Monitoring of primary health care services: an example from western Uganda.

Results from baseline and follow-up surveys of the Basic Health Services Program in Kabarole District, Western Uganda carried out in 1989 and 1991 are presented. Indicators in relation to management capability, infrastructure, levels of basic knowledge and skills of health staff, community involvement and utilization of health services were measured. Subjectivity of the data collection was minimized through use of a randomized study design, and external supervision. Comparability of results between the two surveys was assured by employing the same rapid assessment methodology, using a fixed set of indicators. The results suggest a marked improvement of the health services in Kabarole district since implementation of specific project activities and in direct response to action taken following review of information from the original survey work. Overall, it is felt that this particular method of project monitoring, and using the specific method, Systems' Analysis, generates data particularly useful to national governments and other health organizations.

Who is the child at risk?

Prior to the establishment of a nutrition intervention programme in the Bagamoyo district of rural Tanzania, all children residing in eleven randomly selected villages were weighted and a number of social and community variables collected. The survey served the dual purpose of providing a baseline to subsequently measure programme impact and identifying the child at risk of becoming malnourished. Despite the survey being carried out during a season of relative scarcity of food, results suggest a relatively benign level of malnutrition in relation to other regions of Subsaharan Africa or other developing countries. Age, the total number of children per household, the proportion of child deaths in the family, paternal care, and residence in specific villages showed statistically significant negative correlations with preschool nutritional status. Apart from residence in specific villages, birth weight, breast-feeding status, supplementation with milk and care of the child in the absence of the mother by a sibling or "nanny" provided positive correlations. The fact that residence in certain villages was associated with highly significant positive or negative effects on preschool child nutrition, as revealed by multiple linear regression analyses, suggests that further research into identification of the precise nature of these variables is required before optimization of an intervention package may be achieved.

The burden of disease among preschool children from rural Tanzania.

A study was undertaken to determine disease prevalence of, choice of treatment for, as well as health services utilization by, preschool children living in a rural district of coastal Tanzania. Disease prevalence and choice of treatment were determined through seven-day recall; health services utilization through systematic analysis of Village Health Workers' service records over one calendar year. It was found that the main disease symptoms, i.e. fever, cough, diarrhea, difficult breathing, ear ache and sore throat occurred at frequencies of 15.6, 8.3, 5.7, 2.0, 1.7 and 0.4 episodes respectively, per child per year. Cough, difficult breathing, common cold and ear ache caused about 50% of all episodes of illness. The majority (61%) of all illness episodes were treated in dispensaries, health centres or hospitals. 18.9% were attended by Village Health Workers (VHWs), 14.5% received treatment at home and 3.5% were seen by traditional healers. The use of VHWs was associated with a reduction of home-treatment and reliance on traditional healers for the care of perceived illness. VHW's monthly reports revealed malaria to be the number one health problem both among children and adults, responsible for about 25% of all attendances.

Cost and effectiveness of different approaches to schistosomiasis control in Africa.

In order to analyze the cost-effectiveness of selected mass-chemotherapy, a model is used to compare the treatment of urinary schistosomiasis with metrifonate (3 dose regimen, fortnightly intervals) and praziquantel (one dose regimen). The model was applied to two situations. Setting I, based on experiences in the Peoples Republic of the Congo, assumes that the average distance between the project base and the area of intervention is 80 km, the other, setting II, based on the situation in Mali, assumes an average distance of 250 km. The aim of the project is defined as the reduction of a prevalence of 50% to less than 5% in the absence of reinfection. Using metrifonate, the cost per person rendered negative is calculated at DM 12.57 for the Congo and at DM 32.52 for Mali. Prevalence will be 4.2% after intervention. Using praziquantel, the costs are DM 8.36 and 11.47, respectively, and the prevalence reached at the end of the intervention will be 1.1%. The cost difference is mainly due to the high operational cost incurred by the 3 dose regimen. Once low prevalence levels are reached, operational cost further outweigh drug expenses.

Control of deaths from diarrheal disease in rural communities: II. Motivating and monitoring the community.

In 1980 the Ministry of Health of Egypt undertook a short term investigation into means and methods to reduce the annually excessive number of preschool child deaths from Diarrheal Disease. This investigation sought to identify ways to overcome constraints related to logistics, supplies, and community participation. The unifying theme of this study was to examine the feasibility of stressing Oral Rehydration Therapy (ORT) instead of the then conventional parenteral treatment and heavy use of antibiotics. Study cells were arranged to test feasibility of placing responsibility for the intervention primarily with rural mothers, secondly with itinerant nurses. Appropriate health education programs, revised supervision and data collection systems were developed and implemented. Results limited to mortality indicators demonstrating that mothers could affect a significant decrease in the diarrhea-specific death rate were reported in an earlier paper. In this paper a more comprehensive presentation of various survey data associated with the investigation are presented. These data show that mothers were indeed able to recognize diarrheal disease and institute early and effective treatment, and that they developed remarkable skills of preparing safe oral rehydration fluids from home supplies of sugar and salt. In addition, the data show that health service staff increasingly gained confidence in ORT as demonstrated by increasing rates of utilization of the method, and as mothers indicated ORT to be the preferred method of treatment of diarrheal disease.

