mch programs & community health workers...community health a “three legged stool” according...
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MCH PROGRAMS & Community Health Workers
Lessons learned: 30 years experience in 26 countries
Community HealthA “three legged stool” according to the late
Dr Carl Taylor (Johns Hopkins Univ):Needs input from the community (“bottom
up”)Needs input from a change agent (could
be an NGO, university, or development. project)Needs input/supervision and evaluation
from “top down”- such as the local gov’t and/or ministry of health
Community listening:• Homework: Preliminary info needed on:
community locale, structure (demography) and function (sociology); (use focus groups as well as research info)
• Consider with community (democratic representation from all corners, all ages)
• Problems identified by community• Problems identified by health service
Whose voice is heard? Priorities?What kind of resources; personnel?Best community health workers are
“resident home visitors” (not “outreach workers”) (examples).
Therefore: ask and document! Who is already doing what in this community?
Home visits, with community members at exploratory stage, are necessary
Step 1 – Defining Norms: many meetings
Identifying current feeding, caring and practices in the community
Focus groups: caretakers, decision makers
Hospital Albert Schweitzer, Haiti(150,000 people)
Perry et al., American Journal of Public Health, 2007
The Challenges
Malnourished children at risk TODAY
Community health workers and“HEALTH FOR ALL”
• Resident home visitors; accessible; able to work with women’s groups
• Accountable: to community; to funderinformation system begins with mapping and house numbering; door to door registration; reporting/following unimmunized on pregnancies, deaths, births;
• Able to communicate results, not just give messages
CHW’s and Adult Education• Identify with community behaviours that
want changing.• Focus on the positive: Example: “positive deviant” poor families
with well nourished children; make home visits; identify/use their child feeding practices, caring behaviours; create “practice fields” (PD/Hearths with volunteer moms)
Example: CHW Nutrition Program
• Mother is “apprentice” in safe environment; moms contribute some foods titinerant workshop
Behavioral Change is sought, and practiced
“21 times”
• Practice and understand; discuss recipes/snacks.
• What must we demonstrate? Not so much the foods but the change in the child (!)
• Main demonstration is the change in the child rather than the “foods” after two weeks!
Adult participatory educationAdult cycle of learning
How many times to get a new idea across? (seven?)How many times to repeat a behavior before it becomes habit? 21 times?APPRENTICESHIPS ARE NECESSARY
What do CHW’s do? (Peru)Community helped decide to:Conduct community registration, censusCarry out monthly check list monitoring
women/children; “no child left out”Home visits for orientation, ed, referralConduct or help with demonstration
sessionsFill out monthly reports; attend training
Training for CHW’s“Not your banking method” instead
Skill by Skill on the job.Meet competency standards:Can he/she do this? Yes/no;if no, repeat training
Questions after experienceHow many families can 1 CHW expect to
reach over what period of time? What geographic area? (define the population).Take into account local terrain1 CHW for 200 – 400 families or more is
norm; heavier load means missed eventsWorking with women volunteers in each
neighborhood often necessary 1:20 families
Supervision• Biggest problem; this is what fails often.• Must be direct and indirect.• Not “ punitive” but “formative” (examples)• Use of “guest register” left in house works
best ; CHW signs that s/he visited, date name signature, task accomplished). Examples: Malaria eradication progress in Haiti; bed net distribution in Phillippines
Supervision & TrainingEveryone deserves SupervisionRex Fendall, London School Top Med and Hygiene
Skill by skill on-the-job training is best
What are tasks and why What is the skill? Teach first the knowledgeWhat are th evaluation indicators?Who evaluates? (Is community included?)
17
UndernutritionMalnutrition causes more than 1/3 of
child deaths;Underlies as many as 60% of all deaths
of underfives in LDC’s;Takes heavy social toll: ex: anemia if
not corrected by age two affects IQ for lifeAccounts for 11% of global disease
burden
The Positive DevianceHearth Nutrition Model
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Goal of the Hearth Nutrition Program (HNP)
To enable poorcommunities to
independently andsustainably
address the problemof malnutrition
TODAY
What Development Approach…can alleviate current childhood malnutrition
quickly, affordably & sustainably in a culturally acceptable manner?
