By Amy Harris

Justine Mugabo, Mysette Misenga, Nahla Alsafar, Angélique Ilunga

It all started five years ago with a little red box, a new team of healthcare volunteers, and an English class from the community women’s group In Her Presence, founded by Claudette Ndayininahaze and Abusana (Micky) Bondo. The volunteers had come to teach health literacy at the invitation of Ndayininahaze and Bondo, and the box symbolized the way the team wanted to teach. They believed they needed to build mutual understanding and trust with the women, and the red box was a tool, a way for participants to ask questions anonymously and confidentially, in a safe space.

Many of the women in the English class were survivors of gender-based violence, had untreated medical conditions, or were pregnant and looking for resources. Bondo and Ndayininahaze had recognized that the members of their group wanted to learn more than English, and hoped to build upon their philosophy – that knowledge is power – by inviting local women’s health providers to their weekly English classes.

Over the past five years, since the launch, health care volunteers have learned as much from the women of In Her Presence as the women have learned from them. From the first session, the health team prioritized meeting the women’s needs and honoring their desire for better health. This meant putting aside lesson plans, learning targets, and vocabulary lists. Learning happened by sitting side by side in a circle with the women, listening to their questions, and hearing their stories. As IHP Executive Director Claudette Ndayininahaze said, “This requires someone with patience, thoughtful judgment, and a commitment to developing trusting relationships. It also requires a serious effort to create mutual confidence, bridge the cross-cultural gap, and break the fear and silence.”

Before the pandemic, the health team joined In Her Presence’s Saturday morning English classes once a month. Initially, the team covered only women’s health-related topics such as family planning and menopause. The intimacy shared between the women and with the Volunteer Health Team grew. Teachers and students alike looked forward to the learning sessions. News spread of the great work being done, and the Volunteer Health Team grew from the original three members to the current team of two medical doctors, five nurse practitioners, and four nurse-midwives.

With the onset of the COVID-19 pandemic, the health team transitioned to offering remote education and support. Led by Susan Doughty, NP, Bronwen Berlekamp O’Wril, NP, and Amy Harris, CNM, the team worked to maintain the foundation of trust that was built through in-person learning. In the early days of the pandemic, team members sought to provide direct support to IHP families who had lost jobs and were struggling to survive. They marshaled the support of friends, family, and local businesses, writing fundraising letters to buy food, diapers, masks, and other necessities for IHP families.

Fortunately, In Her Presence and its mission survived the pandemic. Supported by generous donations and volunteer help, IHP participants got access to Wi-Fi, tablets, laptop computers, and Zoom accounts. The Zoom video-class format has been challenging for both teachers and English language learners, however the social connection and ongoing learning opportunities – even through a screen – have proved therapeutic for participants, teachers, and volunteers alike. As Cate Gaynor, nurse practitioner said, “IHP brings light and hope to us all.”
Shifting health education priorities to COVID-19, the team created three activities for 2020-21. In the fall of 2020, the team combined information from the Centers for Disease Control (CDC), the World Health Organization (WHO), the Maine Center for Disease Control, and the American Academy of Nurse Practitioners (AANP) into a presentation that focused on the importance of mask wearing, where to get tested, and how to correctly isolate and quarantine.

Building on the foundations of trust and the team’s favorite learning tool – questions – the health team prepared a second education program for February 27, 2021, to answer questions about the COVID-19 vaccines. Participants submitted questions to the health team ahead of time, via WhatsApp. If they could not ask what they wanted in English, they were encouraged to submit questions in whatever language was most comfortable for them. The team made slides of the questions and answers ahead of time, and also translated them into French to maximize comprehension. During the two-hour question-and-answer InfoZoom session, six health team members answered questions from more than 20 attendees. The event was an overwhelming success. In Her Presence hopes to make the recording available on its website for others to access as a learning resource. Teachers will also distribute handouts of the slides to IHP participants. Some of the questions and answers are reproduced on the facing page.

“After the presentation, we were told that misperceptions about the vaccine were reduced. Everyone had time to reflect and exchange concerns together. This raised awareness and understanding of the topic,” said IHP Program Director Micky Bondo.

To reinforce topics covered in the information session, the health team taught individual language classes, in two-hour sessions, the following week. As part of the IHP structure, each class (beginner, intermediate, advanced, seniors) has a community member who serves as a “class captain” and interpreter. These class captains are essential to the success of remote classes because they troubleshoot technology problems, make sure the women attend class, assist with communication outside of class time, and translate when needed.

