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

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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

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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

24

Step 1 – Defining Norms

Identifying current feeding, caring and practices in the community

target groups: primary caretakers and decision makers

25

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