21
Positive Deviance (PD) Approach
Identifying Solutions to Community Problems Within the Community Today
What enables some poor members of the community
to have well nourished children when their
neighbors do not?…We call these people
Positive Deviants
22
The PD Inquiry
We must discover what they are doing differently from their neighbors
The PD Inquiryis the tool that provides
clues to PDspecial practices
23
PD Inquiry Process
1. Define community norms that effect the nutritional status of children
2. Identify well nourished children from poor families in the community(“Positive Deviant Children”)
3. Conduct Positive Deviant Inquiry (PDI) to discover what uncommon successful behaviors caregivers practice that are accessible to all
4. Share results with community and design an initiative or activity based on PD findings
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Step 1 – Defining Norms
Identifying current feeding, caring and practices in the community
target groups: primary caretakers and decision makers
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Step 2 – Identifying PD Children
• Weigh all children in target area• Select well-nourished children• Identify well-nourished children from poor
families (as defined by community wealth ranking)
Reduction of Child Mortality: 1999-2003
Vurhonga Child Survival ProjectChokwe District, Gaza Province
Mozambique
Pieter Ernst, Meredith Long, Melanie Morrow, _Carl TaylorPROJECT FUNDED BY USAID
Vurhonga I and II• Vurhonga I 1995-1999
– Guija and Mabalane Districts– Population: 107,000
• Vurhonga II 1999-2003– 47 Villages in Chokwe District– Population: 130,000 (140,000 by EOP)– Interventions: Diarrhea, Malaria,
Pneumonia, Nutrition, STI/HIV/AIDS and Child Spacing
Map of Mozambique
Elements of C-IMCI
Element 1• Partnership between
Health Facility and Community
Element 2• Accessible care and
information from community based providers
Element 3• Promotion of key family
practices for child health and nutrition
Element 1: Improving Partnerships between Health facilities and
Communities
• All 47 villages have functioning VHCs
• CG volunteers mobilize the community to attend outreach sessions and assist with GMC
• Communities have a voice with MOH when backed with data
Element 2: Increasing Appropriate Care and Information from CB Providers
• Trained 18 Socorristas selected by VHCs• Functioning health posts increased from 6 to 29;
>95% of population has access to PHC services• Volunteers provided education on all
intervention topics at household level • Improved decision-making lead to decrease in
seeking harmful care from traditional healers
Element 3: Integrated Promotion of Key Family
PracticesIndicator Baseline Final
U5 sleeping under ITN 0.3% 85%Child treated <24 hrs for suspected malaria
28% 90%*
Child treated <24 hrs for suspected pneumonia
2% 60%*
Child with diarrhea treated with ORT 53% 94%Give extra food for 2 weeks following diarrhea
19% 87%
Latrine coverage 28% 75% *24 hours measured as “same day”
Element 3: Key family practices (cont.)
Indicator Baseline Final
Children 12-23 months-old fully-vaccinated
74% 91%
Malnourished children who received enriched porridge
50% 97%
Women using modern methods of birth spacing
3% 29%
Women who know 3 ways to prevent STIs including HIV
0.3% 53%
Key Strategies
Community Structures • Care Group Network: 2350 volunteers are trained
and supervised in 173 Care Groups to reach all HH with BCC and C-HIS; Network used by community itself.
• VHCs: 47 active VHCs make local decisions based on data from the C-HIS that enables them to make changes in their community and advocate for their needs with the MOH.
Tool• C-HIS: Village specific data empower community
members with information specific to their community.
Care Group Structure
Supervisors26 Animatorsrs
173 Care Groups of 10-15
Volunteers 10 HH per
volunteer
5 Supervisors
C-HIS
• Volunteers verbally report vital events for their block of ten households
• Care Group leader records data• Volunteers discuss results• Bi-directional learning with Animator• “Questions of the month” can be added as
needed• Summary data given to Vurhonga Animator
and to village Socorrista
Information Flow
.
CSP
Care Group
MOH
VHC
Animator
Socorrista
Sustainability of Info Flow
.
Care Group
MOH
VHCSocorrista
Key Aspects of HIS
• Analysis and application of data by those involved in collecting it
• Only collect what actually use• Link to lasting community structures
(CGs and VHCs)• Sustained volunteer participation
(<2% drop out per year)
Mortality Data from Census and HIS
3/2000-2/2001 3/2001-2/2002 3/2002-2/2003 3/2000-2/2003Total Births 4557 6244 6410 17211Total Child Deaths 543 408 286 1237 Under 1 year 318 231 153 702Child Death Rate 119 65 45 71.9Infant Death Rate 70 37 23.9 40.8
All Household Census Data (HIS for 2002-3)
For years 3/2000-2/2002, we collected data on child deaths in the previous two yearsfrom every household in the project area with women of reproductive age. We began in March 2000 to avoid counting child deaths immediately associated with the flood.
For the year 3/2002 to 2/2003 we obtained the data from the health information system maintained by the care groups.
Mortality Data from Census/HIS
119
65
45
70
3723.9
0
20
40
60
80
100
120
140
3/2000-2/2001 3/2001-2/2002 3/2002-2/2003
Child Death RateInfant Death Rate
Pregnancy History Method and Sampling
• Interviews– Animators interviewed Women of CBA about their
pregnancies, probing about birth intervals longer than 15 months to ensure that all births (and deaths) were included.
• Sample Selection for 250 Pregnancy Histories – Random selection of 10 villages within one hour of
Chokwe town– 5 randomly selected clusters of 5 interviews were
conducted per village
Mortality Data from Pregnancy Histories
1998-1999 2000 2001-2002 2001-8/2003Total Births 117 58 132 179Total Child Deaths 15 11 4 6 Under 1 year 7 4 1 2Child Death Rate 128.2 189.7 30.3 33.5Infant Death Rate 59.8 69 0.2 11.2
PREGNANCY HISTORY for 250 WOMEN
Mortality Data from Pregnancy Histories
128.2
189.7
33.5
59.869
11.2
020406080
100120140160180200
1998-1999 2000 2001-8/2003
Child Death RateInfant Death Rate
Comparison of Census vs. Pregnancy History
020406080
100120140160180200
Year 2000** Year 2001 Year 2002
Census/HISPregnancy History
**Pregnancy History data for 2000 includes flood deaths
Comparison of MethodsCensus vs. Pregnancy History
Mortality Rates from Census & Pregnancy History: 2000-2002
71.9
40.8
78.9
26.4
0 20 40 60 80 100
CDR
IDR
Pregnancy HistoryCensus/HIS
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