Evaluating tetanus neonatorum as a child survival risk in rural Egypt in the absence of reliable cause-of-death registration.

The principal finding of the investigation is that neonatal tenanus is, indeed an important cause of infant death in rural Egypt even though the normal cause-of-death reporting system had not altered health authorities to the problem. The finding is based on a comparison of registration statistics with (anthropological) reconstruction of pregnancies and child survival using the case-history rather than the epidemiological method. The histories go back ten years and refer to 102 women in two villages of Egypt. An incidental finding is confirmation of the known deficiency of infant death reporting, and associated births, with the extra dividend of showing how serious this may be in the neonatal period. Another incidental finding is the identification of induced abortion as a health problem.

PIP: A short-term study of pregnancy, births, and child mortality was conducted in 2 Egyptian villages to assess the reliability of official statistical records that suggest that neonatal tetanus is rarely a cause of death. Through an anthropologic interview technique based on several visits, reproductive histories were collected from 102 women from 3 age groups: 15-29 years, 30-44 years, and 45 years and over. Respondents from village A, in Upper Egypt, had experienced an average of 8.2 pregnancies, while those from village B, in Lower Egypt, reported 7.3 pregnancies. A total of 114 abortions (14% of all pregnancies) and 14 stillbirths (1.7%) were recorded. Official statistics indicate that 82% of infants in village A and 89% of those in village B survived to age 5 years; however, data from the present study suggest that the 5-year survival rates in these 2 villages were actually 56% and 77%, respectively. Moreover, although vital statistics indicate a rate of neonatal tetanus of 1/6 or less, 75% of the 87 neonatal deaths identified in this study were attributed to tetanus neonatorum/septicemia. Prematurity was the cause of an additional 13% of neonatal deaths in this survey compared with 0.1% of such deaths in official statistics. The results of this study indicate that the underregistration of births and deaths may be a major problem in these 2 villages and probably in other villages in rural Egypt. Neonatal tetanus as a cause of infant mortality was more prevalent in village A (39%) than in village B (9%), presumably because of the higher level of socioeconomic development in the latter region. It is estimated that tetanus immunization of eligible women would have reduced neonatal mortality from 193 to 33/1000 in village A and from 51 to 36/1000 in village B.

Control of deaths from diarrheal disease in rural communities. I. Design of an intervention study and effects on child mortality.

From May through October 1980, the "Strengthening Rural Health Delivery" project (SRHD) under the Rural Health Department of the Ministry of Health of Egypt had conducted an investigation into prevention of child mortality from diarrheal disease through testing various modules of Oral Rehydration Therapy delivery mechanisms. In a six-cell design counting a total of almost 29,000 children, ORT was provided both as hypotonic sucrose/salt solution prepared and administered by mothers and normotonic, balanced electrolyte solution in the hands of both mothers and health care providers and the effects on child mortality during the peak season of diarrheal incidence were measured. In addition, utilization and effects of ORT when made readily available through commercial channels was similarly examined. A cost-benefit analysis was performed on the cost of the services as well as on the outcome for each of five study cells using the sixth, the control, as reference. Results showed that early rehydration with a sucrose/salt solution in the hands of mothers, backed by balanced oral rehydration solution in the hands of health care providers proved the most cost-effective means of reducing diarrhea-specific mortality as well as being as safe as prepackaged commercial preparations.

PIP: A study design consisting of 2 control and 4 treatment cells was used to compare the effectiveness of different compositions of oral rehydration fluids and preventing dehydration and ultimately child deaths from diarrheal disease. Specifically, the extent of reduction in child mortality among 3 groups was compared: 1 group used a combination of oral rehdration therapy (ORT) prepared from the home ingredients of sugar and salt and administered by the mother and ("Oralyte") placed in the hands of the health care providers only; and 1 group used "Oralyte" only administered by both mothers and health care providers. Several data collection processes were employed to collect data on both baseline, intermediate (process), and impact (outcome) variables, including household surveys on demographic composition, sources of (drinking) water, incidence of diarrheal disease, knowledge and practice (KP) of mothers on diarrheal disease (DD) recognition and treatment regimen, availability of utensils and supplies necessary for the preparation of rehydration fluid, sodium concentration of randomly selected samples of home prepared rehydration fluids. In all study villages, the clerk in each health station maintained a regular count of the number of preschool children who had died within the preceding week. Age, sex, house number, and father's name were reported for each death. 2760 children (12.1%) of the total population under care in egypt's "Strengthening Rural Health Delivery" project were seen in the course of outpatient clinics during the 6 months of the program, May through October 1980. Overall, the rate of referral to secondary levels of care was almost 11 times higher in the control than treatment villages. From an initial level of about 22/1000 children per 6 months (May through October) in 1976-77, mortality dropped sigififcantly to a mean of 17.5/1000 in 1978-79 and to a mean of a mean of 10.5 by 1980 in the 3 treatment cells. A most important finding was the demonstration that ordinary household sugar and salt together with potassium containing fruits and vegetables or, intheir absence, tea, may serve as the basic ingredients of an alternative to, and temporary replacement of, the more costly and less readily available prepackaged ORS. This is not to suggest that a simple oral rehydration solution made from sugar and salt is as effective as the balanced "Oralyte", yet this simple solution when backed with adeqate supplies of "Oralyte" in the hands of the health care provider becomes a more cost effective means of reducing high child mortality from diarrheal disease than the "Oralyte" alone.

