dug-out latrines to improve sanitation.

The study shares findings similar to Lassi et al. (2015), which emphasized that community health workers who integrate with local experts have strong ties or relationships, can signal any outbreak of communicable Diseases, And Act Faster To Ameliorate Than Professional Doctors.

Challenges Faced By Chmcs And Chws Insecurity

The conflict is severely impacting healthcare delivery. According to the study, pregnant women and nursing mothers avoid health centers during conflict outbreaks due to fears for their safety. Additionally, health workers are reluctant to report to work, hindering the continuity of services. This situation significantly hampers progress as Community Health Officers (CHOs) struggle to administer vaccines, sometimes resorting to risky measures like distributing vaccines at personal residences, which exposes them to danger, including the risk of gunfire. Moreover, health facilities located between Mamprusis and Kusasis, such as Zongo communities, face considerable challenges as residents are effectively trapped and unable to access essential healthcare services amidst ongoing gun violence.  This revelation coincides with the findings of   (2023) and Yaro et al. that the absence of governmental and civil Health providers has led to significant difficulties when travelling to medical institutions at night due to the high risk of harassment and assault. Also, the armed conflict served as a barrier for pregnant women to have limited access to health facilities.

Another significant challenge faced by the CHPS zones is the unavailability of essential health commodities in the facilities. Health care officers revealed their facilities lack some essential medicines and consumables which affect general health care delivery. For instance, all the five (5) CHPS did not have all the family planning commodities. Norigynon, jadelle and implant were noted as the commonest family planning products commodities that were not available. This challenge is strongly militating against family planning acceptance rate as health care professionals noted that women who visit the CHPS zones and do not get their preferred family planning service never return.

Movement Restrictions

The current study identified that CHMC members lived in remote areas and had to board tri-cycles, popularly known as ‘yellow yellow’ or small canoes, to cross the river before getting to the health facility due to the ban on motorbikes in Bawku. This, however, negatively affects their work because they come from different communities to meet at the main chip compound. Also, movement restrictions have made it difficult for CHWs and caregivers to get access to vaccines on time. Therefore, more children do not receive vaccines on time, and some may not be attended to, affecting their activity schedules. These findings appear to replicate the findings by Yaro et alYaro et al.,( 2023) and Fouad et al., who reported that conflict makes it more difficult for medical professionals to respond to crises and offer appropriate life-saving care.

High Cost

The current research shows that the conflict has notably inflated RAINS’ expenditures, especially concerning the training of key stakeholders. Previously, beneficiaries received training locally within the Municipality. However, due to trust issues, RAINS must now arrange sessions outside the Municipality. This adjustment has resulted in added expenses for transport and lodging for participants. Moreover, participants are hesitant to share meals or consume food prepared by individuals from the same ethnic backgrounds, prompting RAINS to engage a caterer of their choice. These conflict-driven dynamics during training sessions strain the organization’s finances considerably.

RECOMMENDATION

The researchers make a number of recommendations that would further improve health care delivery in the Bawku Municipality. These recommendation we believe can also be applicable in communities affected by conflicts.

These include;

• Although the lack of essential medical communities were not directly linked to the conflicts where trucks do not get access to the municipality, we recommend the effective use of medical drones in the munipality. This will deliver essential medicines and commodities especially in the hotspot of the conflicts.
• All radio stations have been closed down in the Bawku Municipal. This would have been a good medium to use to reach people as durbars are ineffective because of restrictions in gatherings. the use of mobile vans for sensitizations in the Bawku municipality in collaboration with the NCCE would help reach more audience with health messages. This will consolidate the gains that have been made through the efforts of the ASBC activities.

CONCLUSION

Advocacy intervention within the conflict-prone community has yielded positive results as it has contributed to improving attendance of pregnant women and lactating mothers’ visits to the child welfare centres due to the joint of CHMCs and CHWs. Moreover, it played an instrumental role in women consuming nutritious diets in their households. Additionally, there has been a significant behavioural change in the light of personal hygiene, resulting in a reduction in malaria, open defecation, and appropriate and regular use of mosquito nets.

However, the conflict within the operational zones continues to hinder the advocacy intervention. Insecurity was noted as one of the biggest threats which prevent CHWs and CHMCs from performing their duties due to safety reasons. Essential health services include vaccine distribution, family planning, child immunization and breastfeeding sensitization. The ban on motorbikes, aggravated by the movement restrictions, has made work sluggish, and hence, services are not delivered on time. On the other hand, the RAINS has to increase its cost to sustain the project because of a lack of trust between community members who appear to belong to different tribes and, therefore, doubt each other.

Similar research should employ qualitative and quantitative approaches and increase the sample size to provide equitable data to address the phenomenon.

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