For example, many of the IHP women have family members and friends in their home countries with whom they talk frequently, Because COVID-19’s impact on life in some African countries is very different from life in the pandemic here in Maine, many women are confused by these two parallel worlds. They question mandates for mask wearing, social distancing, quarantining, and vaccination efforts here in Maine, because these do not exist in their home villages and countries.

Health team members always start class with the women’s questions. By asking what the women already know about a topic, or what questions they have, valuable class time is saved for answering remaining questions. Participants often struggle to determine what is true and what is not, since friends, family, religious leaders, and other trusted members of their communities inadvertently send misinformation to them, for example, posts about people dying after receiving the COVID-19 vaccine, or bottles of Coca-Cola testing positive for the COVID-19 virus. This misinformation seeds fear and mistrust.

In Her Presence community members are interested in learning more about the vaccine, but they want to know what possible side effects it might have, where they can get the vaccine, and whether vaccination is required by law. By asking what the women already knew about COVID-19 and the vaccine, the health team prioritized valuable class time for answering their remaining questions. The team highlighted credible sources of information: WHO, the Maine CDC, and the women’s own doctors or health centers. Because most women communicate by WhatsApp, not email, class materials needed to be adapted and distributed via WhatsApp.

Because In Her Presence’s primary mission is to build English language acquisition, the health team created COVID-specific, English learning exercises, such as role-plays. For example, over Zoom, the women practiced calling a medical office, in English, to make an appointment for a COVID-19 test or for the COVID-19 vaccine. Teachers created exercises to combine verb practice with new COVID-19 vocabulary and content. Interactive questions related to the timing of infection, when to test, and how to quarantine. Students practiced selecting past and present verb tenses while putting more complex COVID-19 vocabulary into context.

The team shared an educational video produced by the Global Health Media Project (link for digital publication) Global Health Media Project to help bridge the divide between African and Maine pandemic life. The cartoon video showed scenes of mask-wearing and social distancing while shopping in an open-air market. The film also showed how to isolate from a sick family member in a single-room dwelling. Feedback from class attendees showed that the health team decreased the women’s vaccine hesitancy by addressing their questions and fears.
A few participants shared their feedback: “Dr. Margaret and Nurse Susan responded to my worries and to the questions that I was asking myself. It was clear and obvious. I liked the class,” one said. “The session taught us a lot and took away our fears,” said another.

“At first, several of the women in our group were hesitant about receiving a vaccine, but after the discussion, it seemed like there was more openness and the number of great questions that were raised made the whole discussion very lively and humorous. Laughing is good for us, even while talking about something as serious as COVID-19,” said Kathy Beach, CNM.

This year, the Volunteer Health Team adapted its trusty red box to an online GoogleGroup format, so the women could continue to learn from one another’s questions without sacrificing privacy.
The health team is deeply grateful for the opportunity to work with the women of In Her Presence, especially in these challenging pandemic times. From the women, the team has learned several key lessons about culturally competent health education: Ask questions first. Be quiet, be patient, and listen. Let your students be your teachers. Build trust by being present. When able, the health care team members attend the weekly Saturday classes and help teach, even if health topics are not discussed. Create a safe space. Set expectations for mutual respect and confidentiality, especially if discussing sensitive or taboo subjects. Offer a way for participants to anonymously submit questions. Use open-ended questions to assess knowledge gaps, prioritize class time, and stimulate conversation. Examples are: “What do you know about —?” or “What have you heard about —?” Build your team with native-speakers and class champions to help connect with participants and bridge language or cultural roadblocks along the way.

The most significant accomplishment of this collaboration has been creating a safe space where women could gather, share their most intimate questions and experiences, and find a supportive and healing community. Both Ndayininahaze and Bondo recognize that women’s power is built upon the foundation of health, knowledge, and community.

“You can lose everything, but you will never lose your education. Telling the truth, building relationships, accepting each other is the foundation,” said Claudette Ndayininahaze, In Her Presence Executive Director.

Collaboration between health care providers and community-based organizations, such as the In Her Presence model, is a step toward realizing culturally competent health care and health literacy in Maine. Many health team members are still active practitioners, and take what they learn from the IHP women and the COVID-19 education sessions back with them to their practice settings. In this way, In Her Presence participants are helping to shape a more inclusive and accessible health care system in the Greater Portland area. Question by question, building understanding and trust will help bridge knowledge gaps. This understanding empowers both IHP participants and the health care team members to advocate for a more equitable and culturally competent health care system in pandemic times and beyond.