Nutrition intervention: an evaluation of six studies.

Six nutrition intervention studies were evaluated in the context of a predetermined methodology covering several categories of evaluative criteria. After a presentation of reasons for including each study, a summary is presented of the results of each study in light of the present investigators' evaluation and secondary analyses. Nutrition intervention programs can have a positive effect on health indices of infants and children, but much can be done in future nutrition projects to improve project design and thereby assist and facilitate more meaningful evaluations of nutrition intervention. To this end, a set of points for consideration by those designing nutrition intervention projects is provided.

Complement (C3), nutrition, and infection.

Complement (C(3)) was determined and related to various parameters of nutritional status and past infectious disease experience in a group of 53 rural preschool children in North India. Mean complement level was 25% lower than in an age-matched European reference population. Low complement (C(3)) levels were associated mainly with children who were both stunted and wasted, as well as with those who had experienced frequent purulent skin infections in the past.

The Narangwal Nutrition Study: a summary review.

Between April 1968 and May 1973 the department of International Health of The Johns Hopkins University carried out investigations into the interactions of malnutrition and infection and their effects on preschool child growth, morbidity and mortality in 10 villages of Punjab, North India. Base line surveys before the introduction of services revealed a high prevalence of malnutrition and undernutrition and infectious disease morbidity, as well as lack of accessibility, underutilization and poor population coverage of governmental health services. Study villages were selected in separate clusters and allocated to a control group and three service groups in which nutrition care and medical care were provided singly and in combination by auxiliary health workers resident in each village. Outcome effects were measured through means of longitudinal and cross-sectional surveys. Service inputs and service costs were similarly monitored. Results showed significant improvement of growth (weight and height) and hemoglobin levels of children. Perinatal mortality was reduced by nutrition supplementation to pregnant women. Medical care significantly reduced postneonatal and 1 to 3 mortality, and decreased illness duration of all six conditions examined in this paper. The auxiliary health worker capably managed more than 90% of health needs on her own and referred the rest safely to the physician. Analysis of cost per child death averted showed that cost-effectiveness declined with increasing age of the child. Prenatal nutrition care to pregnant women was most cost-effective in preventing perinatal deaths followed by medical care for infants, and then medical care for the 1 to 3 year age group. The relevance of the field research to national or international endeavors to solve present health problems of developing nations and the timeliness of projects such as the Narangwal Nutrition Study is also evaluated.

A successful programme for medical auxiliaries treating childhood diarrhoea and pneumonia.

PIP: Paraprofessionals or medical auxiliaries require in-service training as well as continual analysis of program effectiveness. In a project in Punjab, India death surveys showed that diarrhea and pneumonia caused 66% of the deaths for children 3 years old and younger; therefore, in-service training programs were implemented to develop criteria for recognizing serious cases. Procedures were set up for field health workers to follow in the event of life-threatening illness and responsibility for patient care was left to the medical auxiliaries whenever possible. In diarrhea cases, mothers were taught how to properly care for their ill children since there were too many cases for field workers to handle adequately. To accomplish this, children were visited by paramedicals in their homes so that signs of dehydration could be pointed out. In pneumonia cases, single penicillin injections replaced daily procaine penicillin since mothers rarely returned their children for treatment. Since in-service training began there has been a 50% reduction in deaths due to diarrhea and a 45% reduction in pneumonia deaths despite a rise in both of the diseases.^ieng

Weight-for-age as an index of risk of death in children.

Between April, 1968, and May, 1973, the Department of International Health of Johns Hopkins University studied the effects of the interaction of nutrition and infection in fourteen villages of Punjab, North India. Serial anthropometric measurements (used as index of nutritional status) and vital statistics of almost 3000 children aged 1-36 months showed that, on average, child mortality doubled with each 10% decline below 80% of the Harvard weight median. The relation between season and mortality showed that mortality-rates were highest just before and during the main (wheat) harvest, reflecting the effects of food scarcity, relative child neglect, and climate on child deaths among those already underweight.